About

Linda Adair, PhD, is a biological anthropologist and the Carla Smith Chamblee Distinguished Professor of Global Nutrition at the UNC Gillings School of Global Public Health. Her research primarily focuses on global nutrition problems, especially in low and middle income countries, with an emphasis on the first '1000 Days'—the period from conception through the first two years of a child's life. She explores factors related to healthy pregnancy, birth outcomes, and early child growth, and investigates how early life factors influence health and well-being in adulthood within the context of the developmental origins of adult health and disease (DOHaD). Dr. Adair has led the Cebu Longitudinal Health and Nutrition Survey since 1990, a birth cohort study that contributes to international research on the early origins of obesity and cardiometabolic diseases in low and middle income countries. Her work also includes studies on infant feeding and growth in the context of HIV, focusing on prevention of mother-to-child transmission and the influence of breastfeeding and complementary feeding on infant growth and survival in Malawi, Rwanda, and South Africa. She teaches courses such as International Nutrition and Analytic Methods in Nutritional Epidemiology, and leads the Doctoral Seminar each fall semester. Dr. Adair has received numerous awards for her teaching and research, including the McGavran Award for Excellence in Teaching and the UNC Gillings School of Public Health Teaching Innovation Award.

Research topics

• Medicine
• Genetics
• Biology
• Environmental health
• Evolutionary biology
• Demography
• Sociology
• Computer Science
• Geography
• Computational biology
• Bioinformatics
• Endocrinology
• Economics
• Business
• Gerontology
• Database
• Internal medicine
• Agricultural economics
• Psychiatry
• Psychology
• Environmental science

Selected publications

• Reliability of remote at-home oscillometric blood pressure monitoring in community-dwelling children aged 3–17

  UNC Libraries · 2025-07-02

  articleOpen access

  As hypertension becomes more prevalent, remote assessment of blood pressure (BP) has been proposed as a method to improve BP management in the pediatric population. We investigated the reliability of at-home BP monitoring in children ages 3–17. This study was conducted at six sites across the United States. Children participated in three BP measurements on one occasion by caregivers at home and, on another separate occasion, by trained examiners in a clinic setting. The results were averaged and classified according to the 2017 Pediatric Hypertension Guidelines as normal BP, elevated BP, stage 1 hypertension, or stage 2 hypertension. We collapsed participants with elevated BP, stage 1 hypertension, or stage 2 hypertension into one group: above-normal. We examined the agreement between the caregivers’ and examiners’ BP readings and the ease of the measurement process. One hundred eighteen (118) children participated in this study (48.3% male; mean age 9.65 ± 4.52 years). Most caregivers (78%−93%) and examiners (88%−99%) rated elements of BP measurement as “easy” or “very easy”. Caregiver and examiners’ agreement on BP classification as normal or above-normal ranged from 75.00% to 90.16% across age groups. Caregiver and examiner BP concordance significantly differed by age group (p = .03) and was lower among children with above-normal BPs. Overall, most aspects of the remote BP measurement process were rated as easy, suggesting that remote monitoring of BP in children is feasible. Concordance of BP measurements by caregivers and examiners was high for children in the normal BP range. More research is needed on the reliability of home BP monitoring across the pediatric age range for those with above-normal BP.

  PublisherDOI

• Dietary patterns and predictors of food insecurity and poor diet among children less than 5 years in the arid and semi-arid region of Kenya: a longitudinal study

  medRxiv · 2025-07-03

  preprintOpen access

  ABSTRACT We examined diet among children 6-23 and 24-59 months participating in a 2-year longitudinal study with six waves of data collection in Samburu and Turkana counties, Kenya. Information on child feeding practices was collected using methods recommended by the World Health Organization and UNICEF. Grains, roots, and tubers were nearly universally consumed. Dairy was the dominant animal source food (ASF), though declined sharply from Wave 1-5 among children 6-23 months and remained low across waves among children 24-59 months. The proportion of children who consumed fruits and vegetables, legumes and nuts, and eggs was low across waves. About half of children 6-23 months consumed sweet drinks at Wave 1 and consumption increased thereafter in both counties. Among children 24-59 months, nearly 90% of children in Samburu and about 65% in Turkana consumed a sweet drink across waves. Across all survey waves, only 11% and 5% of observations included foods from four or more food groups (representing minimum dietary diversity) in Samburu and Turkana, respectively. The mean number of food groups consumed ranged between 1.5 and 2.5, even among food secure households, though children in food secure households consumed about 0.5 more food groups. Children were more likely to consume dairy or any other ASF compared with their mothers, suggesting that mothers prioritize the nutritional needs of children over their own. The high prevalence of sweet drink consumption is mainly from sweetened tea, which is most likely given as a substitute for milk when milk is unavailable in pastoral and agropastoral households.

  PublisherOA PDFDOI

• The triple burden of obesity, HIV, and anaemia during pregnancy and associations with delivery outcomes in urban South Africans

  South African Journal of Clinical Nutrition · 2025-04-03 · 1 citations

  articleOpen access

  Objectives: First, to explore the independent associations between obesity, HIV (with ARV treatment), and anaemia and delivery outcomes in urban South African women and, second, to identify any potential interactions between these co-morbidities.Design: Longitudinal observational cohort study.Setting: Soweto, South Africa.Subjects: Mother–infant pairs (789) were recruited when mothers were < 20 weeks pregnant.Outcome measures: Infant gestational age at delivery was calculated, and infant birth weight and length were measured by trained research nurses. Head circumference was measured using a metal head circumference tape measure. Multivariable linear regression and logistic regression models were used to test the associations between obesity, HIV-positive status, and anaemia and delivery outcomes, as well as the potential interactions between the triple burden exposures.Results: At baseline, 14%, 11%, and 22% of women were diagnosed with only obesity, HIV, or anaemia respectively, while 42% had two conditions and 5% were exposed to the triple burden. Maternal obese vs. non-obese status was associated with a 0.32 higher weight-to-length z-score at birth (p < 0.01) and a 2.93 times higher risk of a large-for-gestational age delivery (p < 0.01). There were no interactions between the triple burden exposures on delivery outcomes.Conclusions: This study presents evidence for the importance of prioritising obesity prevention prior to conception in urban African settings such as South Africa. In addition, our findings highlight the need for more research into the complex relationships between maternal co-morbidities, as well as their potential influence (alone and in combination) on maternal and offspring health in the short and longer term.

  PublisherDOI

• Ultraprocessed Food Intake during the Transition to Adulthood Varies According to Sociodemographic Characteristics and Maternal Intake in Cebu, Philippines

  UNC Libraries · 2025-05-01

  articleOpen access
  PublisherDOI

• Extending the Environmental influences on Child Health Outcomes (ECHO) Cohort through 2030: Rationale and study protocol

  UNC Libraries · 2025-02-12

  articleOpen access

  Early life environmental exposures, even those experienced before conception, can shape health and disease trajectories across the lifespan. Optimizing the detection of the constellation of exposure effects on a broad range of child health outcomes across development requires considerable sample size, transdisciplinary expertise, and developmentally sensitive and dimensional measurement. To address this, the National Institutes of Health (NIH) Environmental influences on Child Health Outcomes (ECHO) Cohort Study is an observational longitudinal pediatric cohort study. In the first phase from 2016–2023, the ECHO Program built a robust platform for investigating prenatal and early life environmental exposures on child health outcomes. Now, the ECHO Program is extending longitudinal follow-up of existing ECHO participants <21 years of age and recruiting and following new pregnant participants <20 weeks gestation and their offspring through 2030. Participants will be enrolled at 72 Cohort Study Sites across all 50 US states, the District of Columbia, and Puerto Rico. Exposure assessments span the biological, chemical/physical, lifestyle, and social environment; child health outcomes focus on five broad domains: pre-, peri-, postnatal; airways; obesity; neurodevelopment; and positive health, or one’s physical, mental, and social well-being. Data and biospecimens will be collected annually through August 2030, with an expected total sample size of 60,000 children and their caregivers. The ECHO Cohort Study represents the largest national longitudinal study of children’s health in the US. Here, we describe the ECHO Cohort “Cycle 2” observational study arm and the ECHO Cohort Protocol version 3.0 (ECP v3.0), which delineates the data elements, measures, and biospecimens that all ECHO Cycle 2 Cohort Study Sites will collect and analyze.

  PublisherDOI

• Factors Influencing Wasting in Children Under 5 in Arid Regions of Kenya

  Maternal and Child Nutrition · 2025-04-23 · 2 citations

  articleOpen access

  Child wasting is a major public health problem in low- and middle-income countries. Our study aimed to identify immediate, underlying and basic factors influencing wasting among children in Turkana and Samburu, two arid and semi-arid regions in Kenya. Data are from a longitudinal study of children under 3 years of age at baseline, with follow-up every 4 months for 2 years. Generalized estimating equations were used to assess risk factors of wasting in this population. Among immediate factors, children who recently experienced diarrhoea had 19% and 23% higher odds of wasting, and those who consumed animal-source foods had 12% and 22% lower odds of wasting in Turkana and Samburu, respectively. Among underlying factors, children in Turkana whose caregivers used alcohol had 32% higher odds of wasting, whereas there was no effect of household food insecurity or factors related to water and sanitation on wasting in either county. Children in Turkana whose caregivers had 3-5 or 6 or more children had 39% and 70% higher odds, whereas those in female-headed households had 34% and 81% higher odds of wasting in Turkana and Samburu, respectively. Male children also had increased odds of wasting; 21% and 41% in Turkana and Samburu, respectively. Children in Turkana's fisherfolk communities had 36% higher odds of wasting compared with those in urban or peri-urban areas. Key risk factors for wasting included child sex, reported diarrhoea, caregiver's use of alcohol (in Turkana), caregiver's number of children, female-headed households and fisherfolk livelihood (in Turkana) while consuming animal-source foods was associated with lower risk. Interventions should target these intersecting factors to reduce wasting in these counties.

  PublisherOA PDFDOI

• Maternal Cardiometabolic Risk Factors in Pregnancy and Offspring Blood Pressure at Age 2 to 18 Years

  JAMA Network Open · 2025-05-08 · 5 citations

  articleOpen access

  Importance: Higher blood pressure in early life may signal cardiovascular disease over the life course, but determinants of blood pressure in early life are poorly understood. Objective: To examine the association of maternal cardiometabolic risk factors during pregnancy with offspring blood pressure from age 2 to 18 years and explore whether the association is modified by offspring sex and race and ethnicity. Design, Setting, and Participants: This cohort study analyzed data from the Environmental Influences on Child Health Outcomes program between January 1, 1994, and March 31, 2023. Three common maternal cardiometabolic risk factors during pregnancy were examined: prepregnancy obesity, gestational diabetes, and hypertensive disorders of pregnancy (HDP). Exposure: Maternal cardiometabolic risk factors were retrieved and harmonized from medical records and questionnaires. Main Outcomes and Measures: Offspring systolic blood pressure (SBP) and diastolic blood pressure (DBP) percentiles adjusted for age, sex, and height were calculated. Results: Among 12 480 mother-offspring pairs (mean [SD] maternal age during pregnancy, 29.9 [6.4] years; 856 of 12 303 identifying as Asian [7.0%]; 1908 as Black [15.5%]; 2305 as Hispanic [18.7%]; 6522 as White [52.3%], and 712 as other [5.8%] race and ethnicity), at least 1 maternal cardiometabolic risk factor was present in 5537 (44.4%), with prepregnancy obesity being the most prevalent (3072 [24.6%]), followed by HDP (1693 [13.6%]) and gestational diabetes (805 [6.5%]). Offspring born to mothers with any cardiometabolic risk factors had higher SBP (4.88 percentile points; 95% CI, 3.97-5.82 percentile points) and higher DBP (1.90 percentile points; 95% CI, 1.15-2.64 percentile points) at their first blood pressure measurement, after adjusting for potential confounders, compared with their counterparts without any risk factors. Hypertensive disorders of pregnancy, alone or with either prepregnancy obesity or gestational diabetes, was significantly associated with higher offspring blood pressure. These associations were generally more significant among female compared with male offspring and among Black compared with other racial and ethnic groups. Among 6015 offspring who had 2 or more blood pressure measures, maternal cardiometabolic risk factors were associated with an increased rate of blood pressure change from age 2 to 18 years (SBP percentile, 0.5 [95% CI, 0.2-0.8] per year; DBP percentile, 0.7 [95% CI 0.5-1.0] per year). Conclusions and Relevance: These findings suggest that protecting pregnant individuals from cardiometabolic risk factors may promote healthier blood pressure in the next generation.

  PublisherOA PDFDOI

• Children’s executive functioning and health behaviors across pediatric life stages and ecological contexts

  Journal of Behavioral Medicine · 2025-01-09

  articleOpen access
  PublisherOA PDFDOI

• Racial and ethnic differences in prenatal exposure to environmental phenols and parabens in the ECHO Cohort

  Journal of Exposure Science & Environmental Epidemiology · 2025-02-15 · 3 citations

  articleOpen access

  BACKGROUND: Research suggests racial/ethnic disparities in prenatal exposure to endocrine disrupting environmental phenols (EPs) in limited populations. However, no studies have investigated racial/ethnic disparities in prenatal EP exposure across the U.S. OBJECTIVES: To estimate demographic differences in prenatal urinary EPs among participants in the Environmental influences on Child Health Outcomes (ECHO) Cohort. METHODS: An analysis of 4006 pregnant ECHO participants was performed, with 7854 specimens collected from 1999-2020. Racial/ethnic identity was self-reported. Urinary levels of 2,4-dichlorophenol (2,4-DCP), 2,5-dichlorophenol (2,5-DCP), benzophenone-3 (BP-3), bisphenols A (BPA), F (BPF), and S (BPS), and methyl- (MePb), ethyl- (EtPb), propyl- (PrPb), and butyl- (BuPb) parabens were measured at one or more time points during pregnancy. Effect estimates were adjusted for age, pre-pregnancy body mass index, educational level, gestational age and season at urine collection, and ECHO cohort. RESULTS: Participants were classified as Hispanic of any race (n = 1658), non-Hispanic White (n = 1478), non-Hispanic Black (n = 490), and non-Hispanic Other (n = 362), which included individuals of multiple races. Urinary 2,4-DCP and 2,5-DCP concentrations were 2- to 4-fold higher among Hispanic, non-Hispanic Black, and non-Hispanic Other participants relative to non-Hispanic White participants. MePb was ~2-fold higher among non-Hispanic Black (95% confidence interval (CI): 1.7-3.1) and non-Hispanic Other (95% CI: 1.5-2.8) participants. PrPb was similarly higher among non-Hispanic Black (95% CI: 1.7-3.7) and non-Hispanic Other (95% CI: 1.3-3.1) participants. EtPb was higher among non-Hispanic Black participants (3.1-fold; 95% CI 1.7-5.8). BP-3 was lower in Hispanic (0.7-fold; 95% CI: 0.5-0.9), non-Hispanic Black (0.4-fold; 95% CI: 0.3-0.5), and non-Hispanic Other (0.5-fold; 95% CI: 0.4-0.7) participants. Urinary BuPb, BPA, BPF, and BPS were similar across groups. IMPACT STATEMENT: This multisite, observational cohort study investigated whether there are racial and ethnic differences in prenatal exposure to endocrine disrupting environmental phenols and parabens. Among 4006 participants from multiple U.S. cohorts who provided urine specimens during pregnancy, those who self-reported a racial and ethnic identity other than non-Hispanic White had higher urinary concentrations of 2,4-dichlorophenol, 2,5-dichlorophenol, methyl paraben, ethyl paraben, and propyl paraben and lower urinary concentrations of benzophenone-3 than those reporting as non-Hispanic White. These data show differences in prenatal concentrations of endocrine disrupting environmental phenols and parabens by racial and ethnic identity.

  PublisherOA PDFDOI

• Evaluation of a DNA methylation-based measure of chronic inflammation in two generations of adults in metropolitan Cebu, Philippines

  medRxiv · 2025-03-25

  preprintOpen access

  ABSTRACT Objectives Proxy measures of chronic inflammation derived from DNA methylation (DNAm) data have emerged as promising predictors of cardiometabolic disease risk in high income countries. This study investigates the performance of a recently validated DNAm-based measure of C-reactive protein (DNAm-CRP) in two generations of adults in the Philippines to evaluate its utility in lower and middle income settings experiencing high levels of endemic infections as well as rising rates of chronic degenerative diseases. Methods DNAm-CRP was calculated from 1,468 CpG sites on the Infinium MethylationEPIC v1.0 array applied to genomic DNA from leukocytes in young adults (N=1,665; 20-22 years) and older women (N=1,070; 35-68 years). C-reactive protein was determined in plasma using a high sensitivity immunoturbidimetric assay. Pearson correlation and least squares regression were implemented to evaluate the strength of association between DNAm-CRP and plasma CRP, and to investigate patterns of association between DNAm-CRP and established predictors of chronic inflammation. Results For younger adults, the correlation between DNAm-CRP and log-transformed CRP was 0.41, and DNAm-CRP explained 17.2% of the variance in CRP. For older women, the correlation was 0.47, with 22.7% explained variance in CRP. For both cohorts larger waist circumference was associated with higher DNAm-CRP. The presence of infectious symptoms at the time of blood collection and leukocyte composition were both significant predictors of DNAm-CRP. Conclusions In two generations of adults in the Philippines, we document strong correlations between DNAm-CRP and plasma CRP. DNAm-CRP may be a useful tool for research on chronic inflammation across a range of epidemiological and ecological settings globally, but future applications should consider how recent infections and the distribution of leukocyte subsets may confound or mediate associations of interest.

  PublisherOA PDFDOI

Recent grants

• NIH Grant R03TW00813303

  NIH · $26k · 2012

• NIH Grant R01HD054501

  NIH · $2.0M · 2014

• NIH Grant R03HD057637

  NIH · $71k · 2010

• NIH Grant R03TW00813302

  NIH · $59k · 2011

• NIH Grant R03TW00813301

  NIH · $33k · 2011

Frequent coauthors

• Jun Liu

  University of California, San Francisco

  212 shared

• Wei Zhao

  Michigan United

  205 shared

• Wei Zhou

  Yanbian University

  185 shared

• Reynaldo Martorell

  Emory University

  173 shared

• Sang Lee

  South Australian Health and Medical Research Institute

  167 shared

• Shane A. Norris

  South African Medical Research Council

  162 shared

• Zhe Wang

  Zhejiang University

  150 shared

• Barry M. Popkin

  146 shared

Labs

• UNC Gillings School of Global Public Health - Department of NutritionPI

Awards & honors

• McGavran Award for Excellence in Teaching, University of Nor…
• UNC Gillings School of Global Public Health Teaching Innovat…
• UNC Kellogg International Prize in Nutrition Award and Lectu…