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Early Life Factors for Overweight Risk Among Infants of Hispanic Immigrant Mothers
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Early Life Factors for Overweight Risk Among Infants of Hispanic Immigrant Mothers D1X XKathleen F. Gaffney, D2X XPhD, RN, F/PNP-BC, D3X XDeborah A. Kermer, D4X XMA, D5X XPanagiota Kitsantas, D6X XPhD, D7X XAlbert V. Brito, D8X XMD, D9X XKatya M. Ramos, D10X XBS, D1X XGraciela Pereddo, D12X XBS, & D13X XLuisa Villatoro, D14X XBS TAGEDPABSTRACT Introduction: This study examined postpartum depression, food insecurity, and underestimation of infant size as potential early life factors for overweight risk at 12 months among infants of Hispanic immigrant mothers. Method: Weight-for-length (WFL) measurements and face-to-face interviews were completed during well child visits. Regression
Kathleen F. Gaffney, Professor, School of Nursing, George Mason University, Fairfax, VA. Deborah A. Kermer, Data Services Research Consultant, University Libraries, Data Services, George Mason University, Fairfax, VA. Panagiota Kitsantas, Professor, Health Administration and Policy Department, George Mason University, Fairfax, VA. Albert V. Brito, Medical Director, Inova Cares Clinic for Children, Falls Church, VA. Katya M. Ramos, Research Assistant, School of Nursing, George Mason University, Fairfax, VA. Graciela Pereddo, Research Assistant, Global and Community Health Department, George Mason University, Fairfax, VA. Luisa Villatoro, Research Assistant, School of Nursing, George Mason University, Fairfax, VA. Conflicts of interest: None to report. This study was supported by the National Institute of Child Health and Human Development [R15HD080710]. Correspondence: Kathleen F. Gaffney, PhD, RN, F/PNP-BC, School of Nursing, George Mason University, 4400 University Dr., Fairfax, VA 22030; e-mail: [email protected]. 0891-5245/$36.00 Copyright © 2018 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.pedhc.2018.05.011
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models estimated the impact of early life factors (0-6 months) on overweight risk at 1 year. Results: WFL 85th percentile was found among 2.4% at birth and 42.7% at 1 year. Most mothers (78.6%) experienced food insecurity, a factor that increased the likelihood of infant overweight risk by 2.29 times (1.03 5.09). Maternal underestimation of infant size increased the likelihood of overweight risk 5.07 times (2.57 9.99). Postpartum depression risk did not contribute to infant weight status. Discussion: Assessment for maternal food insecurity and underestimation of infant weight status during early infancy may help reduce overweight risk and subsequent obesity for this vulnerable population. J Pediatr Health Care. (2018) XX, 1 7
TAGEDPKEY WORDS Infant, food security, Hispanic, weight
Hispanic children in the United States are at a disproportionate risk for being overweight and obese. This health disparity was affirmed by a recent report on national childhood obesity trends (Skinner, Ravanbakht, Skelton, Perrin, & Armstrong, 2018). Using population-based National Health and Nutrition Examination Survey (i.e., NHANES) data (1999 2016), composed of height and weight measurements gathered during physical examinations for children aged 2 to 19 years, a consistent upward trend in growth trajectories across the overall pediatric population was identified. The most substantial rise was found among Hispanic children, with nearly half being overweight or obese (females, 45.5%; males, 46.3%) by the 2015 2016 study cycle. This report highlights critical trends that are evident as early as the toddler and preschool years. However, a growing body of evidence suggests that childhood obesity has its origins even earlier in the life cycle. One systematic review examined 282 studies published between 1980 and 2014
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ARTICLE IN PRESS and found that accelerated infant weight gain is an early life factor consistently associated with later childhood obesity (Woo Baidal, Locks, Cheng, Blake-Lamb, Perkins, & Taveras, 2016). The authors pointed out that the bulk of studies took place with high-income populations in which Hispanic children from low-income families were underrepresented. To address this gap, two studies focused on Hispanic children from low-income families and found that rapid weight gain in early infancy also was associated with later obesity risk in this sector of the U.S. population (Gaffney, Brito, Kermer, & Kitsantas, 2018; Polk, Thornton, Caulfield, & Mu~ noz, 2015). Evidence that childhood obesity has its origins in early infancy is consistent with the Life Course Health Development (LCHD) framework, which asserts that the first few months of life make up a critical time in which risk and protective factors have a long-term impact on an individual’s health trajectory across the lifespan (Halfon & Hochstein, 2002; Halfon, Larson, Lu, Tullis, & Russ, 2014). This perspective is supported by a well-established body of evidence confirming that childhood overweight and obesity have a cumulative effect over time and increase the risk for hypertension, diabetes, sleep apnea, and certain cancers as individuals move through adolescence to adulthood (World Health Organization, WHO, 2017a). The LCHD framework has been recommended specifically for pediatric primary care research because it is well aligned with the focus on promoting lifelong wellness (Bates et al., 2018). A recent recommendation for use of the LCHD as a foundation for these studies is to place the examination of risk factors within the context of family health trajectories so that culturally specific social determinants of health may be identified for specific populations ( Jones & Roy, 2017). The present study addresses these recommendations by examining three maternal factors that may contribute to the early trajectory of excessive weight gain among infants of low-income Hispanic immigrant mothers: postpartum depression, food insecurity, and underestimation of infant size. Each has been associated with the risk for childhood obesity in prior research with other populations, but limited evidence is available concerning the early predictors of long-term health outcomes for children of low-income Hispanic immigrants. Postpartum depression is a potentially modifiable factor experienced by approximately 1 in 9 women in the United States (Centers for Disease Control and Prevention [CDC], 2017). Rates for Hispanic immigrant women have been reported to be as high as 54% (Lucero, Beckstrand, Callister, & Sanchez Birkhead, 2012). Furthermore, research has linked postpartum depressive symptoms with nonadherence to the Institute of Medicine’s (2011) recommended infant feeding practices for the prevention of early childhood obesity. The obesogenic practices include early cessation of breastfeeding, controlling feeding styles, and early introduction to cereal and juice (Balbierz, Bodnar-Deren, Wang, & Howell, 2015; Dennis, McQueen, 2007; Hurley, Black, Papas, & Caulfield, 2008). Using the national Infant Feeding 2
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Practices Study II dataset, one study found significantly greater weight gain at 6 months of age among infants of mothers with postpartum depression symptoms than those whose mothers’ scores did not reach the level of clinical risk (10) on the Edinburgh Postnatal Depression Scale. A limitation of the latter study was that Hispanic mothers composed only 5% of the sample (Gaffney, Kitsantas, Brito, & Swamidoss, 2014). A second potentially modifiable factor often experienced by mothers of young infants is food insecurity. The World Health Organization defines food insecurity as a situation in which individuals lack access to sufficient amounts of nutritious food for normal growth and development and a healthy life (WHO, 2017b). In the United States, it is estimated that 16 million children live in food insecure households and are more likely to experience obesity because of a lack of access to healthy foods (AAP Council on Community Pediatrics & Council on Nutrition, 2015). Prior research has identified a link between household food insecurity and child overweight at 2 years of age that operated through infant feeding practices (Bronte-Tinkew, Zaslow, Capps, Horowitz, & McNamara, 2007). Gross, Kitsantas, Brito, and Swamidoss (2012) found that low-income mothers who reported food insecurity were significantly more likely to use restrictive and pressuring infant feeding styles than food secure mothers. Later, their cross-sectional study of mothers of infants aged 2 weeks to 6 months found that low-income Hispanic mothers who were compared with high-income White mothers were more likely to use restrictive and pressuring feeding styles and more likely to have a baby with a weight-for-length (WFL) greater than the 85th percentile. The researchers recommended longitudinal studies to determine the effect of these early life exposures on later weight status (Gross, Mendelsohn, Fierman, Hauser, & Messito, 2014). A third modifiable factor that may have an impact on infant risk for overweight at 1 year of age is a mother’s underestimation of her baby’s weight status in early infancy. A recent meta-analysis examined 69 international studies of maternal perceptions of child weight and found that a substantial proportion (50.7%) of mothers of overweight or obese children underestimated their child’s weight status (Lundahl, Kidwell, & Nelson, 2014). The children in these studies were at least 2 years of age. Although limited research in this area is available concerning the first few months of life, one cross-sectional study of maternal weight perception for infants aged between 5 and 13 months found an association between maternal underestimation of weight status and a pressure-to-eat feeding style (Harrison, Brodribb, Davies, & Hepworth, 2018). Consistent with the LCHD framework, the present study will build on this emerging science by using a longitudinal perspective to assess the relationship between maternal underestimation of weight status in early infancy and risk for overweight at 12 months of age. The purpose of this study was to examine postpartum depression, food insecurity, and underestimation of infant size as potential early life
Journal of Pediatric Health Care
ARTICLE IN PRESS risk factors for overweight status by 12 months of age for infants of low-income Hispanic immigrant mothers. TAGEDH1METHODSTAGEDN Sample and Setting The study was conducted in a large pediatric primary care clinic for low-income families in Virginia. After approval from clinical site and university institutional review boards, informed consent was obtained from 246 mothers who met study inclusion criteria. Sample size calculations were based on an 80% power for a two-tailed test to detect a small to medium effect size (e.g., odds ratio of 1.5 2.5) in infant weight status by 12 months of age at an alpha level of 0.05 (Hsieh, Block, & Larson, 1998). All participants were mothers of infants who were 5 lb or greater and at 37 weeks gestation or greater at birth without medical problems that would interfere with growth and development. The mothers were Hispanic immigrants to the United States who were at least 18 years of age. Data were collected via in person interview conducted in Spanish by undergraduate bilingual research assistants. This approach was used to mirror the history-taking practices used at the clinic and was, therefore, familiar to the mothers. In addition, the interview approach avoided any potential discomfort by mothers with limited literacy. Measures Infants were weighed and measured as part of their regularly scheduled well-child visits during the first year of life by trained medical assistants at the clinical site. Weight-forlength (WFL) z scores and percentiles were calculated using the World Health Organization growth charts, as recommended for children under 2 years of age by the CDC (2010). Postpartum depression was measured using the Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, & Sagovsky, 1987). The scale is composed of 10 items with four Likert-style response options and a possible range of scores from 0 to 30, with higher scores indicating more depressive symptoms. Validated Spanish and English versions have been recommended for use during early wellchild visits (AAP, 2010). Scores of 10 or greater were considered to indicate clinical risk for depression, as in prior research (Balbierz et al., 2015). We first calculated summative scores. Mothers who reached the cutoff score (10) during their first 6 months after giving birth were identified as being at clinical risk for postpartum depression. Food insecurity was measured using the two-item Food Insecurity Scale developed from the Core Food Security Module, which has been widely used in research and validated in both English and Spanish (Gross et al., 2012; Harrison, Stormer, Herman, & Winham, 2003). Four-point Likert-type responses to items about running out of money to buy food range from never to always. Consistent with prior research, mothers who responded sometimes or always to both items were classified as food insecure (Hager et al., 2010).
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This approach yielded dichotomous food insecurity scores (1/0) for the first 6 months postpartum. Consistent with prior research, maternal underestimation of infant weight was assessed based on questions adapted from the Child Feeding Questionnaire (Gross et al., 2012). Mothers were asked if they considered their infants to be underweight, normal weight, or overweight. Using infants’ actual World Health Organization WFL percentiles, we considered underweight as less than the 5th percentile, normal weight between the 5th and 85th percentiles, and overweight as the 85th percentile or greater. Mothers’ responses were compared with these ranges and scored dichotomously as underestimating or not (1/0) during the first 6 months of infancy. The main outcome was overweight risk at 12 months of age, which was operationalized as WFL at the 85th percentile or greater. This cutoff is consistent with prior research (Cartagena, McGrath, & Masho, 2016) and the Institute of Medicine (IOM; 2011) guidelines for prevention of early childhood obesity. Data Analysis Descriptive statistics were used to assess the distribution of all study variables. Logistic regression models were constructed to examine early life predictors of overweight risk at 12 months after controlling for maternal and infant characteristics. TAGEDH1RESULTSTAGEDN In this sample of 246 mother infant dyads, most mothers (45.3%) were between the ages of 26 and 33 years old (Table 1). Approximately 36% had completed less than 9 years of education, 31.4% had completed high school, and a few (9.4%) had completed at least 13 years of education. For mothers in this study, the number of living children was distributed equally across the three groups. The largest proportion of participants came from El Salvador (45.4%), followed by Guatemala (16.7%), Honduras (15.4%), and Bolivia (13%). Most had resided less than 10 years in the Unites States. Approximately 13% were found to be at risk for postpartum depression, and 76.8% were found to be food insecure. Furthermore, 34.5% of the mothers underestimated their infant’s size in early infancy. There was a slightly larger percentage of female infants (58.9%). Infant WFL at the 85th percentile or greater at birth occurred for 2.4% of the sample but rose to 42.7% by 12 months of infant age. The Figure shows growth trajectories from birth to 12 months for this cohort of infants. WFL differences between those who were and were not classified as reaching WFL in the 85th percentile or greater by 1 year appear early in the life cycle. Bivariate analyses found significant mean differences in WFL z score change in the first 6 months between infants who did and did not cross this benchmark (mean [standard deviation] = 2.54 [1.53] vs. 1.21 [1.43], p = .000). In addition, maternal underestimation of infant size in the first 6 months of life was found to be significantly different between infants who did and did not cross the WFL 85th percentile at 1 year of age (61% vs. 17%, p = .000). Bivariate 000 2018
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ARTICLE IN PRESS TABLE 1. Maternal infant characteristics (N = 246) Characteristics Maternal characteristics Age in years 25 26 33 34 Education in years <9 9 11 12 13 Number of living children 1 child 2 children 3+ children Country of origin El Salvador Guatemala Honduras Bolivia Other Years in the United States <5 5 10 >10 Postpartum depression (0 6 months) Clinical risk not present Clinical risk present Food insecurity (0 6 months) Food insecurity not present Food insecurity present Underestimation of infant size (0 6 months) Underestimation not present Underestimation present Infant characteristics Sex Male Female Weight-for-length at birth Underweight (<5th percentile) Normal weight Overweight (85th percentile) Weight-for-length at 12 months Underweight (<5th percentile) Normal weight Overweight (85th percentile)
n
%
67 111 67
27.3 45.3 27.3
89 56 77 23
36.3 22.9 31.4 9.4
79 77 90
32.1 31.3 36.6
112 41 38 32 23
45.4 16.7 15.4 13.0 9.3
78 93 75
31.7 37.8 30.5
214 32
86.9 13.1
57 189
23.2 76.8
161 85
65.5 34.5
101 145
41.1 58.9
86 154 6
35.0 62.6 2.4
1 140 105
0.4 56.9 42.7
comparisons showed no significant group differences based on maternal postpartum depression or food insecurity. To better understand the effects of early life factors on overweight risk at 1 year of age, logistic regression models were constructed. Unadjusted odds ratios showed significant effects of three early life factors on overweight risk at 1 year: WFL z score change, maternal food insecurity, and maternal underestimation of infant size (Table 2). Specifically, after adjusting for maternal age, education, number of living children, and number of years in the United States, increases in the WFL z score between birth to 6 months were found to be associated with an increased likelihood (odds ratio = 1.61, 95% confidence interval = [1.27, 2.03]) of the infant having a WFL at or above the 85th percentile when 12 months old. 4
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In addition, infants of mothers who experienced food insecurity during the first 6 months were 2.29 [1.03, 5.09] times more likely to be at a WFL at or greater than the 85th percentile compared with those who did not experience food insecurity. Maternal underestimation of infant size in the first 6 months of life increased the likelihood of infant WFL at or greater than the 85th percentile by 5.07 times [2.57, 9.99] relative to those whose mothers did not overestimate their baby’s size during that time frame. Maternal postpartum depression in early infancy was not found to significantly affect infant WFL at 1 year. TAGEDH1DISCUSSIONTAGEDN The present study builds on earlier research with a similar demographic sample in which the weight trajectory in early infancy was found to be significantly higher at each 2-month interval between birth and 6 months for infants who reached the benchmark for overweight at 12 months compared with those who did not (Gaffney, Brito, Kermer, Kitsantas, 2018). Using a different sample of infants of lowincome Hispanic immigrants, the present study findings replicate this pattern. Specifically, the growth curve for those who reached overweight status at 12 months showed a steady increase across percentile lines throughout the first 6 months of life, whereas those who did The early growth not reach that point maintained a flatter findings of these growth trajectory line studies prompt that averaged around clinical and the WFL 50th percentile. Together, the early research questions growth findings of these about what early life studies prompt clinical course factors and research questions about what early life contribute to these course factors contribdifferent growth ute to these different trajectories. growth trajectories. The early growth findings of these studies prompt clinical and research questions about what early life course factors contribute to these different growth trajectories. We assessed postpartum depression for its contribution to infant growth because prior research has found an association with obesogenic infant feeding practices, including decreased breastfeeding duration, early introduction of solids, and forceful feeding styles (Balbierz et al., 2015; Dennis & McQueen, 2007; Gaffney et al., 2014; Hurley et al., 2008). Mothers in our study were found to have at risk scores on the EPDS comparable to findings in a recent populationbased report that 1 in 9 women in the United States experience symptoms of postpartum depression in the United States (CDC, 2017). However, the rate of at-risk scores for mothers in our study was lower than that found in two recent studies in which the Spanish version of the EPDS also was used. Specifically, the first study found a 32.26% positive risk screening result among mothers who
Journal of Pediatric Health Care
ARTICLE IN PRESS FIGURE. Early infancy (0 6 months) WFL percentiles by less than versus at or greater than the 85th percentile at 12 months of age. mo, month; WFL, weight-for-length.
immigrated from Mexico, Central America, or South America and were living in an urban area, compared with 13% in our study (Doe et al., 2017). The second study of lowincome Hispanic mothers living in rural areas found that 43% had EPDS scores of 10 or greater (Kim & Dee, 2018). Our study was conducted in a suburban area. The small proportion of mothers with risk scores in the current study limited the potential for identifying postpartum depression as an early modifiable risk factor for infant weight status at 1 year. Conversely, food insecurity was reported by a substantial portion of mothers in the study. This rate far exceeds the current estimate that 1 in 5 U.S. children lives in a family that experiences food insecurity (AAP, 2015). It also exceeds a more recent study using the nationally representative Early Childhood Longitudinal Study dataset that found that 1 in 4
Hispanic children who have foreign-born mothers live in food-insecure households (Arteaga, Potochnick, & Parsons, 2017). Furthermore, for mothers in the current study, food insecurity during the first 6 months of infant life was a factor that increased the odds of overweight status at 12 months of age. This longitudinal perspective contributes to the findings of prior cross-sectional research that has linked maternal food insecurity with obesogenic feeding styles in early infancy (Gross, Mendelsohn, Fierman, Racine, & Messito, 2012). It also adds a new dimension to prior findings of an association between food insecurity in infancy and later childhood weight status in the preschool and adolescent years (Buscemi, Beech, & Relyea, 2011; Metallinos-Katsaras, Must, & Gorman, 2012). Specifically, our finding that the maternal experience of food insecurity during early infancy increased the odds of overweight status as early as 1 year
TABLE 2. Effects of early life factors (0 6 months) on WFL percentile at 12 months of age (N = 246)
Early life course factor Change in WFL z score, 0 6 months Maternal postpartum depression risk, 0 6 months Maternal food insecurity, 0 6 months Maternal underestimation of infant size, 0 6 months
WFL 85th percentile at 12 months, unadjusted odds ratio [95% confidence interval]
WFL 85th percentile at 12 months, adjusted odds ratioa [95% confidence interval]
1.63 [1.31, 2.03] 0.76 [0.31, 1.89]
1.61 [1.27, 2.03] 0.70 [0.26, 1.89]
2.22 [1.05, 4.69] 4.38 [2.32, 8.27]
2.29 [1.03, 5.09] 5.07 [2.57, 9.99]
Note. WFL, weight-for-length. a Odds ratios are adjusted for maternal age, education, number of living children, and number of years living in the United States.
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ARTICLE IN PRESS of age supports the Potential LCHD perspective that moderators of the the first few months of pathways between infancy represent a sensitive time in the life food insecurity and cycle for identifying later infant and child risk and protective facweight gain tors that have both early and cumulative continue to require effects on a child’s further examination. long-term health outcomes. Potential moderators of the pathways between food insecurity and later infant and child weight gain continue to require further examination. Maternal underestimation of weight status during early infancy was found to be a significant factor that distinguished infants who reached the benchmark for overweight status (WFL 85%) at 12 months and those who did not. This longitudinal finding builds on a cross-sectional pilot study (N = 62) with low-income Hispanic maternal infant dyads that found a nonsignificant trend toward differences between maternal perception of infant size and actual weight status (Cartagena, McGrath, & Masho, 2014). It also builds on a systematic review of factors that contribute to infant feeding with Hispanic mothers. Evaluating evidence from 35 studies, the authors found that Hispanic mothers often associate increased body weight with good health and do not recognize obesity as a problem in older children. In addition, the review found that low-income Hispanic mothers often report a preference for having a heavy infant, a notion that has been associated with the belief that “a chubby baby is a healthy baby” and, in turn, contributes to a sense of maternal efficacy (Cartagena et al., 2016). Our findings extend this growing body of evidence by showing that the underestimation of infant weight status for our target population often begins early in the life cycle and is associated with overweight status by 1 year of age. Implications for Research Qualitative and quantitative studies are needed to further identify the pathways through which early life course factors contribute to the current health disparity in overweight and obesity among Hispanic infants and children. Research that uses open-ended questions with Hispanic immigrant mothers and culturally similar interviewers may help gain a deeper understanding of the underpinnings of the disparity and culturally appropriate elements needed for prevention and treatment interventions. In addition, next steps in the quantitative search for answers about the early life factors that contribute to the lifelong health consequences for the infants of Hispanic immigrant mothers include replication and extension studies conducted in different geographic regions in the United States that include both urban and rural environments. In addition to food insecurity as an early stressor for the maternal infant dyad, future studies are needed to examine factors unique to this population, including 6
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stressors such as those related to immigration status. Findings from these qualitative and quantitative studies will help direct the design of future interventions. Implications for Practice In the interim, the current study offers some insights with potential application to clinical practice. First, the high levels of food insecurity found are noteworthy. The American Academy of Pediatrics (2015) has recommended that food insecurity be assessed at well visits, using the same two-question survey cited in this research. Validated English and Spanish versions are available and easy to administer. Routinely including these in well visits for families with infants from the target population may allow for early and more effective referrals to community resources. Second, the study adds to emerging science that shows that WFL differences in infants who reach the 85th percentile at 1 year begin early in the life cycle and warrant clinical attention as early as the first few months of life. The finding that the mothers of these infants were likely to underestimate their baby’s weight status points to a meaningful use for growth curves as a foundation for parent provider dialog to help reduce obesogenic risk. TAGEDH1REFERENCESTAGEDN American Academy of Pediatrics Committee on Psychological Aspects of Child and Family Health. (2010). Clinical report: Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics, 126, 1032–1039. American Academy of Pediatrics Council on Community Pediatrics & Council on Nutrition. (2015). Policy statement: Promoting food security for all children. Pediatrics, 136, e1431–e1438. Arteaga, I., Potochnick, S., & Parsons, S. (2017). Decomposing the household food insecurity gap for children of U.S.-born and foreign-born Hispanics: Evidence from 1998-2011. Journal of Immigrant and Minority Health, 19, 1050–1058. Bates, R. A., Blair, L. M., Schlegel, E. C., McGovern, C. M., Dion Nist, M., Sealschott, S., & Arcoleo, K. (2018). Nursing across the lifespan: Implications of lifecourse theory for nursing research. Journal of Pediatric Health Care, 32, 92–97. Balbierz, A., Bodnar-Deren, S., Wang, J. J., & Howell, E. A. (2015). Maternal depressive symptoms and parenting practices 3months postpartum. Maternal and Child Health Journal, 19, 1212–1219. Bronte-Tinkew, J., Zaslow, M., Capps, R., Horowitz, A., & McNamara, M. (2007). Food insecurity works through depression, parenting, and infant feeding to influence overweight and health in toddlers. The Journal of Nutrition, 137, 2160–2165. Buscemi, J., Beech, B. M., & Relyea, G. (2011). Predictors of obesity in Latino children: Acculturation as a moderator of the relationship between food insecurity and body mass index percentile. Journal of Immigrant and Minority Health, 13, 149–154. Cartagena, D., McGrath, J. M., & Masho, S. W. (2016). Differences in modifiable feeding factors by overweight status in Latino infants. Applied Nursing Research, 30, 210–215. Cartagena, D., McGrath, J. M., Masho, S. W., & Myers, B. J. (2014). Factors contributing to infant overfeeding with Hispanic mothers. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 43, 139–159. Centers for Disease Control and Prevention. (2010). WHO growth standards are recommended for use in the US for infants and children
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ARTICLE IN PRESS 0-2 years of age. Retrieved from Atlanta, GA: Author. Retrieved from https://www.cdc.gov/growthcharts/who_charts.htm Centers for Disease Control and Prevention. (2017). Depression among women. Retrieved from Atlanta, GA: Author. Retrieved from https://www.cdc.gov/reproductivehealth/depression/index.htm Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786. Dennis, C-L., & McQueen, K. (2007). Does maternal postpartum depressive symptomatology influence infant feeding outcomes? Acta Pediatrica, 96, 590–594. Doe, S., LoBue, S., Hamaoui, A., Rezai, S., Henderson, C. E., & Mercado, R. (2017). Prevalence and predictors of positive screening for postpartum depression in minority parturients in South Bronx. Archives in Womens Mental Health, 20, 291–295. Gaffney, K. F., Brito, A. V., Kermer, D. A., & Kitsantas, P. (2018). Sensitive timing for risk of overweight among infants of low-income Hispanic immigrants. Journal of Pediatric Health Care, 32, 76–82. Gaffney, K. F., Kitsantas, P., Brito, A., & Swamidoss, C. S. (2014). Postpartum depression, infant feeding practices, and infant weight gain at six months of age. Journal of Pediatric Health Care, 28, 43–50. Gross, R. S., Mendelsohn, A. L., Fierman, A. H., Hauser, N. R., & Messito, M. J. (2014). Maternal infant feeding behaviors and disparities in early child obesity. Childhood Obesity, 10, 145–152. Gross, R. S., Mendelsohn, A. L., Fierman, A. H., Racine, A. D., & Messito, M. J. (2012). Food insecurity and obesogenic maternal infant feeding styles and practices in low-income families. Pediatrics, 130, 254–261. Hager, E., Quigg, A. M., Black, M. M., Coleman, S. M., Heeren, T., Rose-Jacobs, R., . . . Frank, D. A. (2010). Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics, 126, e26–e32. Halfon, N., & Hochstein, M. (2002). Life course health development: An integrated framework for developing health policy and research. The Milbank Quarterly, 80, 433–479. Halfon, N., Larson, K., Lu, M., Tullis, E., & Russ, S. (2014). Lifecourse health development: Past, present and future. Maternal and Child Health Journal, 18, 344–365. Harrison, G. G., Stormer, A., Herman, D. R., & Winham, D. M. (2003). Development of a Spanish-language version of the U.S. Household Food Security Survey Module. Journal of Nutrition, 133, 1192–1197. Harrison, M., Brodribb, W., Davies, P. S. W., & Hepworth, J. (2018). Impact of maternal infant weight perception on infant feeding and dietary intake. Maternal and Child Health Journal, 22, 1135–1145. Hsieh, F. Y., Block, D. A., & Larson, M. D. (1998). A simple method for sample size calculation for linear and logistic regression. Statistics in Medicine, 17, 1623–1634.
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Hurley, K. M., Black, M. M., Papas, M. A., & Caufield, L. E. (2008). Maternal symptoms of stress, depression, and anxiety are related to nonresponsive feeding styles in a statewide sample of WIC participants. The Journal of Nutrition, 138, 799– 805. Institute of Medicine. (2011). Early childhood obesity prevention policies. Washington, DC: National Academies Press. Jones, M. M., & Roy, K. (2017). Placing health trajectories in family and historical context: A proposed enrichment of the Life Course Health and Development Model. Maternal and Child Health Journal, 21, 1853–1860. Lucero, N. B., Beckstrand, R. L., Callister, L. C., & Sanchez Birkhead, A. C. (2012). Prevalence of postpartum depression among Hispanic immigrant women. Journal of the American Academy of Nurse Practitioners, 24, 726–734. Lundahl, A., Kidwell, K. M., & Nelson, T. D. (2014). Parental underestimates of child weight: A meta-analysis. Pediatrics, 133, e689– e703. Kim, Y., & Dee, V. (2018). Sociodemographic and obstetric factors relate to symptoms of postpartum depression in Hispanic women in rural California. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 47, 23–31. Metallinos-Katsaras, E., Must, A., & Gorman, K. (2012). A longitudinal study of food insecurity on obesity in preschool children. Journal of the Academy of Nutrition and Dietetics, 112, 1949– 1958. ~oz, A. (2015). Rapid Polk, S., Thornton, R. J., Caulfield, L., & Mun weight gain and early childhood obesity in low-income Latinos and non-Latinos. Public Health Nutrition, 19, 1777– 1784. Skinner, A. C., Ravanbakht, S. N., Skelton, J. A., Perrin, E. M., & Armstrong, S. C. (2018). Prevalence of obesity and severe obesity in US children, 1999-2016. Pediatrics, 141, e20173459. World Health Organization. (2017a). Guideline: Assessing and managing children at primary health-care facilities to prevent overweight and obesity in the context of the double burden of malnutrition. Retrieved from Geneva, Switzerland: Author. Retrieved from http://www.who.int/nutrition/publications/guide lines/children-primaryhealthcare-obesity-dbm/en/ World Health Organization. (2017b). Global strategy on diet, physical activity, and health: Why does childhood overweight and obesity matter? Retrieved from Geneva, Switzerland: Author. Retrieved from http://www.who.int/dietphysicalactivity/child hood_consequences/en/ Woo Baidal, J. A., Locks, L. M., Cheng, E. R., Blake-Lamb, T. L., Perkins, M. E., & Taveras, E. M. (2016). Risk factors for childhood obesity in the first 1,000 days: A systematic review. American Journal of Preventive Medicine, 50, 761–779.
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Early Life Factors for Overweight Risk Among Infants of Hispanic Immigrant Mothers D1X XKathleen F. Gaffney, D2X XPhD, RN, F/PNP-BC, D3X XDeborah A. Kermer, D4X XMA, D5X XPanagiota Kitsantas, D6X XPhD, D7X XAlbert V. Brito, D8X XMD, D9X XKatya M. Ramos, D10X XBS, D1X XGraciela Pereddo, D12X XBS, & D13X XLuisa Villatoro, D14X XBS TAGEDPABSTRACT Introduction: This study examined postpartum depression, food insecurity, and underestimation of infant size as potential early life factors for overweight risk at 12 months among infants of Hispanic immigrant mothers. Method: Weight-for-length (WFL) measurements and face-to-face interviews were completed during well child visits. Regression
Kathleen F. Gaffney, Professor, School of Nursing, George Mason University, Fairfax, VA. Deborah A. Kermer, Data Services Research Consultant, University Libraries, Data Services, George Mason University, Fairfax, VA. Panagiota Kitsantas, Professor, Health Administration and Policy Department, George Mason University, Fairfax, VA. Albert V. Brito, Medical Director, Inova Cares Clinic for Children, Falls Church, VA. Katya M. Ramos, Research Assistant, School of Nursing, George Mason University, Fairfax, VA. Graciela Pereddo, Research Assistant, Global and Community Health Department, George Mason University, Fairfax, VA. Luisa Villatoro, Research Assistant, School of Nursing, George Mason University, Fairfax, VA. Conflicts of interest: None to report. This study was supported by the National Institute of Child Health and Human Development [R15HD080710]. Correspondence: Kathleen F. Gaffney, PhD, RN, F/PNP-BC, School of Nursing, George Mason University, 4400 University Dr., Fairfax, VA 22030; e-mail: [email protected]. 0891-5245/$36.00 Copyright © 2018 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.pedhc.2018.05.011
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models estimated the impact of early life factors (0-6 months) on overweight risk at 1 year. Results: WFL 85th percentile was found among 2.4% at birth and 42.7% at 1 year. Most mothers (78.6%) experienced food insecurity, a factor that increased the likelihood of infant overweight risk by 2.29 times (1.03 5.09). Maternal underestimation of infant size increased the likelihood of overweight risk 5.07 times (2.57 9.99). Postpartum depression risk did not contribute to infant weight status. Discussion: Assessment for maternal food insecurity and underestimation of infant weight status during early infancy may help reduce overweight risk and subsequent obesity for this vulnerable population. J Pediatr Health Care. (2018) XX, 1 7
TAGEDPKEY WORDS Infant, food security, Hispanic, weight
Hispanic children in the United States are at a disproportionate risk for being overweight and obese. This health disparity was affirmed by a recent report on national childhood obesity trends (Skinner, Ravanbakht, Skelton, Perrin, & Armstrong, 2018). Using population-based National Health and Nutrition Examination Survey (i.e., NHANES) data (1999 2016), composed of height and weight measurements gathered during physical examinations for children aged 2 to 19 years, a consistent upward trend in growth trajectories across the overall pediatric population was identified. The most substantial rise was found among Hispanic children, with nearly half being overweight or obese (females, 45.5%; males, 46.3%) by the 2015 2016 study cycle. This report highlights critical trends that are evident as early as the toddler and preschool years. However, a growing body of evidence suggests that childhood obesity has its origins even earlier in the life cycle. One systematic review examined 282 studies published between 1980 and 2014
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ARTICLE IN PRESS and found that accelerated infant weight gain is an early life factor consistently associated with later childhood obesity (Woo Baidal, Locks, Cheng, Blake-Lamb, Perkins, & Taveras, 2016). The authors pointed out that the bulk of studies took place with high-income populations in which Hispanic children from low-income families were underrepresented. To address this gap, two studies focused on Hispanic children from low-income families and found that rapid weight gain in early infancy also was associated with later obesity risk in this sector of the U.S. population (Gaffney, Brito, Kermer, & Kitsantas, 2018; Polk, Thornton, Caulfield, & Mu~ noz, 2015). Evidence that childhood obesity has its origins in early infancy is consistent with the Life Course Health Development (LCHD) framework, which asserts that the first few months of life make up a critical time in which risk and protective factors have a long-term impact on an individual’s health trajectory across the lifespan (Halfon & Hochstein, 2002; Halfon, Larson, Lu, Tullis, & Russ, 2014). This perspective is supported by a well-established body of evidence confirming that childhood overweight and obesity have a cumulative effect over time and increase the risk for hypertension, diabetes, sleep apnea, and certain cancers as individuals move through adolescence to adulthood (World Health Organization, WHO, 2017a). The LCHD framework has been recommended specifically for pediatric primary care research because it is well aligned with the focus on promoting lifelong wellness (Bates et al., 2018). A recent recommendation for use of the LCHD as a foundation for these studies is to place the examination of risk factors within the context of family health trajectories so that culturally specific social determinants of health may be identified for specific populations ( Jones & Roy, 2017). The present study addresses these recommendations by examining three maternal factors that may contribute to the early trajectory of excessive weight gain among infants of low-income Hispanic immigrant mothers: postpartum depression, food insecurity, and underestimation of infant size. Each has been associated with the risk for childhood obesity in prior research with other populations, but limited evidence is available concerning the early predictors of long-term health outcomes for children of low-income Hispanic immigrants. Postpartum depression is a potentially modifiable factor experienced by approximately 1 in 9 women in the United States (Centers for Disease Control and Prevention [CDC], 2017). Rates for Hispanic immigrant women have been reported to be as high as 54% (Lucero, Beckstrand, Callister, & Sanchez Birkhead, 2012). Furthermore, research has linked postpartum depressive symptoms with nonadherence to the Institute of Medicine’s (2011) recommended infant feeding practices for the prevention of early childhood obesity. The obesogenic practices include early cessation of breastfeeding, controlling feeding styles, and early introduction to cereal and juice (Balbierz, Bodnar-Deren, Wang, & Howell, 2015; Dennis, McQueen, 2007; Hurley, Black, Papas, & Caulfield, 2008). Using the national Infant Feeding 2
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Practices Study II dataset, one study found significantly greater weight gain at 6 months of age among infants of mothers with postpartum depression symptoms than those whose mothers’ scores did not reach the level of clinical risk (10) on the Edinburgh Postnatal Depression Scale. A limitation of the latter study was that Hispanic mothers composed only 5% of the sample (Gaffney, Kitsantas, Brito, & Swamidoss, 2014). A second potentially modifiable factor often experienced by mothers of young infants is food insecurity. The World Health Organization defines food insecurity as a situation in which individuals lack access to sufficient amounts of nutritious food for normal growth and development and a healthy life (WHO, 2017b). In the United States, it is estimated that 16 million children live in food insecure households and are more likely to experience obesity because of a lack of access to healthy foods (AAP Council on Community Pediatrics & Council on Nutrition, 2015). Prior research has identified a link between household food insecurity and child overweight at 2 years of age that operated through infant feeding practices (Bronte-Tinkew, Zaslow, Capps, Horowitz, & McNamara, 2007). Gross, Kitsantas, Brito, and Swamidoss (2012) found that low-income mothers who reported food insecurity were significantly more likely to use restrictive and pressuring infant feeding styles than food secure mothers. Later, their cross-sectional study of mothers of infants aged 2 weeks to 6 months found that low-income Hispanic mothers who were compared with high-income White mothers were more likely to use restrictive and pressuring feeding styles and more likely to have a baby with a weight-for-length (WFL) greater than the 85th percentile. The researchers recommended longitudinal studies to determine the effect of these early life exposures on later weight status (Gross, Mendelsohn, Fierman, Hauser, & Messito, 2014). A third modifiable factor that may have an impact on infant risk for overweight at 1 year of age is a mother’s underestimation of her baby’s weight status in early infancy. A recent meta-analysis examined 69 international studies of maternal perceptions of child weight and found that a substantial proportion (50.7%) of mothers of overweight or obese children underestimated their child’s weight status (Lundahl, Kidwell, & Nelson, 2014). The children in these studies were at least 2 years of age. Although limited research in this area is available concerning the first few months of life, one cross-sectional study of maternal weight perception for infants aged between 5 and 13 months found an association between maternal underestimation of weight status and a pressure-to-eat feeding style (Harrison, Brodribb, Davies, & Hepworth, 2018). Consistent with the LCHD framework, the present study will build on this emerging science by using a longitudinal perspective to assess the relationship between maternal underestimation of weight status in early infancy and risk for overweight at 12 months of age. The purpose of this study was to examine postpartum depression, food insecurity, and underestimation of infant size as potential early life
Journal of Pediatric Health Care
ARTICLE IN PRESS risk factors for overweight status by 12 months of age for infants of low-income Hispanic immigrant mothers. TAGEDH1METHODSTAGEDN Sample and Setting The study was conducted in a large pediatric primary care clinic for low-income families in Virginia. After approval from clinical site and university institutional review boards, informed consent was obtained from 246 mothers who met study inclusion criteria. Sample size calculations were based on an 80% power for a two-tailed test to detect a small to medium effect size (e.g., odds ratio of 1.5 2.5) in infant weight status by 12 months of age at an alpha level of 0.05 (Hsieh, Block, & Larson, 1998). All participants were mothers of infants who were 5 lb or greater and at 37 weeks gestation or greater at birth without medical problems that would interfere with growth and development. The mothers were Hispanic immigrants to the United States who were at least 18 years of age. Data were collected via in person interview conducted in Spanish by undergraduate bilingual research assistants. This approach was used to mirror the history-taking practices used at the clinic and was, therefore, familiar to the mothers. In addition, the interview approach avoided any potential discomfort by mothers with limited literacy. Measures Infants were weighed and measured as part of their regularly scheduled well-child visits during the first year of life by trained medical assistants at the clinical site. Weight-forlength (WFL) z scores and percentiles were calculated using the World Health Organization growth charts, as recommended for children under 2 years of age by the CDC (2010). Postpartum depression was measured using the Edinburgh Postnatal Depression Scale (EPDS; Cox, Holden, & Sagovsky, 1987). The scale is composed of 10 items with four Likert-style response options and a possible range of scores from 0 to 30, with higher scores indicating more depressive symptoms. Validated Spanish and English versions have been recommended for use during early wellchild visits (AAP, 2010). Scores of 10 or greater were considered to indicate clinical risk for depression, as in prior research (Balbierz et al., 2015). We first calculated summative scores. Mothers who reached the cutoff score (10) during their first 6 months after giving birth were identified as being at clinical risk for postpartum depression. Food insecurity was measured using the two-item Food Insecurity Scale developed from the Core Food Security Module, which has been widely used in research and validated in both English and Spanish (Gross et al., 2012; Harrison, Stormer, Herman, & Winham, 2003). Four-point Likert-type responses to items about running out of money to buy food range from never to always. Consistent with prior research, mothers who responded sometimes or always to both items were classified as food insecure (Hager et al., 2010).
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This approach yielded dichotomous food insecurity scores (1/0) for the first 6 months postpartum. Consistent with prior research, maternal underestimation of infant weight was assessed based on questions adapted from the Child Feeding Questionnaire (Gross et al., 2012). Mothers were asked if they considered their infants to be underweight, normal weight, or overweight. Using infants’ actual World Health Organization WFL percentiles, we considered underweight as less than the 5th percentile, normal weight between the 5th and 85th percentiles, and overweight as the 85th percentile or greater. Mothers’ responses were compared with these ranges and scored dichotomously as underestimating or not (1/0) during the first 6 months of infancy. The main outcome was overweight risk at 12 months of age, which was operationalized as WFL at the 85th percentile or greater. This cutoff is consistent with prior research (Cartagena, McGrath, & Masho, 2016) and the Institute of Medicine (IOM; 2011) guidelines for prevention of early childhood obesity. Data Analysis Descriptive statistics were used to assess the distribution of all study variables. Logistic regression models were constructed to examine early life predictors of overweight risk at 12 months after controlling for maternal and infant characteristics. TAGEDH1RESULTSTAGEDN In this sample of 246 mother infant dyads, most mothers (45.3%) were between the ages of 26 and 33 years old (Table 1). Approximately 36% had completed less than 9 years of education, 31.4% had completed high school, and a few (9.4%) had completed at least 13 years of education. For mothers in this study, the number of living children was distributed equally across the three groups. The largest proportion of participants came from El Salvador (45.4%), followed by Guatemala (16.7%), Honduras (15.4%), and Bolivia (13%). Most had resided less than 10 years in the Unites States. Approximately 13% were found to be at risk for postpartum depression, and 76.8% were found to be food insecure. Furthermore, 34.5% of the mothers underestimated their infant’s size in early infancy. There was a slightly larger percentage of female infants (58.9%). Infant WFL at the 85th percentile or greater at birth occurred for 2.4% of the sample but rose to 42.7% by 12 months of infant age. The Figure shows growth trajectories from birth to 12 months for this cohort of infants. WFL differences between those who were and were not classified as reaching WFL in the 85th percentile or greater by 1 year appear early in the life cycle. Bivariate analyses found significant mean differences in WFL z score change in the first 6 months between infants who did and did not cross this benchmark (mean [standard deviation] = 2.54 [1.53] vs. 1.21 [1.43], p = .000). In addition, maternal underestimation of infant size in the first 6 months of life was found to be significantly different between infants who did and did not cross the WFL 85th percentile at 1 year of age (61% vs. 17%, p = .000). Bivariate 000 2018
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ARTICLE IN PRESS TABLE 1. Maternal infant characteristics (N = 246) Characteristics Maternal characteristics Age in years 25 26 33 34 Education in years <9 9 11 12 13 Number of living children 1 child 2 children 3+ children Country of origin El Salvador Guatemala Honduras Bolivia Other Years in the United States <5 5 10 >10 Postpartum depression (0 6 months) Clinical risk not present Clinical risk present Food insecurity (0 6 months) Food insecurity not present Food insecurity present Underestimation of infant size (0 6 months) Underestimation not present Underestimation present Infant characteristics Sex Male Female Weight-for-length at birth Underweight (<5th percentile) Normal weight Overweight (85th percentile) Weight-for-length at 12 months Underweight (<5th percentile) Normal weight Overweight (85th percentile)
n
%
67 111 67
27.3 45.3 27.3
89 56 77 23
36.3 22.9 31.4 9.4
79 77 90
32.1 31.3 36.6
112 41 38 32 23
45.4 16.7 15.4 13.0 9.3
78 93 75
31.7 37.8 30.5
214 32
86.9 13.1
57 189
23.2 76.8
161 85
65.5 34.5
101 145
41.1 58.9
86 154 6
35.0 62.6 2.4
1 140 105
0.4 56.9 42.7
comparisons showed no significant group differences based on maternal postpartum depression or food insecurity. To better understand the effects of early life factors on overweight risk at 1 year of age, logistic regression models were constructed. Unadjusted odds ratios showed significant effects of three early life factors on overweight risk at 1 year: WFL z score change, maternal food insecurity, and maternal underestimation of infant size (Table 2). Specifically, after adjusting for maternal age, education, number of living children, and number of years in the United States, increases in the WFL z score between birth to 6 months were found to be associated with an increased likelihood (odds ratio = 1.61, 95% confidence interval = [1.27, 2.03]) of the infant having a WFL at or above the 85th percentile when 12 months old. 4
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In addition, infants of mothers who experienced food insecurity during the first 6 months were 2.29 [1.03, 5.09] times more likely to be at a WFL at or greater than the 85th percentile compared with those who did not experience food insecurity. Maternal underestimation of infant size in the first 6 months of life increased the likelihood of infant WFL at or greater than the 85th percentile by 5.07 times [2.57, 9.99] relative to those whose mothers did not overestimate their baby’s size during that time frame. Maternal postpartum depression in early infancy was not found to significantly affect infant WFL at 1 year. TAGEDH1DISCUSSIONTAGEDN The present study builds on earlier research with a similar demographic sample in which the weight trajectory in early infancy was found to be significantly higher at each 2-month interval between birth and 6 months for infants who reached the benchmark for overweight at 12 months compared with those who did not (Gaffney, Brito, Kermer, Kitsantas, 2018). Using a different sample of infants of lowincome Hispanic immigrants, the present study findings replicate this pattern. Specifically, the growth curve for those who reached overweight status at 12 months showed a steady increase across percentile lines throughout the first 6 months of life, whereas those who did The early growth not reach that point maintained a flatter findings of these growth trajectory line studies prompt that averaged around clinical and the WFL 50th percentile. Together, the early research questions growth findings of these about what early life studies prompt clinical course factors and research questions about what early life contribute to these course factors contribdifferent growth ute to these different trajectories. growth trajectories. The early growth findings of these studies prompt clinical and research questions about what early life course factors contribute to these different growth trajectories. We assessed postpartum depression for its contribution to infant growth because prior research has found an association with obesogenic infant feeding practices, including decreased breastfeeding duration, early introduction of solids, and forceful feeding styles (Balbierz et al., 2015; Dennis & McQueen, 2007; Gaffney et al., 2014; Hurley et al., 2008). Mothers in our study were found to have at risk scores on the EPDS comparable to findings in a recent populationbased report that 1 in 9 women in the United States experience symptoms of postpartum depression in the United States (CDC, 2017). However, the rate of at-risk scores for mothers in our study was lower than that found in two recent studies in which the Spanish version of the EPDS also was used. Specifically, the first study found a 32.26% positive risk screening result among mothers who
Journal of Pediatric Health Care
ARTICLE IN PRESS FIGURE. Early infancy (0 6 months) WFL percentiles by less than versus at or greater than the 85th percentile at 12 months of age. mo, month; WFL, weight-for-length.
immigrated from Mexico, Central America, or South America and were living in an urban area, compared with 13% in our study (Doe et al., 2017). The second study of lowincome Hispanic mothers living in rural areas found that 43% had EPDS scores of 10 or greater (Kim & Dee, 2018). Our study was conducted in a suburban area. The small proportion of mothers with risk scores in the current study limited the potential for identifying postpartum depression as an early modifiable risk factor for infant weight status at 1 year. Conversely, food insecurity was reported by a substantial portion of mothers in the study. This rate far exceeds the current estimate that 1 in 5 U.S. children lives in a family that experiences food insecurity (AAP, 2015). It also exceeds a more recent study using the nationally representative Early Childhood Longitudinal Study dataset that found that 1 in 4
Hispanic children who have foreign-born mothers live in food-insecure households (Arteaga, Potochnick, & Parsons, 2017). Furthermore, for mothers in the current study, food insecurity during the first 6 months of infant life was a factor that increased the odds of overweight status at 12 months of age. This longitudinal perspective contributes to the findings of prior cross-sectional research that has linked maternal food insecurity with obesogenic feeding styles in early infancy (Gross, Mendelsohn, Fierman, Racine, & Messito, 2012). It also adds a new dimension to prior findings of an association between food insecurity in infancy and later childhood weight status in the preschool and adolescent years (Buscemi, Beech, & Relyea, 2011; Metallinos-Katsaras, Must, & Gorman, 2012). Specifically, our finding that the maternal experience of food insecurity during early infancy increased the odds of overweight status as early as 1 year
TABLE 2. Effects of early life factors (0 6 months) on WFL percentile at 12 months of age (N = 246)
Early life course factor Change in WFL z score, 0 6 months Maternal postpartum depression risk, 0 6 months Maternal food insecurity, 0 6 months Maternal underestimation of infant size, 0 6 months
WFL 85th percentile at 12 months, unadjusted odds ratio [95% confidence interval]
WFL 85th percentile at 12 months, adjusted odds ratioa [95% confidence interval]
1.63 [1.31, 2.03] 0.76 [0.31, 1.89]
1.61 [1.27, 2.03] 0.70 [0.26, 1.89]
2.22 [1.05, 4.69] 4.38 [2.32, 8.27]
2.29 [1.03, 5.09] 5.07 [2.57, 9.99]
Note. WFL, weight-for-length. a Odds ratios are adjusted for maternal age, education, number of living children, and number of years living in the United States.
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ARTICLE IN PRESS of age supports the Potential LCHD perspective that moderators of the the first few months of pathways between infancy represent a sensitive time in the life food insecurity and cycle for identifying later infant and child risk and protective facweight gain tors that have both early and cumulative continue to require effects on a child’s further examination. long-term health outcomes. Potential moderators of the pathways between food insecurity and later infant and child weight gain continue to require further examination. Maternal underestimation of weight status during early infancy was found to be a significant factor that distinguished infants who reached the benchmark for overweight status (WFL 85%) at 12 months and those who did not. This longitudinal finding builds on a cross-sectional pilot study (N = 62) with low-income Hispanic maternal infant dyads that found a nonsignificant trend toward differences between maternal perception of infant size and actual weight status (Cartagena, McGrath, & Masho, 2014). It also builds on a systematic review of factors that contribute to infant feeding with Hispanic mothers. Evaluating evidence from 35 studies, the authors found that Hispanic mothers often associate increased body weight with good health and do not recognize obesity as a problem in older children. In addition, the review found that low-income Hispanic mothers often report a preference for having a heavy infant, a notion that has been associated with the belief that “a chubby baby is a healthy baby” and, in turn, contributes to a sense of maternal efficacy (Cartagena et al., 2016). Our findings extend this growing body of evidence by showing that the underestimation of infant weight status for our target population often begins early in the life cycle and is associated with overweight status by 1 year of age. Implications for Research Qualitative and quantitative studies are needed to further identify the pathways through which early life course factors contribute to the current health disparity in overweight and obesity among Hispanic infants and children. Research that uses open-ended questions with Hispanic immigrant mothers and culturally similar interviewers may help gain a deeper understanding of the underpinnings of the disparity and culturally appropriate elements needed for prevention and treatment interventions. In addition, next steps in the quantitative search for answers about the early life factors that contribute to the lifelong health consequences for the infants of Hispanic immigrant mothers include replication and extension studies conducted in different geographic regions in the United States that include both urban and rural environments. In addition to food insecurity as an early stressor for the maternal infant dyad, future studies are needed to examine factors unique to this population, including 6
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stressors such as those related to immigration status. Findings from these qualitative and quantitative studies will help direct the design of future interventions. Implications for Practice In the interim, the current study offers some insights with potential application to clinical practice. First, the high levels of food insecurity found are noteworthy. The American Academy of Pediatrics (2015) has recommended that food insecurity be assessed at well visits, using the same two-question survey cited in this research. Validated English and Spanish versions are available and easy to administer. Routinely including these in well visits for families with infants from the target population may allow for early and more effective referrals to community resources. Second, the study adds to emerging science that shows that WFL differences in infants who reach the 85th percentile at 1 year begin early in the life cycle and warrant clinical attention as early as the first few months of life. The finding that the mothers of these infants were likely to underestimate their baby’s weight status points to a meaningful use for growth curves as a foundation for parent provider dialog to help reduce obesogenic risk. TAGEDH1REFERENCESTAGEDN American Academy of Pediatrics Committee on Psychological Aspects of Child and Family Health. (2010). Clinical report: Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics, 126, 1032–1039. American Academy of Pediatrics Council on Community Pediatrics & Council on Nutrition. (2015). Policy statement: Promoting food security for all children. Pediatrics, 136, e1431–e1438. Arteaga, I., Potochnick, S., & Parsons, S. (2017). Decomposing the household food insecurity gap for children of U.S.-born and foreign-born Hispanics: Evidence from 1998-2011. Journal of Immigrant and Minority Health, 19, 1050–1058. Bates, R. A., Blair, L. M., Schlegel, E. C., McGovern, C. M., Dion Nist, M., Sealschott, S., & Arcoleo, K. (2018). Nursing across the lifespan: Implications of lifecourse theory for nursing research. Journal of Pediatric Health Care, 32, 92–97. Balbierz, A., Bodnar-Deren, S., Wang, J. J., & Howell, E. A. (2015). Maternal depressive symptoms and parenting practices 3months postpartum. Maternal and Child Health Journal, 19, 1212–1219. Bronte-Tinkew, J., Zaslow, M., Capps, R., Horowitz, A., & McNamara, M. (2007). Food insecurity works through depression, parenting, and infant feeding to influence overweight and health in toddlers. The Journal of Nutrition, 137, 2160–2165. Buscemi, J., Beech, B. M., & Relyea, G. (2011). Predictors of obesity in Latino children: Acculturation as a moderator of the relationship between food insecurity and body mass index percentile. Journal of Immigrant and Minority Health, 13, 149–154. Cartagena, D., McGrath, J. M., & Masho, S. W. (2016). Differences in modifiable feeding factors by overweight status in Latino infants. Applied Nursing Research, 30, 210–215. Cartagena, D., McGrath, J. M., Masho, S. W., & Myers, B. J. (2014). Factors contributing to infant overfeeding with Hispanic mothers. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 43, 139–159. Centers for Disease Control and Prevention. (2010). WHO growth standards are recommended for use in the US for infants and children
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ARTICLE IN PRESS 0-2 years of age. Retrieved from Atlanta, GA: Author. Retrieved from https://www.cdc.gov/growthcharts/who_charts.htm Centers for Disease Control and Prevention. (2017). Depression among women. Retrieved from Atlanta, GA: Author. Retrieved from https://www.cdc.gov/reproductivehealth/depression/index.htm Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, 782–786. Dennis, C-L., & McQueen, K. (2007). Does maternal postpartum depressive symptomatology influence infant feeding outcomes? Acta Pediatrica, 96, 590–594. Doe, S., LoBue, S., Hamaoui, A., Rezai, S., Henderson, C. E., & Mercado, R. (2017). Prevalence and predictors of positive screening for postpartum depression in minority parturients in South Bronx. Archives in Womens Mental Health, 20, 291–295. Gaffney, K. F., Brito, A. V., Kermer, D. A., & Kitsantas, P. (2018). Sensitive timing for risk of overweight among infants of low-income Hispanic immigrants. Journal of Pediatric Health Care, 32, 76–82. Gaffney, K. F., Kitsantas, P., Brito, A., & Swamidoss, C. S. (2014). Postpartum depression, infant feeding practices, and infant weight gain at six months of age. Journal of Pediatric Health Care, 28, 43–50. Gross, R. S., Mendelsohn, A. L., Fierman, A. H., Hauser, N. R., & Messito, M. J. (2014). Maternal infant feeding behaviors and disparities in early child obesity. Childhood Obesity, 10, 145–152. Gross, R. S., Mendelsohn, A. L., Fierman, A. H., Racine, A. D., & Messito, M. J. (2012). Food insecurity and obesogenic maternal infant feeding styles and practices in low-income families. Pediatrics, 130, 254–261. Hager, E., Quigg, A. M., Black, M. M., Coleman, S. M., Heeren, T., Rose-Jacobs, R., . . . Frank, D. A. (2010). Development and validity of a 2-item screen to identify families at risk for food insecurity. Pediatrics, 126, e26–e32. Halfon, N., & Hochstein, M. (2002). Life course health development: An integrated framework for developing health policy and research. The Milbank Quarterly, 80, 433–479. Halfon, N., Larson, K., Lu, M., Tullis, E., & Russ, S. (2014). Lifecourse health development: Past, present and future. Maternal and Child Health Journal, 18, 344–365. Harrison, G. G., Stormer, A., Herman, D. R., & Winham, D. M. (2003). Development of a Spanish-language version of the U.S. Household Food Security Survey Module. Journal of Nutrition, 133, 1192–1197. Harrison, M., Brodribb, W., Davies, P. S. W., & Hepworth, J. (2018). Impact of maternal infant weight perception on infant feeding and dietary intake. Maternal and Child Health Journal, 22, 1135–1145. Hsieh, F. Y., Block, D. A., & Larson, M. D. (1998). A simple method for sample size calculation for linear and logistic regression. Statistics in Medicine, 17, 1623–1634.
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