Few resources exist for prospective, longitudinal analysis of the relationships between early life environment and later obesity in large diverse samples of children in the United States (US). In 2016, the National Institutes of Health launched the Environmental influences on Child Health Outcomes (ECHO) program to investigate influences of environmental exposures on child health and development. We describe demographics and overweight and obesity prevalence in ECHO, and ECHO’s potential as a resource for understanding how early life environmental factors affect obesity risk.
In this cross-sectional study of 70 extant US and Puerto Rico cohorts, 2003–2017, we examined age, race/ethnicity, and sex in children with body mass index (BMI) data, including 28,507 full-term post-birth to <2 years and 38,332 aged 2–18 years. Main outcomes included high BMI for age <2 years, and at 2–18 years overweight (BMI 85th to <95th percentile), obesity (BMI ≥ 95th percentile), and severe obesity (BMI ≥ 120% of 95th percentile).
The study population had diverse race/ethnicity and maternal demographics. Each outcome was more common with increasing age and varied with race/ethnicity. High BMI prevalence (95% CI) was 4.7% (3.5, 6.0) <1 year, and 10.6% (7.4, 13.7) for 1 to <2 years; overweight prevalence increased from 13.9% (12.4, 15.9) at 2–3 years to 19.9% (11.7, 28.2) at 12 to <18 years. ECHO has the statistical power to detect relative risks for ‘high’ BMI ranging from 1.2 to 2.2 for a wide range of exposure prevalences (1–50%) within each age group.
ECHO is a powerful resource for understanding influences of chemical, biological, social, natural, and built environments on onset and trajectories of obesity in US children. The large sample size of ECHO cohorts adopting a standardized protocol for new data collection of varied exposures along with longitudinal assessments will allow refined analyses to identify drivers of childhood obesity.
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Murray CJ, Atkinson C, Bhalla K, Birbeck G, Burstein R, Chou D, et al. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA. 2013;310:591–608.
Kumar S, Kelly AS. Review of childhood obesity: from epidemiology, etiology, and comorbidities to clinical assessment and treatment. Mayo Clinic Proc. 2017;92:251–65.
Hanson MA, Gluckman PD. Developmental origins of health and disease-global public health implications. Best Pract Res Clin Obstet Gynaecol. 2015;29:24–31.
Skinner AC, Ravanbakht SN, Skelton JA, Perrin EM, Armstrong SC. Prevalence of obesity and severe obesity in US Children, 1999-2016. Pediatrics. 2018.
Pan L, May AL, Wethington H, Dalenius K, Grummer-Strawn LM. Incidence of obesity among young U.S. children living in low-income families, 2008-2011. Pediatrics. 2013;132:1006–13.
Chung A, Backholer K, Wong E, Palermo C, Keating C, Peeters A. Trends in child and adolescent obesity prevalence in economically advanced countries according to socioeconomic position: a systematic review. Obes Rev. 2016;17:276–95.
Trasande L, Cronk C, Durkin M, Weiss M, Schoeller DA, Gall EA, et al. Environment and obesity in the National Children’s Study. Environ Health Perspect. 2009;117:159–66.
O’Connor EA, Evans CV, Burda BU, Walsh ES, Eder M, Lozano P. Screening for obesity and intervention for weight management in children and adolescents: evidence report and systematic review for the US preventive services task force. JAMA. 2017;317:2427–44.
Gluckman PD, Hanson MA. Developmental origins of disease paradigm: a mechanistic and evolutionary perspective. Pediatr Res. 2004;56:311–7.
Hammond RA. Complex systems modeling for obesity research. Prev Chronic Dis. 2009;6:A97.
Centers for Disease Control and Prevention. A SAS program for the 2000 CDC growth charts (ages 0 to <20 years). 2019. https://www.cdc.gov/nccdphp/dnpao/growthcharts/resources/sas.htm. Accessed 18 Sept 2019.
Centers for Disease Control and Prevention. A SAS program for the WHO Growth Charts (ages 0 to <2 years). 2019. https://www.cdc.gov/nccdphp/dnpao/growthcharts/resources/sas-who.htm. Accessed 18 Sept 2019.
Grummer-Strawn LM, Reinold C, Krebs NF. Use of World Health Organization and CDC Growth Charts for Children Aged 0-59 Months in the United States. 2010. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm.
Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC Growth Charts for the United States: Methods and Development. Vital Health Stat. 2002;1–190.
Kelly AS, Barlow SE, Rao G, Inge TH, Hayman LL, Steinberger J, et al. Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: a scientific statement from the American Heart Association. Circulation. 2013;128:1689–712.
Lesko CR, Jacobson LP, Althoff KN, Abraham AG, Gange SJ, Moore RD, et al. Collaborative, pooled and harmonized study designs for epidemiologic research: challenges and opportunities. Int J Epidemiol. 2018;47:654–68.
Ma Y, Chu H, Mazumdar M. Meta-analysis of proportions of rare events-a comparison of exact likelihood methods with robust variance estimation. Commun Stat Simul Comput. 2016;45:3036–52.
Ogden CL, Carroll MD, Kit BK, Flegal KM. PRevalence of childhood and adult obesity in the united states, 2011-2012. JAMA. 2014;311:806–14.
Ogden CL, Carroll MD, Lawman HG, Fryar CD, Kruszon-Moran D, Kit BK. et al. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 Through 2013-2014. JAMA. 2016;315:2292–9.
Hales CM, Fryar CD, Carroll MD, Freedman DS, Ogden CL. Trends in obesity and severe obesity prevalence in US youth and adults by sex and age, 2007–2008 to 2015–2016. JAMA. 2018;319:1723–25.
Duncan DT, Sharifi M, Melly SJ, Marshall R, Sequist TD, Rifas-Shiman SL, et al. Characteristics of walkable built environments and BMI z-scores in children: evidence from a large electronic health record database. Environ Health Perspect. 2014;122:1359–65.
Bancroft C, Joshi S, Rundle A, Hutson M, Chong C, Weiss CC, et al. Association of proximity and density of parks and objectively measured physical activity in the United States: A systematic review. Socail Sci Med. 2015;138:22–30.
Kondo MC, Fluehr JM, McKeon T, Branas CC. Urban green space and its impact on human health. Int J Environ Res Public Health. 2018;15: pii: E445. https://doi.org/10.3390/ijerph15030445.
Timperio A, Reid J, Veitch J. Playability: built and social environment features that promote physical activity within children. Curr Obes Rep. 2015;4:460–76.
Kim JH, Lee C, Sohn W. Urban natural environments, obesity, and health-related quality of life among hispanic children living in inner-city neighborhoods. Int J Environ Res Public Health. 2016;13: pii: E121. https://doi.org/10.3390/ijerph13010121.
Trasande L, Attina TM, Blustein J. Association between urinary bisphenol a concentration and obesity prevalence in children and adolescents. JAMA. 2012;308:1113–21.
Jacobson MH, Woodward M, Bao W, Liu B, Trasande L. Urinary bisphenols and obesity prevalence among US children and adolescents. J Endocr Soc. 2019;3:1715–26. https://doi.org/10.1210/js.2019-00201. eCollection 2019 Sep 1.
Janesick A, Blumberg B. Obesogens, stem cells and the developmental programming of obesity. Int J Androl; 35:437–48.
Kotake Y. Molecular mechanisms of environmental organotin toxicity in mammals. Biol Pharm Bull. 2012;35:1876–80.
Padilla MA, Elobeid M, Ruden DM, Allison DB. An examination of the association of selected toxic metals with total and central obesity indices: NHANES 99-02. Int J Environ Res Public Health. 2010;7:3332–47.
National Institute of Environmental Health Sciences. Exposure analysis resources. 2019. https://www.niehs.nih.gov/research/supported/exposure/chear/index.cfm. Accessed 18 Sept 2019.
Anderson SE, Whitaker RC. Prevalence of obesity among US preschool children in different racial and ethnic groups. Arch Pediatr Adolesc Med. 2009;163:344–8.
Taveras EM, Gillman MW, Kleinman KP, Rich-Edwards JW, Rifas-Shiman SL. Reducing racial/ethnic disparities in childhood obesity: the role of early life risk factors. JAMA Pediatr. 2013;167:731–8.
Ambrosini GL. Childhood dietary patterns and later obesity: a review of the evidence. Proc Nutr Soc. 2014;73:137–46.
Ambrosini GL, Emmett PM, Northstone K, Howe LD, Tilling K, Jebb SA. Identification of a dietary pattern prospectively associated with increased adiposity during childhood and adolescence. Int J Obes. 2012;36:1299–305.
Marshall S, Burrows T, Collins CE. Systematic review of diet quality indices and their associations with health-related outcomes in children and adolescents. J Hum Nutr Diet. 2014;27:577–98.
Mikkila V, Rasanen L, Raitakari OT, Pietinen P, Viikari J. Consistent dietary patterns identified from childhood to adulthood: the cardiovascular risk in Young Finns Study. Br J Nutr. 2005;93:923–31.
Oken E. Maternal and child obesity: the causal link. Obstet Gynecol Clin North Am. 2009;36:361–77. ix-x.
Hodges EA, Johnson SL, Hughes SO, Hopkinson JM, Butte NF, Fisher JO. Development of the responsiveness to child feeding cues scale. Appetite. 2013;65:210–9.
Savage JS, Rollins BY, Kugler KC, Birch LL, Marini ME. Development of a theory-based questionnaire to assess structure and control in parent feeding (SCPF). Int J Behav Nutr Phys Act. 2017;14:9.
Thompson AL. Intergenerational impact of maternal obesity and postnatal feeding practices on pediatric obesity. Nutr Rev. 2013;71 Suppl 1:S55–61.
Showell NN, Cole KW, Johnson K, DeCamp LR, Bair-Merritt M, Thornton RLJ. Neighborhood and parental influences on diet and physical activity behaviors in young low-income pediatric patients. Clin Pediatrics. 2017;56:1235–43.
Grossman DC, Bibbins-Domingo K, Curry SJ, Barry MJ, Davidson KW, Doubeni CA, et al. Screening for obesity in children and adolescents: US preventive services task force recommendation statement. JAMA. 2017;317:2417–26.
Lopez-Quintero C, Berry EM, Neumark Y. Limited English proficiency is a barrier to receipt of advice about physical activity and diet among Hispanics with chronic diseases in the United States. J Am Dietetic Assoc. 2009;109:1769–74.
Thornton RLJ, Hernandez RG, Cheng TL. Putting the US Preventive services task force recommendation for childhood obesity screening in context. JAMA. 2017;317:2378–80.
Felix JF, Bradfield JP, Monnereau C, van der Valk RJ, Stergiakouli E, Chesi A, et al. Genome-wide association analysis identifies three new susceptibility loci for childhood body mass index. Hum Mol Genet. 2016;25:389–403.
Fraser A, Macdonald-Wallis C, Tilling K, Boyd A, Golding J, Davey Smith G, et al. Cohort profile: the avon longitudinal study of parents and children: ALSPAC mothers cohort. Int J Epidemiol. 2013;42:97–110.
Patel R, Oken E, Bogdanovich N, Matush L, Sevkovskaya Z, Chalmers B, et al. Cohort profile: the promotion of breastfeeding intervention trial (PROBIT). Int J Epidemiol. 2014;43:679–90.
Olsen J, Melbye M, Olsen SF, Sorensen TI, Aaby P, Andersen AM, et al. The Danish National Birth Cohort-its background, structure and aim. Scand J Public Health. 2001;29:300–7.
Magnus P, Irgens LM, Haug K, Nystad W, Skjaerven R, Stoltenberg C. Cohort profile: the Norwegian mother and child cohort study (MoBa). Int J Epidemiol. 2006;35:1146–50.
Jaddoe V, Mackenbach J, Moll H, Steegers E, Tiemeier H, Verhulst F, et al. The generation R study: design and cohort profile. Eur J Epidemiol. 2006;21:475–84.
Attina TM, Malits J, Naidu M, Trasande L. Racial/ethnic disparities in disease burden and costs related to exposure to endocrine-disrupting chemicals in the United States: an exploratory analysis. J Clin Epidemiol. 2019;108:34–43.
Crump D, Chiu S, Williams KL. Bisphenol S alters embryonic viability, development, gallbladder size, and mRNA expression in chicken embryos exposed via egg injection. Environ Toxicol Chem. 2016;35:1541–9. https://doi.org/10.1002/etc.3313. Epub 1 Apr 2016.
Ma M, Crump D, Farmahin R, Kennedy SW. Comparing the effects of tetrabromobisphenol-A, bisphenol A, and their potential replacement alternatives, TBBPA-bis(2,3-dibromopropyl ether) and bisphenol S, on cell viability and messenger ribonucleic acid expression in chicken embryonic hepatocytes. Environ Toxicol Chem. 2015;34:391–401.
Trasande L. Further limiting bisphenol a in food uses could provide health and economic benefits. Health Aff (Millwood). 2014;33:316–23.
Trasande L, Attina TM. Association of exposure to Di-2-ethylhexylphthalate replacements with increased insulin resistance in adolescents from NHANES 2009-2012. J Clin Endocrinol Metab. 2015;jc20151686.
Trasande L, Attina TM. Association of exposure to di-2-ethylhexylphthalate replacements with increased blood pressure in children and adolescents. Hypertension. 2015;66:301–8.
Jaddoe VW. Early-life stressors and lifecycle health. https://lifecycle-project.eu/about-lifecycle/project-summary/. (Accessed 18 Oct 2019).
Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC Pediatr. 2013;13:59.
The authors wish to thank our ECHO colleagues; the medical, nursing, and program staff; as well as the children and families participating in the ECHO cohorts.
Research reported in this publication was supported by the Environmental influences on Child Health Outcomes (ECHO) program, Office of The Director, National Institutes of Health, under Award Numbers U2COD023375, U24OD023382, UG3OD023271, UG3OD023289, UG3OD023286, UG3OD023248, UH3OD023290, P50 ES009600, UG3OD023275 NIEHS P01ES022832, EPA RD 83544201, UG3OD023286, 4UG3OD023287-03, K01HL141589, UG3OD023285, UG3OD023316, UG3OD023289, UG3OD023289, UG30D023318, UH3OD023249, 1UG1HD090899-01, UG3OD023320, UG3 (UH3) OD023305.
Conflict of interest
The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors declare that they have no conflict of interest.
Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Members of the Environmental influences on Child Health Outcomes are listed at the Supplementary Information “ECHO Program Collaborators”.
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Tylavsky, F.A., Ferrara, A., Catellier, D.J. et al. Understanding childhood obesity in the US: the NIH environmental influences on child health outcomes (ECHO) program. Int J Obes 44, 617–627 (2020). https://doi.org/10.1038/s41366-019-0470-5
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