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Int J Obes (Lond). 2019 Oct 24. doi: 10.1038/s41366-019-0470-5. [Epub ahead of print]

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

Author information

Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.
Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA.
RTI International, Research Triangle Park, Triangle Park, NC, USA.
Division of Chronic Disease Research Across the Lifecourse (CoRAL), Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA.
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Departments of Epidemiology and Pediatrics, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Denver, CO, USA.
Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.
Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
Department of Public Health Sciences, Henry Ford Hospital, Detroit, MI, USA.
Welch Center for Epidemiology, Prevention and Clinical Research, Johns Hopkins University Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA.
National Heart, Lung, and Blood Institute, Bethesda, MD, USA.
NIH Office of the Director, ECHO Program, Bethesda, MD, USA.
Epidemiology and Genomics Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Rockville, MD, USA.
Department of Obstetrics and Gynecology, Institute of Environmental Health Sciences, Wayne State University, Detroit, MI, USA.
Departments of Pediatrics and Epidemiology, University of Colorado, Denver, CO, USA.
Department of Pediatrics and Centro SOL, Johns Hopkins School of Medicine, Baltimore, MD, USA.
Department of Pediatrics, University of Utah, Salt Lake City, UT, USA.
Department of Pediatrics, Emory University, Atlanta, GA, USA.
Department of Pediatrics, West Virginia University School of Medicine, Morgantown, WV, USA.
National Institute of Nursing Research and Environmental Influences on Child Health Outcomes Program, National Institutes of Health, Rockville, MD, USA.
Department of Pediatrics and Obstetrics, Gynecology and Women's Health, Albert Einstein College of Medicine, Bronx, NY, USA.
Departments of Pediatrics, Environmental Medicine and Population Health, NYU School of Medicine, New York, NY, USA.



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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