Grantee Research Project Results

Final Report: Growing Up Healthy in East Harlem (Community-Based Participatory Research)

EPA Grant Number: R831711C001
Subproject: this is subproject number 001 , established and managed by the Center Director under grant R831711
(EPA does not fund or establish subprojects; EPA awards and manages the overall grant for this center).
Center: Center for Research on Early Childhood Exposure and Development in Puerto Rico
Center Director: Alshawabkeh, Akram
Title: Growing Up Healthy in East Harlem (Community-Based Participatory Research)
Investigators: Brenner, Barbara , Wolff, Mary S. , Galvez, Maida , Teitelbaum, Susan
Institution: Mount Sinai School of Medicine
EPA Project Officer: Callan, Richard
Project Period: November 1, 2003 through October 31, 2008 (Extended to October 31, 2010)
RFA: Centers for Children's Environmental Health and Disease Prevention Research (2003) RFA Text | Recipients Lists
Research Category: Children's Health , Human Health

Objective:

Project 1 is a Community-Based Participatory Research (CBPR) project to investigate the role of the environment on childhood obesity. Building on community partnerships established in 1998-2003, we enrolled a cohort of 373 African-American and Hispanic children -- 268 girls and 105 boys, ages 6-8, who were residents of East Harlem -- and followed them for 3 years to examine the relationships between structural features in the urban built environment of East Harlem, exposure to endocrine-disrupting chemicals (EDCs or EDs), specifically phthalates and BPA, and growth. We examined how chemicals and neighborhood factors influence risk of childhood obesity as well as diets and physical activity levels. Twelve (12) children (8 girls and 4 boys) were consented but did not follow through with any data collection. Recruitment sites included pediatric practices at The Mount Sinai Hospital, North General Hospital and the Children's Aid Society and at community health and social service agencies and public schools.

SPECIFIC AIMS:

To characterize children's exposures to endocrine disruptors (EDs) using urinary biomarkers
To examine relationships between obesity in East Harlem children and ED exposures, diet, physical activity, and structural factors in the urban built environment
To characterize the urban built environment of East Harlem using geocoded information on food stores, fast food outlet, playground and park locations
To characterize these children's levels of physical activity, their use of parks and playgrounds, and their participation in sports and other organized youth activities.

Summary/Accomplishments (Outputs/Outcomes):

An annual in-person, interviewer administered visit included collection of (1) anthropometry (measured height, weight and percent body fat via use of a Tanita bioimpedance scale and RJL device); (2) family demographics; (3) characteristics related to diet, physical activity, and product use, (4) neighborhood information about resource utilization by children in East Harlem as well as concerns about existing resources which are potential environmental determinants of diet and physical activity; and (5) biologic specimen collection (urine collected for environmental exposure analysis, specifically phenols and phthalates and buccal swabs to collect DNA). To quantify diet, parent/legal guardians were asked to complete four 24-hour dietary recalls at baseline. Physical activity was monitored at baseline; children were given a pedometer that provided objective measurements of physical activity over one week's duration. At the two subsequent follow-up visits, anthropometry was re-assessed, pertinent information such as medical history was updated, and a dietary history, physical activity measurement, and a urine specimen were collected. Each participant's address was geocoded for use with the East Harlem Geographic Information System (GIS).

Community Based Participatory Research

Community participation has been integral to the research conducted by the Mount Sinai Center for Children's Environmental Health and Disease Prevention Research since its inception in 1998. The Center joined with Boriken Health Center and Settlement Health, two federally qualified health centers, to design and implement Growing Up Healthy in East Harlem (1) 1998-2003.The study demonstrated the effectiveness of integrated pest management (IPM) in reducing cockroaches and use of chemical pesticides in homes of low income pregnant women residing in East Harlem. In 1999, we organized an ongoing structure for community input, and support the "Growing Up Healthy" Community Advisory Board (CAB) whose members represented residents, community based organizations and more recently, parents of study participants. Composed of 20 active community stakeholders, the CAB met semi-annually to review study progress and informational materials and initiate community education activities.

Our community research partners and the CAB identified childhood obesity as the most understudied critical health problem in East Harlem and led the Center to pursue Growing Up Healthy in East Harlem (2) (2003-2008). This exposure study of the "built environment," including endocrine disrupting chemicals, and their relationship to obesity, generated much interest and several community organizations agreed to collaborate as study recruitment sites, including: Children's Aid Society Dunlevy Milbank Clinic, North General Hospital Pediatrics Clinic, Union Settlement Association, Little Sisters of the Assumption Family Health Services and the New York City Department of Education. The CAB gained new members and a reorganized group of fifteen (15) opted for more participation in study implementation and translation of results to both parents of participating children and the larger East Harlem community. Meetings were held on a quarterly basis and collaboration with the Center's Community Outreach and Translation Core Activities was initiated. Themes and issues that were addressed throughout the five year study period included:

clarifying benefits of joining the study for parents and children;
offering suggestions for recruitment and retention strategies;
ensuring appropriate translation of study purpose, methods and results to parents with low literacy skills;
reviewing the "built environment" questionnaire;
advising the COTC on the relevance and readability of newsletters and fact sheets;
advocating for an enhanced community education program.

Conclusions:

SPECIFIC AIM: To characterize children's exposures to EDs using urinary biomarkers. We found that:

ED exposures are ubiquitous and wide ranging among the Growing Up Healthy children. The levels in our inner-city children are generally higher or the same as the levels reported in U.S. children between the ages of 6-11. Medium levels of one chemical found in mothballs and toilet sanitizers, 25DCP, was found to be significantly higher in our cohort than in the national sample of children provided by the CDC.

In a temporal variability pilot study among East Harlem children not enrolled in our main study, we found that a single urine sample provides reliable ranking for phthalate metabolites, BP3 as well as other phenols and phytoestrogens; a single sample collected either at the beginning, end or during a 6-month period reliably predicted the 6-month mean concentration. This suggested that these biomarkers were appropriate for use in studies of environmental exposures and health outcomes in children.

We investigated sources of ED exposure and ED concentrations (phthalates and phenols) from the pilot study and compared urine results with product-use question responses. There were significant, positive associations for personal care product use and urinary ED biomakers. Past week use of several personal care products (e.g., shampoo, hair gel, and body moisturizer) was significantly associated with higher concentrations of several urinary metabolites.

SPECIFIC AIM: To examine relationships between obesity in East Harlem children and ED exposures, diet, physical activity, and structural factors in the urban built environment. We found that:

The prevalence of childhood obesity in the Growing Up Healthy in East Harlem population is higher than the national prevalence. A staggering forty-three percent of East Harlem children (53% of boys and 39% of girls) in our study were considered overweight and obese using the CDC definition (BMI > 85th percentile for age and gender), significantly higher than the 19.6 per cent reported in NHANES (2007-2008) survey data for children 6 - 11.

Children with larger body size measures had higher ED concentrations. These findings suggest that phthalates and BP3 exposure may contribute to increased overweight in children.

1. Age and race/ethnicity adjusted mEP geometric means (ug/L) were significantly higher for girls in the upper quartile of several body size characteristics compared to girls in the combined lower 3 quartiles.

2. Adjusted high molecular weight phthalate geometric means were elevated for girls in the upper quartile of HC and WC

3. Adjusted BP3 geometric means (ug/L) were significantly higher for girls in the upper quartile of BMI percentile, WC and HC

4. None of the phthalates were associated with increased body size measurements in boys; many were associated with decreased body size measurements.

SPECIFIC AIM: To characterize the urban built environment of East Harlem using geocoded information on food stores, fast food outlet, playground and park locations. We found that:

Inequities exist in food store availability by race/ethnicity within the community. 100% of African American Census blocks had neither supermarkets nor grocery stores. African American census blocks were less likely to have convenience stores (prevalence ratio 0.25, 95% confidence interval 0.07-0.86) compared with racially mixed census blocks. In contrast, predominantly Latino census blocks were more likely to have convenience stores (1.8, 1.20-2.70), specialty food stores (3.74, 2.06-7.15), full-service restaurants (1.87, 1.04-3.38) and fast-food restaurants (2.14, 1.33-3.44) compared with racially mixed census blocks. These inequities have implications for racial/ethnic differences in dietary quality, obesity and obesity-related disorders.

East Harlem children have easy access to unhealthy foods: 55% live on a block with a convenience store. 41% live on a block with fast food stores. The school food environment presents children with many unhealthy options. 95% (n = 20) of elementary schools have unhealthy food stores within a 125 meter radius. 67% (n = 14) have 3 or more unhealthy food resources in the same vicinity.

The presence of convenience stores on the same block as a childs home was associated with a higher BMI-percentile. Children (n = 177) living on a block with one or more convenience stores (range 1-6) were more likely to have a BMI-percentile in the top tertile (odds ratio 1.53, 95% CI 1.02-2.30), compared with children having no convenience stores (n = 146). This has potential implications for both child and neighborhood level interventions with respect to childhood obesity. (Galvez et al 2009, Academic Pediatrics).

The presence of fast food stores in the same census tract as a child's home increased the likelihood that a child would meet dietary recommendations for total fat and saturated fat.

Of those East Harlem children in the study with school drink vending machines (38%) or snack vending machines (11%), only 14% of children report purchasing drinks and 2% report purchasing snacks. In contrast, 92% of children have access to convenience stores, 81% to food stands, and 62% to fast food stores on the way home from school. 72% report purchasing food from convenience stores, 64% from food stands, and 35% from fast food stores on their way home from school at least once per week.

We further characterized dietary intake for a cohort of NYC girls. Except for grains, intake in the main food groups was lower than the recommended intake according to the USDA. Fruit and vegetable consumption averages were the lowest (GUH: 2.2 and 1.2 servings respectively vs USDA: 3 and 2 servings). These results were shared with parents. Recommendations are to eat more whole grains, eat and drink low fat dairy products and use the girls' hands to estimate appropriate portion sizes.

The average caloric intake for this group was 1467 kcal/day. The Dietary Guidelines for Americans 2005 recommend that girls in this age range require 1200 kcal-1800 kcal to maintain energy balance depending on their physical activity level. The data suggest that while NYC children are meeting their daily caloric requirements, they are not meeting current standards for a balanced diet, which may play a role in the rates of obesity.

SPECIFIC AIM: To characterize these children's levels of physical activity, their use of parks and playgrounds, and their participation in sports and other organized youth activities.

To better estimate factors in childhood growth, we assessed physical activity and resource availability for physical activity in East Harlem. Maps were developed for East Harlem play-spaces, open areas, and food sources, to use as measures of the built-environment in this community. 81% (n = 21) of elementary schools surveyed in East Harlem have either extracurricular activities or outdoor play areas available. 90% (n = 31) of East Harlem New York City Housing Authority (NYCHA) housing projects have playgrounds on site. However, access, quality of resources and safety concerns may limit use of these resources.

Reported use of neighborhood summer camps was associated with lower likelihood of being obese. Using odds ratios, we estimated risk of a child's BMI-percentile being greater than the 85^th percentile based on number and types of food stores and physical activity resources utilized as reported in the Neighborhood questionnaire. Reported use of summer camps was associated with a lower BMI percentile [OR = 0.52 (0.26-1.01)]. Odds ratios were adjusted for race, income, and population density.

Reported use of physical activity resources in East Harlem is as follows: parks (96%), after school programs (61%), recreational facilities (50%), and summer camps (39%) (Galvez et al 2009 PAS abstract).

85% of girls reported walking to school ≥3 days per week, compared to less than 16% for national children aged 5-15. Yet, pedometer data averaged 9,933 steps/day compared to AAP's 11-12,000 steps/day recommendation. Girls reported 6.2 hrs/week in non-scheduled physical activity, 4.7 hours of which were spent outdoors. However, only 34% of girls reported participating in organized sports or after school programs, compared to 56% of national 9th grade girls. This accounted for 43 min/week in organized sports. This is less than AAP's 1 hour/day recommendation.

Girls spent only 56 min/week in P.E. classes per week compared to 180 min/week for national 8th graders. With respect to sedentary behaviors, girls reported an average of 2.6 hours of screen time daily, compared to the AAP's < 2 hours recommendation. NYC girls reported unique physical activity patterns which can inform targeted interventions. While the majority of girls walk to school this is insufficient to meet daily step requirements.

We assessed Travel Patterns and Definitions of Neighborhood by Urban Minority Children and their Families.

Mean distances traveled to fast food restaurants, food stores, and physical activity resources were 396, 550, and 524 meters, respectively. Distance traveled to supermarkets was significantly greater than distance traveled to other food stores (p < .001). In contrast, mean distance traveled to fast food restaurants was significantly less than both food stores (p < 0.001) and physical activity resources (p < 0.001). Data suggest gender-specific differences in distance traveled to fast food restaurants (p = 0.07); the distance traveled to physical activity resources did not differ by gender (p = 0.12).

Mean distances traveled by Blacks/Black Hispanics and by English interview were significantly farther than non-Black Hispanics and Spanish interview for both food stores and food establishments. Those with a family income > $25K traveled farther to food stores than those earning < $25K (720m vs. 462m, p < 0.001); this relationship was not seen for food establishments. Distance traveled by children to neighborhood physical activity resources did not differ significantly by race/ethnicity, language or income.

Additional Results: Childhood Asthma, Obesity and Endocrine Disruptors

The data collected in Project 1 provided the opportunity to explore another important East Harlem concern, childhood asthma.

Evidence for an association between increased body fat and asthma exists and we have been able to confirm this using cross-sectional data from Growing Up Healthy (Vangeepuram N. ISEE abstract 2008). In multivariate adjusted models, there were strong associations between each body fat measure and asthma diagnosis. The prevalence of asthma for children in the highest quintile of BMI was 1.7 times higher than those in the lower 40% of the BMI distribution. Asthmatic children also had statistically significantly more sedentary activity and fewer metabolic hours per week from recreational activity.

Additionally, we examined the association between phthalate exposure and asthma, which has been reported in the literature. Adjusted geometric means for high molecular weight phthalates were significantly higher for children with doctor diagnosed asthma [Yes: 0.976 (0.811-1.174) vs. No: 0.757 (0.630-0.908); P = 0.04].

Summary of Aims and Highlighted Findings:

Consistent with our expectations, phthalate and phenol exposures in the urban environment are substantial and represent a major source of toxicant exposures to children. In addition, we found a number of structural characteristics in the neighborhood that were associated with unhealthy diets and sedentary lifestyle.

All publications for this project are reported under the Final Report for the main Center abstract (see Final Report for Grant No. R831711).

Journal Articles:

No journal articles submitted with this report: View all 91 publications for this subproject

Supplemental Keywords:

Biochemistry, Chemicals, childhood development, children's environmental health, Children's Health, children's vulnerablity, endocrine disrupting chemicals, endocrine disruptors, Environmental Chemistry, Environmental Exposure & Risk, environmental health, environmental management, exposure pathways, exposure studies, fast food, Health, Health Risk Assessment, human health, lipase, neurodevelopment, neurodevelopmental toxicity, obesity, paraoxonase, pesticide exposure, pesticides, phthalates, pollutants/toxics, RFA, Risk Assessment, Scientific Discipline, Health, RFA, Scientific Discipline, ENVIRONMENTAL MANAGEMENT, POLLUTANTS/TOXICS, Health Risk Assessment, Environmental Chemistry, Endocrine Disruptors - Human Health, Children's Health, endocrine disruptors, Biochemistry, Endocrine Disruptors - Environmental Exposure & Risk, Chemicals, Risk Assessment, Human Health Risk Assessment, childhood obesity, neurodevelopmental toxicity, phtalates, dietary factors, exposure studies, endocrine disrupting chemicals, children's vulnerablity, environmental health, community-based intervention, children's environmental health, exposure pathways

Relevant Websites:

The Mount Sinai Hospital

Progress and Final Reports:

Original Abstract

Main Center Abstract and Reports:

R831711 Center for Research on Early Childhood Exposure and Development in Puerto Rico

Subprojects under this Center: (EPA does not fund or establish subprojects; EPA awards and manages the overall grant for this center).
R831711C001 Growing Up Healthy in East Harlem (Community-Based Participatory Research)
R831711C002 Pesticides, Endocrine Disruptors, Childhood Growth and Development (Birth Cohort)
R831711C003 Genetics of Phthalate and Bisphenol A Risk in Minority Populations (Individual Susceptibility)

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