New Research: New Hope for Children

SPH experts work to reverse unhealthy trends and benefit the next generation

From the start, children encounter threats to health. They are vulnerable to risks in an environment determined by parents, community, and society. Some health issues have clear causes. A fetus, for example, may be affected by particulates or chemicals in the air an expectant mother breathes. And while measures of air pollution and lead levels have decreased in children since 1997, they remain higher than recommended— and noticeably higher in black children than white children.

Other issues are more complex. Researchers lack definitive answers about the causes of autism, which has increased during the last decade from one in 166 U.S. births to one in every 110 births.

With no simple solution in sight, obesity also increasingly burdens children at younger ages. Over 30 years, the rate of obesity has tripled among those ages 6 to 11 and doubled among children 2 to 5. For ethnic minority children, the outlook is worse: one in two will develop type 2 diabetes, primarily due to obesity.

And children’s access to health care still demonstrates gaps, despite a federal program that’s more than a decade old. Disparities in children’s health insurance coverage can be seen in groups defined by ethnicity, income, and age.

Can we ensure a healthier future for tomorrow’s children? School of Public Health researchers are studying and tackling these daunting issues in novel ways to set a new direction for tomorrow’s children.

Comprehensive research approaches to children’s health include a seven-year, broad-based Twin Cities study to prevent obesity in preschoolers who live in low-income neighborhoods, as well as the National Children’s Study, which will start before birth and follow children to age 21.

At the same time, the National Children’s Study reaches deep, seeking links between environmental factors and individuals’ genetic profiles to improve understanding of children’s health issues. On a smaller scale, the Gopher Kids Study has started examining environmental interactions with genes in Minnesota children.

As these studies move forward, health risks will be better identified and protective factors will be promoted. Additionally, in the coming years, more children should be covered by historic health reform measures. The unhealthy trends of the late 20th century should bend back—and children’s health in the 21st century take a turn for the better.

Taking the long view of America’s children

The largest long-term study of children’s health in the United States will examine the interactions of genes and the environment— and the SPH is involved. “It’s huge,” says Pat McGovern, an environmental health expert at the school and principal investigator for the Ramsey County study site for the National Children’s Study. Nationwide, the observational study seeks to enroll 100,000 children from before birth and follow their health through age 21.

“It’s an amazing opportunity to learn about conditions that kids and families have been struggling with the last two decades,” McGovern says. She collaborates with colleagues from the Medical School and Institute of Child Development on the Ramsey County study.

The University’s team is one of the many at 105 sites that will examine how health is influenced by environment— broadly defined to include everything from chemicals in the home to cultural factors and safety of the neighborhood. With a multi-million dollar budget, the National Children’s Study is managed by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, in collaboration with other federal partners.

Researchers expect to discover interactions between environment and genes that contribute to the high rate of preterm births, as well as asthma, allergies, diabetes, obesity, and autism. Along with health risks, they expect to find protective factors too.

In Ramsey County, McGovern and team collaborate with community partners in clinics, hospitals, and health departments to identify women who are pregnant or may become pregnant soon. Their vanguard study is testing methods for recruiting about 300 potential future mothers in randomly selected households.

The team also will assess responses to high-intensity research approaches, such as home visits during which biological or environmental samples are collected, or low-intensity methods, limited to surveys.

“It could go either way,” McGovern says of the pilot that began this winter. “Some people may really like the personal relationship of having someone visit their home to collect more comprehensive data, while others may prefer only answering questionnaires by mail or online.” Once pilot studies at Ramsey County and selected other sites help determine study methods, the National Children’s Study expects to launch its main study in 2012.

McGovern is enthusiastic about the long-term potential for the study to make a difference in health services and policies. “Over time,” she says, “it will influence the health of your grandchildren—and the health of future generations.”

Getting together with children at the fair

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For 10 days in late summer, families all over the state bring their children to the Minnesota State Fair—so why not bring researchers there to study the genetic origins of obesity and differences in child growth? In 2010, that novel idea became a reality called the Gopher Kids Study, led by principal investigators Ellen Demerath, an SPH epidemiologist, and Logan Spector, an epidemiologist in the Medical School.

“We were not limited by the interest of the families coming to the fair,” says Demerath. “We were limited by the fact that we had just a part of the space.” In several shifts totaling 36 hours, faculty and 50 student volunteers staffed the study area in the University of Minnesota building at the State Fair.

“It was absolutely frenetic,” Demerath says. “There’s a lot involved, particularly with the informed consent.” Researchers kept the study fairly straightforward, she says. “It’s very difficult to do any kind of fasting study at the fair.” The team measured children’s height, weight, waist, and blood pressure, collected DNA samples with “spit kits,” asked parents to agree to complete a questionnaire to be mailed this winter, and requested they return to the State Fair for more study in 2011 and 2012.

Despite the time commitment, families were eager to participate. In the end, about 800 children enrolled; add their parents and the number in the study rises to about 1,500. Gopher Kids is a feasibility study funded by the University of Minnesota Academic Health Center that Demerath and Spector hope can ultimately attract funding with the National Institutes of Health. Demerath is excited about the possibilities.

For instance, the State Fair venue means the researchers avoid transportation costs while studying a dispersed population. In addition, they are educating the public about genetics because the Gopher Kids Study, like the National Children’s Study, looks at the interaction between genes and environmental factors. While scientists’ understanding of genetic susceptibility to obesity is increasing, Demerath says, they still don’t know how the 32 or so genes influencing obesity and body fat may be modified by healthy lifestyles. “We don’t understand how the same obesity-promoting environment produces obesity in one child and normal weight in another child.”

The outlook for the next generation, Demerath says, is not bright. It will require a “full-court press” to turn around the health threats associated with obesity, including premature puberty and potentially shorter life expectancy for future generations.

So much of a child’s environment is controlled by parents, she says, that “it speaks to how important parents are in creating a home that’s healthy for their children.”

Targeting preschoolers where they live, learn, and get care

The influence of family, community, and even neighborhood businesses on the health of low-income and ethnically diverse preschoolers is the focus of researchers at the new Childhood Obesity Center, a federally funded study.

“By targeting those different types of settings and wrapping it all together around parents, we’re hoping to have an impact and have it be sustainable,” says SPH childhood nutrition expert Simone French. She and fellow school faculty member Nancy Sherwood from Health Partners Research Foundation are the principal investigators.

Previous obesity-prevention efforts aimed at very young children, Frenchsays. But teaching Head Start enrollees about eating fruits and vegetables had little effect. “Preschoolers don’t do the grocery shopping,” she says.

Preschoolers’ parents do the grocery shopping; they take their children to see primary care providers for well-child visits; and, in the Twin Cities, they attend Early Childhood and Family Education (ECFE) courses. These are the arenas where French and team will reach parents.

First, for the neighborhood component, French and colleagues collaborate with the Minneapolis Department of Health and Family Support and the local Institute for Agriculture and Trade Policy to connect families to farmers’ markets and community centers. They also reach those who run corner stores and groceries, to help them gain affordable access to fresh fruits and vegetables to sell. “You have to make it work for the store owners,” French says.

Second, partnering with pediatricians and other physicians who see these families is a key part of this research that hasn’t been included in previous studies, French says. Primary care physicians will talk with parents about the importance of healthy eating and physical activity.

Finally, the existing ECFE courses already teach parenting skills, such as setting limits and using positive reinforcement as part of preparing children for school. ECFE is well accepted by families of all backgrounds and includes family advocates who understand a variety of cultures and languages.

The obesity-prevention project will piggyback on ECFE. “We’ll be engaging with parents on more than five-a-day,” says French, referring to the recommended serving of fruits and vegetables. “Limiting screen time, promoting activity, good nutrition—it’s all about the healthy child.” And the researchers will leverage ECFE advocates’ home visits with families.

French is excited that the project is funded for seven years because “obesity is complicated.” She is optimistic that this multi-pronged project targeting preschoolers will result in many of them avoiding obesity—and the concomitant lifelong health problems. She and Sherwood, with their research partners, hope they can bend the trend toward healthier habits.

Lacking health insurance, lacking access

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Disparities in health insurance coverage by age, household income, and race or ethnicity— as well as a surprising increase in the number of uninsured children—have been documented by recent studies carried out by the University of Minnesota’s State Health Access Data Assistance Center (SHADAC).

“The expansions to health insurance coverage, passed as part of the Affordable Care Act, will help relieve these disparities,” says Lynn Blewett, principal investigator for SHADAC, based in the School of Public Health and funded by the Robert Wood Johnson Foundation.

“For democracy to work, you need a good political debate informed by reliable and unbiased data—and that’s what we do,” Blewett says.

A recent SHADAC study found that, nationwide, children who were more likely to lack insurance were more likely to be 14 years old or older, non-white or Hispanic, or live in the lowest income households. Children without health insurance may lack access to care—and may be sicker when they do seek care, often resulting in higher health care costs.

“There’s been a concerted effort in this country to provide affordable health insurance coverage for all children,” Blewett says. “Both sides of the aisle supported the initial passage of the Children’s Health Insurance Program in 1997 and reauthorization passed in 2009. But despite CHIP and the Medicaid program, which cover more than 20 million children in United States, there are still 9 million children without health insurance.”

SHADAC found that in Nevada, 21 percent of children still lack health insurance, compared with 2 percent in Massachusetts, a state that has initiated comprehensive health insurance reform. In Minnesota, coverage gaps are substantial. Even though only 6 percent of Minnesota’s children are uninsured, Hispanic children in the state are five times more likely than whites to be uninsured.

Blewett also cites estimates within a recent report released by the U.S. Census Bureau, written by SPH alum Annie Mach, that found a statistically significant increase in uninsured children in Minnesota and Alaska between 2008 and 2009—while all other states have stayed steady or increased levels of coverage. This raises additional concerns for children’s coverage in Minnesota.

Blewett believes that more attention should be placed on getting children enrolled in the programs they are eligible for and in reducing the gaps in coverage. “Numbers do drive policy,” she says, “and our goal is to drive the best outcome that we can.”

Seeking better outcomes and brighter futures for children are goals for Blewett, French, Demerath, McGovern, and their colleagues. They are working with policymakers, community members, and parents to prevent some of the health problems children face today—and to ensure a healthier future for the next generation.