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New ECHO Research Identifies Energy-efficient Foods to Boost Prenatal Nutrient Intake

Posted on by Jodi Snare
Katherine Sauder, PhD

Collaborative ECHO Cohort research led by Katherine Sauder, PhD and Catherine Cohen, PhD, RD of the University of Colorado Denver – Anschutz Medical Campus identified more than 2,300 energy-efficient foods that could help provide the right amounts of six key nutrients for a healthy pregnancy. This research, titled “Identifying Foods that Optimize Intake of Key Micronutrients During Pregnancy” is published in The Journal of Nutrition.

Most pregnant women in the U.S. are at risk of not getting enough of the nutrients vitamin A, vitamin D, folate, calcium, iron, and omega-3 fatty acids from foods alone. Previous ECHO Cohort research found that only one prenatal supplement available in the U.S. may give pregnant women the optimal amounts of each of these six nutrients. However, that supplement costs $200 per month and requires the patient to take seven pills a day.

Researchers in this study wanted to identify nutrient-rich foods to supplement a pregnant woman’s diet to meet nutrient targets, in the same way that supplements do. They identified more than 2,300 low-calorie foods with enough of at least one of the six nutrients important in pregnancy, including many with reasonable serving amounts to avoid excessive intake. However, no single food evaluated gave enough of each nutrient to fill all six nutrient gaps. One food—raw seaweed—contained five of the key nutrients—vitamin A, folate, calcium, iron, and omega-3 fatty acid—but required up to 7 cups a day to meet daily requirements. Twenty-one other foods and beverages (mainly fish, vegetables, and beverages) provided target amounts of four of the six key nutrients. Few foods met targets for vitamin D or iron, suggesting that dietary supplements may be necessary to meet those nutrient needs.  Other foods could be added in limited amounts to help meet intake targets without exceeding caloric recommendations or nutrient safety limits.

The study included 2,450 pregnant participants from six ECHO Cohort Study Sites across the U.S. ECHO researchers looked at foods and drinks that pregnant participants consumed during their pregnancies and then calculated how much of these six nutrients they were getting from their diet. The researchers compared the participants’ diets to nutrition recommendations for pregnancy to determine the amount of nutrients the participants would need from foods to make up for the gaps in their diet.

“Our analysis indicates that more substantial shifts in dietary intake are likely needed to meet nutrient intake targets, as well as improve prenatal intake more generally,” Dr. Sauder said. “Clinicians can encourage pregnant females to reduce intake of nutrient-poor, energy-dense foods so that more nutrient-rich foods can be consumed without inducing excess calorie intake.”

Read the research summary.

New ECHO Research Finds Association Between Some Prenatal Chemical Exposures and Postpartum Depression

Posted on by Jodi Snare

Collaborative ECHO research led by Melanie Jacobson, PhD, MPH of the NYU Grossman School of Medicine, investigates the role of prenatal synthetic chemicals in postpartum depression. This research, titled “Prenatal Exposure to Nonpersistent Environmental Chemicals and Postpartum Depression,” is published in JAMA Psychiatry.

Postpartum depression affects up to 20% of new mothers, making it the most common pregnancy complication to occur after delivery. Postpartum depression can impact a mother’s daily functioning, quality of life, and long-term health. Furthermore, it is associated with poor mother-child attachment, which can impact child health and development.

Factors like genetics and stress can make some people more likely to experience postpartum depression, but researchers are still trying to understand how synthetic chemicals might also play a role. Chemicals such as phenols, phthalates, and parabens can be found in plastics and personal care products. While these chemicals are nonpersistent, meaning that they don’t linger in the environment, their presence is widespread due to frequent exposure through diet, absorption through skin, and inhalation.

Researchers used data from 2,174 pregnant individuals across five study sites to examine the extent to which exposure to these chemicals might be associated with postpartum depression symptoms. They measured the concentrations of nonpersistent chemicals in urine samples during pregnancy and collected data using self-reported postnatal depression assessments after delivery completed by the same individuals.

The study found that prenatal phthalate concentrations were associated with increased odds of slightly higher postpartum depression scores. Of the many synthetic chemicals investigated, only phthalate concentrations were associated with increased odds of postpartum depression. This suggests that finding ways to reduce prenatal exposure to phthalates might reduce the frequency of postpartum depression. Researchers also observed that postpartum depression was more likely in people who were Hispanic, had lower educational attainment, and had prenatal depression.

“From a public health perspective, any way to help prevent postpartum depression would be important, since most known risk factors such as genetics, psychiatric history, and stressful life events, cannot be easily changed,” Dr. Jacobson said. “Therefore, focusing on prenatal exposure to these types of chemicals represents a novel interventional target.”

While this is believed to be the largest study to date examining the effects of environmental chemicals on postpartum depression, future studies are needed to replicate this research with larger sample sizes in diverse populations.

Read the research summary.

New ECHO Research Observed Shortened Social Responsiveness Scale to be Comparable to Full Version in Autism Risk Factor Estimation

Posted on by Jodi Snare

Collaborative ECHO research led by Marisa Patti, PhD and Kristen Lyall, ScD of AJ Drexel Autism Institute investigates how a shortened version of the Social Responsiveness Scale (SRS) compares to the full questionnaire in order to potentially decrease the time participants need to take assessments. This research, titled “A Comparative Analysis of the Full and Short Versions of the Social Responsiveness Scale in Estimating an Established Autism Risk Factor Association in ECHO: Do we Get the Same Estimates?” is published in the Journal of Autism and Developmental Disorders.

The SRS questionnaire is used to measure social communication and autism-related traits. Researchers have developed a shortened version with only 16 questions out of the original 65. This shortened version is intended to provide a similar summary of overall traits as the longer version, but take less time to complete.

The shorter SRS has been tested to ensure that it measures autism-related traits. Before this study, it was not clear if the short SRS could be used in the same way as the full SRS to study autism risk factors in different research projects and get similar results. In order to address whether the short version can detect associations in the same way as the full version, researchers examined associations with established risk factors for autism- preterm birth and gestational age.

In this study, which included 2,760 child-parent pairs from 11 research sites, younger gestational age and pre-term birth were associated with higher SRS scores, suggesting these may be risk factors for autism-related behaviors in children. The study also found similar associations using the shortened SRS, suggesting both the short and longer versions can detect autism risk factor associations in comparable ways.

Gathering meaningful information for research studies can be time-consuming for participants. This study suggests that shorter assessments can be as useful as longer ones to help reduce the time participants spend answering questionnaires.

“Studies like ours show that the same information can be collected using shorter, less time-consuming assessments to alleviate participant burden by reducing the administration time of assessments,” Dr. Patti said. “In future work, the short SRS can be used without compromising the ability of the assessment to correctly identify associations.”

Future research studies are needed to investigate how comparable estimates are between the full and short SRS using other established risk factors. Researchers may also consider using the short SRS in place of the full SRS in future studies to reduce the overall amount of time participants spend on a research study.

Read the research summary.

ECHO Researchers Investigate Link Between Neighborhood Conditions During Childhood and Asthma Incidence

Posted on by Jodi Snare
Izzuddin Aris, PhD

Collaborative ECHO research led by Izzuddin Aris, PhD, of Harvard Medical School examined the association of conditions and resources available in neighborhoods during different development stages with childhood asthma incidence.

Neighborhood conditions, such as access to housing, healthy food, transportation, and education centers, can influence the development of childhood asthma. Researchers often measure these conditions using the Child Opportunity Index and the Social Vulnerability Index, which link residential addresses at birth, infancy (age 0.5‒1.5 years), and early childhood (age 2.0‒4.8 years) to census-tract data about the opportunities and resources available in the surrounding neighborhood.

ECHO researchers used data from 10,516 children at 46 research sites participating in the ECHO Program. The participants had at least one residential address from birth and a parent or caregiver report of a physician’s diagnosis of asthma.

Children born in high-opportunity neighborhoods had an asthma incidence rate of 23.3 cases per 1,000 children, while those born in very low and low-opportunity neighborhoods had rates of 35.3 per 1,000 and 27 per 1,000, respectively.

“Neighborhood conditions could help researchers identify vulnerable children who are at high risk for developing asthma,” said Dr. Aris. “This information can also guide policymakers, researchers, and community groups to improve children’s health and foster equity across neighborhoods.”

Future studies can explore the impact of investing in early life health and environmental, social, and economic resources on improving health outcomes for children in disadvantaged neighborhoods. Follow-up studies can also focus on how these neighborhood-level factors are affecting asthma rates and how moving may alter asthma development.

This research, titled “Associations of Neighborhood Opportunity and Vulnerability with Incident Asthma Among U.S. Children in the ECHO cohorts,” is published in JAMA Pediatrics.

Read the research summary.

New ECHO Research Suggests Caregiver Education Levels and Child Age Shaped Families’ Concerns During the COVID-19 Pandemic

Posted on by Jodi Snare

Collaborative ECHO research led by Kaja LeWinn, ScD of the University of California, San Francisco and Lisa Jacobson, ScD of Johns Hopkins University investigates the influence of a caregiver’s educational background and their child’s age on the experiences of children and families during the COVID-19 pandemic. This research, titled “Sociodemographic Differences in COVID-19 Pandemic Experiences Among Families in the United States,” is published in JAMA Network Open.

The COVID-19 pandemic and resulting public health measures presented unique challenges for families, frequently influenced by factors such as income and caregiver educational background as well as their children’s ages during the pandemic. Using the ECHO Program’s existing research sites and COVID-19 questionnaires, researchers were able to observe the social and economic factors that were affecting families and children at the height of the pandemic while many population-based studies were put on hold. The study analyzed data from 14,646 ECHO children and 13,644 ECHO caregivers between April 2020 and March 2022.

Researchers found that caregivers with less than a high school education were more likely to report difficulties getting COVID-19 tests for their children, were less likely to work remotely, and reported financial concerns and access to necessities such as food as top sources of stress. Caregivers with a master’s degree or higher, on the other hand, were more likely to name social distancing as the top source of their pandemic stress and were more likely to have the option to work remotely.

Caregivers with children between the ages of 1 and 5 years reported the least support from school systems, the most difficulty finding childcare, and fewer remote learning options. They were also more likely to have healthcare appointments canceled due to COVID-19 concerns and were most concerned about how the pandemic would affect their ability to work.

This study underscores the importance of understanding how children and caregivers from various backgrounds experienced the COVID-19 pandemic. This understanding can help uncover social inequities that could worsen conditions for some populations during future public health crises and can be used to create safeguards to protect vulnerable populations.

“Programs and policies that provide financial assistance and mandate more work flexibility for families of lower socioeconomic status during times of crisis may help mitigate their burdens,” said study author Dr. LeWinn. “Our findings also suggest that families with young children may need more support related to childcare and work flexibility, especially when school disruptions are involved.”

Future research may look into the long-term effects these pandemic challenges may have on children in the ECHO Program over time.

Read the research summary.

New ECHO Research Develops a National Exposure Index for Combined Environmental Hazards and Social Stressors

Posted on by Jodi Snare

Collaborative ECHO research led by Sheena Martenies, PhD, MPH of the University of Illinois Urbana-Champaign developed a national exposure index for easier analysis of multiple factors at once. This research, titled “Developing a National-Scale Exposure Index for Combined Environmental Hazards and Social Stressors and Applications to the Environmental influences on Child Health Outcomes (ECHO) Cohort,” is published in the International Journal of Environmental Research and Public Health.

There is growing interest in understanding the combined effect of multiple environmental hazards and social stressors on the health and development of children. While there are a number of tools for assessing these factors, they can be limiting when trying to analyze the cumulative effects of various exposures.

In this study, researchers developed a combined exposure index with national coverage that compiled data from several environmental and social indicators during prenatal and early-life periods. The data included variables such as air pollution and neighborhood socioeconomic status and analyzed how combined exposure to several factors during pregnancy may impact health.

The combined exposure index, which facilitated ECHO-wide analyses considering exposures to multiple neighborhood-level hazards and stressors at the same, differed by region. The level of combined exposure was highest in the western and northeastern regions of the United States. Researchers found that pregnant participants who identified as Black and Hispanic were more likely to have higher exposures to hazards compared to White and non-Hispanic participants. Exposure values were also higher for pregnant participants with lower educational attainment.

“Our study results complement those from a previous study that found these combined exposures were associated with a higher risk of adverse birth outcomes for some demographic groups,” Dr. Martenies said. “The results of these studies suggest there is a role for neighborhood quality in healthy pregnancy outcomes. More work is needed to identify interventions that might reduce prenatal exposures and improve pregnancy outcomes.”

Researchers may use this exposure index in future studies to look at how neighborhood features influence child health outcomes. Future studies would benefit from national datasets for key environmental health concerns, such as water contaminants and pesticides, and social stressors that may disproportionally affect certain groups.

Read the research summary.

New ECHO Research Looks into Potential Correlation Between Maternal Stress and Early Childhood Obesity

Posted on by Jodi Snare

Collaborative ECHO research led by Callie Brown, MD, MPH of Wake Forest University, and Charles Wood, MD, MPH of Duke University, investigates how maternal stress can affect children’s later body mass index (BMI). This research, titled “Maternal stress and early childhood BMI among US children from the Environmental influences on Child Health Outcomes (ECHO) program,” is published in Pediatric Research.

Obesity affects millions of adults, adolescents, and children in the United States. Many children in the United States enter their school years with obesity, and children with obesity at 3 years of age have a 90% probability of having overweight or obesity as an adolescent.

While existing literature suggests a relationship between parental stress and childhood body mass index (BMI), the exact way in which parental stress might affect BMI in children isn’t fully understood. Researchers looked at 1,694 mother-child pairs across 15 research sites in the United States over time to evaluate how maternal stress might be associated with the child’s BMI.

The study did not find any significant link between maternal stress measured in the first year after childbirth and the child’s BMI. While the study did not find an association between maternal stress levels and childhood obesity, it did reveal other information about both maternal stress and childhood BMI.  Researchers found that higher stress levels were more likely among Hispanic and Black mothers, and less likely among mothers with private health insurance. Furthermore, higher child BMI was more likely among Hispanic mothers, when a mother’s BMI before birth was higher, and when the child’s birth weight was higher.

The study’s results suggest that factors other than a mother’s stress level appear to be stronger predictors of increased childhood BMI.

“Parental stress has been associated with childhood obesity and may affect stress levels and eating, sleep, and physical activity patterns during childhood,” said study author Dr. Wood. “There are many factors in the first year of life that are related to higher weight gain and earlier obesity in children, but our results suggest that the level of a mother’s stress in the first year of life is not a risk factor. This may be because stress during pregnancy, stress later in childhood, and the child’s own stress level are stronger predictors of differences in childhood BMI.”

Future studies may look at additional factors that influence children’s risk for increased BMI such as BMI in later childhood, other periods of stress, parent or caregiver-measured stress measured, or specific types of stress.

Read the research summary.

ECHO Researchers Use Computer Modeling to Tailor Strategies to Cut Sugar-sweetened Beverage Consumption in Children

Posted on by Jodi Snare

Collaborative ECHO research led by Matt Kasman, PhD, of The Brookings Institution, used computer modeling to help tailor effective strategies to reduce sugar-sweetened beverage consumption in children. This research, titled “Childhood Sugar-sweetened Beverage Consumption: An Agent-based Model of Context-specific Reduction Efforts,” is published in the American Journal of Preventive Medicine.

Health experts have long recognized the need to reduce the consumption of sugary drinks among children in the U.S. Large-scale interventions have been expensive and have shown limited effects. ECHO researchers used computer modeling to simulate interventions and measured their impact on reducing consumption in different populations. In the study, data from children ages 2 to 7 years old from three ECHO research sites were input into a computational model of childhood sugar-sweetened beverage consumption.

Researchers found that limiting access to sugary drinks in the home is key, with the potential to reduce childhood consumption by as much as 87%. Reducing sugar-sweetened drink availability at school and childcare facilities was also helpful. The amount of the reductions also varied between the groups of children simulated.

“These findings highlight the importance of tailoring interventions to reduce sugar-sweetened drink consumption based on the characteristics and needs of specific populations,” said Dr. Kasman. “Using computer modeling, we can gain valuable insights to develop effective and targeted strategies.”

In future studies, researchers plan to include older children and adjust computer models to explore the consumption of other foods and beverages with health implications. A summary of a previous study that applied computational modeling to a single ECHO research site can be found here.

Read the research summary.

New ECHO Research Suggests Link Between Prenatal Depression and Autism-related Traits

Posted on by Jodi Snare

Collaborative ECHO research led by Lyndsay A. Avalos, PhD and Lisa A. Croen, PhD of Kaiser Permanente Northern California Division of Research investigates the potential link between prenatal depression or a history of depression prior to pregnancy and autism-related traits in children. This research, titled “Prenatal Depression and Risk of Child Autism-Related Traits Among Participants in the Environmental influences On Child Health Outcomes Program,” is published in Autism Research.

Previous research suggests an association between prenatal depression or a history of depression prior to pregnancy and autism spectrum disorder (ASD) in children, but most studies have focused on a formal ASD diagnosis, rather than autism-related traits.

This study examined parent-child pairs at 33 prenatal and pediatric research sites in the United States. The primary analysis included 3,994 parent-child pairs with prenatal depression diagnosis data; a secondary analysis included 1,730 parent-child pairs with depression severity data. Children of mothers with prenatal depression had slightly more autism-related traits compared to those without. The association was similar among boys and girls. Prenatal depression also increased the likelihood of moderate to severe autism-related traits, indicating a higher likelihood of ASD diagnosis.

“Autism-related traits can significantly impact a child’s physical, social, and psychological development, regardless of their clinical diagnosis. Screening and treating pregnant patients for depression and detecting autism-related traits in these children early on can lead to timely support of healthy development and outcomes for mothers and children,” said study author Dr. Avalos.

This study adds to the understanding of how prenatal depression may be associated with neurodevelopment in children, such as social communication and behavioral characteristics that may not reach a clinical threshold but can still impact a child’s social and behavioral functioning. These findings highlight the need for early ASD screening for children whose parents had prenatal depression to promote early intervention and support their healthy development. Mental health screening and prevention efforts for depression in pregnant individuals could also be beneficial.

Read the research summary.

New ECHO Research Finds Higher Caregiver Stress Levels Linked to Sleep Issues in Children

Posted on by Jodi Snare

Collaborative ECHO research led by Maxwell Mansolf, PhD and Courtney K. Blackwell, PhD, of Northwestern University investigates the potential link between poor sleep health of school-age children and stress experienced by their caregivers. This research, titled “Caregiver Perceived Stress and Child Sleep Health: An Item-Level Individual Participant Data Meta-Analysis,” is published in the  Journal of Child and Family Studies.

Up to 50% of children and adolescents in the United States might experience sleep problems, which is an issue because poor sleep can negatively impact brain development, learning, and physical and emotional well-being.

There have been prior studies suggesting a link between poor sleep in children and stress experienced by their caregivers, but those were mainly limited to infants and young children. This study involved school-age children and teens, specifically 2,641 children between the ages of 6 and 18 from 12 ECHO research sites.

Caregivers participating in the study completed the Perceived Stress Scale (PSS) to provide data about their personal stress levels. They also completed the Child Behavior Checklist (CBCL), a parent-reported survey that provides information about a child’s well-being, including their sleep habits. Responses from the PSS and CBCL were compared and analyzed to evaluate how caregiver stress affected child sleep patterns, particularly by looking at CBCL responses that addressed children’s experiences with nightmares, insomnia, ongoing tiredness, and excessive and troubled sleep.

The study found that children whose caregivers reported increased perceived stress from their life circumstances may be at higher risk for sleep issues, reaffirming existing links between caregiver psychosocial state and child well-being. This association was consistent across different groups of child and caregiver pairs studied, even after accounting for mental and physical health conditions, highlighting the importance of screening for caregiver stress to create plans for children who may be at risk for sleep issues.

“This research suggests that children whose caregivers are under increased stress may be at particular risk for sleep issues, and screening for caregiver stress may represent a potential pathway for screening and intervention of child sleep issues,” said Dr. Mansolf. “This research also demonstrates the utility of cross-cohort harmonization, as responses from multiple versions of the Perceived Stress Scale were harmonized for use here.”

Future sleep interventions may consider a more global approach to improving child and adolescent sleep health. Continued research on the factors that influence family health and well-being may guide interventions that address the entire family and the dynamics of the family relationship.

Read the research summary.