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Understanding childhood obesity in the US: the NIH environmental influences on child health outcomes (ECHO) program



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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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.

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Correspondence to Leonardo Trasande.

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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).

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