April 2020


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Childhood Obesity Resources Related to COVID-19

NCCOR, April 28, 2020

With children staying at home during the pandemic, risk factors for obesity are on the rise. This comes as no surprise, as research finds children are more likely to gain weight during summer months when they are home from school.

Whether you are a teacher, parent, researcher, or practitioner, we all have a role to play in keeping kids healthy and safe during the COVID-19 pandemic.

Check out these resources!

For teachers and parents trying to keep kids active:

Nutrition guidance for practitioners:

For grad students and faculty learning and teaching virtually:

  • Measures Registry Learning Modules: NCCOR’s Learning Modules highlight key concepts from the four domain-specific Measures Registry User Guides in four 15-minute videos, making it easier to understand measurement issues in the four major domains of the Measures Registry: individual diet, food environment, individual physical activity, and physical activity environment. If you’re working on a project virtually, watch this webinar to learn more about how this free, online tool can help you.
  • NCCOR’s Connect & Explore webinar archive: NCCOR brings together experts from across the childhood obesity research field for webinars on a variety of diet and physical activity topics. Take advantage and get access to these experts without leaving home.
  • Exercise, Immunity, and the COVID-19 Pandemic: Learn more about the science of how exercise boosts immunity in this piece from Richard J. Simpson, PhD.

For those looking for general guidance:

Be sure to follow us on social media for more of the latest in childhood obesity and COVID-19 resources!

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Publications & Tools

NCCOR's Toolbox

If you’re a graduate student or faculty member transitioning to distance learning right now, NCCOR has free online tools and resources for you. Learn more here about all of our digital resources.

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The High Obesity Program Special Collection

CDC’s High Obesity Program published key findings in a Special Collection in the April 2020 issue of Preventing Chronic Disease.

See the collection

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Prioritizing Health in State ESSA Plans and Report Cards to Support the Whole Child

An analysis of all 50 states plus D.C. examined how health and wellness provisions were prioritized in State Plans and report cards required by the Every Student Succeeds Act (ESSA). The study was conducted by the University of Illinois at Chicago’s Institute for Health Research and Policy, with support from Healthy Eating Research.

See the report

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Childhood Obesity Research & News

Endless Summer Puts Homebound Kids at Risk for Weight Gain

New York Times, April 28, 2020

With tens of thousands of schools in dozens of states now shuttered through the remainder of the school year because of the coronavirus pandemic, an estimated 55 million students will be home from school for double the length of their normal summer vacations, if not longer.

Now some experts are warning that one of the likely health consequences for many housebound children will be an increase in the unhealthy levels of weight gain typically seen during summer breaks.

“The stay-at-home orders and the social distancing are the right thing to do” to slow spread of the virus, said Andrew G. Rundle, the lead author of a new report in the journal Obesity on school closings and childhood weight gain. “But this six month period or longer is doubling out-of-school time, and it’s magnifying or exacerbating all of the risk factors that we think about for summer weight gain.”

While focusing on the immediate effects of the pandemic is a priority, Dr. Rundle and his co-authors point out that when it subsides one of its lingering effects could be a worsening of the obesity crisis among children. Childhood obesity rates have been on the rise in America for the past four decades, with more than a third of all youth under the age of 19 classified as overweight or obese. Studies show that overweight children are much more likely to become overweight adults, and that puts them at a higher risk of developing heart disease, cancer and Type 2 diabetes.

But in recent years researchers have begun to recognize that summer recess plays a major role in unhealthy weight gain. At least a half dozen studies have found that children gain weight at a faster rate during the summer months than during the school year. The effect is especially pronounced for children in minority groups or those who are already overweight.

One large study that tracked thousands of schoolchildren for five years starting in kindergarten found that school had a protective effect on their body compositions: On average, children saw their body mass index fall by 1.5 percentile points during the school year and then jump about 5 percentile points during their summer vacations.

“What is very apparent from the data is that kids experience unhealthy weight gain during the summer, that it’s more so for African-American and Hispanic kids, and that the weight gain that occurs during the summer does not get worked off during the school year,” said Dr. Rundle, an associate professor of epidemiology at the Columbia University Mailman School of Public Health. “It’s a stepwise pattern where the summer is the step up and the school year is the flat part of the step.”

Ultimately, some experts believe that the structured nature of the school day, with its scheduled exercise periods and limited chances to snack, is what helps protect children from excess weight gain. When children are at home for the summer, their days may be less regimented and less supervised, allowing them to indulge in more snacks and sedentary behaviors — similar to the factors that lead adults to eat more on weekends and pack on extra pounds during the holidays.

Data are limited, but there are early signs that the coronavirus shutdowns have prompted a rise in unhealthy behaviors that drive weight gain. Americans have stocked up on shelf-stable foods of all kinds, but sales of ultra-processed comfort foods like Oreo cookies, potato chips and macaroni and cheese have soared. Television and online video game usage have surged. Many playgrounds, especially in large urban areas, are now closed.

Though no two schools are the same, there are many reasons school environments can prevent excessive weight gain. Most schools offer students some level of exercise through physical education, team sports, and daily lunch and recess periods. Many children get about half their daily calories at school, which are required to provide meals that meet nutrition standards for components like sodium, whole grains, lean protein and fruits and vegetables. While junk foods can still be found in school cafeterias, many schools have worked to eliminate sugary beverages, candy and chips from their lunch lines and vending machines.

During the summer vacation, it’s the reverse. Studies find that children spend more time sitting in front of screens watching television and playing video games. They tend to consume more snacks and sugary beverages and eat fewer fruits and vegetables. That may especially be the case for children from low-income households that depend on schools to provide healthy meals. About 30 million children across the country receive free or subsidized school meals.

Dr. Rundle and his colleagues suggested in their new paper that schools, parents and policymakers could mitigate the long-term impact of the pandemic on children’s health by promoting exercise and healthy eating — where possible — during the lockdowns. Some schools, for example, have developed home lesson plans for exercise to go along with their lesson plans for math and English. Schools that are able to stream classes online might consider having their P.E. teachers stream exercise classes too, Dr. Rundle said.

Food is the trickier part of the equation. For some families right now, venturing outside to find healthy options at depleted grocery stores may not be possible. And with many parents stressed about their jobs, finances and other challenges, the prospect of fighting with their kids about food can be a hard sell — especially if they are worried about being able to put any food on their tables at all.

But with children facing limited options for physical activity, now more than ever is the time to try to limit unnecessary calories from sugar-sweetened beverages and excessive snacking, said Dr. Rundle. One good resource for stressed families is the American Heart Association, which provides quick, heart-healthy recipes on its website — like tuna stir frychicken saladhummus and vegetarian three-bean chili — that can be made with canned foods and other inexpensive pantry items.

For families that rely on school meals to feed their children, many school districts across the country have been providing grab-and-go meals. Some are offering five meals at a time and allowing parents to pick up food without their children being present. In some districts, schools are packing up meals and having bus drivers deliver them to families along their normal routes.

Parents can find out where to get free meals through their school districts. They can also find meal service sites in their neighborhood using the federal government’s Summer Food Service Program website. For many children, these services could mean the difference between having a nutritious lunch and breakfast or not having any food at all, said Eliza Kinsey, a co-author of the new paper and a research scientist in the department of epidemiology at the Mailman School of Public Health.

That could set the stage for many consequences: Studies show that children who grow up in food-stressed households face a higher risk of obesity, behavioral issues and other chronic health problems.

“If kids are missing meals and not able to get replacements, then we’re looking at a very large increase in food insecurity,” she said. “There are a lot of serious long-term health implications for low-income families if those meals are missed and not being replaced.”

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Who's Hit Hardest by COVID-19? Why Obesity, Stress and Race All Matter

NPR, April 18, 2020

As data emerges on the spectrum of symptoms caused by COVID-19, it’s clear that people with chronic health conditions are being hit harder.

While many people experience mild illness, 89% of people with COVID-19 who were sick enough to be hospitalized had at least one chronic condition. About half had high blood pressure and obesity, according to data from the Centers for Disease Control and Prevention. And about a third had diabetes and a third had cardiovascular disease. So, what explains this?

“Obesity is a marker for a number of other problems,” explains Dr. Aaron Carroll, a public health researcher at the Indiana University School of Medicine. It’s increasingly common for those who develop obesity to develop diabetes and other conditions, as well. So, one reason COVID-19 is taking its toll on people who have obesity is that their overall health is often compromised.

But does obesity specifically affect the immune system? Perhaps.

Prior research has shown that people with obesity are less protected by the flu vaccine. They tend to get sicker from the respiratory disease even if they’ve been immunized. In fact, researchers have found that as people gain excess weight, their metabolism changes and this shift can make the immune system less effective at fighting off viruses.

“What we see with obesity is that these [immune] cells don’t function as well,’ says Melinda Beck, a health researcher at University of North Carolina, Chapel Hill. Basically, she explains, obesity throws off the fuel sources that immune cells need to function. “The [immune cells] are not using the right kinds of fuels,” Beck says. And, as a result, the condition of obesity seems to “impair that critical immune response [needed] to deal with either the virus infection or [the ability] to make a robust response to a vaccine.”

So this is one explanation as to why people with obesity seem more vulnerable to serious infection. But, there are many more questions about why some people are hit harder, including whether race is a factor.

The CDC found that 33% of people who’ve been hospitalized with COVID-19 are African American, yet only 13% of the U.S. population is African American. Some local communities have found a similar pattern in their data. Among the many (26) states reporting racial data on COVID-19, blacks account for 34% of COVID deaths, according to research from Johns Hopkins University.

This disproportionate toll can be partially explained by the fact that there’s a higher prevalence of obesity, high blood pressure and diabetes among African Americans compared with whites.

And as Dr. Anthony Fauci of the National Institutes of Health said last week at a White House coronavirus task force briefing, this crisis “is shining a bright light on how unacceptable that is, because yet again, when you have a situation like the coronavirus, [African Americans] are suffering disproportionately.”

There are several factors, including some genetic ones, that may make African Americans more vulnerable to COVID-19. There have been a few studies that have pointed to African Americans potentially having genetic risk factors that make them more salt-sensitive,” says Renã Robinson, a professor of chemistry who researches chronic disease at Vanderbilt University. This may increase the likelihood of high blood pressure, which, in turn, is linked to more serious forms of COVID-19. “It could be a contributing factor,” she says, but there are likely multiple causes at play.

Another issue to consider, she says, may be high stress levels. She says when a person experiences racial discrimination, it can contribute to chronic stress. She points to several studies that link discrimination and stress to higher levels of inflammation among black adults. “And chronic stress can make one more vulnerable to infection because it can lower your body’s ability to fight off an infection,” she says.

Chronic stress is linked to poverty — so this could be a risk factor for low-income communities. In fact, research has shown that people who report higher levels of stress are more likely to catch a cold, when exposed to a virus, compared with people who are not stressed.

According to a new survey from Pew Research Center, health concerns about COVID-19 are much higher among Hispanics and blacks in the U.S. While 18% of white adults say they’re “very concerned” that they will get COVID-19 and require hospitalization, 43% of Hispanic respondents and 31% of black adults say they’re “very concerned” about that happening.

And other aspects of structural racism could contribute to the elevated risk for black Americans.

“Every major crisis or catastrophe hits the most vulnerable communities the hardest,” say Marc Morial, president and CEO of the National Urban League. And he points to several factors that help to explain the racial divide.

“Black workers are more likely to hold the kinds of jobs that cannot be done from home,” Morial says. So, they may be more likely to be exposed to the virus, if they are working in places where it’s difficult to maintain social distancing. In addition, he points to longstanding inequities in access to quality care.

“There also is bias among health care workers, institutions and systems that results in black patients … receiving fewer medical procedures and poorer-quality medical care than white individuals,” he says. He says an expansion of Medicaid into those states that still haven’t expanded would be one effective policy to address these inequities.

The characteristics of the communities where people live could affect risk, too especially for those who live in low-income neighborhoods. The roots of chronic illness stem from the way people live and the choices that may or may not be available to them. People who develop the chronic illnesses that put them at higher risk of COVID-19 often lack access to affordable and healthy foods or live in neighborhoods where it’s not safe to play or exercise outside.

“Let’s take a patient with diabetes for example. They are already at high risk for COVID-19 by having a chronic condition,” says Joseph Valenti, a physician in Denton, Texas, who promotes awareness of the social determinants of health through his work with the Physicians Foundation.

“If they also live in a food desert, they have to put themselves in greater risk if they want access to healthy food. They may need to take a bus, with people that have COVID-19 but aren’t showing symptoms, to get access to nutritious food or even their insulin prescription,” he says.

Poor nutrition, and the obesity linked to it, is a leading cause of premature death around the globe. And, this pandemic brings into focus the vulnerability of the millions of people living with lifestyle-related, chronic disease.

“We’re seeing the convergence of chronic disease with an infection,” says UNC’s Beck. And the data suggest that the combination of these two can lead to more serious illness. “We’re seeing that obesity can have a great influence on infection,” she says.

So, will this shine a spotlight on the need to address these issues? “Hopefully,” Beck says. “I think paying attention to these chronic diseases like obesity is in everybody’s best interest.”

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Feeding Low-Income Children During the COVID-19 Pandemic

The New England Journal of Medicine, March 30, 2020

As Covid-19 spreads throughout the United States, schools and child care facilities are balancing their role of helping to prevent disease transmission with ensuring access to food for children who rely on the federal nutrition safety net. Together, the U.S. Department of Agriculture (USDA) National School Lunch Program, School Breakfast Program, and Child and Adult Care Food Program serve nearly 35 million children daily, delivering vital nutrition and financial assistance to families in need.1 With such programs interrupted, an essential element of the Covid-19 response will be feeding children from low-income families.

Meals and snacks from schools or child care centers fulfill up to two thirds of children’s daily nutritional needs and are generally healthier than those brought from home. The short-term health effects of missed meals include fatigue and reduced immune response, which increase the risk of contracting communicable diseases. Even brief periods of food insecurity can cause long-term developmental, psychological, physical, and emotional harms. Children from low-income households, who are already at higher risk for poorer health and academic performance than children from high-income households, may be further disadvantaged by nutrition shortfalls.

Lost access to school meals also highlights the fragile financial health of families in the federal nutrition safety net. When schools and child care centers close, children miss out on food services worth at least $30 per week.2 The true cost to families of feeding children is probably higher, because this figure doesn’t account for time spent purchasing or preparing foods or the higher price of retail foods as compared with schools’ bulk-purchasing rates. Increased food-related financial burdens can harm all household members by forcing families to ration food or forgo other critical needs, such as medication, utilities, and rent.

The current situation is unprecedented, and it’s unclear how long school closures will last. The USDA hasn’t mandated that schools offer food service during closures. Instead, local education authorities (such as school superintendents and school boards) are being permitted to apply approaches from the USDA’s summer feeding programs and have been “encouraged to ensure that the needs of low-income children are met during extended school dismissals.”3 However, many schools lack experience with summer feeding initiatives, which reach only one in seven children who usually receive free or reduced-price meals during the school year,4 and summer programs don’t follow the same strict nutritional standards as school breakfast and lunch programs. The USDA has begun releasing national waivers for mealtime and congregant meal-setting requirements, allowing schools to adopt innovative approaches to providing meals and to practice appropriate social distancing.

As federal guidance emerges, several states and schools are developing their own solutions, adapting traditional service models to reduce disease transmission. For example, the Department of Education in South Carolina (where more than 15% of the population lives in rural areas) announced “Grab-n-Go” meal sites throughout the state that can provide up to 5 days of meals at once. Several districts in Michigan and New York are arranging meal deliveries to school bus stops or homes. The USDA has also initiated a public–private partnership in rural areas to deliver shelf-stable food packages that include food that children can prepare independently, though the program’s reach is limited. Although such approaches are innovative, it’s unclear whether they can ensure that food is distributed effectively and equitably while preventing disease transmission, and it remains to be seen which programs will prove cost-effective and sustainable for the duration of school closures.

Given geographic diversity and variation in Covid-19 prevalence, solutions for feeding children who usually participate in federal nutrition programs will need to be flexible, tailored, and thoughtful — so as not to stigmatize children for receiving emergency meals, which might discourage participation. Federal guidance on best practices for handling meals to reduce viral spread is also needed. We currently don’t know which models for food delivery are most in line with social-distancing recommendations or easily activated and scaled. This guidance is critical for local decision making as the number and duration of school closures increase.

Guidelines for the Child and Adult Care Food Program, which reaches 4.3 million children daily,1 are even less detailed. Under this program, child care providers often prepare food themselves and probably can’t operate a food service if their facilities are closed. Districts and child care centers are essentially having to “build the plane while they fly it.” Missteps can have serious nutritional and health implications for millions of children.

Recent legislative efforts may help address the challenges associated with feeding children, although additional steps will surely be needed. President Donald Trump declared a national emergency under the Stafford Act, thereby authorizing federal aid to state and local governments. These funds could be used to expand access to food assistance, but the bulk of aid appears to be directed toward waiving regulations that hamper access to health care (e.g., additional support for hiring more emergency workers or obtaining medical supplies and vaccine).

The Families First Coronavirus Response Act, which was signed into law on March 18 and authorizes $100 billion in relief, includes explicit provisions for nutrition assistance. The legislation allows states to request waivers for providing temporary, emergency benefits under the Supplemental Nutrition Assistance Program (SNAP) to households already enrolled in the program with children who would normally receive free or reduced-price meals, up to the maximum monthly allotment of $646 for a family of four. Pilot tested in summer months — when many children lose access to school meals — this approach has reduced severe food insecurity.5 However, results from pilot tests are preliminary, and the program hasn’t been scaled up and may fall short of reaching many children affected by Covid-19. For example, children don’t qualify if they are served by the Child and Adult Care Food Program or if they are undocumented immigrants whose families don’t qualify for SNAP but rely on school meals.

The shift in responsibility for feeding children from the National School Lunch Program and School Breakfast Program to SNAP may also have negative health implications. School meals are required to align with the latest nutrition science (although the USDA may waive meal-pattern requirements if the food supply is disrupted). By contrast, SNAP places few limits on allowable purchases, so relying more heavily on this program may inadequately address children’s nutritional needs. This shift may also lead to increased weight gain, particularly among racial and ethnic minorities and overweight children, since there is evidence that these children tend to gain weight more quickly during the summer than during the school year.

On March 27, Trump also signed into law the Coronavirus Aid, Relief, and Economic Security (CARES) Act, which includes a $15.8 billion appropriation for SNAP and $8.8 billion for child nutrition programs. Increases in SNAP funding will not expand eligibility or increase benefit size; instead, funding will cover anticipated surges in administrative and benefit costs resulting from increased unemployment.

The Covid-19 pandemic highlights the need for policy-based solutions that ensure food security for millions of American children. Whereas means-tested programs such as SNAP have traditionally received bipartisan support, recent efforts to protect access to this program have been met with substantial partisan opposition. The current situation is made more tenuous by proposed changes to SNAP that could reduce or eliminate benefits for more than 1 million households with children, such as a proposed rule to limit broad-based categorical eligibility. In addition, changes to the “public charge” rule went into effect in February 2020. These changes could now deny a path to citizenship for people who use public benefits such as SNAP, which will probably discourage documented immigrant families from obtaining access to emergency provisions, leaving them increasingly vulnerable during the Covid-19 pandemic. Short-term policy solutions may help address immediate issues of food insecurity resulting from loss of access to meals provided by schools or child care centers. Unfortunately, broader policies that discourage enrollment or reduce access to nutrition-assistance programs have undermined our response to Covid-19.

As we grapple with Covid-19, it’s critical to ensure that the nutritional needs of vulnerable children are met in order to avoid exacerbating disparities in health and educational attainment for years to come (see box for preliminary suggestions). We should examine in real time the strategies being used, acknowledge the broader political landscape in which they’re being implemented, and improve our ability to adapt how, when, and where we provide nutritional support to children.

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A Media Literacy-Based Nutrition Program Fosters Parent–Child Food Marketing Discussions, Improves Home Food Environment, and Youth Consumption of Fruits and Vegetables

Childhood Obesity, April 20, 2020

Background: Media use is a known contributor to childhood obesity, but encouraging reductions in screen use only partially eliminates media influence. We tested a family-centered, media literacy-oriented intervention to empower parents and children 9–14 years to skillfully use media to reduce marketing influences, enhance nutrition knowledge, improve the selection of foods in the home environment, and improve fruit and vegetable consumption.

Methods: A community-based, 6-U program included separate parent and youth (ages 9–14 years) sessions, each of which was followed by a session together in which skills from the individual sessions were reinforced. A pretest to posttest field test with control groups (N = 189, parent–child dyads) tested the intervention’s efficacy.

Results: Standardized mean differences from the multiple analysis of covariance tests showed that the intervention group demonstrated improvements on parents’ use of nutrition labels (0.29), the ratio of healthy to unhealthy food in the home environment (0.25), youth’s fruit (0.30) and vegetable (0.25) consumption, parent and youth media literacy skills, and family communication dynamics about food. The largest effects found were for negative parental mediation (0.48) and parents’ report of child-initiated discussion (0.47). Consistent but weaker results were revealed for Latinx families.

Conclusions: This family-centered approach helped family members practice using media together to make better nutrition decisions without depending on the ability of parents to limit media use. It successfully addressed the often-negative impact of the media on behaviors that increase obesity risk while also cultivating the potential for media to provide useful information that can lead to behaviors that decrease obesity risk.

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Mapping Local Patterns of Childhood Overweight and Wasting in Low- and Middle-Income Countries Between 2000 and 2017

Nature Medicine, April 20, 2020

A double burden of malnutrition occurs when individuals, household members or communities experience both undernutrition and overweight. Here, we show geospatial estimates of overweight and wasting prevalence among children under 5 years of age in 105 low- and middle-income countries (LMICs) from 2000 to 2017 and aggregate these to policy-relevant administrative units. Wasting decreased overall across LMICs between 2000 and 2017, from 8.4% (62.3 (55.1–70.8) million) to 6.4% (58.3 (47.6–70.7) million), but is predicted to remain above the World Health Organization’s Global Nutrition Target of <5% in over half of LMICs by 2025. Prevalence of overweight increased from 5.2% (30 (22.8–38.5) million) in 2000 to 6.0% (55.5 (44.8–67.9) million) children aged under 5 years in 2017. Areas most affected by double burden of malnutrition were located in Indonesia, Thailand, southeastern China, Botswana, Cameroon and central Nigeria. Our estimates provide a new perspective to researchers, policy makers and public health agencies in their efforts to address this global childhood syndemic.

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Exercise During Pregnancy Reduces Obesity Among Offspring

EurekAlert!, April 17, 2020

When physically fit women exercise during pregnancy they could be setting their children up for better fitness too.

That’s according to a study published today in Science Advances led by Min Du, professor of animal sciences at Washington State University, and his PhD student Jun Seok Son.

They found exercise during pregnancy stimulates the production of brown adipose tissue, commonly known as brown fat, in a developing fetus. Brown fat’s primary role in the body is to burn off heat. It is often called good fat. White adipose tissue or white fat, on the other hand, is responsible for obesity and harder to burn off. It is commonly known as bad fat.

Du and Son’s results show the offspring of physically fit mice that exercised daily during pregnancy not only had a greater proportion of brown fat relative to body weight but also burned white fat off quicker than the offspring of a control group of pregnant mice that did not exercise. This helped prevent obesity and also improved metabolic health.

Their study is unique because up to now, the impacts of exercise during pregnancy on fetal development have only been examined in obese mothers.

“Previous research has shown that exercise among overweight women during pregnancy protects against metabolic dysfunction and obesity in their offspring,” Du said. “This new study shows these benefits may also extend to the offspring of women who are healthy and in shape.”

As exercise during pregnancy is becoming less common and obesity rates in children are increasing among mothers with various body mass indices, the researchers hope their findings will encourage healthy and fit women to continue living an active lifestyle during pregnancy.

“These findings suggest that physical activity during pregnancy for fit women is critical for a newborn’s metabolic health,” Son said. “We think this research could ultimately help address obesity in the United States and other countries.”

In the study, healthy maternal mice were assigned either to a sedentary lifestyle or to exercise daily. Their offspring were then subjected to a high energy/caloric diet.

Notably, female and male offspring from the experimental group whose mothers had exercised consumed more feed than offspring from the control group. Nonetheless, the experimental group mice showed less weight gain.

Additionally, there was an improvement in glucose tolerance in the female and male offspring from the experimental group. Glucose intolerance is a precursor to developing diabetes and other obesity-related diseases later in life.

Exercise during pregnancy also stimulated the production of apelin, an exercise-induced hormone, in both mothers and their fetuses. Apelin stimulates brown fat development and improves metabolic health.

Du and Son also found administering apelin to the pregnant mice in the control group mimicked some of the beneficial effects of exercise on their offspring.

“This suggests that the apelinergic system could be a possible target for developing drugs that help prevent obesity,” Du said.

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