***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective : To use an ecological systems approach to examine individual- , family- , community- and area-level risk factors for overweight ( including obesity )  in 3-year-old children . Methods : A prospect i ve nationally representative cohort study conducted in Engl and , Wales , Scotl and , Northern Irel and . Participants included 13 188 singleton children aged 3 years in the Millennium Cohort Study , born between 2000 and 2002 , who had complete height/weight data . The main outcome measure was childhood overweight ( including obesity ) defined by the International Obesity TaskForce cut-offs for body mass index . Results : 23.0 % of 3-year-old children were overweight or obese . In the fully adjusted model , primarily individual- and family-level factors were associated with early childhood overweight : birthweight z-score ( adjusted odds ratio , 1.36 , 95 % CI 1.30 to 1.42 ) , black ethnicity ( 1.41 , 1.11 to 1.80 ) ( compared with white ) , introduction to solid foods < 4 months ( 1.12 , 1.02 to 1.23 ) , lone motherhood ( 1.32 , 1.15 to 1.51 ) , smoking during pregnancy ( 1–9 cigarettes daily : 1.34 , 1.17 to 1.54 ; 10–19 : 1.49 , 1.26 to 1.75 ; 20 + : 1.34 , 1.05 to 1.70 ) , parental overweight ( both : 1.89 , 1.63 to 2.19 ; father only : 1.45 , 1.28 to 1.63 ; mother only : 1.37 , 1.18 to 1.58 ) , prepregnancy overweight ( 1.28 , 1.14 to 1.45 ) and maternal employment ⩾21 hours/week ( 1.23 , 1.10 to 1.37 ) ( compared with never worked ) . Breastfeeding ⩾4 months ( 0.86 , 0.76 to 0.97 ) ( compared with none ) and Indian ethnicity ( 0.63 , 0.42 to 0.94 ) were associated with a decreased risk of early childhood overweight . Children from Wales were also more likely to be overweight than children from Engl and . Conclusions : Most risk factors for early childhood overweight are modifiable or would allow at-risk groups to be identified . Policies and interventions should focus on parents and providing them with an environment to support healthy behaviours for themselves and their children OBJECTIVE To investigate the predictive association between  preschool childcare arrangements and  overweight/obesity in childhood . STUDY DESIGN Children were enrolled in a prospect i ve birth cohort in Quebec , Canada ( n = 1649 ) . Information about childcare obtained via question naires to the mothers at ages 1.5 , 2.5 , 3.5 , and 4 years was used to compute a main childcare arrangement exposure variable ( center-based/family-based/care by a relative/nanny ) . Body mass index was derived from measured weights and heights at ages 4 , 6 , 7 , 8 , and 10 years and children were classified as overweight/obese versus normal weight . Generalized estimating equations were used to model the effect of main childcare arrangement ( center-based/family-based/relative/nanny ) ( vs parental care ) on overweight/obesity adjusting for several potential confounding factors . RESULTS Compared with parental care , children who attended a center-based childcare  ( OR : 1.65 , 95 % CI : 1.13 - 2.41 ) or were cared for by a relative ( OR : 1.50 ; 95 % CI : 0.95 - 2.38 , although with greater uncertainty ) had higher odds of being overweight/obese in childhood ( 4 - 10 years ) . Analyses of number of hours additionally suggested that each increment of 5 hours spent in either center-based or relative childcare increased the odds of overweight/obesity in the first decade of life by 9 % . Associations were not explained by a wide range of confounding factors , including socioeconomic position , breastfeeding , maternal employment , and maternal body mass index . CONCLUSION Overweight/obesity was more frequently observed in children who received  non-parental care  in center-based setting s or care by a relative other than the parent . " Obesogeonic " features of these childcare arrangements should be investigated in future studies Background : In young children , the eating environment is an important social context within which eating behaviors develop . Among many low-income young children , the responsibility for feeding may have shifted from family members to child care providers because these children spend the majority of their day in child care setting s. Methods : To examine the influence of feeding among low-income children in child care setting s , feeding behaviors of child care providers in Head Start were observed and food consumption was assessed . Head Start , a comprehensive child development program that serves children from ages 3 to 5 , was chosen because of the large percentage of minorities , the low-income status of the families , and the age of the children . Fifty child care providers ( 25 African-American ; 25 Hispanic ) r and omly selected from Head Start centers in a large , urban southwestern city were observed on three mealtime occasions and self-reported feeding styles were assessed . Observed feeding behaviors were categorized into four feeding patterns based on their conceptual similarity to a general parenting typology ( i.e. , authoritarian , authoritative , indulgent , and uninvolved ) . Measures of food consumption were assessed on 549 children sitting with the child care providers during lunch at the Head Start centers . Results : Indulgent feeding behaviors were positively related to children ’s consumption of vegetables , dairy , entrée , and starch ; authoritative feeding behaviors were positively related to dairy consumption . Conclusion : This research highlights the important influence that child care providers have in the development of healthy and unhealthy eating behaviors in minority children . Implication s for intervention training for child care providers to promote healthy eating among Head Start children are discussed Background Low levels of physical activity are characteristic in preschoolers . To effectively promote physical activity , it is necessary to underst and factors that influence young children 's physical activity . The present study aim ed to investigate how physical activity levels are influenced by environmental factors during recess in preschool . Methods Preschool playground observations and pedometry during recess were carried out in 39 r and omly selected preschools ( 415 boys and 368 girls ; 5.3 ± 0.4 years old ) . In order to examine the contribution of playground variables to physical activity levels , taking adjustment for clustering of subjects within preschools into account , multilevel analyses were conducted . Results During recess boys took significantly more steps per minute than girls ( 65 ± 36 versus 54 ± 28 steps/min ) . In both genders higher step counts per minute were significantly associated with less children per m2 and with shorter recess times . Only in boys a hard playground surface was a borderline significant predictor for higher physical activity levels . In girls higher step counts were associated with the presence of less supervising teachers . Playground markings , access to toys , the number of playing or aim ing equipment pieces and the presence of vegetation or height differences were not significant physical activity predictors in both genders . Conclusion In preschool children physical activity during outdoor play is associated with modifiable playground factors . Further study is recommended to evaluate if the provision of more play space , the promotion of continued activity by supervisors and the modification of playground characteristics can increase physical activity levels in preschoolers BACKGROUND : The majority of infants in the United States are in nonparental child care , yet little is known about the effect of child care on development of obesity . OBJECTIVE : To examine the relationship between child care attendance from birth to 6 months and adiposity at 1 and 3 years of age . METHODS : We studied 1138 children from a prospect i ve cohort of pregnant women and their offspring . The main exposure was time in child care from birth to 6 months of age , overall and by type of care : ( 1 ) child care center ; ( 2 ) someone else 's home ; and ( 3 ) child 's own home by nonparent . The main outcomes were weight-for-length ( WFL ) z score at 1 year and BMI z score at 3 years of age . RESULTS : A total of 649 ( 57 % ) infants attended child care ; 17 % were cared for in a center , 27 % in someone else 's home , and 21 % in their own home by a nonparent . After adjustment for confounders , overall time in child care was associated with an increased WFL z score at 1 year and BMI z score at 3 years of age but not skinfold thicknesses . Center and own home care were not associated with the outcomes , but care in someone else 's home was associated with an increase in both the 1- and 3-year outcomes . CONCLUSION : Child care in the first 6 months of life , especially in someone else 's home , was associated with an increased WFL z score at 1 year and BMI z score at 3 years of age BACKGROUND Previous research has shown that children in child-care do not comply with dietary intake recommendations ( i.e. either exceeding or not meeting recommendations ) , which may be attributable to specific features of the child-care environment . The present study explored the relationship between the social and physical child-care ( day-care ) environment and dietary intake of 2- and 3-year-olds in Dutch child-care centres . METHODS The dietary intake of 135 children , aged 2 and 3 years , who were in child-care was assessed by observing r and omly selected children at three meals ( morning snack , lunch and afternoon snack ) to determine dietary intake ( i.e. saturated fat , dietary fibre and energy intake ) . The environment was observed using the Environment and Policy Assessment and Observation checklist , a structured instrument assessing the physical and social environment . RESULTS Children consumed a mean of 486 kJ ( 116 kcal ) during the morning snack , 2043 kJ ( 488 kcal ) during lunch and 708 kJ ( 169 kcal ) during the afternoon snack . There were some gender and age differences in dietary intake . Several environmental factors ( e.g. serving style and staff 's model dietary behaviour ) were significantly associated with the children 's dietary intake . CONCLUSIONS Overall , energy intake was in the upper range of recommended intake for children in child-care . The associations of several environmental factors with dietary intake stress the importance of the child-care environment for children 's dietary behaviour . Intervening in this setting could possibly contribute to the comprehensive prevention of childhood obesity OBJECTIVE A r and omized controlled pilot study to test the hypothesis that increasing preschool children 's  outdoor free play time increases their daily physical activity levels . METHODS Physical activity was assessed by accelerometers for four consecutive school days in thirty-two Latino children ( 3.6+/-0.5 years ) attending a preschool for low-income families . After two days of baseline physical activity assessment , participants were r and omly assigned to an intervention ( RECESS ; n = 17 ) or control ( CON ; n = 15 ) group . The RECESS group received two additional 30-minute periods of outdoor free play time per day for two days . The CON group followed their normal classroom schedule . Between group differences in physical activity variables were tested with a Wilcoxon rank-sum test . RESULTS There were no statistically significant differences between groups in changes from baseline in average total daily ( CON , 48.2+/-114.5 ; RECESS , 58.2+/-74.6 ) and during school day ( CON , 64.6+/-181.9 ; RECESS , 59.7+/-79.1 ) counts per minute , or total daily ( CON , 0.4+/-1.3 ; RECESS , 0.3+/-0.8 ) and during school day ( CON , 0.6+/-2.1 ; RECESS , 0.5+/-0.8 ) percent of time spent in moderate to vigorous physical activity . CONCLUSIONS Substantially increasing preschoolers '  outdoor free play time did not increase their physical activity levels OBJECTIVES We aim ed to investigate the effects of providing play equipment and markings at the pre-school playground on physical activity engagement levels . METHODS We performed a cluster r and omised control trial . In November and December 2007 , a convenience sample of 40 public pre-schools in Fl and ers , Belgium , was r and omly assigned to one of the following conditions : 1 ) in 10 pre-schools play equipment was provided , 2 ) in 10 pre-schools markings were painted on the playground , 3 ) in 10 schools play equipment was provided and markings were painted , 4 ) 10 schools served as a control condition . Accelerometer-based physical activity levels during recess were evaluated at baseline and 4 to 6 weeks after the implementation of the intervention in 583 children ( 52 % boys ; mean age 5.3 years , SD 0.4 ) . RESULTS At baseline pre-schoolers spent only 11.2 % ( average : 4.7 min ) of recess time in moderate to vigorous activity , while 61.3 % ( average : 25.7 min ) was spent in sedentary activity . The interventions were not effective in increasing the average activity levels or the percentages of engagement in moderate or vigorous activity , or in decreasing sedentary time . CONCLUSION Providing playground markings or play equipment is not sufficient to increase activity levels and decrease levels of sedentary activity during pre-school recess . More activating supervision and the inclusion of more structured physical activity seem needed Objective : We evaluated the effects of a preschool 
    Output:
    
Discussion Several studies support the hypothesis that the influence of the childcare environment on  children ’s physical activity and diet is moderated by child characteristics ( age , gender ) , but interaction between environmental types as well as between micro-systems is hardly examined in the field of behavioral nutrition and physical activity .