Publications by authors named "Eliana M Perrin"

107 Publications

Updates to the Pediatrics Asthma Management Guidelines.

JAMA Pediatr 2021 Jun 7. Epub 2021 Jun 7.

Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina.

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http://dx.doi.org/10.1001/jamapediatrics.2021.1494DOI Listing
June 2021

Recommendations for Assessment of Social, Emotional, and Behavioral Health for the National Children's Study.

Front Pediatr 2021 4;9:624524. Epub 2021 May 4.

Department of Medical Social Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States.

The Social Emotional Behavioral (SEB) Team of the National Children's Study (NCS) was tasked with making recommendations for assessment of important aspects of social-emotional health and function in children. This paper describes the constructs recommended for assessment along with the rationale for their assessment. These constructs, representing aspects of Social Relationships, Social Capital, Temperament, Negative Affect, Externalizing Behavior, Social Competence, Self-efficacy, Self-image, Psychological well-being, Ethnic/racial Socialization, Perceived Discrimination, Sexual Orientation, Religiosity, and Perceived Stress and Resilience were identified as being critical to the understanding of children's health and development from birth to age 21.
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http://dx.doi.org/10.3389/fped.2021.624524DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8129017PMC
May 2021

A Health-Literacy Intervention for Early Childhood Obesity Prevention: A Cluster-Randomized Controlled Trial.

Pediatrics 2021 May;147(5)

Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee; and.

Background And Objectives: Children who become overweight by age 2 have greater risk of long-term obesity and health problems. The study aim was to assess the effectiveness of a primary care-based intervention on the prevalence of overweight at age 24 months.

Methods: In a cluster-randomized trial, sites were randomly assigned to the Greenlight intervention or an attention-control arm. Across 4 pediatric residency clinics, we enrolled infant-caregiver dyads at the 2-month well-child visit. Inclusion criteria included parent English- or Spanish-speaking and birth weight ≥1500 g. Designed with health-literacy principles, the intervention included a parent toolkit at each well-child visit, augmented by provider training in clear-health communication. The primary outcome was proportion of children overweight (BMI ≥85th percentile) at age 24 months. Secondary outcomes included weight status (BMI score).

Results: A total of 459 intervention and 406 control dyads were enrolled. In total, 49% of all children were overweight at 24 months. Adjusted odds for overweight at 24 months (treatment versus control) was 1.02 (95% confidence interval [CI]: 0.63 to 1.64). Adjusted mean BMI score differences (treatment minus control) were -0.04 (95% CI: -0.07 to -0.01), -0.09 (95% CI: -0.14 to -0.03), -0.19 (-0.33 to -0.05), -0.20 (-0.36 to -0.03), -0.16 (95% CI: -0.34 to 0.01), and 0.00 (95% CI -0.21 to 0.21) at 4, 6, 12, 15, 18, and 24 months, respectively.

Conclusions: The intervention resulted in less weight gain through age 18 months, which was not sustained through 24 months. Clinic-based interventions may be beneficial for early weight gain, but greater intervention intensity may be needed to maintain positive effects.
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http://dx.doi.org/10.1542/peds.2020-049866DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8086006PMC
May 2021

Computational Methods to Measure Patterns of Gaze in Toddlers With Autism Spectrum Disorder.

JAMA Pediatr 2021 Apr 26. Epub 2021 Apr 26.

Department of Electrical and Computer Engineering, Duke University, Durham, North Carolina.

Importance: Atypical eye gaze is an early-emerging symptom of autism spectrum disorder (ASD) and holds promise for autism screening. Current eye-tracking methods are expensive and require special equipment and calibration. There is a need for scalable, feasible methods for measuring eye gaze.

Objective: Using computational methods based on computer vision analysis, we evaluated whether an app deployed on an iPhone or iPad that displayed strategically designed brief movies could elicit and quantify differences in eye-gaze patterns of toddlers with ASD vs typical development.

Design, Setting, And Participants: A prospective study in pediatric primary care clinics was conducted from December 2018 to March 2020, comparing toddlers with and without ASD. Caregivers of 1564 toddlers were invited to participate during a well-child visit. A total of 993 toddlers (63%) completed study measures. Enrollment criteria were aged 16 to 38 months, healthy, English- or Spanish-speaking caregiver, and toddler able to sit and view the app. Participants were screened with the Modified Checklist for Autism in Toddlers-Revised With Follow-up during routine care. Children were referred by their pediatrician for diagnostic evaluation based on results of the checklist or if the caregiver or pediatrician was concerned. Forty toddlers subsequently were diagnosed with ASD.

Exposures: A mobile app displayed on a smartphone or tablet.

Main Outcomes And Measures: Computer vision analysis quantified eye-gaze patterns elicited by the app, which were compared between toddlers with ASD vs typical development.

Results: Mean age of the sample was 21.1 months (range, 17.1-36.9 months), and 50.6% were boys, 59.8% White individuals, 16.5% Black individuals, 23.7% other race, and 16.9% Hispanic/Latino individuals. Distinctive eye-gaze patterns were detected in toddlers with ASD, characterized by reduced gaze to social stimuli and to salient social moments during the movies, and previously unknown deficits in coordination of gaze with speech sounds. The area under the receiver operating characteristic curve discriminating ASD vs non-ASD using multiple gaze features was 0.90 (95% CI, 0.82-0.97).

Conclusions And Relevance: The app reliably measured both known and new gaze biomarkers that distinguished toddlers with ASD vs typical development. These novel results may have potential for developing scalable autism screening tools, exportable to natural settings, and enabling data sets amenable to machine learning.
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http://dx.doi.org/10.1001/jamapediatrics.2021.0530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8077044PMC
April 2021

A scalable computational approach to assessing response to name in toddlers with autism.

J Child Psychol Psychiatry 2021 Feb 28. Epub 2021 Feb 28.

Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA.

Background: This study is part of a larger research program focused on developing objective, scalable tools for digital behavioral phenotyping. We evaluated whether a digital app delivered on a smartphone or tablet using computer vision analysis (CVA) can elicit and accurately measure one of the most common early autism symptoms, namely failure to respond to a name call.

Methods: During a pediatric primary care well-child visit, 910 toddlers, 17-37 months old, were administered an app on an iPhone or iPad consisting of brief movies during which the child's name was called three times by an examiner standing behind them. Thirty-seven toddlers were subsequently diagnosed with autism spectrum disorder (ASD). Name calls and children's behavior were recorded by the camera embedded in the device, and children's head turns were coded by both CVA and a human.

Results: CVA coding of response to name was found to be comparable to human coding. Based on CVA, children with ASD responded to their name significantly less frequently than children without ASD. CVA also revealed that children with ASD who did orient to their name exhibited a longer latency before turning their head. Combining information about both the frequency and the delay in response to name improved the ability to distinguish toddlers with and without ASD.

Conclusions: A digital app delivered on an iPhone or iPad in real-world settings using computer vision analysis to quantify behavior can reliably detect a key early autism symptom-failure to respond to name. Moreover, the higher resolution offered by CVA identified a delay in head turn in toddlers with ASD who did respond to their name. Digital phenotyping is a promising methodology for early assessment of ASD symptoms.
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http://dx.doi.org/10.1111/jcpp.13381DOI Listing
February 2021

The Dose-Response Relationship Between Physical Activity and Cardiometabolic Health in Adolescents.

Am J Prev Med 2021 01;60(1):95-103

Duke Clinical Research Institute, Durham, North Carolina; Duke Center for Childhood Obesity Research, Duke University School of Medicine, Durham, North Carolina; Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; Duke Children's Health and Discovery Initiative, Duke University School of Medicine, Durham, North Carolina.

Introduction: This study examines the dose-response relationship between moderate-to-vigorous physical activity and cardiometabolic measures in adolescents.

Methods: Cross-sectional spline analyses were performed using 2003-2016 National Health and Nutrition Examination Survey data among adolescents (aged 12-19 years, N=9,195) on objectively measured (2003-2006) and self-reported (2007-2016) weekly mean minutes of moderate-to-vigorous physical activity and cardiometabolic measures (systolic and diastolic blood pressure, total cholesterol, high-density lipoprotein, BMI, and cardiorespiratory fitness). Inflection points were determined for nonlinear relationships.

Results: For objective moderate-to-vigorous physical activity, female adolescents had significant nonlinear associations with inflection points at 90 minutes/week for BMI percentile and systolic blood pressure. Male adolescents had inflection points at 150 weekly minutes of objective activity for BMI percentile and cardiorespiratory fitness. BMI percentile was about 7% lower for female and male adolescents at 150 weekly minutes of objectively measured moderate-to-vigorous physical activity than at 0 minutes. For self-reported moderate-to-vigorous physical activity, inflection points were at 375 minutes/week (diastolic blood pressure for female adolescents) and 500 minutes/week (systolic blood pressure for male adolescents).

Conclusions: Among several significant dose-response relationships between physical activity and cardiometabolic health in adolescents, consistent and often nonlinear relationships were identified for BMI, with inflection points at 90-150 minutes of objective moderate-to-vigorous physical activity. Notable differences in associations and linearity were identified by sex and physical activity measure (objective or self-reported). These results support calls for any increase in physical activity among adolescents and suggest that recommendations closer to the adult guidelines of 150 weekly minutes of physical activity may be health promoting and more attainable for youth than the current recommendation of 420 weekly minutes.
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http://dx.doi.org/10.1016/j.amepre.2020.06.027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7769140PMC
January 2021

Infant Television Watching Predicts Toddler Television Watching in a Low-Income Population.

Acad Pediatr 2020 Nov 5. Epub 2020 Nov 5.

Department of Pediatrics, Duke University (CT Wood, JB Howard, and EM Perrin), Vienna, Austria; Duke Center for Childhood Obesity Research, Duke University School of Medicine (CT Wood, JB Howard, and EM Perrin), Durham, NC. Electronic address:

Objective: This study examines the development of active television (TV) watching behaviors across the first 2 years of life in a racially and ethnically diverse, low-income cohort and identifies caregiver and child predictors of early TV watching.

Methods: We used longitudinal data from infants enrolled in the active control group (N = 235; 39% Latino; 29% Black; 15% White) of Greenlight, a cluster randomized multisite trial to prevent childhood obesity. At preventive health visits from 2 months to 2 years, caregivers were asked: "How much time does [child's first name] spend watching television each day?" Proportional odds models and linear regression analyses were used to assess associations among TV introduction age, active TV watching amount at 2 years, and sociodemographic factors.

Results: Sixty-eight percent of children watched TV by 6 months, and 88% by 2 years. Age of TV introduction predicted amount of daily active TV watching at 2 years, with a mean time of 93 minutes if starting at 2 months; 64 minutes if starting at 4 or 6 months; and 42 minutes if starting after 6 months. Factors predicting earlier introduction included lower income, fewer children in household, care away from home, male sex, and non-Latino ethnicity of child.

Conclusions: Many caregivers report that their infants actively watch TV in the first 6 months of life. Earlier TV watching is related to sociodemographic factors yet predicts more daily TV watching at 2 years even controlling those factors. Interventions to limit early TV watching should be initiated in infancy.
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http://dx.doi.org/10.1016/j.acap.2020.11.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8096856PMC
November 2020

Estimation of Body Fat Percentage for Clinical Pharmacokinetic Studies in Children.

Clin Transl Sci 2021 03 22;14(2):509-517. Epub 2020 Nov 22.

Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.

Obesity is a prevalent childhood condition and the degree of adiposity appears likely to be an important covariate in the pharmacokinetics (PKs) of many drugs. We undertook these studies to facilitate the evaluation and, where appropriate, quantification of the covariate effect of body fat percentage (BF%) on PK parameters in children. We examined two large databases to determine the values and variabilities of BF% in children with healthy body weights and in those with obesity, comparing the accuracy and precision of BF% estimation by both clinical methods and demographically derived techniques. Additionally, we conducted simulation studies to evaluate the utility of the several methods for application in clinical trials. BF% was correlated with body mass index (BMI), but was highly variable among both children with healthy body weights and those with obesity. Bio-impedance and several demographically derived techniques produced mean estimates of BF% that differed from dual x-ray absorptiometry by < 1% (accuracy) and a SD of 5% or less (precision). Simulation studies confirmed that when the differences in precision among the several methods were small compared with unexplained between-subject variability of a PK parameter, the techniques were of similar value in assessing the contribution of BF%, if any, as a covariate for that PK parameter. The combination of sex and obesity stage explained 68% of the variance of BF% with BMI. The estimation of BF% from sex and obesity stage can routinely be applied to PK clinical trials to evaluate the contribution of BF% as a potential covariate.
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http://dx.doi.org/10.1111/cts.12896DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7993323PMC
March 2021

Relationship Between Parental Locus of Control and Childhood Injury.

J Prim Prev 2020 12 26;41(6):547-565. Epub 2020 Oct 26.

Department of Pediatrics, Division of Primary Care and Duke Center for Childhood Obesity Research, Durham, NC, USA.

Although pediatricians routinely counsel parents about preventing childhood injuries, we know little about parents' locus of control (LOC) in regards to preventing their children from being injured. We performed an observational analysis of sociodemographic differences in LOC for injury prevention, as measured by four items adapted from the Parental Health Beliefs Scales, in English- and Spanish-speaking parents of infants participating in the treatment arm of an obesity prevention study. First, we examined associations of parental LOC for injury prevention at the time their children were 2 months old with parents' age, race/ethnicity, income, and education. Next, we analyzed time trends for repeated LOC measures when the children were 2, 6, 9, 12, and 24 months old. Last, we examined the association between injury-related LOC items and children's injury (yes/no) at each time point. Of 452 parents, those with lower incomes had both lower internal and higher external LOC. Lower educational achievement was associated with higher external LOC. Both internal and external LOC scores decreased over time. Injuries were more common in children whose parents endorsed low internal and high external LOC. Future studies should examine whether primary care-based interventions can increase parents' sense of control over their children's safety and whether that, in turn, is associated with lower injury rates.Clinical Trial Registration: NCT01040897.
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http://dx.doi.org/10.1007/s10935-020-00615-yDOI Listing
December 2020

Assessing Diet Quality in a Racially and Ethnically Diverse Cohort of Low-income Toddlers.

J Pediatr Gastroenterol Nutr 2020 11;71(5):679-685

Duke Center for Childhood Obesity Research and Duke Department of Pediatrics, Duke University Medical Center Durham, NC.

Background: Low-income racially and ethnically diverse children are at higher risk for obesity compared with their counterparts; yet, few studies have assessed their diet quality.

Objective: The aim of the study was to evaluate the diet quality of a racially and ethnically diverse cohort of 2-year-olds using the Healthy Eating Index (HEI)-2010.

Methods: We used 24-hour dietary recall data from caregivers of toddlers (24-34 months) at 4 pediatric resident clinics that participated in the Greenlight Study to calculate compliance with the Dietary Guidelines for Americans (DGA) using total HEI score (range 0-100) and 12 component scores.

Results: Participants (n = 231) were mostly Hispanic (57%) or non-Hispanic black (27%) and from low-income families. Mean HEI-2010 score was 62.8 (standard deviation [SD] 10.5). Though not significant, Hispanics had the highest HEI score. Toddlers of caregivers without obesity, older than 35 years and born outside the United States had higher HEI scores. Most had high HEI component scores for dairy, fruit, and protein foods, but few achieved maximum scores, particularly for whole grains (13%), vegetables (10%), and fatty acid ratio (7%).

Conclusions: Despite scores reflective of DGA recommendations for fruit, dairy and protein foods, toddlers in this diverse sample had low quality diets as measured by the HEI, driven largely by low component scores for whole grains, vegetables, and ratio of unsaturated to saturated fatty acids.
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http://dx.doi.org/10.1097/MPG.0000000000002871DOI Listing
November 2020

Effects of Breastfeeding, Formula Feeding, and Complementary Feeding on Rapid Weight Gain in the First Year of Life.

Acad Pediatr 2021 03 19;21(2):288-296. Epub 2020 Sep 19.

Division of Primary Care Pediatrics and Duke Center for Childhood Obesity Research, Department of Pediatrics, Duke University School of Medicine (CT Wood and EM Perrin), Durham, NC.

Objective: To determine whether proportion of breast versus formula feeding and timing of complementary food introduction affect the odds of rapid gain in weight status in a diverse sample of infants.

Methods: Using data from Greenlight Intervention Study, we analyzed the effects of type of milk feeding (breastfeeding, formula, or mixed feeding) from the 2- to 6-month well visits, and the introduction of complementary foods before 4 months on rapid increase in weight-for-age z-score (WAZ) and weight-for-length z-score (WLZ) before 12 months using multivariable logistic regression models.

Results: Of the 865 infants enrolled, 469 had complete data on all variables of interest, and 41% and 33% of those infants had rapid increases in WAZ and WLZ, respectively. Odds of rapid increase in WAZ remained lowest for infants breastfeeding from 2 to 6 months (adjusted odds ratio [aOR] 0.34; 95% confidence interval [CI]: 0.17, 0.69) when compared to infants who were formula-fed. Adjusted for feeding, introduction of complementary foods after 4 months was associated with decreased odds of rapid increase in WLZ (aOR 0.64; 95% CI: 0.42, 0.96).

Conclusions: Feeding typified by predominant breastfeeding and delaying introduction of complementary foods after 4 months reduces the odds of rapid increases in WAZ and WLZ in the first year of life.
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http://dx.doi.org/10.1016/j.acap.2020.09.009DOI Listing
March 2021

Changes in the Recreational Built Environment and Youth Body Mass Index.

Acad Pediatr 2021 Jan-Feb;21(1):76-83. Epub 2020 Sep 8.

Duke Center for Childhood Obesity Research (MJ White, J Howard, AC Skinner, and EM Perrin), Duke University School of Medicine, Durham, NC; Department of Pediatrics (MJ White, J Howard, and EM Perrin), Duke University School of Medicine, Durham, NC.

Objective: Many cities have implemented programs to improve the recreational built environment. We evaluated whether neighborhood recreational built environmental changes are associated with change in body mass index (BMI).

Methods: We performed a longitudinal assessment of association between the recreational built environment and BMI percent of 95th percentile (BMIp95). Patient data from 2012 to 2017 were collected from electronic medical records including height, weight, sex, race/ethnicity, insurance type, and address. BMIp95 was calculated. Environmental data including sidewalks, trails, Healthy Mile Trails, and parks were collected. Patients' neighborhood environments were characterized using proximity of features from home address. Multilevel linear regressions with multiple encounters per patient estimated effects of recreational features on BMIp95 and stratified models estimated effect differences.

Results: Of 8282 total patients, 27.7% were non-Hispanic White, half were insured by Medicaid, and 29.5% changed residence. Median BMIp95 was 86.3%. A decrease in BMIp95 was associated with park proximity in the full cohort (-2.85; 95% CI [confidence interval]: -5.47, -0.24; P = .032), children with obesity at baseline (-6.50; 95% CI: -12.36, -0.64; P = .030) and privately insured children (-4.77; 95% CI: -9.14, -0.40; P = .032). Healthy Mile Trails were associated with an increase in BMIp95 among children without obesity (1.00; 95% CI 0.11, 1.89; P = .027) and children living in higher income areas (6.43; 95% CI: 0.23, 12.64; P = .042).

Conclusions: Differences in effect indicate that built environment changes may improve or exacerbate disparities. Improving obesity disparities may require addressing family-level barriers to the use of recreational features in addition to proximity.
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http://dx.doi.org/10.1016/j.acap.2020.09.004DOI Listing
September 2020

The Dose-Response Relationship Between Physical Activity and Cardiometabolic Health in Young Adults.

J Adolesc Health 2020 08 19;67(2):201-208. Epub 2020 Jun 19.

Duke Clinical Research Institute, Durham, North Carolina; Duke Center for Childhood Obesity Research, Duke University School of Medicine, Durham, North Carolina; Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; Children's Health and Discovery Institute, Duke University School of Medicine, Durham, North Carolina. Electronic address:

Purpose: Guidelines recommend 150 minutes of weekly moderate-to-vigorous physical activity (MVPA) for all adults, although physical activity level correlation with cardiometabolic health is not well characterized for young adults. We determined the dose-response relationship of MVPA on measures of cardiometabolic health in young adults.

Methods: We examined young adults (aged 20-29 years; N = 5,395, 47.9% female) in the 2003-2016 National Health and Nutrition Examination Survey. Exposures were objective (accelerometer based) and self-reported weekly mean minutes of MVPA. Cardiometabolic outcome measures were body mass index (BMI), high-density lipoprotein (HDL), total cholesterol, systolic blood pressure, and diastolic blood pressure. The dose-response relationships were assessed with unadjusted spline analyses. Sex-stratified outcomes were modeled using multivariable linear regression with mean estimated change presented for 150-minute dose increases of MVPA.

Results: Among females, associations between objective activity and cardiometabolic measures were all linear. Compared with no activity, 150 minutes of objective activity was associated with a lower BMI (-1.37 kg/m) and total cholesterol (-4.89 mg/dL), whereas 150 minutes of self-reported activity was associated with a higher HDL (1 mg/dL) and lower diastolic blood pressure (-.42 mm Hg). Among males, an inflection point was identified in the dose-response curves for objective activity with BMI around 100 minutes. Compared with no activity, 150 self-reported minutes was associated with lower BMI (-.26 kg/m), higher HDL (.52 mg/dL), and lower total cholesterol (-1.35 mg/dL).

Conclusions: The dose-response relationships between physical activity and cardiometabolic markers in young adults were predominantly linear, supporting public health calls for any increase in physical activity in this population.
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http://dx.doi.org/10.1016/j.jadohealth.2020.04.021DOI Listing
August 2020

Associations Between Food Insecurity and Parental Feeding Behaviors of Toddlers.

Acad Pediatr 2020 Nov - Dec;20(8):1163-1169. Epub 2020 May 31.

Department of Pediatrics and Duke Center for Childhood Obesity Research, Duke University School of Medicine (S Ravanbakht and EM Perrin), Durham, NC.

Objective: We examined associations between household food insecurity status and parental feeding behavior, weight perception, and child weight status in a diverse sample of young children.

Methods: Cross-sectional analysis of 2-year-old children in Greenlight, a cluster randomized trial to prevent childhood obesity. The exposure was food insecurity, defined as a positive response to a validated screen. Outcomes were parent feeding behaviors/beliefs measured by the Child Feeding Questionnaire and child weight status. t tests and linear regression were used to assess associations between food insecurity and each outcome. We adjusted for child sex, race/ethnicity, parent education, employment, site, number of children in the home, and Special Supplemental Nutrition Program for Women, Infants, and Children status.

Results: Five hundred three households (37%) were food insecure. After adjusting for covariates, parents from insecure households reported more pressuring feeding behaviors (mean factor score 3.2 compared to food secure parents mean factor score 2.9, P = .01) and were more worried about their child becoming overweight (mean factor score 2.3 vs 2.0; P = .02). No differences were observed in monitoring or restrictive feeding behaviors. After adjusting for covariates, there was no difference in weight status or prevalence of overweight/obesity of children or parents based on household food insecurity status.

Conclusions: Parents from food insecure households reported more pressuring feeding behaviors. This finding underscores the need to address food insecurity and potentially prevent harmful effects on child feeding. Parents in food insecure households might benefit from linkage with resources and education to develop healthier feeding behaviors.
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http://dx.doi.org/10.1016/j.acap.2020.05.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655687PMC
May 2020

Are Low-Income, Diverse Mothers Able to Meet Breastfeeding Intentions After 2 Months of Breastfeeding?

Breastfeed Med 2020 07 30;15(7):435-442. Epub 2020 Apr 30.

Duke University, Durham, North Carolina, USA.

Little is known about intended breastfeeding duration of women who initiate breastfeeding. We describe the association between intended and actual breastfeeding duration among low-income, diverse mothers who report maintaining breastfeeding for the first 2 months postpartum. We included mothers (64% Hispanic, 17% non-Hispanic black) participating in Greenlight, a cluster randomized childhood obesity prevention trial, who were providing breast milk at the 2-month preventive service visit and reported intended breastfeeding duration at this visit. Breastfeeding status was assessed at subsequent visits, up to 24 months. Poisson regression with a robust variance estimator was used to estimate risk ratios and 95% confidence intervals for meeting breastfeeding intentions. Covariates included race/ethnicity, income, receiving benefits from the Special Supplemental Nutrition Assistance Program for Women, Infants and Children (WIC), education, age, employment, depression, maternal obesity, U.S. born, whether infant was first born, and study site. Median intended breastfeeding duration was 11.5 months (interquartile range [IQR]: 6-12) and median actual breastfeeding duration was 8.6 months (IQR: 4-14) ( = 349). Approximately half (49%) met intended breastfeeding duration. Breastfeeding duration differed based on milk type provided at the 2-month visit in that mothers providing mostly or only breast milk had increased likelihood of meeting breastfeeding intentions. Regardless of milk type provided at 2 months, the longer a mother intended to breastfeed, the less likely she was to meet her breastfeeding intentions. In this diverse sample of women less than half met breastfeeding intentions despite maintaining breastfeeding for 2 months. Understanding factors that prevent mothers from attaining intended breastfeeding duration is critical to improving breastfeeding outcomes, especially in low income and ethnic minority populations.
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http://dx.doi.org/10.1089/bfm.2020.0025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7374637PMC
July 2020

Rationale, design, and methodology for the healthy mothers-healthy children study: a randomized controlled trial.

BMC Nutr 2019 16;5:58. Epub 2019 Dec 16.

10Division of Primary Care, Department of Pediatrics, Duke Center for Childhood Obesity Research, Duke University School of Medicine, DUMC 102645, 146 Civitan Building, 2213 Elba Street, Durham, NC 27705 USA.

Background: Hispanic women and children who become overweight or obese are at risk for developing prediabetes, type 2 diabetes, and cardiovascular disease later in life. Interdisciplinary interventions which target Hispanic women and their 3-5-year old children to improve nutrition and physical activity behaviors, manage adiposity and weight in mothers, and prevent excessive adiposity and weight gain trajectory in their children offer promise to break the intergenerational cycle.

Methods: Using a randomized two-group, repeated measures experimental design, the goal of the proposed study is to investigate the efficacy of a 12-week nutrition and physical activity program including education, coping skills training, and home-based intervention in Hispanic women and their 3-5-year old children. The program includes 6 months of continued monthly contact to help overweight and obese Hispanic mothers and their children improve adiposity, weight (trajectory for children), health behaviors (nutrition and physical activity), and self-efficacy We will partner with two federally qualified health departments in Durham and Chatham counties, North Carolina to enroll participants. We will partner with community centers to deliver the intervention. A total of 294 Hispanic women with a BMI ≥ 25 kg/m and 294 Hispanic 3-5-year old children with a ≥ 25th BMI percentile will be enrolled over 4 years and randomized to the experimental or equal attention control group. Data will be collected at Time 1 (0 months [baseline]) to Time 2 (9 months [completion of the intervention]) and Time 1 to Time 3 (15 months [after 6 months with no contact from the study staff]). Data collected will include adiposity and weight in mothers and children (primary outcomes). Secondary outcomes will include health behaviors and self-efficacy in the mothers and in the children. We will also evaluate the cost of delivering the program for public health departments. We will use general linear mixed models to test the hypotheses.

Discussion: Decreasing overweight and obesity in Hispanic women and slowing adiposity and weight gain trajectory in young Hispanic children is urgently needed to decrease morbidity, mortality, and future health care costs.

Trial Registration: NCT03866902. (March 7, 2019).
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http://dx.doi.org/10.1186/s40795-019-0322-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7050912PMC
December 2019

A randomized controlled trial examining an exam room poster to prompt communication about weight.

Pediatr Obes 2020 07 18;15(7):e12625. Epub 2020 Feb 18.

Department of Pediatrics, Duke University, Durham, North Carolina.

Background: Recognition of childhood weight status is important to the adoption of healthy lifestyle behaviours.

Objectives: We assessed whether an exam room educational poster addressing weight and healthy lifestyle behaviours was acceptable to parents, prompted parent-provider communication or improved parental weight perception accuracy.

Methods: In this multi-site randomized controlled trial, exam rooms were randomized to display the posters (English and Spanish) or not. Children ages 3 to 8 years (N = 965) attending well visits were weighed and roomed per usual clinic protocol. After the visit, parents completed a questionnaire assessing demographics, child weight status perceptions and whether they discussed weight status with provider or were shown growth charts. We used separate logistic regression analyses to examine associations between intervention status and: asking provider about child weight, being shown growth charts, and accuracy of weight perception, adjusting for covariates and clustering by exam room.

Results: Of the parents who saw the poster, 97% liked seeing it and reported greater understanding of weight status visualization (96%) and healthy lifestyle behaviours (94%). Parents who saw the poster were more likely to report being shown a growth chart (OR 1.87, 95% 1.06, 3.30) but were not more likely to ask about their child's weight status nor accurately report their child's weight status.

Conclusions: An educational exam room poster about healthy weight was well-received by parents and prompted providers to show the child's growth chart but did not prompt parent-initiated conversations about weight status nor improve parental weight perception accuracy.
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http://dx.doi.org/10.1111/ijpo.12625DOI Listing
July 2020

Associations between milk fat content and obesity, 1999 to 2016.

Pediatr Obes 2020 05 6;15(5):e12612. Epub 2020 Jan 6.

Department of Population Health Sciences, Duke Clinical Research Institute, Duke Center for Childhood Obesity Research, Duke University, Durham, North Carolina.

Background: The relationship between milk fat content and body mass index (BMI) remains unclear. The objective of this study was to determine if milk fat content is associated with obesity in children, adolescents and young adults.

Methods: We used repeated cross sections of National Health and Nutrition Examination Survey (NHANES), 1999 to 2016. Using logistic regression, we measured associations between first milk consumed after formula/breast milk (whole, 2%, 1%, or fat-free) and weight status (≥85th to <95th BMI percentile, overweight; ≥95th BMI percentile, obesity) among children 2 to 6 years (n = 8367). We also assessed associations between current milk type and weight status among those 2 to 20 years of age (n = 26 750).

Results: Children 2 to 6 years with obesity were less likely to have been weaned to whole milk versus healthy weight children (adjusted odds ratio [aOR], 0.77; 95% CI, 0.60-0.98; P = .031). Individuals 2 to 20 years with overweight or obesity were less likely to drink whole milk as their current milk and more likely to drink fat-free or 1% milk compared with healthy weight children.

Conclusions: Whole milk consumers are less likely to have obesity. It is unclear whether this relationship is causal or a reflection of United States Department of Agriculture recommendations. Further examination of the factors that influence milk choice among diverse cohorts would lend clarity to this important issue.
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http://dx.doi.org/10.1111/ijpo.12612DOI Listing
May 2020

Structure and Function in Cross-sectional Work-A Cautionary Tale.

JAMA Pediatr 2020 02;174(2):129-130

Duke Center for Childhood Obesity Research, Division of Primary Care Pediatrics, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina.

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http://dx.doi.org/10.1001/jamapediatrics.2019.4722DOI Listing
February 2020

Back in the Day: Nostalgia Frames Rural Residents' Perspectives on Diet and Physical Activity.

J Nutr Educ Behav 2020 02 11;52(2):126-133. Epub 2019 Oct 11.

Division of Primary Care Pediatrics, Department of Pediatrics, Duke University School of Medicine, Durham, NC.

Objective: To observe and interpret cultural influences on health behaviors in a rural area with a high prevalence of obesity.

Design: Descriptive, qualitative study.

Setting: Lenoir County, NC, US.

Participants: Four focus groups (n = 33) were conducted. Participants were 76% African American and with an average of 25 years of county residence.

Phenomenon Of Interest: Diet, physical activity, environment ANALYSIS: Content analysis and thematic data analysis to identify key themes using qualitative analysis software.

Results: Participants frequently evoked nostalgia to frame recurrent themes including decreased opportunities for physical activity and changing food access and preparation in the community, contrasting with memories of enjoying local produce and safe outdoor recreation. They interpreted present health behaviors in the context of these past losses.

Conclusions And Implications: Nostalgia is an important element in our participants' cultural repertoires, revealing elements of place-based culture. Nostalgic narratives may foster a sense of reduced options for healthy eating and exercise by over-emphasizing loss. The incorporation of place-specific obesogenic cultural factors, including the way residents juxtapose past and present, may improve obesity interventions in rural settings.
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http://dx.doi.org/10.1016/j.jneb.2019.05.601DOI Listing
February 2020

Defining picky eating and its relationship to feeding behaviors and weight status.

J Behav Med 2020 08 19;43(4):587-595. Epub 2019 Jul 19.

Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

We assessed the individual constructs that comprise "picky eaters" and determined the relationship of each construct to parental perception of their child's weight status, parental pressure-to-eat, and the child's body mass index z-score (BMIz). We developed a questionnaire including 7 commonly used measures of picky eating, which was completed by parents of 2-8 year-olds in pediatric clinics. We performed exploratory factor analysis, confirmatory factor analysis, and model fit. Regression models assessed the association of each picky eating factor to weight perception, pressure-to-eat, and BMIz. We identified three distinct picky eating factors: trying new foods, eating sufficient quantity, and desire for specific food preparation. Each factor had Cronbach's alpha > 0.7 and acceptable model fit. No factors were associated with weight perception. Parents who were more concerned their child did not eat enough were more likely to pressure-to-eat, and these children had lower BMIz. These components of picky eating should be addressed by primary care providers.
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http://dx.doi.org/10.1007/s10865-019-00081-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7737340PMC
August 2020

Medicaid and CHIP Child Health Beneficiary Incentives: Program Landscape and Stakeholder Insights.

Pediatrics 2019 08 9;144(2). Epub 2019 Jul 9.

Department of Pediatrics, School of Medicine.

Objectives: To describe the landscape of Medicaid and the Children's Health Insurance Program beneficiary incentive programs for child health and garner key stakeholder insights on incentive program rationale, child and family engagement, and program evaluation.

Methods: We identified beneficiary health incentive programs from 2005 to 2018 through a search of peer-reviewed and publicly available documents and through semistructured interviews with 80 key stakeholders (Medicaid and managed-care leadership, program evaluators, patient advocates, etc). This study highlights insights from 23 of these stakeholders with expertise on programs targeting child health (<18 years old) to understand program rationale, beneficiary engagement, and program evaluation.

Results: We identified 82 child health-targeted beneficiary incentive programs in Medicaid and the Children's Health Insurance Program. Programs most commonly incentivized well-child checks ( = 77), preventive screenings ( = 30), and chronic disease management ( = 30). All programs included financial incentives (eg, gift cards, premium incentives); some also offered incentive material prizes ( = 12; eg, car seats). Loss-framed incentives were uncommon ( = 1; eg, lost benefits) and strongly discouraged by stakeholders. Stakeholders suggested family engagement strategies including multigenerational incentives or incentives addressing social determinants of health. Regarding evaluation, stakeholders suggested incentivizing evidence-based preventive services (eg, vaccinations) rather than well-child check attendance, and considering proximal measures of child well-being (eg, school functioning).

Conclusions: As the landscape of beneficiary incentive programs for child health evolves, policy makers have unique opportunities to leverage intergenerational and social approaches for family engagement and to more effectively increase and evaluate programs' impact.
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http://dx.doi.org/10.1542/peds.2018-3161DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6855824PMC
August 2019

Food Insecurity Associated With Underestimation of Weight Status in Children With a Healthy Weight.

Acad Pediatr 2020 03 25;20(2):188-192. Epub 2019 Apr 25.

Department of Pediatrics (EM Perrin and CL Brown), University of North Carolina at Chapel Hill; CL Brown is now with the Departments of Pediatrics and Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC. Electronic address:

Objective: Accurate parental weight perception of one's child is an important step in addressing healthy behaviors, but its associations with socioeconomic status (SES) and household food insecurity (HFI) are unclear. We aimed to assess the association of parental weight perception with HFI.

Methods: This was a secondary data analysis of a cross-sectional study of 284 children ages 2 to 8 years whose parents completed surveys about weight perception, SES, and HFI. Height and weight were measured to determine the children's body mass index scores and were self-reported by parents. We performed chi-square tests to compare HFI and accuracy of parental weight perception and used logistic regression to assess accuracy, adjusting for significant covariates and stratifying by child weight category.

Results: Approximately two thirds of children had healthy weight, 18% had overweight, and 15% had obesity. About one third of parents inaccurately identified their child's weight category, almost always underestimating weight status. Twenty-eight percent of the families were food insecure. HFI was not associated with parental weight perception in bivariate analysis. When stratified by weight status, food insecure families with children at healthy weight had 0.16 times the odds of accurately perceiving their children's weight status. There was no association between HFI and accuracy of weight perception in children with overweight or obesity.

Conclusions: Food insecurity was associated with a decrease in the accuracy of parental weight perceptions in children with healthy weight. Pediatricians should clearly communicate about weight status, as families with HFI may adopt unhealthy eating behaviors under the incorrect assumption that their child is underweight.
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http://dx.doi.org/10.1016/j.acap.2019.04.009DOI Listing
March 2020

Concordance of Child and Parent Reports of Children's Screen Media Use.

Acad Pediatr 2019 07 11;19(5):529-533. Epub 2019 Apr 11.

Division of Primary Care Pediatrics and Duke Center for Childhood Obesity Research, Department of Pediatrics (CT Wood, JB Howard, and EM Perrin),; Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics (CT Wood, CL Brown, JB Howard, MJ Steiner, and EM Perrin).

Objective: Little is known about the concordance of parent and child reports of children's media consumption, even though parents are often asked to report for their children in clinical care settings. Our objective was to understand how parent and child reports of children's media consumption differ in an era of changing screen media consumption via personal devices.

Methods: As part of a larger study about the reception of health-related cues from children's media, children ages 9 to 11 years (N = 114) and their parents independently completed identical questionnaires about specific media use and health behaviors. To examine concordance between child and parent reports of children's screen media use, we calculated the mean number of minutes per day and proportions reported by the child and parent and assessed concordance with t-tests and chi-square tests.

Results: On a typical day, children reported nearly an hour each of video and app game use, computer use, and television exposure. Overall, child and parent reports were similar, usually within 10 minutes of each other; however, among 3 measures of TV use, parents consistently reported less TV exposure than children. There was significant discordance in the percentages of parents and children reporting the presence of a TV in the child's room.

Conclusions: Parent and child reports of children's media use were generally concordant; however, there were important disagreements, such as TV use in the child's room and during meals. We discuss possible causes of discrepancies and implications.
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http://dx.doi.org/10.1016/j.acap.2019.04.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6612580PMC
July 2019

Adolescent and Young Adult Recreational, Occupational, and Transportation Activity: Activity Recommendation and Weight Status Relationships.

J Adolesc Health 2019 07 1;65(1):147-154. Epub 2019 Apr 1.

Duke Center for Childhood Obesity Research, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina; Division of Primary Care, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina; Duke Children's Health and Discovery Initiative, Duke University School of Medicine, Durham, North Carolina. Electronic address:

Purpose: Physical activity can occur in many settings, or domains, including recreation, occupation, and transportation. We described patterns of adolescent and young adult (YA) activity in each domain, and the extent that accounting for different domains impacts activity recommendation adherence. We also examined activity domain associations with weight status.

Methods: We examined physical activity among 11,157 adolescents and YAs in recreational, occupational, and transportation domains in the 2007-2016 National Health and Nutrition Examination Survey. We calculated proportions meeting weekly activity recommendations (adolescents: 420 minutes; YAs: 150 minutes) by domain. We compared adjusted odds of performing any activity in each domain by weight status. All estimates are weighted and stratified by age (adolescents: 12-19 years; YAs: 20-29 years) and sex.

Results: Most adolescents (90.9%) and YAs (86.7%) reported activity in at least one domain. Recreational activity accounted for an average of 60.2% (adolescents) and 42.5% (YAs) of an individual's total activity. Approximately half of YAs (50.2%) reported any occupational activity, which accounted for 44.6% (males) and 37.4% (females) of total activity minutes. Transportation accounted for 18.1% (adolescents) and 16.2% (YAs) of total activity. Activity recommendation adherence estimates increased when adding domains: recreation alone (34.9% adolescents, 45.6% YAs); recreation and occupation (47.2% adolescents, 68.7% YAs); and recreation, occupation, and transportation (53.5% adolescents, 74.7% YAs). Weight status was generally not associated with activity domains.

Conclusions: Adolescents and YAs accumulate substantial occupational and some transportation-related physical activity, resulting in more youth meeting activity recommendations when accounting for these activity domains than recreation alone.
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http://dx.doi.org/10.1016/j.jadohealth.2019.01.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6589358PMC
July 2019

Antecedents of Obesity Among Children Born Extremely Preterm.

Pediatrics 2018 11 5;142(5). Epub 2018 Oct 5.

Division of Neonatal-Perinatal Medicine, Department of Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.

Background: Childhood obesity is a pervasive public health problem with risk factors such as maternal prepregnancy BMI and rapid infant weight gain. Although catch-up weight gain promotes more favorable neurodevelopment among infants born preterm, it is not clear whether faster weight gain early in life, or other correlates of preterm birth, are associated with later obesity in this population.

Methods: We used prospective data from the multicenter, observational Extremely Low Gestational Age Newborn Study. Among 1506 eligible individuals in the initial cohort, 1198 were eligible for follow-up at 10 years of age. We examined BMI in 871 children (58% of the cohort; 74% of survivors) and analyzed relationships between antecedents and overweight or obesity at 10 years of age. A time-oriented approach to multinomial multivariable regression enabled us to calculate odds of overweight and obesity associated with pre- and postnatal antecedents.

Results: Prepregnancy maternal BMI ≥25 and top quartile infant weight gain in the first year were associated with increased risk of both overweight and obesity at 10 years of age. Single marital status was a risk factor for later child obesity and exposure to tobacco smoke was a risk factor for later child overweight.

Conclusions: The risk profiles for overweight and obesity at 10 years of age among children born extremely preterm appear to be similar to the risk profiles of overweight and obesity among children born at term.
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http://dx.doi.org/10.1542/peds.2018-0519DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6317645PMC
November 2018

Parental Feeding Beliefs and Practices and Household Food Insecurity in Infancy.

Acad Pediatr 2019 Jan - Feb;19(1):80-89. Epub 2018 Sep 21.

Department of Pediatrics and Duke Center for Childhood Obesity Research (SN Ravanbakht, CT Wood, and EM Perrin), Duke University Medical Center, Durham, NC. Electronic address:

Objective: Food insecurity is associated with childhood obesity possibly mediated through caregiver feeding practices and beliefs. We examined if caregiver feeding practices differed by household food security status in a diverse sample of infants. We hypothesized that feeding practices differ based on food security status.

Patients And Methods: Included in the baseline cross-sectional analysis of data from a randomized controlled trial to prevent obesity were 842 caregivers of 2-month-old infants presenting for well-child care at 4 academic institutions. Food insecurity exposure was based on an affirmative answer to 1 of 2 items in a 2-item validated questionnaire. Chi-square tests examined the association between parent feeding practices and food security status. Logistic regression adjusted for covariates. Differences in caregiver feeding practices by food security status and race/ethnicity were explored with an interaction term (food security status x race/ethnicity).

Results: Forty-three percent of families screened as food insecure. In adjusted logistic regression, parents from food-insecure households were more likely to endorse that "the best way to make an infant stop crying is to feed him or her" (adjusted odds ratio [aOR], 1.72; 95% confidence interval [CI], 1.28-2.29) and "when my baby cries, I immediately feed him or her" (aOR, 1.40; 95% CI, 1.06-1.83). Food-insecure caregivers less frequently endorsed paying attention to their baby when he or she is full or hungry (OR, 0.57; 95% CI, 0.34-0.96). Racial/ethnic differences in beliefs and behaviors were observed by food security status.

Conclusions: During early infancy, feeding practices differed among caregivers by household food security status. Further research is needed to examine whether these practices are associated with increased risk of obesity and obesity-related morbidity.
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http://dx.doi.org/10.1016/j.acap.2018.09.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6599601PMC
February 2020

Neighborhood Commute to Work Times and Self-Reported Caregiver Health Behaviors and Food Access.

Acad Pediatr 2019 Jan - Feb;19(1):74-79. Epub 2018 Jul 21.

Division of Primary Care Pediatrics and Duke Center for Childhood Obesity Research, Department of Pediatrics (EM Perrin), Duke University School of Medicine, Durham, NC.

Objective: Time spent commuting is associated with obesity. The objective of this study was to assess the relationship between neighborhood-level commute to work (CTW) times and self-reported health behaviors and food access.

Methods: We conducted a cross-sectional analysis of caregivers with infants as part of the Greenlight Study, a multisite obesity trial in Chapel Hill, New York City, Nashville, and Miami. ZIP code-based commuting estimates were determined using the US Census American Community Survey. Self-reported health behaviors and food access data were collected by directed interview. Logistic and linear regression models were used to determine associations between neighborhood CTW times and health behaviors and food access.

Results: The average neighborhood CTW time for all ZIP codes was 29 minutes (n = 846). Caregivers in longer CTW time neighborhoods were more likely to endorse fewer food choices (adjusted odds ratio [AOR], 1.39; 95% confidence interval [CI], 1.15-1.69; P = .001) and difficulty accessing markets with fresh produce (AOR, 1.51; 95% CI, 1.02-2.25; P = .04). Neighborhood CTW time >30 minutes was associated with less caregiver physical activity (AOR, 0.58; 95% CI, 0.34-0.98; P = .044). Neighborhood CTW time was inversely related to infant television time (adjusted mean, 399 minutes/day for ≤30 minutes and 256 minutes/day for >30 minutes; P = .025). New York families in longer CTW neighborhoods were more likely to report difficulty accessing markets with fresh produce (AOR, 1.80; 95% CI, 1.03-3.14; P = .039).

Conclusions: Neighborhood CTW time is associated with several self-reported health behaviors and perceived food access among caregivers with children. Neighborhood CTW times may represent city-specific features, including transportation infrastructure, which may impact the health of families.
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http://dx.doi.org/10.1016/j.acap.2018.07.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6321776PMC
February 2020

Obesity Prevention and Treatment in Primary Care.

Acad Pediatr 2018 Sep - Oct;18(7):736-745. Epub 2018 May 29.

Department of Pediatrics and Department of Epidemiology and Prevention (Dr Brown), Wake Forest School of Medicine, Winston-Salem, NC; Department of Pediatrics and Duke Center for Childhood Obesity Research (Dr Perrin), Duke University School of Medicine, Durham, NC.

Despite extensive public health and clinical interventions, obesity rates remain high, and evidence-based preventive strategies are elusive. Many consensus guidelines suggest that providers should screen all children after age 2 years for obesity by measuring height and weight, calculating body mass index (BMI), and sensitively communicating weight status in the context of health to the family at each visit. However, preventive counseling should begin in infancy and focus on healthy feeding, activity, and family lifestyle behaviors. For children with overweight or obesity, the American Academy of Pediatrics outlines 4 stages of treatment: 1) Primary care providers should offer "prevention plus," the use of motivational interviewing to achieve healthy lifestyle modifications in family behaviors or environments; 2) children requiring the next level of obesity treatment, structured weight management, need additional support beyond the primary care provider (such as a dietitian, physical therapist, or mental health counselor) and more structured goal setting with the team, including providers adept at weight management counseling; 3) children with severe obesity and motivated families may benefit from referral to a comprehensive multidisciplinary intervention, such as an obesity treatment clinic; and 4) tertiary care interventions are provided in a multidisciplinary pediatric obesity treatment clinic with standard clinical protocols for evaluation of interventions, including medications and surgery. Although it is certainly a challenge for providers to fit in all the desired prevention and treatment counseling during preventive health visits, by beginning to provide anticipatory guidance at birth, providers can respond to parents' questions, add to parents' knowledge base, and partner with parents and children and adolescents to help them grow up healthy. This is especially important in an increasingly toxic food environment with numerous incentives and messages to eat unhealthfully, barriers to appropriate physical activity, and concomitant stigma about obesity. Focusing on key nutrition and physical activity habits and establishing these healthy behaviors at an early age will allow children to develop a healthy growth trajectory. However, much more work is needed to determine the best evidence-based practices for providers to counsel families on improving target behaviors, environmental modifications, and parenting skills and to decrease abundant disparities in obesity prevalence and treatment.
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http://dx.doi.org/10.1016/j.acap.2018.05.004DOI Listing
November 2019

Prevalence of Obesity and Severe Obesity in US Children, 1999-2016.

Pediatrics 2018 03;141(3)

Duke Clinical Research Institute, Durham, North Carolina.

Objectives: To provide updated prevalence data on obesity trends among US children and adolescents aged 2 to 19 years from a nationally representative sample.

Methods: We used the NHANES for years 1999 to 2016. Weight status was determined by using measured height and weight from the physical examination component of the NHANES to calculate age- and sex-specific BMI. We report the prevalence estimates of overweight and obesity (class I, class II, and class III) by 2-year NHANES cycles and compared cycles by using adjusted Wald tests and linear trends by using ordinary least squares regression.

Results: White and Asian American children have significantly lower rates of obesity than African American children, Hispanic children, or children of other races. We report a positive linear trend for all definitions of overweight and obesity among children 2-19 years old, most prominently among adolescents. Children aged 2 to 5 years showed a sharp increase in obesity prevalence from 2015 to 2016 compared with the previous cycle.

Conclusions: Despite previous reports that obesity in children and adolescents has remained stable or decreased in recent years, we found no evidence of a decline in obesity prevalence at any age. In contrast, we report a significant increase in severe obesity among children aged 2 to 5 years since the 2013-2014 cycle, a trend that continued upward for many subgroups.
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http://dx.doi.org/10.1542/peds.2017-3459DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109602PMC
March 2018