Sociodemographic and cardiometabolic risk correlates of adherence to pediatric behavioral guidelines: an ecological momentary assessment study

Background Modifiable daily behaviors are important predictors of pediatric cardiovascular health. The 9-5-2-1-0 mnemonic, based on ≥ 9 hours of sleep, ≥ 5 servings of fruits/vegetables, ≤ 2 hours of screen time, ≥ 1 hour of physical activity, and 0 sugar-sweetened beverages (SSB), provides an accessible framework for pediatric health promotion, yet adherence has not been evaluated using real-time behavioral assessment, and its association with cardiometabolic risk indicators in children remains insufficiently characterized. This study used ecological momentary assessment (EMA) to describe daily adherence patterns to the 9-5-2-1-0 guidelines, examine sociodemographic correlates of adherence, and explore associations between adherence and cardiometabolic risk indicators among children from predominantly low-income and racially and ethnically diverse households. Methods Data were drawn from the Family Matters cohort (Minneapolis/St. Paul, Minnesota). A subsample completed 7 days of EMA ( n = 562), and a subset underwent objective assessment of cardiometabolic risk indicators ( n = 330). EMA characterized daily adherence to the 9-5-2-1-0 guidelines. Higher adherence was defined as meeting 4–5 guidelines versus 0–3. Generalized estimating equations with robust standard errors were used to estimate prevalence ratios for sociodemographic correlates and mean differences for associations with cardiometabolic outcomes (blood pressure, waist circumference, heart rate, and BMI percentile). Results Children contributed 3,596 observation days; most daily scores reflected moderate adherence (2–4), while meeting none of the guidelines was rare. On days when only one guideline was met, adherence most commonly reflected screen time or sleep, whereas fruit/vegetable intake, physical activity, and limiting SSB intake co-occurred primarily on higher-adherence days. Higher adherence was less common among Black, Hispanic, Hmong, and Native American children and among those living in households with lower income, lower caregiver education, and experiencing food insecurity. Higher adherence was associated with more favorable cardiometabolic profiles, particularly lower systolic blood pressure and BMI percentile. Conclusions EMA data revealed meaningful disparities in adherence to the 9-5-2-1-0 guidelines and suggest that greater adherence may be associated with more favorable indicators of cardiometabolic health in childhood. Clinical and public health strategies to improve adherence to these behavioral guidelines should be culturally responsive and aligned with the social and structural contexts that shape families’ capacity to adopt and sustain lifestyle behaviors.