DRG and AZ are joint senior authors.
STRENGTHS AND LIMITATIONS OF THIS STUDY
Large multisite study of over 16 000 children that is geographically and demographically diverse.
Food insecurity is a complex concept that is difficult to capture, and the LILA exposure metrics we used, as published by the US Department of Agriculture, have been widely adopted for health studies but are imperfect.
Asthma is difficult to diagnose in early childhood.
Important risk factors were adjusted for and considered as modifiers in this study.
Background
Asthma is the most common chronic childhood disease in the USA with a prevalence of about 6.5%, which equates to about 4.5 million children.1 Given the progression of normal lung development in humans, we know that childhood is a critical period for lung growth when rapid expansion of gas exchange surface and cell maturation is taking place.2 3 Thus, any perturbations to lung function, such as the development of asthma, in the first few years of life can have both immediate and long-term consequences into adulthood.4 The vulnerability of children in early life is reflected by evidence that the incidence rate of asthma with recurrent exacerbations decreases with age5 and by the higher prevalence of asthma attacks, emergency and urgent care visits and hospitalisation among children under age 5 years compared with older children.6
Asthma is primarily driven by chronic inflammation,7 and a nutritious diet has been shown to reduce airway inflammation.8 9 High consumption of fruits and vegetables can make symptoms more manageable among asthmatics and reduce the risk of developing asthma, while diets that emphasise the consumption of animal products and excess-free-fructose intake can increase asthma risk and worsen symptoms.10–12 However, eating a nutritious diet is not easily achievable in many areas in the USA, such as inner city13 and disadvantaged communities,14 that bear a disproportionate burden of the disease due to restricted or non-existent access to affordable and high-quality healthy foods. These areas have been coined as ‘low-income-low-food-access’ (or LILA) neighbourhoods by the US Department of Agriculture and reflect the influence of both socioeconomic and physical factors.15 Living in a LILA neighbourhood has been linked to obesity in children,16 17 a risk factor for developing asthma and worsened symptoms in asthmatics.18 However, there is currently limited work on LILA neighbourhoods and childhood asthma, with peer-reviewed abstracts finding increased distance to grocery stores to be associated with lower lung function among infants19 and higher asthma prevalence among children.20 A cross-sectional study observed food insecurity at the household level (as opposed to neighbourhood level) to be associated with 4% (95% CI 2% to 6%) higher odds of asthma among third graders (aged ~8–9 years), and being both food-insecure and poor was associated with an OR of 2.00 (95% CI 1.97 to 2.03),21 which is consistent with another peer-reviewed abstract.22
To further understand whether residing in a LILA neighbourhood is associated with the incidence of childhood asthma, we conducted survival analyses using racially/ethnically and geographically diverse data from 35 longitudinal site sites in the Environmental influences on Child Health Outcomes (ECHO) programme from across the contiguous USA. We additionally aimed to identify how individual-level characteristics may serve as modifiers. We hypothesised that restricted access to healthy foods would be positively associated with asthma incidence, with estimates differing across sociodemographic lines.
Methods
Study population
Within the ECHO programme, which has been described in detail elsewhere,23 we identified 34 613 children with residential history data during childhood. For participants who consented to sharing their residential address with the consortium, the ECHO Data Analysis Center geocoded each address using ArcGIS geospatial software V.2.7.0 and linked them to census tracts based on decennial US Census Tract Boundaries.23 We excluded 3030 children due to poor geocoding quality (ie, unmatched, could not be matched to census tract or more finely), and since LILA metrics were available only for years 2015 and 2019, we further restricted our dataset to geocoded residential data 2010 and onwards (182 children only have residential data before 2010 and were excluded). Among the remaining 31 401 participants, 17 154 had any asthma data from birth up to age 11. We further excluded eight sites with incomplete data harmonisation (eg, unexpected missingness, miscoded values) and 15 sites with <50 participants that contributed to the sample, resulting in 16 012 children born in 1998–2021 from 35 sites in our analysis. Four of these sites consisted exclusively of individuals born preterm. A participant flowchart is shown in online supplemental eFigure 1, and a list of the included sites can be found in online supplemental eTable 1. For a snapshot of the follow-up period for each site included in our analyses, please see online supplemental eFigure 2.
Low-income low-access (LILA) neighbourhoods
The US Department of Agriculture’s Food Access Research Atlas (FARA) tool identifies low-income low-access (LILA) neighbourhoods (no/yes) in the continuous USA in 2015 and 2019. FARA defines low-income neighbourhoods as census tracts with ≥20% living under the federal poverty rate or a median family income ≤80% of that statewide, and the definition of low access is based on urbanicity and distance to the nearest supermarket.15 There are several variations of the LILA metric, and detailed documentation of how each LILA metric was derived can be found on the FARA website.15 Briefly, there are three core LILA metrics, including: LILA0.5 and 10 (>0.5 mile in urban and >10 miles in rural areas), LILA1 and 10 (nearest supermarket >1 mile in urban and >10 miles in rural areas) and LILA1 and 20 (>1 mile in urban and >20 miles in rural areas). We also considered a newer LILA metric that incorporates vehicle availability into the measure: LILAvehicle (>100 households are without a vehicle and nearest supermarket >0.5 mile; or, nearest supermarket >20 miles). To account for residential mobility, a timeline of each participant’s census tract-level residential history was created, and the FARA metrics were linked (2015 and 2019 metrics assigned to participant residences in years 2010–2017 and 2017–2023, respectively) and averaged within each participant to obtain weighted cumulative exposure values separately for each asthma endpoint. A child was classified as living in a LILA neighbourhood if they resided in a LILA census tract at least 75% of the time during follow-up.
Individual-level asthma incidence and characteristics
Cumulative early and middle childhood asthma were defined as a physician diagnosis of asthma reported by the caregiver from birth through age 5 and from birth through age 11, respectively. We obtained several other participant characteristics as harmonised by the ECHO Data Analysis Center, including sex assigned at birth (male/female), race/ethnicity (White, Hispanic, Black, Other), gestational smoking (no/yes), maternal education (<high school, high school, >high school) and parental history of asthma (no/yes).24
Statistical analysis
Imputation of individual-level covariates
Missing values of participant sex (0.3%), race/ethnicity (2.6%), maternal education (4.2%), gestational smoking (10.9%) and parental history of asthma (12.5%) were imputed with 10 iterations per 10 imputations using multiple imputation by chained equations25 26. Because the covariate structure may differ across sites, imputations were conducted separately by site.
Main analysis
We estimated the association between living in a LILA neighbourhood (each LILA metric was considered separately) and asthma diagnosis during cumulative early and middle childhood using Cox proportional hazard models. Here, our time scale was year of life (beginning at birth). The event of interest was defined as caregiver-reported physician diagnosis of asthma, and participants were right censored in the dataset when they were lost to follow-up prior to the occurrence of the event or administratively censored if they had not experienced the event at the conclusion of their site’s study period. All models were adjusted for sex, race/ethnicity, gestational smoking, maternal education and parental history of asthma, and confounding by geography and long-term time trends were accounted for using an indicator term for each site and year of birth, respectively. Effect modification by each participant-level characteristic was examined separately by introducing an interaction term between each LILA metric and modifier. Using Rubin’s Rule to pool the estimates across imputation sets,25 26 HRs were reported alongside their corresponding 95% CIs.
Sensitivity analysis
Fully adjusted logistic regressions ignoring the time-to-event nature of asthma diagnosis were also fitted to further confirm our findings. We also varied the exposure cut-off to be at least 50% and 100% of the time during follow-up for a more relaxed and stringent definition, respectively, of whether a child resided in a LILA neighbourhood.
Considering that our cumulative exposure assessment is based on where participants lived over time from constructed lifetime residential histories in ECHO, we conducted sensitivity analyses restricting the exposure definition to only time periods where residential information was ascertained with greater confidence, where only up to a 2-year gap in residential information was imputed or filled in. Sites and their corresponding sample size included in this sub-analysis can be found in online supplemental eTable 2.
Because individuals born prematurely may not have completed normal in utero lung development, which can lead to greater vulnerability to chronic dysfunction27 and may have experienced different residential neighbourhood environments in early life (eg, more time spent in hospitals) than those born term, analysis including sites that consist exclusively of individuals born preterm may not be generalisable to births across the USA. Therefore, in a sensitivity analysis, we stratified our analysis by whether the sites only enrolled children born prematurely.
Patient and public involvement
This study was conducted using data that was previously collected from many sites across the USA, and participants were not involved in the study design process.
Results
Summary statistics showed that study participant characteristics remained similar after individual-level covariate imputation (table 1). Almost half of our 16 012 participants were female at birth and were White. A minority of children were exposed to smoking during pregnancy (11.7%) and had at least one parent who had asthma (27.3%), while most mothers had achieved more than a high school degree (80.7%). Most incident asthma diagnoses occurred during the cumulative early childhood period aged 0 through 5 years, with 20% of all 2727 asthma cases identified in this study diagnosed during middle childhood aged 6 through 11 years. As shown in table 2, the proportion of children who had lived in a LILA1 and 10 or LILA1 and 20 neighbourhood hovered around 7%. About a quarter and just over a tenth of participants lived in a LILA0.5 and 10- and LILAvehicle-defined neighbourhood, respectively.
Table 1Characteristics of study participants pre- and post-imputation
| Pre-imputation n=16 012 | Post-imputation*† n=16 012 | |
| Cumulative early childhood asthma‡ | 2219 (13.9%) | -- |
| Cumulative middle childhood asthma§ | 2727 (17.0%) | -- |
| Female | 7631 (47.7%) | 7652 (47.8%) |
| Missing | 43 (0.3%) | 0 (0.0%) |
| Race/ethnicity | ||
| White | 8366 (52.2%) | 8544 (53.4%) |
| Hispanic | 3039 (19.0%) | 3155 (19.7%) |
| Black | 2403 (15.0%) | 2472 (15.4%) |
| Other | 1794 (11.2%) | 1842 (11.5%) |
| Missing | 410 (2.6%) | 0 (0.0%) |
| Maternal education | ||
| > High school | 12 432 (77.6%) | 12 919 (80.7%) |
| High school | 1907 (11.9%) | 2017 (12.6%) |
| < High school | 1004 (6.3%) | 1076 (6.7%) |
| Missing | 669 (4.2%) | 0 (0.0%) |
| Gestational smoking | 1587 (9.9%) | 1880 (11.7%) |
| Missing | 1750 (10.9%) | 0 (0.0%) |
| Parental history of asthma | 3798 (23.7%) | 4366 (27.3%) |
| Missing | 1996 (12.5%) | 0 (0.0%) |
*All counts and percentages were calculated across the ten imputed datasets. Counts were divided by 10 and rounded.
†Health outcomes were not imputed and are the same pre- and post-imputation.
‡Birth through age 5.
§4Birth through age 11.
Table 2Summary statistics of food desert exposures
| n=16 012 | ||
| Cumulative early childhood asthma* | Cumulative middle childhood asthma† | |
| LILA0.5 and 10 | 4061 (25.4%) | 3898 (24.3%) |
| LILA1 and 10 | 1270 (7.9%) | 1170 (7.3%) |
| LILA1 and 20 | 1211 (7.6%) | 1113 (7.0%) |
| LILAvehicle | 2109 (13.2%) | 1984 (12.4%) |
*Birth through age 5.
†Birth through age 11.
LILA1 and 20, >1 mile in urban and>20 miles in rural areas); LILA1 and 10, nearest supermarket >1 mile in urban and >10 miles in rural areas); LILA0.5 and 10, >0.5 mile in urban and >10 miles in rural areas; LILAvehicle, >100 households are >0.5 mile without a vehicle or >20 miles.
Overall, residing in a LILA neighbourhood (most of the time from birth until censoring) as measured by LILA0.5 and 10 and LILAvehicle was associated with a higher risk of incident asthma, particularly in early childhood (table 3). However, the association was null for the other exposure metrics considered. More specifically, living in a LILA0.5 and 10, LILA1 and 10, LILA1 and 20 and LILAvehicle neighbourhood had a hazard of developing asthma during cumulative early childhood (birth through age 5) 1.13 (95% CI 1.02 to 1.24), 0.98 (95% CI 0.85 to 1.14), 0.98 (95% CI 0.84 to 1.14) and 1.13 (95% CI 1.01 to 1.27), respectively, times that among those not living in such areas. During cumulative middle childhood (birth through age 11), living in a LILA0.5 and 10 and LILAvehicle neighbourhood was again positively associated with developing asthma (where only the association for LILA0.5 and 10 was statistically significant), while the associations for LILA1 and 10 and LILA1 and 20 were null. The estimates remained similar when we considered the 50% and 100% thresholds for cumulative exposure and when we fitted logistic regressions (online supplemental eTable 3). Interestingly, the associations were more strongly positive when we restricted our analysis to participants with fewer than 2 years of imputed residential address data, though the CIs were also larger (online supplemental eTable 4). Similarly, the associations were also more strongly positive when we excluded preterm sites, while only the LILA0.5 and 10 association remained positive among the preterm sites (online supplemental eTable 5).
Table 3Association of residential low-income low-access (LILA) neighbourhood with early and middle childhood asthma incidence
| Hazard ratio (95% CI) of residing vs not residing in a LILA neighbourhood | ||||
| LILA0.5 and 10 | LILA1 and 10 | LILA1 and 20 | LILAvehicle | |
| Cumulative early childhood (aged 0–5 years) | 1.13 (1.02, 1.24) | 0.98 (0.85, 1.14) | 0.98 (0.84, 1.14) | 1.13 (1.01, 1.27) |
| Cumulative middle childhood (aged 0–11 years) | 1.10 (1.01, 1.20) | 0.96 (0.83, 1.10) | 0.95 (0.83, 1.10) | 1.09 (0.97, 1.21) |
LILA1 and 10, nearest supermarket >1 mile in urban and >10 miles in rural areas; LILA1 and 20, >1 mile in urban and >20 miles in rural areas; LILA0.5 and 10, >0.5 mile in urban and >10 miles in rural areas; LILAvehicle, >100 households are >0.5 mile without a vehicle or >20 miles.
In terms of effect modification (figure 1 for asthma in cumulative early childhood and figure 2 for asthma in cumulative middle asthma), the associations were mostly elevated among females (vs males), Hispanic (vs White, Black and other race/ethnicities) children and those with less than high school maternal education level (vs high school and greater than high school education) and were generally consistent across asthma endpoints/time points and exposure metrics. However, only sex (for LILA1 and 10, LILA1 and 20 and LILAvehicle in both cumulative early and middle childhood) and race (for LILA0.5 and 10 in cumulative middle childhood) reached statistical significance.
Enlarge this image.Figure 1. Modification of the association between residential low-income low-access (LILA) neighbourhoods and asthma in cumulative early childhood by participant characteristics. Black points represent the estimated HR of asthma incidence from birth through age 5 (early childhood) for each LILA metric by each potential individual-level modifier, and the error bars show the corresponding 95% CIs. The dotted black line denotes the null. HS: high school; LILA 0.5 and 10, >0.5 mile in urban and >10 miles in rural areas; LILA 1 and 10, nearest supermarket >1 mile in urban and >10 miles in rural areas; LILA 1 and 20, >1 mile in urban and >20 miles in rural areas; LILA vehicle, >100 households are >0.5 mile without a vehicle or >20 miles.
Enlarge this image.Figure 2. Modification of the association between residential low-income low-access (LILA) neighbourhoods and asthma in cumulative middle childhood by participant characteristics. Black points represent the estimated HR of asthma incidence from birth through age 11 (middle childhood) for each LILA metric by each potential individual-level modifier, and the error bars show the corresponding 95% CIs. The dotted black line denotes the null. HS: high school; LILA 1 and 10, nearest supermarket >1 mile in urban and >10 miles in rural areas; LILA 1 and 20, >1 mile in urban and >20 miles in rural areas;; LILA 0.5 and 10, >0.5 mile in urban and >10 miles in rural areas; LILA vehicle, >100 households are >0.5 mile without a vehicle or >20 miles.
Discussion
In this large study from 35 longitudinal ECHO sites, residing in a LILA neighbourhood was associated with higher hazard of asthma diagnosis in early and middle childhood. Female (assigned at birth) children, Hispanic children and whose mother/caregiver had a lower educational attainment were identified as potentially sensitive subgroups.
Although the estimated HRs for all LILA metrics were positive, associations with asthma incidence were statistically significant only for LILA0.5 and 10 and LILAvehicle (and not for LILA1 and 10 and LILA1 and 20). That is, the association became stronger as we relaxed the exposure definition (eg, all LILA1 and 20 neighbourhoods are encompassed in LILA1 and 10 neighbourhoods; all LILA1 and 20 and LILA1 and 10 neighbourhoods are encompassed in LILA0.5 and 10 neighbourhoods). This highlights the importance of the food environment immediately around a child’s place of residence and children’s sensitivity to the proximity component of a LILA neighbourhood. LILAvehicle is distinct from the other FARA metrics because it takes into consideration vehicle access and only overlaps moderately with the other metrics.15 Vehicle access may be critical in rural areas and areas without alternative transportation and may be a reason for HR being strongest for LILAvehicle. Furthermore, we observed the HR to be larger for asthma in cumulative early compared with middle childhood, in line with the current understanding that exposure may be particularly pertinent during the first few years of life.6 9 Though the estimates became stronger after the exclusion of preterm sites, there is an indication that there may be mechanisms at play that may in some way protect preterm individuals from the effects of limited food access (eg, spending more time in hospital, experiencing the environment differently than children born term) or amplifying the effects of other risk factors, such as lung disorders related to preterm birth; the wide confidence intervals from stratification preclude us from further interpretation. Despite our statistically significant findings, we acknowledge that the magnitude of the associations may be small compared with other risk factors. This may relate to its relative contribution to the risk of childhood asthma, or alternatively to the precision of our estimates for food access and the exposure that it may signify (eg, quality of nutrition, chemical toxicants in food wrapping, residual pesticide).
As previously discussed, the epidemiologic literature on LILA neighbourhoods and childhood asthma is extremely limited despite surrounding evidence on obesity and inflammation supporting its plausibility, which mostly consists of a handful of academic abstracts and some adjacent literature on lung function in elderly individuals,28 child hunger29 and access to allergen-free food.30 Emerging evidence suggests that the pathway between diet and asthma may be mediated by the gut-lung axis, which includes a range of inflammatory/anti-inflammatory mechanisms and interactions with the intestinal microbiome and obesity.31 Some studies have begun characterising the exact microbial constituents that may be promoting asthma development in early life.32–35 Obesity had been previously linked to changes in the nasal and lung microbiota,36 and one study suggests that restoring gut microbiota via probiotics can reduce childhood asthma susceptibility.35 In addition to direct effects of foods on asthma incidence, there are also indirect pathways to consider, as LILA exposure is also a function of being in a low-income area (which is an indicator of socioeconomic factors more broadly), where there may be persistent disinvestment and other structural forces at play (eg, air pollution, where toxic sources are located) that may lend itself to increased asthma susceptibility with or without limited access to foods.
The geographically and racially/ethnically diverse composition of our study participants allowed us to examine for effect heterogeneity by several individual-level characteristics. While there is consistent evidence of females being more susceptible to some environmental pollutants than males among adults,37 the evidence is less clear for children, with some suggestion that males may be more sensitive.38 39 In the present study, we identified females as more susceptible to limited food access (as it relates to asthma incidence) than males, and future work is needed to confirm this result and to investigate potential pathways in which this disparity manifests. Given that minority groups are more likely to be simultaneously subject to a range of adverse environmental conditions and pollutants,14 40 it may not be surprising that Hispanic individuals were identified to be a vulnerable subgroup. However, it is interesting that the LILA neighbourhood-asthma association for Black children was similar to those for White children, given the importance of racism for health inequities41 and previous work on air pollution.42 This could be tied to differing food consumption patterns and relationship with foods across racial/ethnic groups.43 44 Finally, although not statistically significant, the association was more pronounced with higher maternal education for LILAvehicle and more pronounced with lower maternal education for the other three exposure metrics in our study. Lower maternal educational attainment can affect health literacy and understanding about childhood asthma prevention,45 46 and the socioeconomic facet vehicle access represents may differ by educational level.
Our study has several limitations. One is that asthma is notoriously difficult to diagnose and is frequently misdiagnosed in children under the age of 5 years since there is currently no gold standard diagnostic test.47 However, there has not been evidence of consistent over- or under-diagnosis,48 and misdiagnosis is unlikely to be related to whether the child lived in a FARA-defined LILA neighbourhood. Thus, the non-differential misclassification of the outcome is expected to not introduce bias, though CIs may be inflated. Our study is also limited by the length of follow-up. The ECHO programme leveraged and harmonised data from existing and new sites, each designed with a different focus, though they have the commonality of being interested in studying children’s health endpoints surrounding birth and early childhood, and we were able to benefit from the large sample size. However, the length of follow-up from birth varied by site and may not span the entirety of birth through age 11, as carrying out studies spanning longer periods of childhood is resource intensive. Furthermore, as shown in online supplemental eFigure 2, many sites were newly established sites that did not have the opportunity to follow their participants through the end of middle childhood. Thus, it may be unsurprising that in this study, we had complete follow-up data from birth through age 5 (cumulative early childhood) on over 80% of children (ie, 3078 (19%) children were right censored), but most had been lost to follow-up or administratively censored by site design (9155 (57%) children were right censored) by the end of age 11 (cumulative middle childhood). This limitation is in part due to the limited temporal availability of the exposure metrics, and future work in expanding those metrics further back in time is needed to take advantage of existing cohorts that have had the opportunity to collect long follow-up data during middle childhood and other critical periods of development in later childhood. It is also important to keep in mind that statistical significance does not necessarily translate to clinical significance. While our study suggests that food access and nutrition may contribute to the development of asthma, further studies are required to understand the extent to which improving food access may impact childhood asthma directly or indirectly. Another limitation is with regard to our exposure assessment. As with other studies on neighbourhood-level determinants of health, it is difficult to tease out the food access-specific association because access to healthy foods is inexplicably tied to other adverse environmental exposures (eg, poor housing, air pollution, other correlated exposures).14 49 That is, it is difficult to show whether the culprit is truly access to healthy foods, particularly since our food access exposure metric is only available for two time points (ie, temporality is unclear). Still, we found a measurable association between living in a LILA neighbourhood and early and middle childhood asthma, showing the importance of a child’s neighbourhood-level environment. Future studies may wish to evaluate how toxic chemicals and nutrients may mediate the associations we observed in a dataset where the timing of food access and other variables of interest are clear. Moreover, we measured our exposure on the census tract level, which may not capture all the relevant areas in which participants are accessing their foods. Finally, individual-level food insecurity may also be of interest, but these data were largely missing in our dataset.
Our large cohort study of over 16 000 children from across the country is one of the only studies on LILA neighbourhoods and childhood asthma, filling a gap in the food environment literature. Another strength is that we used FARA metrics that have been widely used to study other health endpoints28 50 to identify LILA neighbourhoods, though we also recognise that these metrics are imperfect (eg, overemphasises distance, simplifies the definition of access).51 We also adjusted for important individual-level risk factors and further considered how these risk factors may serve as modifiers, providing insights that may be relevant to policymaking and resource allocation. Moreover, we conducted a series of sensitivity analyses, using logistic regression and varying the inclusion/exclusion of specialised sites and exposure definitions to demonstrate the robustness of our findings.
In this study, cumulative exposure to living in a neighbourhood with limited access to healthy foods and mitigation ability (as captured by census tract income level and vehicle access) was associated with the development of asthma in early and middle childhood. Given the economic and health burden childhood asthma poses,1 52 further work to confirm our findings and to clarify underlying pathways is needed to develop effective interventions aimed at asthma prevention.
The authors wish to thank our ECHO Colleagues; the medical, nursing and programme staff; and the children and families participating in the ECHO sites.
Data availability statement
Data are available upon reasonable request. Select de-identified data from the ECHO Program are available through NICHD’s Data and Specimen Hub (DASH). Information on study data not available on DASH, such as some Indigenous datasets, can be found on the ECHO study DASH webpage.
Ethics statements
Patient consent for publication
Not applicable.
Ethics approval
This study involved human participants. A properly constituted IRB of record, formally designated to review and monitor research involving human subjects, was accountable for compliance with regulatory requirements for the ECHO Cohort Data and Biospecimen Collection Protocol at participating Cohort Study Sites. The work of the ECHO Data Analysis Center is approved through the Johns Hopkins Bloomberg School of Public Health Institutional Review Board. The sIRB (WCG IRB #20181210) reviewed the protocol and all informed consent/assent forms, HIPAA Authorization forms, recruitment materials, and other relevant information prior to the initiation of any ECHO Cohort Data and Biospecimen Collection Protocol-related procedures or activities. The sIRB also reviewed any amendments to the protocol prior to their implementation. Participants gave informed consent to participate in the study before taking part.
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Collaborators ECHO Cohort Consortium: P Brian Smith (Division of Neonatology, Department of Pediatrics, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA), L Kristin Newby (Division of Cardiology, Department of Medicine, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA), Linda Adair (Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA), Lisa P. Jacobson (Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, USA), Diane Catellier (N/A, Research Triangle Institute, Research Triangle Park, North Carolina, USA), Monica McGrath (Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, USA), Christian Douglas (N/A, Research Triangle Institute, Research Triangle Park, North Carolina, USA), Priya Duggal (Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, USA), Emily Knapp (Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, USA), Amii Kress (Department of Epidemiology, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, Maryland, USA), Courtney K. Blackwell (Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA), Maxwell A. Mansolf (Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA), Jin-Shei Lai (Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA), Emily Ho (Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA), David Cella (Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA), Richard Gershon (Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA), Michelle L. Macy (Department of Pediatrics, Feinberg School of Medicine, Northwestern University and Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA), Suman R. Das (Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA), Jane E. Freedman (Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA), Simon A. Mallal (Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA), John A. McLean (Department of Chemistry, Vanderbilt University, Nashville, Tennessee, USA), Ravi V. Shah (Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA), Meghan H. Shilts (Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA), Akram N. Alshawabkeh (College of Engineering, Northeastern University, Boston, Massachusetts, USA), Jose F. Cordero (College of Public Health, Department of Epidemiology & Biostatistics, University of Georgia, Athens, Georgia; USA), John Meeker (Environmental Health Sciences, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA), Leonardo Trasande (Departments of Pediatrics and Population Health, NYU Grossman School of Medicine, New York, New York, USA), Carlos A. Camargo Jr. (Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA), Kohei Hasegawa (Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA), Zhaozhong Zhu (Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA), Ashley F. Sullivan (Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA), Dana Dabelea (Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA), Wei Perng (Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA), Traci A. Bekelman (Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA), Greta Wilkening (Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA), Sheryl Magzamen (Environmental and Radiological Health Sciences, Colorado School of Public Health, Colorado State University, Fort Collins, Colorado, USA), Brianna F. Moore (Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA), Anne P. Starling (Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA), Deborah J. Rinehart (Center for Health Systems Research, Denver Health and Hospital Authority, Denver, Colorado, USA), Daphne Koinis Mitchell (Department of Pediatrics, Rhode Island Hospital, The Alpert Medical School of Brown University, Providence, Rhode Island, USA), Viren D'Sa (Department of Pediatrics, Rhode Island Hospital, The Alpert Medical School of Brown University, Providence, Rhode Island, USA), Sean C.L. Deoni (Division of Gender Equality, Maternal, Newborn & Child Health Discovery & Tools Team, Bill & Melinda Gates Foundation, Seattle, Washington, USA), Hans-Georg Mueller (Department of Statistics, University of California, Davis, Davis, California, USA), Cristiane S. Duarte (Division of Child and Adolescent Psychiatry, Columbia University - NYSPI, New York, New York, USA), Catherine Monk (Department of Obstetrics & Gynecology, Columbia University - NYSPI, New York, New York, USA), Glorisa Canino (Behavioral Sciences Research Institute, University of Puerto Rico, School of Medicine, Rio Piedras, Puerto Rico), Jonathan Posner (Child & Family Mental Health & Community Psychiatry Division, Duke University School of Medicine, Duke Psychiatry & Behavioral Sciences, Durham, North Carolina, USA), Tenneill Murray (Division of Child and Adolescent Psychiatry, Columbia University - NYSPI, New York, New York, USA), Claudia Lugo-Candelas (Division of Child and Adolescent Psychiatry, Columbia University - NYSPI, New York, New York, USA), Anne L. Dunlop (Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA), Patricia A. Brennan (Department of Psychology, Emory University, Atlanta, Georgia, USA), Christine Hockett (N/A; Department of Pediatrics, Avera Research Institute; University of South Dakota School of Medicine, Rapid City, South Dakota, USA; Sioux Falls, South Dakota, USA), Amy Elliott (N/A; Department of Pediatrics, Avera Research Institute; University of South Dakota School of Medicine, Sioux Falls, South Dakota, USA), Assiamira Ferrara (Division of Research, Kaiser Permanente Northern California, Oakland, California, USA), Lisa A. Croen (Division of Research, Kaiser Permanente Northern California, Oakland, California, USA), Monique M. Hedderson (Division of Research, Kaiser Permanente Northern California, Oakland, California, USA), John Ainsworth (Centre for Health Informatics, University of Manchester, Manchester, United Kingdom), Leonard B. Bacharier (Department of Pediatrics, Monroe Carell Jr Children’s Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee, USA), Casper G. Bendixsen (National Farm Medicine Center, Marshfield Clinic Research Institute, Marshfield, Wisconsin, USA), James E. Gern (Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA), Diane R. Gold (The Channing Division of Network Medicine; Department of Medicine, Brigham and Women’s Hospital; Harvard Medical School, Boston, Massachusetts, USA), Tina V. Hartert (Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Department of Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA), Daniel J. Jackson (Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA), Christine C. Johnson (Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA), Christine L.M. Joseph (Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA), Meyer Kattan (Department of Pediatrics, Columbia University Medical Center, New York, New York, USA), Gurjit K. Khurana Hershey (Division of Asthma Research, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA), Robert F. Lemanske, Jr. (Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA), Susan V. Lynch (Department of Medicine, University of California, San Francisco, California, USA), Rachel L. Miller (Department of Medicine; Division of Clinical Immunology, Icahn School of Medicine at Mount Sinai, New York, New York, USA), George T. O’Connor (Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts, USA), Carole Ober (Department of Human Genetics, University of Chicago, Chicago, Illinois, USA), Dennis Ownby (Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA), Katherine Rivera-Spoljaric (Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri, USA), Patrick H. Ryan (Department of Pediatrics and College of Medicine; Division of Biostatistics and Epidemiology, University of Cincinnati, Cincinnati, Ohio, USA), Christine M. Seroogy (Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA), Anne Marie Singh (Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA), Robert A. Wood (Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA), Edward M. Zoratti (Division of Allergy and Clinical Immunology, Henry Ford Health, Detroit, Michigan, USA), Rima Habre (Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA), Shohreh Farzan (Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA), Frank D. Gilliland (Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California, USA), Irva Hertz-Picciotto (MIND Institute and Department of Public Health Sciences, University of California, Davis, Davis, California, USA), Deborah H. Bennett (Department of Public Health Sciences, University of California, Davis, Davis, California, USA), Julie B. Schweitzer (Department of Psychiatry and Behavioral Science and the MIND Institute, University of California, Davis, Davis, California, USA), Rebecca J. Schmidt (MIND Institute and Department of Public Health Sciences, University of California, Davis, Davis, California, USA), Janine M. LaSalle (Medical Microbiology and Immunology; MIND Institute, University of California, Davis, Davis, California, USA), Alison E. Hipwell (Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA), Kate E. Keenan (Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, Illinois, USA), Catherine J. Karr (Department of Pediatrics, School of Medicine; Department of Environmental and Occupational Health Sciences; School of Public Health, University of Washington, Seattle, Washington, USA), Nicole R. Bush (Department of Psychiatry and Behavioral Sciences and Department of Pediatrics, School of Medicine, University of California, San Francisco, San Francisco, California, USA), Kaja Z. LeWinn (Department of Psychiatry and Behavioral Sciences, School of Medicine, University of California, San Francisco, San Francisco, California, USA), Sheela Sathyanarayana (Department of Pediatrics, School of Medicine; Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington and Seattle Children's Research Institute, Seattle, Washington, USA), Qi Zhao (Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA), Frances Tylavsky (Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA), Kecia N. Carroll (Department of Pediatrics, Department of Environmental Medicine & Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA), Christine T. Loftus (Department of Environmental and Occupational Health Sciences; School of Public Health, University of Washington, Seattle, Washington, USA), Leslie D. Leve (Department of Counseling Psychology and Human Services & Prevention Science Institute, University of Oregon, Eugene, Oregon, USA), Jody M. Ganiban (Department of Psychological and Behavioral Sciences, George Washington University, Washington, DC, USA), Jenae M. Neiderhiser (Department of Psychology, Penn State University, University Park, Pennsylvania, USA), Scott T. Weiss (Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA), Augusto A. Litonjua (Pediatric Pulmonary Division, Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York, USA), Cindy T. McEvoy (Division of Neonatology, Department of Pediatrics, Oregon Health & Science University, Portland, Oregon, USA), Eliot R. Spindel (Division of Neuroscience, Oregon National Primate Research Center, Beaverton, Oregon, USA), Robert S. Tepper (Division of Pediatric Pulmonology, Department of Pediatrics, Indiana School of Medicine, Indianapolis, Indiana, USA), Craig J. Newschaffer (College of Health and Human Development, Penn State, State College, Pennsylvania, USA), Kristen Lyall (AJ Drexel Autism Institute, Drexel University, Philadelphia, Pennsylvania, USA), Heather E. Volk (Mental Health, Johns Hopkins University, Baltimore, Maryland, USA), Rebecca Landa (Department of Psychiatry and Behavioral Sciences, Center for Autism and Related Disorders, Kennedy Krieger Institute, Johns Hopkins University, Baltimore, Maryland, USA), Sally Ozonoff (MIND Institute, Department of Psychiatry, University of California Davis, Sacramento, California, USA), Joseph Piven (Department of Psychiatry, University of North Carolina, Chapel Hill, North Carolina, USA), Heather Hazlett (Department of Psychiatry, University of North Carolina, Chapel Hill, North Carolina, USA), Juhi Pandey (Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA), Robert Schultz (Center for Autism Research, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA), Steven Dager (Department of Radiology, University of Washington, Seattle, Washington, USA), Kelly Botteron (Department of Psychiatry, Washington University, St Louis, Missouri, USA), Daniel Messinger (Department of Psychology, University of Miami, Miami, Florida, USA), Wendy Stone (Department of Psychology, University of Washington, Seattle, Washington, USA), Jennifer Ames (Kaiser Permanente Division of Research, Kaiser Permanente, Oakland, California, USA), Thomas G. O'Connor (Departments of Psychiatry, Neuroscience, Obstetrics and Gynecology, University of Rochester, Rochester, New York, USA), Richard K. Miller (Departments of Obstetrics and Gynecology, University of Rochester, Rochester, New York, USA), Emily Oken (Division of Chronic Disease Research Across the Lifecourse, Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School, Boston, Massachusetts, USA), Michele R. Hacker (Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA), Tamarra James-Todd (Department of Environmental Health, Harvard Chan School of Public Health, Boston, Massachusetts, USA), T. Michael O'Shea Jr. (Division of Neonatology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA), Rebecca C. Fry (Department of Environmental Sciences and Engineering, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina, USA), Jean A. Frazier (EK Shriver Center and Psychiatry, UMASS Chan Medical School, Worcster, Massachusetts, USA), Rachana Singh (Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts, USA), Caitlin Rollins (Department of Neurology, Harvard Medical School, Boston, Massachusetts, USA), Angela Montgomery (Division of Neonatology, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, USA), Ruben Vaidya (Department of Pediatrics, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts, USA), Robert M. Joseph (Department of Anatomy & Neurobiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA), Lisa K. Washburn (Pediatrics, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA), Semsa Gogcu (Section of Neonatology, Department of Pediatrics; Department of Pediatrics, Wake Forest School of Medicine; Wake Forest University School of Medicine/Atrium Health Wake Forest, Winston-Salem, North Carolina, USA), Kelly Bear (Section of Neonatology, Department of Pediatrics, ECU Health, Greenville, North Carolina, USA), Julie V. Rollins (Division of Neonatology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA), Stephen R. Hooper (Department of Health Sciences, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA), Genevieve Taylor (Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA), Wesley Jackson (Division of Neonatology, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA), Amanda Thompson (Department of Anthropology, Department of Nutrition, University of North Carolina at Chapel Hill; Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA), Julie Daniels (Epidemiology and Maternal and Child Health, University of North Carolina at Chapel Hill; Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA), Michelle Hernandez (Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA), Kun Lu (Environmental Sciences and Engineering, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA), Michael Msall (Kennedy Research Center on Intellectual and Neurodevelopmental Disabilities, University of Chicago Medicine: Comer Children's Hospital, Chicago Illinois, USA), Madeleine Lenski (Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA), Rawad Obeid (Pediatrics, Beaumont Hospital, Royal Oak, Michigan, USA), Steven L. Pastyrnak (Pediatrics, Corewell Health, Helen DeVos Children's Hospital, Grand Rapids, Michigan, USA), Elizabeth Jensen (Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA), Christina Sakai (Pediatrics, Mass General Hospital for Children, Boston, Massachusetts, USA), Hudson Santos (Dean's Office Graduate School, School of Nursing and Health Studies, University of Miami, Coral Gables, Florida, USA), Jean M. Kerver (Departments of Epidemiology & Biostatistics, and Pediatrics & Human Development, Michigan State University, College of Human Medicine, East Lansing, Michigan, USA), Nigel Paneth (Departments of Epidemiology & Biostatistics, and Pediatrics & Human Development, Michigan State University, College of Human Medicine, East Lansing, Michigan, USA), Charles J. Barone (Department of Pediatrics, Henry Ford Health, Detroit, Michigan, USA), Michael R. Elliott (Department of Biostatistics, University of Michigan, Ann Arbor, Michigan, USA), Douglas M. Ruden (Department of Obstetrics and Gynecology, Institute of Environmental Health Sciences (IEHS), C.S. Mott Center for Human Health and Development, Wayne State University, Detroit, Michigan, USA), Chris Fussman (Lifecourse Epidemiology and Genomics Division, Michigan Department of Health and Human Services (MDHHS), Lansing, Michigan, USA), Julie B. Herbstman (Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, New York, USA), Amy Margolis (Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA), Susan L. Schantz (Beckman Institute for Advanced Science and Technology; Department of Comparative Biosciences, University of Illinois Urbana-Champaign, Urbana, Illinois, USA), Sarah Dee Geiger (Beckman Institute for Advanced Science and Technology; Department of Kinesiology and Community Health, University of Illinois Urbana-Champaign, Urbana, Illinois, USA), Andrea Aguiar (Beckman Institute for Advanced Science and Technology; Department of Comparative Biosciences, University of Illinois Urbana-Champaign, Urbana, Illinois, USA), Karen Tabb (Beckman Institute for Advanced Science and Technology; Department of Social Work, University of Illinois Urbana-Champaign, Urbana, Illinois, USA), Rita Strakovsky (Department of Food Science and Human Nutrition, Michigan State University, East Lansing, Michigan, USA), Tracey Woodruff (Program on Reproductive Health and the Environment, University of California, San Francisco, San Francisco, California, USA), Rachel Morello-Frosch (Department of Environmental Science, Policy and Management and School of Public Health, University of California, Berkeley, Berkeley, California, USA), Amy Padula (Program on Reproductive Health and the Environment, University of California, San Francisco, San Francisco, California, USA), Joseph B. Stanford (Department of Family and Preventive Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA), Christina A. Porucznik (Department of Family and Preventive Medicine, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA), Angelo P. Giardino (Department of Pediatrics, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA), Rosalind J. Wright (Department of Environmental Medicine & Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA), Robert O. Wright (Department of Environmental Medicine & Public Health, Icahn School of Medicine at Mount Sinai, New York, New York, USA), Brent Collett (Department of Psychiatry and Behavioral Medicine, University of Washington, Seattle Children's Research Institute, Seattle, Washington, USA), Nicole Baumann-Blackmore (Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA), Ronald Gangnon (Department of Population Health Sciences, University of Wisconsin, Madison, Wisconsin, USA), Chris G. McKennan (Department of Statistics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA), Jo Wilson (Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA), Matt Altman (Department of Medicine, University of Washington, Seattle, Washington, USA), Judy L. Aschner (Department of Pediatrics, Albert Einstein College of Medicine; Hackensack Meridian School of Medicine; Center for Discovery and Innovation, Bronx, New York, USA; Nutley, New Jersey, USA), Annemarie Stroustrup (Department of Pediatrics, Northwell Health, Cohen Children's Medical Center, and the Zucker School of Medicine at Hofstra / Northwell, New Hyde Park, New York, USA), Stephanie L. Merhar (Department of Pediatrics, Cincinnati Children's, Cincinnati, Ohio, USA), Paul E. Moore (Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA), Gloria S. Pryhuber (Department of Pediatrics, University of Rochester Medical Center, Rochester, New York, USA), Mark Hudak (Department of Pediatrics, University of Florida College of Medicine, Jacksonville, Florida, USA), Ann Marie Reynolds Lyndaker (Department of Pediatrics, University of Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA), Andrea L. Lampland (Department of Pediatrics, Children's Minnesota, Minneapolis, Minnesota, USA), Burton Rochelson (Department of Obstetrics and Gynecology, Northwell Health and the Zucker School of Medicine at Hofstra / Northwell, New Hyde Park, New York, USA), Sophia Jan (Department of Pediatrics, Northwell Health, Cohen Children's Medical Center, and the Zucker School of Medicine at Hofstra / Northwell, New Hyde Park, New York, USA), Matthew J. Blitz (Department of Obstetrics and Gynecology, Northwell Health and the Zucker School of Medicine at Hofstra / Northwell, New Hyde Park, New York, USA), Michelle W. Katzow (Department of Pediatrics, Northwell Health, Cohen Children's Medical Center, and the Zucker School of Medicine at Hofstra / Northwell, New Hyde Park, New York, USA), Zenobia Brown (Department of Science Education, Northwell Health and the Zucker School of Medicine at Hofstra / Northwell, New Hyde Park, New York, USA), Codruta Chiuzan (Institute of Health System Science, Northwell Health, Feinstein Institutes for Medical Research, Manhasset, New York, USA), Timothy Rafael (Department of Obstetrics and Gynecology, Northwell Health and the Zucker School of Medicine at Hofstra / Northwell, New Hyde Park, New York, USA), Dawnette Lewis (Department of Obstetrics and Gynecology, Northwell Health and the Zucker School of Medicine at Hofstra / Northwell, New Hyde Park, New York, USA), Natalie Meirowitz (Department of Obstetrics and Gynecology, Northwell Health and the Zucker School of Medicine at Hofstra / Northwell, New Hyde Park, New York, USA), Brenda Poindexter (Department of Pediatrics, Children's Healthcare of Atlanta Emory University, Atlanta, Georgia, USA), Tebeb Gebretsadik (Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA), Sarah Osmundson (Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, Tennessee, USA), Jennifer K. Straughen (Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA), Amy Eapen (Division of Allergy and Clinical Immunology, Henry Ford Health, Detroit, Michigan, USA), Andrea Cassidy-Bushrow (Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA), Ganesa Wegienka (Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA), Alex Sitarik (Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA), Kim Woodcroft (Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA), Audrey Urquhart (Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA), Albert Levin (Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA), Tisa Johnson-Hooper (Department of Pediatrics, Henry Ford Health, Detroit, Michigan, USA), Brent Davidson (Department of Women's Health, Henry Ford Health, Detroit, Michigan, USA), Tengfei Ma (Department of Public Health Sciences, Henry Ford Health, Detroit, Michigan, USA), Emily S. Barrett (Department of Biostatistics and Epidemiology, Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, New Jersey, USA), Martin J. Blaser (Center for Advanced Biotechnology & Medicine, Rutgers University, Piscataway, New Jersey, USA), Maria Gloria Dominguez-Bello (Departments of Biochemistry and Microbiology & Anthropology, Rutgers University, New Brunswick, New Jersey, USA), Daniel B. Horton (Department of Pediatrics, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA), Manuel Jimenez (Departments of Pediatrics, Family Medicine, and Community Health, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA), Todd Rosen (Department of Obstetrics, Gynecology, and Reproductive Sciences, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA), Kristy Palomares (Department of Obstetrics and Gynecology, Saint Peter's University Hospital, New Brunswick, New Jersey, USA), Lyndsay A. Avalos (Division of Research, Kaiser Permanente Northern California, Oakland, California, USA), Yeyi Zhu (Division of Research, Kaiser Permanente Northern California, Oakland, California, USA), Kelly J. Hunt (Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA), Roger B. Newman (Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina, USA), Michael S. Bloom (Department of Global and Community Health, George Mason University, Fairfax, Virginia, USA), Mallory H. Alkis (Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina, USA), James R. Roberts (Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA), Sunni L. Mumford (Department of Biostatistics, Epidemiology and Informatics; Department of Obstetrics and Gynecology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA), Heather H. Burris (Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA), Sara B. DeMauro (Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA), Lynn M. Yee (Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA), Aaron Hamvas (Division of Neonatology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA), Antonia F. Olidipo (Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA), Andrew S. Haddad (Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA), Lisa R. Eiland (Division of Neonatology, Department of Pediatrics, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA), Nicole T. Spillane (Division of Neonatology, Department of Pediatrics, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA), Kirin N. Suri (Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, Hackensack University Medical Center, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA), Stephanie A. Fisher (Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA), Jeffrey A. Goldstein (Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA), Leena B. Mithal (Division of Infectious Diseases, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA), Raye-Ann O. DeRegnier (Division of Neonatology, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA), Nathalie L. Maitre (Division of Neonatology, Department of Pediatrics, Emory University School of Medicine and Cerebral Palsy Foundation, Atlanta, Georgia, USA and New York, New York, USA), Ruby H.N. Nguyen (Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, USA), Meghan M. JaKa (Division of Research & Evaluation, HealthPartners Institute, Minneapolis, Minnesota, USA), Abbey C. Sidebottom (Care Delivery Research, Allina Health, Minneapolis, Minnesota, USA), Michael J. Paidas (Department of Obstetrics and Gynecology, University of Miami Miller School of Medicine, Miami, Florida, USA), JoNell E. Potter (Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA), Natale Ruby (Mailman Center for Child Development, University of Miami Miller School of Medicine, Miami, Florida, USA), Lunthita Duthely (Department of Obstetrics, Gynecology and Reproductive Sciences and Department of Public Health Sciences, University of Miami School of Medicine, Miami, Florida, USA), Arumugam Jayakumar (Department of Obstetrics, Gynecology and Reproductive Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA), Karen Young (Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA), Isabel Maldonado (School of Nursing and Health Studies, University of Miami, Miami, Florida, USA), Meghan Miller (Psychiatry and Behavioral Sciences; MIND Institute, University of California Davis, Sacramento, California, USA), Jonathan L. Slaughter (Center for Perinatal Research, Abigail Wexner Research Institute and Division of Neonatology, Nationwide Children's Hospital and Department of Pediatrics, College of Medicine and Division of Epidemiology, College of Public Health, The Ohio State University, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA), Sarah A. Keim (Center for Biobehavioral Health, Abigail Wexner Research Institute, Nationwide Children's Hospital and Department of Pediatrics, College of Medicine and Division of Epidemiology, College of Public Health, The Ohio State University, Nationwide Children's Hospital and The Ohio State University, Columbus, Ohio, USA), Courtney D. Lynch (Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Medicine and Division of Epidemiology, College of Public Health, The Ohio State University, The Ohio State University, Columbus, Ohio, USA), Kartik K. Venkatesh (Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Medicine and Division of Epidemiology, College of Public Health, The Ohio State University, The Ohio State University, Columbus, Ohio, USA), Kristina W. Whitworth (Center for Precision Environmental Health and Department of Medicine, Baylor College of Medicine, Houston, Texas, USA), Elaine Symanski (Center for Precision Environmental Health and Department of Medicine, Baylor College of Medicine, Houston, Texas, USA), Thomas F. Northrup (Department of Family and Community Medicine, University of Texas Health Science Center at Houston (UTHealth Houston) McGovern Medical School, Houston, Texas, USA), Hector Mendez-Figueroa (Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston (UTHealth Houston) McGovern Medical School, Houston, Texas, USA), Ricardo A. Mosquera (Department of Pediatrics, University of Texas Health Science Center at Houston (UTHealth Houston) McGovern Medical School, Houston, Texas, USA), Margaret R. Karagas (Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA), Juliette C. Madan (Departments of Psychiatry, Pediatrics & Epidemiology, Geisel School of Medicine at Dartmouth, Dartmouth Hitchcock Medical Center, Hanover, New Hampshire, USA), Debra M. MacKenzie (Community Environmental Health Program, Department of Pharmaceutical Sciences, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA), Johnnye L. Lewis (Community Environmental Health Program, Department of Pharmaceutical Sciences, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA), Brandon J. Rennie (Center for Development and Disability, University of New Mexico, Albuquerque, New Mexico, USA), Bennett L. Leventhal (Community Environmental Health Program, Department of Pharmaceutical Sciences UNM, College of Pharmacy, University of New Mexico Health Sciences Center; University of Chicago, Albuquerque, New Mexico, USA; Chicago, Illinois, USA), Young Shin Kim (Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA), Somer Bishop (Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA), Sara S. Nozadi (Community Environmental Health Program, Department of Pharmaceutical Sciences, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA), Li Luo (Department of Internal Medicine, Comprehensive Cancer Center, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA), Barry M. Lester (Department of Pediatrics, Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA), Carmen J. Marsit (Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA), Todd Everson (Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA), Cynthia M. Loncar (Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA), Elisabeth C. McGowan (Department of Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA), Stephen J. Sheinkopf (Department of Pediatrics, Thompson Center for Autism & Neurodevelopment, University of Missouri, Columbia, Missouri, USA), Brian S. Carter (Department of Pediatrics, Children's Mercy-Kansas City, Kansas City, Missouri, USA), Jennifer Check (Department of Pediatrics, Wake Forest School of Medicine, Winston, Salem North Carolina, USA), Jennifer B. Helderman (Department of Pediatrics, Wake Forest School of Medicine, Winston, Salem North Carolina, USA), Charles R. Neal (Department of Pediatrics, University of Hawaii John A Burns School of Medicine, Honolulu, Hawaii, USA), Lynne M. Smith (Department of Pediatrics, UCLA Clinical and Translational Science Institute at The Lundquist Institute, Harbor-UCLA Medical Center, Los Angeles, California, USA).
Contributors All authors made significant contributions to the writing and review of this manuscript. VW and RH: conceptualisation, methodology, formal analysis, writing-original draft. DRG and AZ: conceptualisation, methodology, formal analysis, writing-original draft, funding acquisition and supervision. SD, HL-G, JB, and HS: data curation, writing-review and editing. PR, RLM, FG, CB, SF, CC, JBK, CJK, LL, DD, MRK, DB, FLN, JA, TMO and CM: data curation, funding acquisition, writing-review and editing. IA, AC, AMK, DL and EK: writing-review and editing. Other contributors are listed under Collaborators. DRG is the guarantor.
Funding The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Research reported in this publication was supported by the Environmental influences on Child Health Outcomes (ECHO) Program, Office of the Director, National Institutes of Health, under Award Numbers U2COD023375 (Coordinating Center), U24OD023382 (Data Analysis Center), U24OD023319 with co-funding from the Office of Behavioral and Social Science Research (Measurement Core), U24OD035523 (Lab Core), ES0266542 (HHEAR), U24ES026539 (HHEAR Barbara O’Brien), U2CES026533 (HHEAR Lisa Peterson), U2CES026542 (HHEAR Patrick Parsons, Kannan Kurunthacalam), U2CES030859 (HHEAR Manish Arora), U2CES030857 (HHEAR Timothy R. Fennell, Susan J. Sumner, Xiuxia Du), U2CES026555 (HHEAR Susan L. Teitelbaum), U2CES026561 (HHEAR Robert O. Wright), U2CES030851 (HHEAR Heather M. Stapleton, P. Lee Ferguson), UG3/UH3OD023251 (Akram Alshawabkeh), UH3OD023320 and UG3OD035546 (Judy Aschner), UH3OD023332 (Clancy Blair, Leonardo Trasande), UG3/UH3OD023253 (Carlos Camargo), UG3/UH3OD023248 and UG3OD035526 (Dana Dabelea), UG3/UH3OD023313 (Daphne Koinis Mitchell), UH3OD023328 (Cristiane Duarte), UH3OD023318 (Anne Dunlop), UG3/UH3OD023279 (Amy Elliott), UG3/UH3OD023289 (Assiamira Ferrara), UG3/UH3OD023282 (James Gern), UH3OD023287 (Carrie Breton), UG3/UH3OD023365 (Irva Hertz-Picciotto), UG3/UH3OD023244 (Alison Hipwell), UG3/UH3OD023275 (Margaret Karagas), UH3OD023271 and UG3OD035528 (Catherine Karr), UH3OD023347 (Barry Lester), UG3/UH3OD023389 (Leslie Leve), UG3/UH3OD023344 (Debra MacKenzie), UH3OD023268 (Scott Weiss), UG3/UH3OD023288 (Cynthia McEvoy), UG3/UH3OD023342 (Kristen Lyall), UG3/UH3OD023349 (Thomas O’Connor), UH3OD023286 and UG3OD035533 (Emily Oken), UG3/UH3OD023348 (Mike O’Shea), UG3/UH3OD023285 (Jean Kerver), UG3/UH3OD023290 (Julie Herbstman), UG3/UH3OD023272 (Susan Schantz), UG3/UH3OD023249 (Joseph Stanford), UG3/UH3OD023305 (Leonardo Trasande), UG3/UH3OD023337 (Rosalind Wright), UG3OD035508 (Sheela Sathyanarayana), UG3OD035509 (Anne Marie Singh), UG3OD035513 and UG3OD035532 (Annemarie Stroustrup), UG3OD035516 and UG3OD035517 (Tina Hartert), UG3OD035518 (Jennifer Straughen), UG3OD035519 (Qi Zhao), UG3OD035521 (Katherine Rivera-Spoljaric), UG3OD035527 (Emily S Barrett), UG3OD035540 (Monique Marie Hedderson), UG3OD035543 (Kelly J Hunt), UG3OD035537 (Sunni L Mumford), UG3OD035529 (Hong-Ngoc Nguyen), UG3OD035542 (Hudson Santos), UG3OD035550 (Rebecca Schmidt), UG3OD035536 (Jonathan Slaughter) and UG3OD035544 (Kristina Whitworth). This work was also supported by NIEHS P30 ES000002 and P30 ES007048 and NIH T32 ES007069.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer-reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
1 CDC. Most recent national asthma data. 2023. Available: https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm
2 Miller MD, Marty MA. Impact of environmental chemicals on lung development. Environ Health Perspect 2010; 118: 1155–64. doi:10.1289/ehp.0901856
3 Iliodromiti Z, Zygouris D, Sifakis S, et al. Acute lung injury in preterm fetuses and neonates: mechanisms and molecular pathways. J Matern Fetal Neonatal Med 2013; 26: 1696–704. doi:10.3109/14767058.2013.798284
4 Grant T, Brigham EP, McCormack MC. Childhood Origins of Adult Lung Disease as Opportunities for Prevention. J Allergy Clin Immunol Pract 2020; 8: 849–58. doi:10.1016/j.jaip.2020.01.015
5 Miller RL, Schuh H, Chandran A, et al. Incidence rates of childhood asthma with recurrent exacerbations in the US Environmental influences on Child Health Outcomes (ECHO) program. J Allergy Clin Immunol 2023; 152: 84–93. doi:10.1016/j.jaci.2023.03.016
6 Zahran HS, Bailey CM, Damon SA, et al. Vital Signs: Asthma in Children - United States, 2001-2016. MMWR Morb Mortal Wkly Rep 2018; 67: 149–55. doi:10.15585/mmwr.mm6705e1
7 Murdoch JR, Lloyd CM. Chronic inflammation and asthma. Mutation Research/Fundamental and Molecular Mechanisms of Mutagenesis 2010; 690: 24–39. doi:10.1016/j.mrfmmm.2009.09.005
8 Verduci E, Köglmeier J. Immunomodulation in Children: The Role of the Diet. J Pediatr Gastroenterol Nutr 2021; 73: 293–8. doi:10.1097/MPG.0000000000003152
9 Gold DR, Sordillo JE, Coull BA. Lung Function Tracking throughout Childhood: Growth Trajectories May Not Be Set in Stone. J Allergy Clin Immunol Pract 2020; 8: 1272–4. doi:10.1016/j.jaip.2020.01.043
10 Alwarith J, Kahleova H, Crosby L, et al. The role of nutrition in asthma prevention and treatment. Nutr Rev 2020; 78: 928–38. doi:10.1093/nutrit/nuaa005
11 DeChristopher LR, Tucker KL. Excess free fructose, apple juice, high fructose corn syrup and childhood asthma risk - the National Children’s Study. Nutr J 2020; 19: 60. doi:10.1186/s12937-020-00578-0
12 Zhang J, He M, Yu Q, et al. The Effects of a Healthy Diet on Asthma and Wheezing in Children and Adolescents: A Systematic Review and Meta-Analysis. J Asthma Allergy 2023; 16: 1007–24. doi:10.2147/JAA.S423884
13 Grant TL, Wood RA. The influence of urban exposures and residence on childhood asthma. Pediatr Allergy Immunol 2022; 33: e13784. doi:10.1111/pai.13784
14 Grant T, Croce E, Matsui EC. Asthma and the social determinants of health. Ann Allergy Asthma Immunol 2022; 128: 5–11. doi:10.1016/j.anai.2021.10.002
15 US Department of Agriculture Economic Reserach Service. Food access reserach atlas documentation. Available: https://www.ers.usda.gov/data-products/food-access-research-atlas/documentation/ [Accessed 20 Apr 2024 ].
16 Key J, Burnett D, Babu J, et al. The Effects of Food Environment on Obesity in Children: A Systematic Review. Children (Basel) 2023; 10: 98. doi:10.3390/children10010098
17 Ghosh-Dastidar B, Cohen D, Hunter G, et al. Distance to store, food prices, and obesity in urban food deserts. Am J Prev Med 2014; 47: 587–95. doi:10.1016/j.amepre.2014.07.005
18 Lang JE, Bunnell HT, Hossain MJ, et al. Being Overweight or Obese and the Development of Asthma. Pediatrics 2018; 142: e20182119. doi:10.1542/peds.2018-2119
19 Wolff G, Slaven J, Colbert J, et al. Food Deserts and Lung Function During Early Life. Journal of Allergy and Clinical Immunology 2022; 149: AB84. doi:10.1016/j.jaci.2021.12.302
20 Preston D, Morales M, Plunk A. O022 The relationship between asthma and food deserts in the hampton roads area. Ann Allergy Asthma Immunol 2016; 117: S8. doi:10.1016/j.anai.2016.09.382
21 Mangini LD, Hayward MD, Dong YQ, et al. Household Food Insecurity is Associated with Childhood Asthma. J Nutr 2015; 145: 2756–64. doi:10.3945/jn.115.215939
22 Mahmood S, Cheetham S, Brown L. A systematic review of the impact of food insecurity on the risk of developing asthma, or having poor asthma control, in childhood. Eur Respir J 2020; 56. doi:10.1183/13993003.congress-2020.3510
23 Knapp EA, Kress AM, Parker CB, et al. The Environmental Influences on Child Health Outcomes (ECHO)-Wide Cohort. Am J Epidemiol 2023; 192: 1249–63. doi:10.1093/aje/kwad071
24 Jacobson LP, Parker CB, Cella D, et al. Approaches to protocol standardization and data harmonization in the ECHO-wide cohort study. Pediatr Res 2024; 95: 1726–33. doi:10.1038/s41390-024-03039-0
25 Rubin DB. Multiple imputation for nonresponse in surveys. John Wiley & Sons, Incorporated; 1987. Available: http://ebookcentral.proquest.com/lib/harvard-ebooks/detail.action?docID=469854 [Accessed 16 Apr 2024 ].
26 Little RJ, Rubin DB. Statistical analysis with missing data. In: Statistical Analysis with Missing Data. John Wiley & Sons, Ltd, 2002: i–xv.
27 Copland I, Post M. Lung development and fetal lung growth. Paediatr Respir Rev 2004; 5 Suppl A: S259–64. doi:10.1016/s1526-0542(04)90049-8
28 Moughames E, Woo H, Galiatsatos P, et al. Disparities in access to food and chronic obstructive pulmonary disease (COPD)-related outcomes: a cross-sectional analysis. BMC Pulm Med 2021; 21: 139. doi:10.1186/s12890-021-01485-8
29 Kirkpatrick SI, McIntyre L, Potestio ML. Child hunger and long-term adverse consequences for health. Arch Pediatr Adolesc Med 2010; 164: 754–62. doi:10.1001/archpediatrics.2010.117
30 Coleman AT, Sharma H, Robinson A, et al. Access to Allergen-Free Food Among Black and White Children with Food Allergy in the FORWARD Study. J Allergy Clin Immunol Pract 2022; 10: 182–8. doi:10.1016/j.jaip.2021.08.005
31 Budden KF, Gellatly SL, Wood DLA, et al. Emerging pathogenic links between microbiota and the gut-lung axis. Nat Rev Microbiol 2017; 15: 55–63. doi:10.1038/nrmicro.2016.142
32 Vael C, Nelen V, Verhulst SL, et al. Early intestinal Bacteroides fragilis colonisation and development of asthma. BMC Pulm Med 2008; 8: 19. doi:10.1186/1471-2466-8-19
33 Abrahamsson TR, Jakobsson HE, Andersson AF, et al. Low gut microbiota diversity in early infancy precedes asthma at school age. Clin Experimental Allergy 2014; 44: 842–50. doi:10.1111/cea.12253
34 Orivuori L, Mustonen K, de Goffau MC, et al. High level of fecal calprotectin at age 2 months as a marker of intestinal inflammation predicts atopic dermatitis and asthma by age 6. Clin Experimental Allergy 2015; 45: 928–39. doi:10.1111/cea.12522
35 Arrieta M-C, Stiemsma LT, Dimitriu PA, et al. Early infancy microbial and metabolic alterations affect risk of childhood asthma. Sci Transl Med 2015; 7: 307ra152. doi:10.1126/scitranslmed.aab2271
36 Michalovich D, Rodriguez-Perez N, Smolinska S, et al. Obesity and disease severity magnify disturbed microbiome-immune interactions in asthma patients. Nat Commun 2019; 10: 5711. doi:10.1038/s41467-019-13751-9
37 Kuźma Ł, Struniawski K, Pogorzelski S, et al. Gender Differences in Association between Air Pollution and Daily Mortality in the Capital of the Green Lungs of Poland-Population-Based Study with 2,953,000 Person-Years of Follow-Up. J Clin Med 2020; 9: 2351. doi:10.3390/jcm9082351
38 Clougherty JE. A growing role for gender analysis in air pollution epidemiology. Environ Health Perspect 2010; 118: 167–76. doi:10.1289/ehp.0900994
39 Dong G-H, Chen T, Liu M-M, et al. Gender differences and effect of air pollution on asthma in children with and without allergic predisposition: northeast Chinese children health study. PLoS ONE 2011; 6: e22470. doi:10.1371/journal.pone.0022470
40 Jbaily A, Zhou X, Liu J, et al. Air pollution exposure disparities across US population and income groups. Nature New Biol 2022; 601: 228–33. doi:10.1038/s41586-021-04190-y
41 Bailey ZD, Krieger N, Agénor M, et al. Structural racism and health inequities in the USA: evidence and interventions. The Lancet 2017; 389: 1453–63. doi:10.1016/S0140-6736(17)30569-X
42 Zanobetti A, Ryan PH, Coull BA, et al. Early-Life Exposure to Air Pollution and Childhood Asthma Cumulative Incidence in the ECHO CREW Consortium. JAMA Netw Open 2024; 7: e240535. doi:10.1001/jamanetworkopen.2024.0535
43 Bennett G, Bardon LA, Gibney ER. A Comparison of Dietary Patterns and Factors Influencing Food Choice among Ethnic Groups Living in One Locality: A Systematic Review. Nutrients 2022; 14: 941. doi:10.3390/nu14050941
44 Dorrance Hall E, Ma M, Azimova D, et al. The Mediating Role of Family and Cultural Food Beliefs on the Relationship between Family Communication Patterns and Diet and Health Issues across Racial/Ethnic Groups. Health Commun 2021; 36: 593–605. doi:10.1080/10410236.2020.1733213
45 Morrison AK, Glick A, Yin HS. Health Literacy: Implications for Child Health. Pediatr Rev 2019; 40: 263–77. doi:10.1542/pir.2018-0027
46 Seibert RG, Winter MR, Cabral HJ, et al. Health Literacy and Income Mediate Racial/Ethnic Asthma Disparities. Health Lit Res Pract 2019; 3: e9–18. doi:10.3928/24748307-20181113-01
47 Kavanagh J, Jackson DJ, Kent BD. Over- and under-diagnosis in asthma. Breathe (Sheff) 2019; 15: e20–7. doi:10.1183/20734735.0362-2018
48 Yang CL, Gaffin JM, Radhakrishnan D. Question 3: Can we diagnose asthma in children under the age of 5 years? Paediatr Respir Rev 2019; 29: 25–30. doi:10.1016/j.prrv.2018.10.003
49 Bower KM, Thorpe RJ Jr, Rohde C, et al. The intersection of neighborhood racial segregation, poverty, and urbanicity and its impact on food store availability in the United States. Prev Med 2014; 58: 33–9. doi:10.1016/j.ypmed.2013.10.010
50 Aris IM, Lin P-I, Wu AJ, et al. Birth outcomes in relation to neighborhood food access and individual food insecurity during pregnancy in the Environmental Influences on Child Health Outcomes (ECHO)-wide cohort study. Am J Clin Nutr 2024; 119: 1216–26. doi:10.1016/j.ajcnut.2024.02.022
51 Johnson R, Low-Income SND. Defining low-income, low-access food areas (food deserts). 2021.
52 Perry R, Braileanu G, Palmer T, et al. The Economic Burden of Pediatric Asthma in the United States: Literature Review of Current Evidence. Pharmacoeconomics 2019; 37: 155–67. doi:10.1007/s40273-018-0726-2
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; Habre, Rima 2 ; Ryan, Patrick H 3 ; Datta, Soma 4 ; Luttmann-Gibson, Heike 1 ; Blossom, Jeff 5 ; Aris, Izzuddin M 6 ; Chandran, Aruna 7 ; Kress, Amii M 7 ; Gilliland, Frank 2 ; Breton, Carrie 2 ; Farzan, Shohreh F 2 ; Camargo, Carlos A, Jr 8 ; Liang, Donghai 9 ; Kerver, Jean M 10 ; Karr, Catherine J 11 ; Leve, Leslie D 12
; Dabelea, Dana 13 ; Karagas, Margaret R 14 ; Bennett, Deborah H 15 ; Nkoy, Flory L 16 ; Aschner, Judy 17 ; T Michael O’Shea 18 ; McEvoy, Cindy T 19 ; Knapp, Emily A 7 ; Schuh, Holly B 7 ; Miller, Rachel L 20 ; Gold, Diane R 21 ; Zanobetti, Antonella 1 1 Environmental Health, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA
2 University of Southern California Keck School of Medicine, Los Angeles, California, USA
3 Division of Epidemiology and Biostatistics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
4 Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
5 Center for Geographic Analysis, Harvard University, Cambridge, Massachusetts, USA
6 Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
7 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
8 Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
9 Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
10 Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan, USA
11 Department of Environmental and Occupational Health Sciences, School of Public Health, University of Washington, Seattle, Washington, USA
12 Prevention Science Institute, University of Oregon, Eugene, Oregon, USA
13 Department of Epidemiology and Department of Pediatrics, Colorado School of Public Health, University of Colorado School of Medicine, Aurora, Colorado, USA
14 Department of Epidemiology, Geisel School of Medicine and Children’s Environmental Health and Disease Prevention Research Center at Dartmouth, Dartmouth Medical School, Lebanon, New Hampshire, USA
15 Department of Public Health Sciences, University of California Davis, Davis, California, USA
16 Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
17 Hackensack Meridian School of Medicine, Hackensack, New Jersey, USA; Albert Einstein College of Medicine, Bronx, New York, USA
18 Department of Pediatrics, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
19 Department of Pediatrics, Papé Pediatric Research Institute, Oregon Health and Science University, Portland, Oregon, USA
20 Icahn School of Medicine at Mount Sinai, New York, New York, USA
21 Environmental Health, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA; Channing Division of Network Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA