Published online October 1, 2007
PEDIATRICS Vol. 120 No. 4 October 2007, pp. 805-813 (doi:10.1542/10.1542/peds.2007-0500)
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ARTICLE

Overweight, Race, and Psychological Distress in Children in the Childhood Asthma Management Program

Bruce G. Bender, PhDa,b, Anne Fuhlbrigge, MD, MSc, Natalie Walders, PhDb,d and Lening Zhang, PhDe

a Department of Pediatrics
d Divisions of Psychosocial Medicine
e Biostatistics, National Jewish Medical and Research Center, Denver, Colorado
b Department of Psychiatry, University of Colorado Health Sciences Center, Denver, Colorado
c Channing Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVE. The purpose of this work was to determine whether overweight in youth with mild-to-moderate asthma occurs with increased frequency and is accompanied by impaired psychological functioning.

PATIENTS AND METHODS. The interrelationships among BMI and demographic and psychological characteristics were examined in 1005 children (aged 5–12 years) enrolled in the Childhood Asthma Management Program and seen for repeated visits over 41/2 years.

RESULTS. Baseline rates of overweight (BMI for age: ≥95th percentile) were comparable, but rates of overweight risk (BMI for age: 85th to <95th percentile) among children in the Childhood Asthma Management Program were elevated in comparison with the general population of children in the United States. Rates of overweight and overweight risk did not increase over the course of the longitudinal study. Overweight and overweight risk were more frequent among black and Hispanic than white children, although they were not higher relative to same-race groups in the general population. Overweight at baseline was associated with lower IQ, more social withdrawal, and greater internalized psychological distress. As the children became older, the overweight group demonstrated increased evidence of behavior problems and decreased physical activity.

CONCLUSIONS. This study identifies an increase in overweight risk but not overweight in children with mild-to-moderate asthma. Comorbidity between asthma and overweight may be underestimated, because children with severe asthma and those from impoverished backgrounds were not represented in this sample. For the 14% of children who were overweight, some associated psychological difficulties were present in childhood, and additional problems were seen during adolescence. These results suggest a need for programs that encourage greater vigilance and intervention for overweight children with asthma.

Key Words: asthma • overweight • race • psychological functioning

Abbreviations: CAMP—Childhood Asthma Management Program • CBCL—Child Behavior Checklist • CDC—Centers for Disease Control and Prevention • NHANES—National Health and Nutrition Examination Survey • ANCOVA—analysis of covariance

Asthma and obesity are increasingly common public health priorities. A complex overlap exists between these conditions, with research reports suggesting that obesity occurs more often among children with asthma than in the general population.1–3 Evidence of a disproportionate comorbidity between asthma and obesity has emerged in prospective studies,4–7 as well as in cross-sectional studies of the general population,7–9 people with asthma,10–12 and overweight populations.13–15 Although frequencies of overweight vary across studies, obesity in children with asthma has been reported to be as high as twice that of other children.16 In addition to higher rates of obesity among youth with asthma, research suggests that overweight individuals experience a more severe and complicated course of asthma. For instance, overweight children with asthma were shown to have a threefold increased risk for subsequent persistent wheezing and twofold increased risk for persistent asthma in adolescence over those at normal weight.17 In a previous report from the Childhood Asthma Management Program (CAMP), an increase in BMI of 5 units was associated with a decrease in the ratio of forced expiratory volume at 1 second to forced vital capacity of >1%, suggesting that even among children with mild-to-moderate asthma, increased weight may result in detrimental changes in pulmonary functions.18

Obesity has psychological, as well as physical, health consequences for children, but little is known about the emotional and functional impact of co-occurring asthma and obesity. Studies of obesity in the general population have reported lower self-esteem19 and compromised quality of life among overweight children.20 In addition, whereas most obese persons do not have a psychological disorder, obesity is a risk factor for depression.21 Furthermore, the relationship between mood and obesity may be bidirectional; just as obese children may develop depression, children and adolescents with major depressive disorder are at increased risk for developing obesity.21 Few prospective studies of childhood obesity have been conducted, and the psychological implications of asthma and obesity have yet to be studied. The CAMP study, a large multicenter clinical trial of pediatric asthma, provides the opportunity to test the hypothesis that the frequency of overweight is increased and associated with diminished psychological functioning in children with mild-to-moderate asthma.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
The Childhood Asthma Management Program
The frequency and correlates of overweight were evaluated in a cohort of 1041 children with mild-to-moderate asthma enrolled in the CAMP study. Children with severe asthma were excluded from the CAMP study. The CAMP study was a 41/2-year, multicenter, randomized, double-blind clinical trial of the efficacy and safety of inhaled budesonide, nedocromil, and placebo.22,23

Institutional review board approval was obtained from each of the 8 clinical sites (Albuquerque, NM; Baltimore, MD; Boston, MA; Denver, CO; St Louis, MO; San Diego, CA; Seattle, WA; and Toronto, Ontario, Canada). Before participation, the parent or guardian of each child provided consent and the child provided assent. During a 6-week run-in period limited to as-needed albuterol and prednisone, evidence of mild-to-moderate asthma was documented. Screening assessments before random assignment were designed to evaluate disease characteristics and administer a battery of tests that included measures of calibrated growth indices, cognitive ability, and psychological adjustment. The cognitive tests were repeated at the visit 36 months after random assignment, whereas the psychological adjustment questionnaires were administered annually.

Demographic Variables
Age, gender, race, parent education level (highest level of either parent), and household income were documented at study entry. Race was self-assessed as white, black, Hispanic, or other.

Cognitive Ability
Measures at baseline and 36 months into the study included an IQ approximation24 (block design, picture completion, vocabulary, and similarities subtests from the Wechsler Intelligence Scale for Children, Third Edition,25 or the Wechsler Preschool and Primary Scale of Intelligence26) and measurement of academic (reading, spelling, and mathematics subtests of the Woodcock-Johnson Psychoeducational Battery, Revised27) and attention skills (vigilance, distractibility, and efficiency ratio subtests from the Gordon Diagnostic System28). The IQ and achievement-test scores are standardized with a score of 100 representing the 50th percentile relative to age-matched children, with higher scores representing stronger skills.26

Emotions and Behavior
Measures of psychological adjustment, collected at baseline and annually thereafter, included parent responses to the Child Behavior Checklist (CBCL),29 producing a social competence score; 3 composite scores reflecting externalizing (including inappropriate and sometimes aggressive behavior), internalizing (including withdrawn and depressive behavior), and total problems (a composite of all of the problem scales); 9 behavioral subtest scores (withdrawn, somatic complaints, anxious/depressed, social problems, thought problems, attention problems, delinquent behavior, and aggressive behavior); and a physical activity scale. With the exception of the physical activity score, all of the CBCL scores are standardized with a score of 50 representing the 50th percentile relative to age- and gender-matched children. Higher CBCL scores represent increased behavior problems, with the exception of the social competence score, where higher scores indicate greater competence. The child completed the Children's Depression Inventory30 and the Revised Children's Manifest Anxiety.31 Higher scores on each of these measures reflect increased problems.

Overweight and Overweight Risk
BMI percentile was used to assess weight status for children and teenagers in accordance with the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics year 2000 data (www.cdc.gov/nccdphp/dnpa/growthcharts/sas.htm). Because of the variability of growth parameters among youth, BMI percentiles provide age- and gender-specific measures of weight for height.32,33 The CDC uses the term overweight, rather than obese, to characterize individuals with a BMI at or above the 95th percentile. Although significant overweight is often characterized as obese, CDC criteria and categorical labels were adopted as follows: (1) underweight, BMI for age at <5th percentile; (2) normal weight, BMI for age at the 5th percentile to <85th percentile; (3) overweight risk, BMI for age at the 85th percentile to <95th percentile; and (4) overweight, BMI for age at ≥95th percentile.

Data Analysis
All of the statistical analyses were completed with the SAS 9.1 (SAS Institute Inc, Cary, NC). Demographic variables were compared using an analysis of variance model for age and a {chi}2 test for categorical variables. Analyses were conducted first to determine if overweight and overweight risk were increased in children in the CAMP study compared with the general population and subsequently to determine whether demographic and psychological differences separated those in the different weight groups at baseline, 36 months, and 48 months into the study. Distributions of overweight and overweight risk at baseline were compared with the National Health and Nutrition Examination Survey (NHANES) 1999–2000 data34 using a 1-sample test for a binomial proportion and included all 1031 of children in the CAMP study with a completed BMI measurement. Group comparisons for psychological characteristics excluded children with underweight status (BMI < 5%) and were conducted by using baseline and 36- and 48-month data with an analysis of covariance (ANCOVA) model controlling for age, race, and clinic (age was used as a continuous variable, whereas race had 4 categories: white, black, Hispanic, and other). Treatment group was also added as a covariate for the analysis of 36- and 48-month data, but it was omitted from the final model because it was not significant in any of the models. For the longitudinal data analysis, all of the available data points were used. Except for the cognitive skills variables, which included only 2 measures on each subject, all of the psychological variables had ≤6 measurements on each subject. A repeated-measurement ANCOVA model was used. The fact that each subject had multiple measurements was accounted for by a random statement in SAS Proc Mixed. BMI grouping at baseline was used as the predictor variable, controlling for age, race, and clinic. For all of the analyses, 2-tailed tests were used, and P values of <.05 were claimed to be statistically significant.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Participant Demographic Characteristics
Mean age at baseline for the 1031 participants with completed BMI measurement was 9.0 years (SD: 2.1; range: 5–12 years). The group was 60% male and 32% nonwhite; 88% of families included a parent who had attended college, and 73% of households had income of $30000 or greater, whereas 6.5% had incomes of $15000 or less at baseline.

Overweight, Overweight Risk, and Normal Weight Frequencies
At baseline, the proportion of normal, overweight risk, and overweight CAMP participants was contrasted with national population statistics from the 1999–2000 NHANES35 (Table 1). The proportion of CAMP participants in the overweight risk group was greater than that in the general population (17.1% vs 14.1%; P = .002), whereas the proportion of overweight children did not differ between the 2 groups (14.1% vs 14.5%; P = .66). The proportion of children who were overweight (14.1%, 14.6%, 16.3%, 16.9%, and 17.2% at baseline and years 1, 2, 3, and 4, respectively) or overweight risk (17.1%, 16.8%, 16.8%, 17.6%, and 19.7%, at baseline and years 1, 2, 3, and 4, respectively) did not differ significantly over the 4 years of the CAMP study ({chi}2 test: P = .18).


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  		TABLE 1 Frequency of Overweight in Study Cohort and General Population

 
Relationship Between Baseline Weight Status and Patient Demographic Characteristics
Marked race differences were found in distributions across the weight groups. Overweight or overweight risk occurred in a greater proportion of black (23.4% and 19.6%) and Hispanic (22.5% and 25.8%) than in white (11.2% and 16.8%) children ({chi}2 test: P < .0001). The proportion of overweight black children did not exceed population statistics for overweight black children based on NHANES data34; however, the proportion of overweight risk among white and Hispanic children was significantly greater than within race-specific population data (Table 1). No associations were found among the 3 weight groups in gender, parent education, or household income (Table 2). Mean age in the overweight and overweight risk groups was higher than in the normal weight group.


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  		TABLE 2 Demographic Characteristics According to Weight Category

 
Relationship Between Weight Status and Baseline Psychological Characteristics
Cognitive Ability
At baseline, IQ scores were lowest in the overweight group. No significant differences among the 3 weight groups occurred on any of the Woodcock-Johnson Psychoeducational Battery, Revised, or Gordon Diagnostic System scores (Table 3). At 36 months into the study, no BMI-related differences emerged for any cognitive variable.


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  		TABLE 3 Weight Category Differences in Psychological Characteristics of Study Cohort at Baseline, 36 Months, and 48 Months

 
Emotions and Behavior
At baseline, no significant differences for the 3 weight groups could be detected on the Children's Depression Inventory or Revised Children's Manifest Anxiety Scale (Table 3). Because of the known association between obesity and depression, the incidence of Children's Depression Inventory scores over the 90th percentile was contrasted among the overweight (7.9%), overweight risk (4.0%), and normal (4.7%%) groups but was not significantly different ({chi}2 test: P = .237). Nonetheless, the trend suggested a greater frequency of depression in the overweight group, which also had significantly elevated problem scores on the baseline CBCL social, internalizing, and total behavior problem scales in comparison with 1 or both of the lower-weight groups (Table 3). These score differences among weight categories occurred regardless of race, and CBCL score differences between overweight and normal groups were similar across racial groups (data not shown). The overweight risk group did not differ from the normal group on any variable. The increased scores in the overweight group found at baseline on the CBCL scales were also present at 36 and 48 months into the study. In addition, elevated scores were found at 36 months and 48 months on the physical activity scale and at 48 months on the externalizing scale (Table 3). To determine whether these mean score differences between groups at 36 and 48 months represented a difference in clinically important problems, frequency of CBCL scores >6335 was examined at each of the 3 time points. Frequency of social problem scores elevated above this cutoff was significantly greater in the overweight group at all 3 of the time points ({chi}2 test: P < .0001). Total behavior problem score frequency, reflecting the combination of the internalizing and externalizing scores, was significantly elevated only at 48 months in the overweight (15.3%) in contrast to the overweight risk (8.7%) and normal weight (8.5%) groups ({chi}2 test: P = .035; data not shown).

Longitudinal Data Analyses
A repeated-measurement ANCOVA model was used to examine whether baseline BMI status could predict future psychological behaviors. The results duplicated most of those from the analyses at each individual time point, with decreased physical activity scores and increased CBCL internalizing, externalizing, and total behavior problem scores significantly associated with increased BMI percentiles (data not shown).


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Rates of overweight, the CDC term for obesity, were comparable among children with mild-to-moderate asthma and those in the general population. However, 17% of the children with asthma were in the overweight risk category (BMI percentage between the 85th and 95th percentiles), a significantly greater proportion compared with the general population. The proportions of overweight and overweight risk participants remained stable across the 41/2 years of the CAMP study, indicating that most children with mild-to-moderate asthma did not gain more weight and progress into either category of elevated BMI through childhood in contrast with children of the same age group without asthma. These findings stand in contrast to previous reports of an association between overweight and asthma in children or a tendency for increasing numbers of children with asthma to become overweight with age.2,17,36–39 Differences in recruitment, cohort characteristics, and asthma severity across studies may account for variation in the proportion of identified overweight children with asthma. Furthermore, the inconsistent identification of an association between obesity and asthma across studies may reflect overreliance on self-report, imprecise definitions of asthma, assumptions that correlations establish causality, inadequate accounting for potential confounding variables, and an intensified search for asthma symptoms once obesity was identified.2 Patients with severe asthma, not included in this cohort, are likely at greater risk of overweight.40,41 Despite the fact that overweight frequency was not increased over the general population, the elevated frequency of overweight risk indicates a concerning trend. BMI that falls between 85% and 95% does not meet CDC criteria for overweight but nonetheless indicates a health risk. The absence of an increased frequency of overweight in the group of children with mild-to-moderate asthma in this report cannot rule out the possibility that the children at overweight risk may, over time, demonstrate greater health compromise and that those who are or become overweight may experience a worsening of their asthma.

The psychological burden of having increased weight is significant for children with asthma just as it is for children without asthma. Overweight children in this asthma cohort had lower IQs at baseline but not at 36 months, although the small difference in scores between these 2 time points is not meaningful. Overall, cognitive differences did not distinguish those who were overweight from those who were not. The overweight children were more likely to withdraw socially and internalize psychological distress than those with weight in the reference range. As they became older, the overweight children evidenced decreased physical activity and more problem behaviors than the overweight risk or normal groups. The finding that parents, rather than children, reported more internalizing problems likely reflects both a difference in questionnaires completed by the 2 groups and a tendency for parents to more easily identify emotional and behavior problems than their children.42,43 Other studies of obesity in children with asthma have reported social withdrawal, lower self-esteem, and increased body dissatisfaction.19,44,45 Results from those studies in combination with findings reported here suggest that the cost of obesity in children with asthma may be reflected in both their physical and psychological health and underscore recommendations for earlier and more intensive interventions for overweight children with asthma. These may include interventions directed at increasing exercise, changing eating patterns, and improving psychological well-being.46,47 Previous studies have reported that many children, particularly those with more severe asthma, may adopt sedentary lifestyles as a means of avoiding asthma symptoms.17,37,48 Encouraging lifestyle changes to include more physical activity remains an important preventative and remediative component to offset the deleterious impact of obesity combined with childhood asthma.

The racial differences in frequency of overweight or overweight risk were large and concerning. Nearly 1 in 5 black and Hispanic children with asthma were overweight. The proportion of children with overweight risk was increased relative to race-matched population statistics among white and Hispanic children and nearly so for Black children. Although increased obesity among urban ethnic minority children with asthma has been reported,16,41 analyses did not include comparisons both within and between races. The high overweight frequencies in ethnic minority racial groups reported here did not account for psychological differences among the 3 weight groups; mild psychological distress accompanied obesity in all of the racial groups (data not shown). Overweight rates may be proportionately higher for minority children from low-income families.49 For instance, a survey of 143 adults attending an inner-city asthma center reported that 72% were obese.40 Although the CAMP study included a fairly large group of minority participants, few were from low-income urban environments. Hence, these findings may underestimate of the propensity for overweight among minority youth with asthma.


   CONCLUSIONS
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
The racial, psychological, socioeconomic, and gender correlates of obesity in patients with asthma, emerging from this and other studies, underscore the importance of identifying asthma subtypes at particular risk for complications of obesity. Additional investigation is necessary to understand the relationship between asthma and obesity, including race-based differences in this relationship. Although the present report compares obesity frequencies between the study cohort and general population, longitudinal studies that include children with and without asthma will allow a more informative assessment of differences between healthy children and those with asthma. Educational and behavioral interventions to decrease childhood obesity are important for all children but may be particularly essential for children with asthma because of the compounded psychological and physical burdens of the 2 disorders. Although interventions used with obese children without asthma may be adopted for children with asthma, these interventions may be more effective if tailored to the specific requirements of chronically ill children, emphasizing the specific needs of those from minority groups. Additional investigation is clearly essential to understanding what constitutes the most effective interventions for obese children with asthma.

Members of the CAMP Research Group
Clinical Centers
Asthma, Inc (Seattle, WA): Gail G. Shapiro, MD (director), Thomas R. DuHamel, PhD (codirector), Mary V. Lasley, MD (codirector), Tamara Chinn, MSN, ARNP (coordinator). Michele Hinatsu, MSN, ARNP, Clifton T. Furukawa, MD, Leonard C. Altman, MD, Frank S. Virant, MD, Paul V. Williams, MD, Michael S. Kennedy, MD, Jonathan W. Becker, MD, Grace White, C. Warren Bierman, MD (1992–1997), Dan Crawford, RN (1996–2002), Heather Eliassen, BA (1996–1999), Babi Hammond (1996–1999), Dominick A. Minotti, MD (1992–2003), Chris Reagan (1992–2003), Marian Sharpe, RN (1992–1994), and Timothy G. Wighton, PhD (1994–1998); Brigham and Women's Hospital (Boston, MA): Scott Weiss, MD, MS (director), Anne Fuhlbrigge, MD (principal investigator), Anne Plunkett, NP, MS (coordinator), Nancy Madden, RN, BSN, Peter Barrant, MD, Christine Darcy, Kelly Thompson, MD, Walter Torda, MD (coinvestigator director, 1993–2003), Martha Tata, RN (1993–2002), Sally Babigian, RN (1997–1999), Linda Benson (1998–2004), Jose Caicedo (1998–1999), Tatum Calder (1998–2001), Anthony DeFilippo (1994–2000), Cindy Dorsainvil (1998–2001), Julie Erickson (1998–1999), Phoebe Fulton (1997), Mary Grace, RN (1994–1996), Jennifer Gilbert (1997–1998), Dirk Greineder, MD (1993–2000), Stephanie Haynes (1993–1998), Margaret Higham, MD (1996–1998), Deborah Jakubowski (1999), Susan Kelleher (1993–1997), Jay Koslof, PhD (1993–1995), Dana Mandel (1996–1998), Patricia Martin (2001–2003), Agnes Martinez (1994–1997), Jean McAuliffe (1994–1995), Erika Nakamoto (2002–2004), Paola Pacella (1993–1998), Paula Parks (1993–1995), Johanna Sagarin (1998–1999), Kay Seligsohn, PhD (1995–2004), Susan Swords (2003–2005), Meghan Syring (1998–2001), June Traylor, MSN, RN (1996–1998), Melissa Van Horn, PhD (1996–1999), Carolyn Wells, RN (1993–1995), and Ann Whitman, RN (1994–1996); Hospital for Sick Children (Toronto, Ontario, Canada): Ian MacLusky, MD, FRCP(C) (director), Joe Reisman, MD, FRCP(C), MBA (director, 1996–1999), Henry Levison, MD, FRCP(C) (director, 1992–1996), Anita Hall, RN (coordinator), Jennifer Chay, Melody Miki, RN, BScN, Renée Sananes, PhD, Yola Benedet (1994–1999), Susan Carpenter, RN (1998–2001), Michelle Collinson, RN (1994–1998), Jane Finlayson-Kulchin, RN (1994–1998), Kenneth Gore, MA (1993–1999), Noreen Holmes, RRT (1998–1999), Sharon Klassen, MA (1999–2000), Joseé Quenneville, MSc (1993–1995), and Christine Wasson, PhD (1999); Johns Hopkins Asthma and Allergy Center (Baltimore, MD): N. Franklin Adkinson, Jr, MD (director), Peyton Eggleston, MD (codirector), Elizabeth H. Aylward, PhD, Karen Huss, DNSc (coinvestigator), Leslie Plotnick, MD (coinvestigator), Margaret Pulsifer, PhD (coinvestigator), Cynthia Rand, PhD (coinvestigator), Nancy Bollers, RN (coordinator), Deborah Bull, LPN, Robert Hamilton, PhD, Kimberly Hyatt, Susan Limb, MD, Mildred Pessaro, Stephanie Philips, RN, and Barbara Wheeler, RN, BSN; National Jewish Medical and Research Center (Denver, CO): Stanley Szefler, MD (director), Harold S. Nelson, MD (codirector), Bruce Bender, PhD (coinvestigator), Ronina Covar, MD (coinvestigator), Andrew Liu, MD (coinvestigator), Joseph Spahn, MD (coinvestigator), D. Sundström (coordinator), Melanie Phillips, Michael P. White, Kristin Brelsford (1997–1999), Jessyca Bridges (1995–1997), Jody Ciacco (1993–1996), Michael Eltz (1994–1995), Jeryl Feeley, MA (coordinator, 1992–1995), Michael Flynn (1995–1996), Melanie Gleason, PA-C (1992–1999), Tara Junk-Blanchard (1997–2000), Joseph Hassell (1992–1998), Marcia Hefner (1992–1994), Caroline Hendrickson, RN (1995–1998, coordinator, 1995–1997), Daniel Hettleman, MA (1995–1996), Charles G. Irvin, PhD (1992–1998), Jeffrey Jacobs, MD (1996–1997), Alan Kamada, PharmD (1994–1997), Sai Nimmagadda, MD (1993–1996), Kendra Sandoval (1995–1997), Jessica Sheridan (1994–1995), Trella Washington (1993–1997), and Eric Willcutt, MA (1996–1997) (we also thank the pediatric allergy and immunology fellows for their participation: Kirstin Carel, MD, Neal Jain, MD, Harvey Leo, MD, Beth Macomber, MD, Chris Mjaanes, MD, Lora Stewart, MD, and Ben Song, MD); University of California San Diego and Kaiser Permanente Southern California Region (San Diego, CA): Robert S. Zeiger, MD, PhD (director), Noah Friedman, MD (coinvestigator), Michael H. Mellon, MD (coinvestigator), Michael Schatz, MD (coinvestigator), Kathleen Harden, RN (coordinator), Elaine M. Jenson, Serena Panzlau, Eva Rodriguez, RRT, James G. Easton, MD (codirector, 1993–1994), M. Feinberg (1997–1998), Linda L. Galbreath (1991–2002), Jennifer Gulczynski (1998–1999), Ellen Hansen (1995–1997), Al Jalowayski, PhD (coinvestigator, 1991–2005), Alan Lincoln, PhD (coinvestigator, 1991–2003), Jennie Kaufman (1994), Shirley King, MSW (1992–1999), Brian Lopez (1997–1998), Michaela Magiari-Ene, MA (1994–1998), Kathleen Mostafa, RN (1994–1995), Avraham Moscona (1994–1996), Catherine A. Nelle, RN (1991–2005), Jennifer Powers (2001–2003), Karen Sandoval (1995–1996), and Nevin W. Wilson, MD (codirector, 1991–1993); University of New Mexico (Albuquerque, NM): H. William Kelly, PharmD (director), Aaron Jacobs (coinvestigator), Mary Spicher, RN (coordinator), Hengameh H. Raissy, Robert Annett, PhD (coinvestigator, 1993–2004), Teresa Archibeque (1994–1999), Naim Bashir, MD (coinvestigator, 1998–2005), H. Selda Bereket (1995–1998), Marisa Braun (1996–1999), Shannon Bush (2002–2006), Michael Clayton, MD (coinvestigator, 1999–2001), Angel Colon-Semidey, MD (coinvestigator, 1997–2000), Sara Devault (1993–1997), Roni Grad, MD (coinvestigator, 1993–1995), David Hunt, RRT (1995–2004), Jeanne Larsson, RN (1995–1996), Sandra McClelland, RN (coordinator, 1993–1995), Bennie McWilliams, MD (coinvestigator, director, 1992–1998), Elisha Montoya (1997–2000), Margaret Moreshead (1996–1999), Shirley Murphy, MD (coinvestigator, 1992–1994), Barbara Ortega, RRT (1993–1999), David Weers (1997–1998), and Jose Zayas (1995–1996); and Washington University (St Louis, MO): Robert C. Strunk, MD (director), Leonard Bacharier, MD (coinvestigator), Gordon R. Bloomberg, MD (coinvestigator), James M. Corry, MD (coinvestigator), Denise Rodgers, RFPT (coordinator), Lila Kertz, MSN, RN, CPNP, Valerie Morgan, RRT, Tina Oliver-Welker, CRTT, and Deborah K. White, RPFT, RRT.

Resource Centers
Chair's Office, National Jewish Medical and Research Center (Denver, CO): Reuben Cherniack, MD (Study Chair).

Coordinating Center
Johns Hopkins University (Baltimore, MD): James Tonascia, PhD (director), Curtis Meinert, PhD (codirector), Patricia Belt, Karen Collins, Betty Collison, Ryan Colvin, MPH, John Dodge, Michele Donithan, MHS, Judith Harle, Rosetta Jackson, Hope Livingston, Jill Meinert, Kapreena Owens, Michael Smith, Alice Sternberg, ScM, Mark Van Natta, MHS, Margaret Wild, Laura Wilson, ScM, Robert Wise, MD, and Katherine Yates, ScM.

Project Office
National Heart, Lung, and Blood Institute (Bethesda, MD): Virginia Taggart, MPH (project officer), Lois Eggers, James Kiley, PhD, Gang Zheng, PhD, Paul Albert, PhD (1991–1999), Suzanne Hurd, PhD (1991–1999), Sydney Parker, PhD (1991–1994), Pamela Randall (1992–2003), Margaret Wu, PhD (1991–2001).

Committees
Data and Safety Monitoring Board
Howard Eigen, MD (chair), Michelle Cloutier, MD, John Connett, PhD, Leona Cuttler, MD, David Evans, PhD, Meyer Kattan, MD, Rogelio Menendez, MD, F. Estelle R. Simons, MD, Clarence E. Davis, PhD (1993–2003), and Sanford Leikin, MD (1993–1999).

Executive Committee
Reuben Cherniack, MD (chair), Robert Strunk, MD, Stanley Szefler, MD, Virginia Taggart, MPH, James Tonascia, PhD, and Curtis Meinert, PhD (1992–2003).

Steering Committee
Reuben Cherniack, MD (chair), Robert Strunk, MD (vice-chair), N. Franklin Adkinson, MD, Robert Annett, PhD (1992–1995, 1997–1999), Bruce Bender, PhD (1992–1994, 1997–1999), Mary Caesar, MHS (1994–1996), Thomas R. DuHamel, PhD (1992–1994, 1996–1999), H. William Kelly, PharmD, Henry Levison, MD (1992–1996), Alan Lincoln, PhD (1994–1995), Ian MacLusky, MD, Bennie McWilliams, MD (1992–1998), Curtis L. Meinert, PhD, Sydney Parker, PhD (1991–1994), Joe Reisman, MD, FRCP(C), MBA (1991–1999), Denise Rodgers (2003–2005), Kay Seligsohn, PhD (1996–1997), Gail G. Shapiro, MD, Marian Sharpe (1993–1994), D Sundström (1998–1999), Stanley Szefler, MD, Virginia Taggart, MPH, Martha Tata, RN (1996–1998), James Tonascia, PhD, Scott Weiss, MD, MS, Barbara Wheeler, RN, BSN (1993–1994), Robert Wise, MD, and Robert Zeiger, MD, PhD.


   ACKNOWLEDGMENTS
 
The CAMP study is supported by contracts NO1-HR-16044, -16045, -16046, -16047, -16048, -16049, -16050, -16051, and -16052 with the National Heart, Lung, and Blood Institute and General Clinical Research Center grants M01RR00051, M01RR0099718-24, M01RR02719-14, and RR00036 from the National Center for Research Resources.


   FOOTNOTES
 
Accepted May 21, 2007.

Address correspondence to Bruce G. Bender, PhD, Pediatric Behavioral Health, National Jewish Medical and Research Center, 1400 Jackson St, Denver, CO 80206. E-mail: benderb{at}njc.org

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

  1. Weiss S, Shore S. Obesity and asthma: directions for research. Am J Respir Crit Care Med. 2004;169 :963 –968[Free Full Text]
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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C. Gundersen, B. J. Lohman, S. Garasky, S. Stewart, and J. Eisenmann
Food Security, Maternal Stressors, and Overweight Among Low-Income US Children: Results From the National Health and Nutrition Examination Survey (1999-2002)
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