The home environment and childhood obesity in low-income households: indirect effects via sleep duration and screen time

Bradley M Appelhans 0 Stephanie L Fitzpatrick 0 Hong Li 0 Vernon Cail 0 Molly E Waring 2 Kristin L Schneider 1 Matthew C Whited 6 Andrew M Busch 4 5 Sherry L Pagoto 3 0 Department of Preventive Medicine, Rush University Medical Center , 1700 W. Van Buren St., Suite 470, Chicago, IL 60612 , USA 1 Department of Psychology, Rosalind Franklin University , North Chicago, IL , USA 2 Department of Quantitative Health Sciences, University of Massachusetts Medical School , Worcester, MA , USA 3 Division of Preventive and Behavioral Medicine in the Department of Medicine, University of Massachusetts Medical School , Worcester, MA , USA 4 The Miriam Hospital , Providence, RI , USA 5 Department of Psychiatry and Human Behavior, Brown University , Providence, RI , USA 6 Department of Psychology, East Carolina University , Greenville, NC , USA Background: Childhood obesity disproportionally affects children from low-income households. With the aim of informing interventions, this study examined pathways through which the physical and social home environment may promote childhood overweight/obesity in low-income households. Methods: Data on health behaviors and the home environment were collected at home visits in low-income, urban households with either only normal weight (n = 48) or predominantly overweight/obese (n = 55) children aged 6-13 years. Research staff conducted comprehensive, in-person audits of the foods, media, and sports equipment in each household. Anthropometric measurements were collected, and children's physical activity was assessed through accelerometry. Caregivers and children jointly reported on child sleep duration, screen time, and dietary intake of foods previously implicated in childhood obesity risk. Path analysis was used to test direct and indirect associations between the home environment and child weight status via the health behaviors assessed. Results: Sleep duration was the only health behavior associated with child weight status (OR = 0.45, 95% CI: 0.27, 0.77), with normal weight children sleeping 33.3 minutes/day longer on average than overweight/obese children. The best-fitting path model explained 26% of variance in child weight status, and included paths linking chaos in the home environment, lower caregiver screen time monitoring, inconsistent implementation of bedtime routines, and the presence of a television in children's bedrooms to childhood overweight/obesity through effects on screen time and sleep duration. Conclusions: This study adds to the existing literature by identifying aspects of the home environment that influence childhood weight status via indirect effects on screen time and sleep duration in children from low-income households. Pediatric weight management interventions for low-income households may be improved by targeting aspects of the physical and social home environment associated with sleep. - Background Childhood obesity disproportionally affects low-income children [1], which may contribute to socioeconomic disparities in obesity-related chronic diseases throughout the lifespan [2]. Socioecologic models attribute childhood obesity to intersecting social, economic, environmental, and psychobiologic drivers of energy intake and expenditure [3]. Prior work based on this model has largely focused on neighborhood-level factors, such as local access to healthy and unhealthy foods, geographic density of fast food outlets and supermarkets, and venues for physical activity in relation to childhood obesity risk [4,5]. A few recent studies have highlighted the role of the home environment in childhood obesity, including both its physical features and social processes involving children and caregivers [6]. Physical home environments characterized by greater availability of unhealthy foods, fewer fruits and vegetables, more media equipment throughout the home and in the childs bedroom, and fewer sports/ recreational equipment items have been linked to childhood obesity risk [7-10]. Aspects of the social home environment, including caregiver modeling and policies towards healthy eating and physical activity, are also important influences [11,12]. Very little research to date has examined childhood obesity risk factors in the home environments of lowincome households. In particular, little is known about aspects of the home environment that are associated with short sleep duration, which is highly prevalent among low-income minority youth [13] and has been consistently associated with weight gain and obesity status in prospective and cross-sectional studies [14-16]. This study compared the home environments of normal weight and overweight/obese children from low-income households. Consistent with socioecologic models of health and prior studies in non-disadvantaged populations, it was hypothesized that features of the physical and social home environment associated with healthy dietary intake, increased physical activity, reduced screen time, and longer sleep duration would discriminate between low-income households with exclusively normal weight children from those with predominantly overweight/obese children. An improved understanding of the features of the home environment most strongly associated with childhood obesity in low-income households could be leveraged to develop novel pediatric obesity interventions for this population. By comparing normal weight versus overweight/obese children within an entirely low-income population, this study reduced confounding by household income, and ensured that any therapeutic changes to the home environment suggested by the findings would be financially feasible for low-income families. Methods This manuscript reports the primary analyses from the Home Environment Comparison Study, a cross-sectional investigation of home environmental childhood obesity risk factors in low-income, urban households. Data were collected in Chicago, IL, USA during 20122013. Subjects Households were recruited through posted advertisements, pediatrician referrals, and word-of-mouth between May 2012 and March 2013. Eligible households were located in the city of Chicago, had at least one child between ages 6 and 13 years, reported a household income 250% of the Federal Poverty Threshold (FPT; <$57,625/year for a 4-member household), and included an adult caregiver who made the majority of household food purchases and was willing to participate (index caregiver). Households also met criteria as cases or controls. In overweight/obese households (cases), at least 50% of children had a body mass index 85th percentile for their age and sex (consistent with the Centers for Disease Control and Preventions definition [17]). In normal weight households (controls), all children ages 6 to 18 years had a body mass index <85th percentile for their age and sex. Households in which 1%-49% of children ages 6 to 18 were overweight or obese were excluded to maximize observed group differences in home environments. Data col (...truncated)