The relative contribution of layers of the Social Ecological Model to childhood obesity

Exploring the Broader Benefits of Obesity Prevention Community-based Interventions From the Perspective of Multiple Stakeholders

Community-based interventions (CBIs) show promise as effective and cost-effective obesity prevention initiatives. CBIs are typically complex interventions, including multiple settings, strategies and stakeholders. Cost-effectiveness evidence, however, generally only considers a narrow range of costs and benefits associated with anthropometric outcomes. While it is recognised that the complexity of CBIs may result in broader non-health societal and community benefits, the identification, measurement, and quantification of these outcomes is limited. This study aimed to understand the perspectives of stakeholders on the broader benefits of CBIs and their measurement, as well as perceptions of CBI cost-effectiveness. Purposive sampling was used to recruit participants from three stakeholder groups (lead researchers, funders, and community stakeholders of CBIs). Online semi-structured interviews were conducted, taking a constructivist approach. Coding, theme development and analysis were based on published guidance for thematic analysis. Twenty-six stakeholders participated in the interviews (12 lead researchers; 7 funders; 6 community stakeholders). Six key themes emerged; (1) Impacts of CBIs (health impacts and broader impacts); (2) Broader benefits were important to stakeholders; (3) Measurement of benefits are challenging; (4) CBIs were considered cost-effective; (5) Framing CBIs for community engagement (6) Making equitable impacts and sustaining changes-successes and challenges. Across all stakeholders, broader benefits, particularly the establishment of networks and partnerships within communities, were seen as important outcomes of CBIs. Participants viewed the CBI approach to obesity prevention as cost-effective, however, there were challenges in measuring, quantifying and valuing broader benefits. Development of tools to measure and quantify broader benefits would allow for more comprehensive evaluation of the cost-effectiveness of CBIs for obesity prevention.

Parental Perceptions About Energy Balance Related Behaviors and Their Determinants Among Children and Adolescents Living with Disability: A Qualitative Study in Greece

Background/Objectives: The prevalence of obesity is high among children living with disability. The present study aimed to examine the perceptions of parents and caregivers of children living with disability regarding children's energy balance related behaviors (EBRBs) and their determinants. Methods: Parents/caregivers of children living with disability (n = 45) from Thessaly, Crete and Attica Regions of Greece, participated in semi-structured interviews between November and December 2023. The interviews were recorded, transcribed and transferred to N-VIVO software. The results were analyzed according to the framework of the socio-ecological model, using deductive thematic analysis. Results: Parents/caregivers reported that eating habits of children living with disability and their physical activity levels were poorer compared to the general population. At an individual level, certain disabilities may affect children's food preferences and parents' ability to prepare healthy foods. At a familial level, financial difficulties may influence healthy eating, whereas some parents/caregivers act as children's role models to encourage them to be physically active. Home food environments may also influence children's eating patterns and peer influence on their EBRBs. At a community level, lack of trained personnel, available amenities/equipment and food education initiatives and the availability of unhealthy foods in school canteens were described as major barriers to healthy EBRBs. At an organizational level, lack of accessible/safe facilities, the marginalization/stigma that children living with disability may experience and lack of dietitians/nutritionists in health centers were named as the main factors influencing children's EBRBs. Conclusions: The findings of this study highlight the importance of designing multi-sectoral policy interventions to promote healthy EBRBs and tackle obesity in children living with disability in Greece.

Prospective relationship between family screen time rules, obesogenic behaviours, and childhood obesity

Family screen use rules (FSRs) could plausibly protect against the development of childhood obesity, although the mechanisms underlying these protective effects remain largely unexplored. This research aimed to investigate prospectively the associations between exposure to FSRs at age 24 months, obesogenic behaviours (excessive screen time and short sleep duration) at age 45 months, and obesity at age 54 months. Additionally, a model proposing the mediating role of obesogenic behaviours in the association between FSRs and childhood obesity was tested. Data were obtained from 5733 children and their mothers participating in the 'Growing Up in New Zealand' study. Logistic regressions examined the association between three FSRs (rules on quality, quantity and timing of screen time, and different numbers of FSRs), obesogenic behaviours, and childhood obesity. Structural equation modelling (SEM) was applied to assess the potential mediating roles of obesogenic behaviours in the association between FSRs and zBMI. Neither exposure to individual nor all three FSRs was significantly associated with lower odds of obesity. However, protective effects of FSRs were observed concerning obesogenic behaviours. Exposure to individual or all three FSRs correlated with reduced odds of not meeting screen time and sleep duration recommendations. SEM analysis indicated no direct association between FSRs and zBMI; nevertheless, a significant indirect association was identified through the mediation of obesogenic behaviours. These findings suggest the potential benefits of promoting the adoption of FSRs as a promising population-based strategy to enhance child health behaviours and mitigate the risk of childhood obesity.

A Scoping Review of Tailoring in Pediatric Obesity Interventions

Background: Families with children who have or are at risk for obesity have differing needs and a one-size-fits-all approach can negatively impact program retention, engagement, and outcomes. Individually tailored interventions could engage families and children through identifying and prioritizing desired areas of focus. Despite literature defining tailoring as individualized treatment informed by assessment of behaviors, intervention application varies. This review aims to exhibit the use of the term "tailor" in pediatric obesity interventions and propose a uniform definition. Methods: We conducted a scoping review following PRISMA-ScR guidelines among peer-reviewed pediatric obesity prevention and management interventions published between 1995 and 2021. We categorized 69 studies into 6 groups: (1) individually tailored interventions, (2) computer-tailored interventions/tailored health messaging, (3) a protocolized group intervention with a tailored component, (4) only using the term tailor in the title, abstract, introduction, or discussion, e) using the term tailor to describe another term, and (5) interventions described as culturally tailored. Results: The scoping review exhibited a range of uses and lack of explicit definitions of tailoring in pediatric obesity interventions including some that deviate from individualized designs. Effective tailored interventions incorporated validated assessments for behaviors and multilevel determinants, and recipient-informed choice of target behavior(s) and programming. Conclusions: We urge interventionists to use tailoring to describe individualized, assessment-driven interventions and to clearly define how an intervention is tailored. This can elucidate the role of tailoring and its potential for addressing the heterogeneity of behavioral and social determinants for the prevention and management of pediatric obesity.

Control of childhood obesity and implications for policy in China

Prevention and control of childhood obesity in China is complex. Despite numerous existing policy endeavours, particularly Healthy China 2030, accompanied by multiministerial initiatives, childhood obesity persists and even exacerbates. In this paper, we review current national policies, assess progress of the existing system managing childhood weight, and identify implementation challenges. Leveraging insights from existing literature and guided by a PEDALS (ie, problem, evidence-based practice, determinants, actions, long term, and scalability) framework, we propose a strategy to refine and integrate current policies, interventions, and research into a policy framework, embedding evidence-based practices into practical solutions for childhood obesity prevention and control in China.

Prevalence and factors associated with overweight and obesity among adolescents in Nagarjun municipality: a cross-sectional study

Introduction

Overweight and obesity are a growing global public health threat increasingly prevalent among adolescents in low-income and middle-income countries such as Nepal. These conditions are influenced by multifaceted social, behavioural, and habitual factors. Adolescents are particularly at risk due to changing dietary and lifestyle patterns. Additionally, the current nutritional shift, economic progress and rapid urbanisation pose significant threats to nutrition-related health outcomes. This study aims to assess the prevalence and factors associated with overweight and obesity among adolescents in Nepal.

Methods

A school-based cross-sectional study was conducted from September 2022 to January 2023 among 768 randomly selected adolescents from 10 schools in the Nagarjun municipality of Nepal. Anthropometric measurements of height and weight were assessed using standard tools, and the corresponding body mass index (BMI) was calculated. Factors associated with overweight/obesity were examined using the χ2 tests, followed by logistic regression analyses. The statistical significance was set at p<0.05 and 95% Confidence Intervals (CIs).

Results

The overall prevalence of overweight/obesity among adolescents was 6.38% (95% CI 4.64% to 8.11%). The mean weight, height and BMI of the participants were 50.22±9.37 kg, 160.17±9.14 cm and 19.56±3.24 kg/m2, respectively. Adolescents studying in higher grades (AOR 3.61, 95% CI 1.26 to 10.30), uninvolved in any kind of physical activity (AOR 4.97, 95% CI 2.38 to 10.34) and various games and extracurricular activities at school (AOR 2.49, 95% CI 1.16 to 5.28) and consuming high-calorie sugar-rich foods as lunch (AOR 3.02, 95% CI 1.31 to 6.94) were more likely of being overweight/obese than their respective counterparts.

Conclusion

Overweight and obesity are significantly influenced by lifestyles that involve minimal to no physical activity and by the dietary habits of adolescents. The findings warrant interventions in educational and home settings aiming to improve the lifestyles of adolescents.

Prevalence of Overweight and Obesity and Association with Risk Factors in Secondary School Children in Croatia

BACKGROUND

Childhood and adolescent overweight and obesity represent significant global health concerns. The primary objective of this study was to assess the prevalence and associations of some potential risk factors with overweight and obesity among Croatian adolescents aged 15 to 18.

METHODS

This cross-sectional study included 344 secondary school students from Croatia's Mediterranean region, with data collected through an anonymous questionnaire. The questionnaire gathered sociodemographic information, adherence to the Mediterranean diet of both children and their parents, and the children's dietary habits and physical activity levels.

RESULTS

Weight status data revealed that 2.6% of participants were underweight, 82% had normal weight, 11% were overweight, and 4.4% were classified as obese. The results indicated that boys (p < 0.001), children who skip breakfast (p = 0.031), those with less active lifestyles compared to their peers (p = 0.001), children whose mothers have a higher BMI (p < 0.001), and children from smaller families (p = 0.034) are at greater risk of being overweight or obese.

CONCLUSIONS

This study provides valuable insights into the risk factors associated with overweight and obesity in this age group, which can support the development of targeted strategies for this population.

A Scoping Review of Existing Policy Instruments to Tackle Overweight and Obesity in India: Recommendations for a Social and Behaviour Change Communication Strategy

Background

The Indian government is committed to addressing various manifestations of malnutrition, including overweight and obesity, inorder to improve individual health and well-being. The scoping review aims to map existing national policy instruments (programmes, schemes, regulations and guidelines) addressing overweight and obesity in India and analysing them for Social and Behaviour Change Communication (SBCC) strategies.

Methods

Systematic identification and selection of policy instruments using 'Arksey and O'Malley' framework was conducted from central government ministry websites, between March and June 2023. These instruments focused on nutrition and/or physical activity, targeting specific demographic groups like pregnant women, lactating mothers, children (0-5 years and 5-9 years), or adolescents (10-19 years); excluding those focusing on specific diseases like micronutrient deficiencies, wasting, and stunting. Based on search strategy six policy instruments were included and analysed for SBCC strategies.

Results

While many policy instruments incorporated SBCC plans; the 'National Programme for Prevention of Non-Communicable Diseases (NP-NCD)' stands out as a significant policy initiative specifically targeting the prevention of overweight and obesity within the broader context of Non-Communicable Diseases. It adopts a comprehensive approach addressing key drivers contributing to overweight/obesity across multiple levels of behavioural influence i.e., individual, interpersonal, community and organisation for health promotion. However, there's need to strengthen SBCC strategies related to prevention and management of obesity, especially screening and counselling, to cover all age groups with a particular focus on adolescents and youth. SBCC strategies can also be incorporated into India's Integrated Nutrition Support Programme (POSHAN 2.0) and/or Reproductive, Maternal, New-born, Child, Adolescent Health and Nutrition (RMNCAH+N) under the National Health Mission.

Conclusion

This paper underscores the necessity for comprehensive strategies to address multifaceted origins of overweight and obesity. The NP-NCD stands out as a noteworthy initiative, and there is considerable potential for other programmes to emulate SBCC strategies to bolster their overall effectiveness. Note : *Policy instruments throughout the paper have been used to cover programmes, schemes, regulations and guidelines.

The Role of Energy Balance-Related Behaviors (EBRBs) and their Determinants on the Prevalence of Overweight and Obesity in Children in Need, in Greece: A Scoping Review

BACKGROUND/AIM

There is scarce literature concerning 'children in need' at a European level (including Greece), particularly regarding energy balance-related behaviors (EBRBs) associated with overweight and obesity. This scoping review aimed to synthesize evidence on the EBRBs associated with overweight and obesity among 'children in need' in Greece and their key determinants.

METHODS

Inclusion criteria included children (0-18 years) who were 'in need', living with overweight or obesity, residing in Greece, and which included data on EBRBs and their potential determinants. APA PsychInfo, CINAHL, Cochrane CENTRAL, EMBASE, MEDLINE, as well as grey literature (in Greek/English), were searched (without publication date limitations). Data was extracted using an adapted Joanna Briggs Institute tool.

RESULTS

Seven studies were identified (n = 141-7,283 participants), highlighting prevalent EBRBs, categorized into groups; nutrition (lower diet quality, poor dietary habits, higher intake of carbohydrates, sugar sweetened beverage consumption, low adherence to the Mediterranean diet pattern, lack of daily breakfast consumption), sleep (low sleep duration), and sedentary behaviors / physical activity (television in children's bedrooms, high screen time, low physical activity, high sedentary time). Key determinants included low parental education, food culture, food preparation by grandmothers, the home environment, parental dietary choices, and lower socioeconomic status, etc. CONCLUSION: This review identified specific EBRBs associated with overweight and obesity affecting children in need in Greece and their determining factors. These findings should guide future research, tailored intervention programs, and public health policies (i.e. the European Child Guarantee Strategy) targeted at this understudied priority population of children in need, in Greece. Review registration number: Open Science Framework: https://osf.io/w7qdu.

Student and caregiver acceptability of a school-based intervention to improve sugar-sweetened beverage behaviors: a mixed methods study

Kids SIPsmartER is a 6-month behavioral and health literacy intervention effective at reducing sugar-sweetened beverage (SSB) intake among middle school students and their caregivers in the rural Appalachian region. This exploratory mixed methods study utilized a convergent parallel design to assess participant acceptability of a school-based curriculum for students and a text messaging program for caregivers. Acceptability was assessed using surveys (873 students and 453 caregivers), five focus groups (34 students) and telephone interviews (22 caregivers). Quantitative data were analyzed descriptively, and qualitative data were content coded. On a 5-point scale, average quantitative survey acceptability ratings ranged from 2.7 to 3.3 among three student-rated questions and 4.1 to 4.2 among four caregiver-rated questions. Qualitative focus group findings suggested that students preferred curricular activities that were hands-on and involved social interaction, while caregiver interview results showed high acceptability of the text messaging program's design, including usability, content messages and personalization. Students and caregivers reported similar program benefits: increased knowledge of SSBs and health risks, increased awareness of SSB behaviors and support to make beverage behavior changes. Results from this study can be used to understand Kids SIPsmartER's effectiveness data, communicate the intervention's acceptability with stakeholders and plan for future implementation studies.

Proteomics, Human Environmental Exposure, and Cardiometabolic Risk

BACKGROUND

The biological mechanisms linking environmental exposures with cardiovascular disease pathobiology are incompletely understood. We sought to identify circulating proteomic signatures of environmental exposures and examine their associations with cardiometabolic and respiratory disease in observational cohort studies.

METHODS

We tested the relations of >6500 circulating proteins with 29 environmental exposures across the built environment, green space, air pollution, temperature, and social vulnerability indicators in ≈3000 participants of the CARDIA study (Coronary Artery Risk Development in Young Adults) across 4 centers using penalized and ordinary linear regression. In >3500 participants from FHS (Framingham Heart Study) and JHS (Jackson Heart Study), we evaluated the prospective relations of proteomic signatures of the envirome with cardiovascular disease and mortality using Cox models.

RESULTS

Proteomic signatures of the envirome identified novel/established cardiovascular disease-relevant pathways including DNA damage, fibrosis, inflammation, and mitochondrial function. The proteomic signatures of the envirome were broadly related to cardiometabolic disease and respiratory phenotypes (eg, body mass index, lipids, and left ventricular mass) in CARDIA, with replication in FHS/JHS. A proteomic signature of social vulnerability was associated with a composite of cardiovascular disease/mortality (1428 events; FHS: hazard ratio, 1.16 [95% CI, 1.08-1.24]; P=1.77×10-5; JHS: hazard ratio, 1.25 [95% CI, 1.14-1.38]; P=6.38×10-6; hazard ratio expressed as per 1 SD increase in proteomic signature), robust to adjustment for known clinical risk factors.

CONCLUSIONS

Environmental exposures are related to an inflammatory-metabolic proteome, which identifies individuals with cardiometabolic disease and respiratory phenotypes and outcomes. Future work examining the dynamic impact of the environment on human cardiometabolic health is warranted.

Understanding Accelerated Summer Body Mass Index Gain by Tracking Changes in Children's Height, Weight, and Body Mass Index Throughout the Year

Background: Drivers of summer body mass index (BMI) gain in children remain unclear. The Circadian and Circannual Rhythm Model (CCRM) posits summer BMI gain is biologically driven, while the Structured Days Hypothesis (SDH) proposes it is driven by reduced structure. Objectives: Identify the mechanisms driving children's seasonal BMI gain through the CCRM and SDH. Methods: Children's (N = 147, mean age = 8.2 years) height and weight were measured monthly during the school year, and once in summer (July-August). BMI z-score (zBMI) was calculated using CDC growth charts. Behaviors were measured once per season. Mixed methods regression estimated monthly percent change in children's height (%HΔ), weight (%WΔ), and monthly zBMI for school year vs. summer vacation, seasonally, and during school months with no breaks vs. school months with a break ≥1 week. Results: School year vs. summer vacation analyses showed accelerations in children's %WΔ (Δ = 0.9, Standard Error (SE) = 0.1 vs. Δ = 1.4, SE = 0.1) and zBMI (Δ = -0.01, SE = 0.01 vs. Δ = 0.04, SE = 0.3) during summer vacation, but %HΔ remained relatively constant during summer vacation compared with school (Δ = 0.3, SE = 0.0 vs. Δ = 0.4, SE = 0.1). Seasonal analyses showed summer had the greatest %WΔ (Δ = 1.8, SE = 0.4) and zBMI change (Δ = 0.05, SE = 0.03) while %HΔ was relatively constant across seasons. Compared with school months without a break, months with a break showed higher %WΔ (Δ = 0.7, SE = 0.1 vs. Δ = 1.6, SE = 0.2) and zBMI change (Δ = -0.03, SE = 0.01 vs. Δ = 0.04, SE = 0.01), but %HΔ was constant (Δ = 0.4, SE = 0.0 vs. Δ = 0.3, SE = 0.1). Fluctuations in sleep timing and screen time may explain these changes. Conclusions: Evidence for both the CCRM and SDH was identified but the SDH may more fully explain BMI gain. Interventions targeting consistent sleep and reduced screen time during breaks from school may be warranted no matter the season.

Study design and rationale for TEENS+REACH: Evaluating ripple effects of a family-based lifestyle intervention to untreated family members

Background

Understanding the effects of family-based lifestyle intervention beyond the treated adolescent is important, given that obesity is a familial disease and there are likely bidirectional relations between an adolescent's treatment success and broader household changes. However, it is unknown if recommended household-wide changes are adopted or if untreated family members experience weight-related benefits.

Methods

TEENS + REACH leverages our ongoing randomized clinical trial of TEENS+, a family-based lifestyle intervention for adolescents with obesity, to determine: 1) if household-wide changes to the shared home environment are implemented, 2) if ripple effects to untreated family members are observed, and 3) whether these changes are predictive of adolescents' weight management success. TEENS + REACH will expand trial assessments to include comprehensive assessments of the shared home feeding, weight, and physical activity environment of the target adolescents. Specifically, we will enroll untreated children (8-17yrs) and caregivers living in the same household as the target parent/adolescent dyad (N = 60 families). At 0, 2, 4 (primary endpoint), and 8-months, the target parent/adolescent dyad and other untreated children and caregivers in the home will complete anthropometric assessments.

Discussion

Results will determine the familial reach of TEENS+ and reveal potential mediators of treatment response, which can inform future efforts to optimize family-based lifestyle interventions.

Trial registration

TEENS + REACH was retrospectively registered in Clinicaltrials.gov March 22, 2023 (NCT05780970) as an observational study ancillary to the TEENS + clinical trial, registered February 22, 2019 (NCT03851796).

The Combined Effects of Social Determinants of Health on Childhood Overweight and Obesity

Background: To characterize the association between multiple social determinants of health (SDOH) and overweight and obesity among US children. Methods: We conducted a cross-sectional analysis using the 2016-2020 National Survey of Children's Health. SDOH domains consisted of Economic Stability, Social and Community Context, Neighborhood and Built Environment, and Health Care Access and Quality. We used ordinal logistic regression to model associations between SDOH and weight status and calculate predicted probabilities of having overweight or obesity for various SDOH profiles. Results: Data from 81,716 children represented a weighted sample of 29,415,016 children ages 10-17 years in the United States. Of these, 17% had overweight and 17% had obesity. Compared with children with the theoretically lowest-risk SDOH profile, children with the highest-risk SDOH profiles in all four domains had an odds ratio of having a higher BMI category of 4.38 (95% confidence interval 1.67-7.09). For the lowest risk profile, the predicted probability of obesity varied from 8% to 11%, depending on race. For the highest risk profile, the predicted probability of obesity varied from 26% to 34%, depending on race. Conclusions: While high-risk values in each SDOH domain were associated with higher predicted probability of overweight and obesity, it was the combination of highest risk values in all the SDOH domains that led to greatest increases. This suggests a complex and multilayered relationship between the SDOH and childhood obesity, necessitating a comprehensive approach to addressing health equity to reduce childhood obesity.

"Associations between maternal perceptions of social support and adolescent weight status: A longitudinal analysis"

Social support is a well-established predictor of improved physical health outcomes among adults. Establishing whether maternal social support may have an inter-generational positive impact on their child's physical health will provide important information for developing potential interventions and policies. Elevated body mass index (BMI) is one indicator of child health that is linked to increased risk for cardiovascular disease and other morbidities later in life. There is some evidence that maternal social support is associated with improved child and adolescent weight status; however, no studies have examined whether specific aspects of social support are more impactful than others or whether support availability is differentially impactful across developmental stages. The present study examined whether maternal perceptions of specific types of social support (i.e., financial support, non-monetary instrumental support, partner emotional support, and having a close supportive contact) were associated with lower adolescent BMI z-scores using longitudinal data collected over a 15-year period from the Future of Families and Child Wellbeing Study (n = 3146), which includes a high proportion of families experiencing socioeconomic disadvantage. Findings from linear regression models using specific types of social support measured across six waves of data collected over a 15-year period indicated that maternal perceptions of greater financial support were associated with lower adolescent BMI z-scores at 15 years (B = -0.05, 95% CI: -0.10, -0.004, P = 0.04), while the other types of support were not. Additional timing analyses demonstrated that perceived financial support during late childhood to adolescence was associated with lower adolescent BMI z-scores (B = -0.06, 95% CI: -0.11, -0.01, P = 0.01), whereas associations between support during infancy and early childhood were not detected. Study findings provide important insights for developing interventions and policies that improve maternal social supports to benefit child health.

"It Takes a Village": Reflections from participants after a Hispanic community-based health promotion program

BACKGROUND

Physical activity (PA) among Hispanic and other minority adolescents in the U.S. lag behind White, non-Hispanic adolescents. Previous studies have examined the beneficial impact of culturally informed, community-based health programs within the Hispanic community on PA levels. There is a need for longer term follow up to determine the impact on family and individual habits over time. Our study aims to explore the aspects of a two-year PA and nutrition program, Families Inspired Together 4 Youth Empowered to Succeed (FIT4YES), that continue to influence family health habits and child development.

METHODS

Community-based focus groups were held in Milwaukee, WI with Hispanic parent participants of the FIT4YES program three years after program conclusion. A semi-structured guide of open-ended questions was used to facilitate the discussion of the lasting impact of FIT4YES. Each group was audio recorded, transcribed, and translated from Spanish when necessary. Four student researchers utilized a grounded theory qualitative approach to identify overarching themes.

RESULTS

Three focus groups with 16 total parents (N = 16) spoke about the program. Three overarching themes emerged from the transcripts indicating that cultural exposure, relationships, and self-growth were necessary for families to sustain the healthy behaviors promoted in FIT4YES. Specifically, parents discussed increased comfort levels with their children participating in school sports, the impact of shared experiences with community members, and continued skills initially taught and practiced during active programming.

CONCLUSIONS

Our group adapted our previously published model to a "post-program" state that incorporated the major themes and sub-themes with levels of the social-ecological model. Although the FIT4YES program ended, multiple ideals instilled by the program continued, we believe, due to the common themes illustrated by our model. This study utilized a community check-in approach to gain insight into the long-term impacts of the FIT4YES program. We propose three recommendations for consideration in the creation of community-based health programs: utilize dynamic, culturally appropriate components based on the intended community; understand the strength of the program as a whole is dependent on the strength of each individual component; and incorporate an anchor institution for consistency and trust within the community.

[Childhood obesity risk index (IROBIC) for small administrative areas in Chile]

Introduction

Introduction: although the prevalence of childhood obesity (CO) is high globally, there are no composite indices to estimate territorial aspects associated with its risk Objective: to develop an obesity risk index (IROBIC) for small administrative units, called "comunas" in Chile Methods: we used 2019 data from public sources on children under 10 years living in "comunas" of the two largest regions. IROBIC includes 16 indicators standardized for each "comuna" and grouped together into four domains, determined by principal component analysis (health, socio-economic, built-in and educational environments). IROBIC was calculated as a weighted geometric mean. Differences in obesity risk between the 10 and 5 "comunas" with the highest and lowest IROBIC and of each domain, were calculated with the disparity ratio. Results: in spite of the poorest "comunas" having the highest IROBIC, when its value and that for each domain were considered, we observed that the effect of inequality could be mitigated. The 10 and 5 "comunas" with the highest IROBIC have a 2.41 and 4.05 higher risk of CO compared to those with the lowest values Conclusions: IROBIC is a useful tool for monitoring the risk of CO and its factors from a territorial perspective.

Nutrition Interventions for Pediatric Obesity Prevention: An Umbrella Review of Systematic Reviews

Nutrition interventions to prevent pediatric obesity can help to establish healthy habits to improve current and future health. The objective of this umbrella review of systematic reviews (SRs) is to examine the impact of obesity prevention interventions with a nutrition component on body mass index measures, overweight/obesity prevalence, and cost-effectiveness in participants 2-17 years old. Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods were used, and this umbrella review was registered on PROSPERO (CRD42023443033). Included SRs were required to search ≥2 databases and to assess the risk of bias (RoB) of primary studies, and they were published 2017-June 2023. Database searches identified 4776 articles, and 31 SRs were included. In all age groups combined, interventions with both nutrition and physical activity were effective and cost-effective in all settings combined, and in the community setting specifically. In children ≤5 years old, interventions in the home and family, community, and healthcare settings demonstrated some efficacy, whereas in children 6-12 years old, school interventions were most effective. Evidence with individuals 13-17 years was limited. The certainty of evidence was generally low due to RoB in included studies, inconsistency, and imprecision. Pediatric obesity prevention interventions with nutrition should be tailored to the developmental stage to ensure appropriateness and efficacy.

Food Environments Within and Outside of Schools Play a Critical Role in Curtailing the Rise in Obesity among School-Aged Children over Time

BACKGROUND

Sound evidence for effective community-based strategies is needed to curtail upward trends in childhood obesity in the United States (US).

OBJECTIVES

The aim of the study was to assess the association between school and community food environments and the prevalence of obesity over time.

METHODS

Data were collected from K-12 schools in 4 low-income New Jersey cities in the US. School-level obesity prevalence, calculated from nurse-measured heights and weights at 4 time points, was used as the outcome variable. Data on the school food environment (SFE) measured the healthfulness of school lunch and competitive food offerings annually. The community food environment (CFE), i.e., the number of different types of food outlets within 400 m of schools, was also captured annually. The count and presence of food outlets likely to be frequented by students were calculated. Exposure to composite environment profiles both within schools and in communities around schools was assessed using latent class analysis. Data from 106 schools were analyzed using multilevel linear regression.

RESULTS

The prevalence of obesity increased from 25% to 29% over the course of the study. Obesity rates were higher in schools that had nearby access to a greater number of limited-service restaurants and lower in schools with access to small grocery stores and upgraded convenience stores participating in initiatives to improve healthful offerings. Interaction analysis showed that schools that offered unhealthier, competitive foods experienced a faster increase in obesity rates over time. Examining composite food environment exposures, schools with unhealthy SFEs and high-density CFEs experienced a steeper time trend (β = 0.018, P < 0.001) in obesity prevalence compared to schools exposed to healthy SFE and low-density CFEs.

CONCLUSIONS

Food environments within and outside of schools are associated with differential obesity trajectories over time and can play an important role in curtailing the rising trends in childhood obesity.

Results From La Vida Buena (The Good Life): A Quasi-Experimental Intervention of a Community Health Worker-Led Family-Based Childhood Obesity Program for Latino Children 5-8 Years of Age on the U.S.-Mexico Border

OBJECTIVE

To evaluate the effectiveness of the 8-week, community health worker (CHW)-led La Vida Buena childhood obesity program among Latino children 5 to 8 years old in a rural county along the U.S.-Mexico border.

METHODS

This quasi-experimental study used a community-based participatory research approach to compare the effectiveness of the La Vida Buena (The Good Life) curriculum as compared with a single educational session. We took anthropomorphic measures and administered parent-reported nutrition and physical activity surveys at baseline, 3 months, and 6 months. The study took place between 2017 and 2020 in Santa Cruz County, Arizona.

RESULTS

Change in body mass index (BMI) z-score was negligible for both groups. The parent-reported behavior indicated a shift toward healthier family behaviors and environment in the intervention group.

IMPLICATIONS FOR PRACTICE

This study adds to the growing literature of CHW-led childhood obesity interventions. The engagement of the CHWs in all aspects of the intervention helped to facilitate important behavior changes. Future interventions should emphasize health and wellness rather than BMI z-score and include community, socioeconomic, and systems-level interventions to promote healthy environments.

A Review of the Role of Built Environment and Temperature in the Development of Childhood Obesity

The burden of obesity is rising globally and is studied widely, yet the evidence for the association of environmental factors (both built and natural) with childhood obesity remains inconsistent. A relation with temperature as a proxy for natural environmental factors for obesity has not been reviewed previously. The purpose of this review was to assimilate updated evidence on environmental factors of childhood obesity. Three databases, MEDLINE (Medical Literature Analysis and Retrieval System Online), Web of Science, and Cochrane, were searched for articles related to the effect of built environment and temperature on childhood obesity in 6-12-year-olds published in the last five years. Twelve studies were identified: four longitudinal and eight cross-sectional. The studies were appraised using the National Institute of Health Quality (NIH) Assessment Tool. A review of included studies showed that built environmental features like higher residential and population density, higher intersection density, more playgrounds, and all park features like the presence or availability of parks, high number of parks, proximity to parks, and an increased park land area, showed a protective association against childhood obesity while land use mix showed a promoting association for the development of childhood obesity. Inconclusive evidence was observed for other built environmental features. The search strategy did not retrieve any literature published in the past five years studying the association between temperature and the development of childhood obesity. Standardization of definitions of exposure and outcome measures is recommended. Further research studying the relationship between environmental temperature and the development of childhood obesity is recommended.

Socioecologic Factors Associated With Obesity in Adolescents With Epilepsy in the United States

BACKGROUND

Obesity among youth with epilepsy has multifactorial etiology, yet socioecologic obesity risk factors (eg, neighborhood factors) have not been examined in this population. This study examined (1) the prevalence of obesity adjusting for relevant covariates and (2) socioecologic correlates of obesity in adolescents with epilepsy aged 10-17 years.

METHODS

This cross-sectional study used 2017-2018 National Survey of Children's Health data (total n = 27,094; epilepsy n = 184). Chi-square tests compared weighted prevalence of obesity with relevant covariates among all adolescents and adolescents with epilepsy. Weighted multiple logistic regression models were conducted to adjust for covariates.

RESULTS

The prevalence of obesity in adolescents with epilepsy was 27.8% (95% confidence interval [CI] 15.4%-40.3%) vs 15.1% (95% CI 14.1%-16.2%) for the non-epilepsy group. Adolescents with epilepsy also had higher odds of obesity after adjusting for age, gender, race/ethnicity, household income, physical activity, and medical home (odds ratio [OR] 2.1, 95% CI 1.2-3.8). Adjusting for sociodemographics, anxiety (OR 4.5, 95% CI 1.3-15.6), 2 or more adverse childhood experiences (OR 7.3, 95% CI 1.6-33.4), neighborhood detracting elements (eg, OR 5.2, 95% CI 1.5-18.5 for 1 detracting element), and forgone care (ie, unmet health care needs) (OR 22.4, 95% CI 3.8-132.8) were associated with obesity in adolescents with epilepsy. Adjusting for multiple comparisons, neighborhood detracting elements (P < .0001) and forgone care (P < .0007) remained significant.

CONCLUSION

Variables related to mental health, family functioning, built environment, and forgone care were associated with obesity in adolescents with epilepsy, but the association was not fully explained by these factors. Obesity interventions for this population should consider multiple levels of influence including the community and special health care needs of this population.

Multilevel Factors Associated With Obesity Among South Korean Adolescents Before and During the COVID-19 Pandemic

Background: Coronavirus disease 2019 (COVID-19)-necessitated lockdowns and school closures have limited social interactions among adolescents, which result in unhealthy behaviors. This study compared the multilevel factors associated with obesity among adolescents in South Korea before and during the pandemic. Method: We applied the social-ecological model and analyzed the 2019 and 2020 Korea Youth Risk Behavior Web-based Survey (KYRBS), including middle and high school students. We considered factors at the individual, family, and community levels in the logistic regression. Age and gender-adjusted obesity (body mass index ≥ the 95th percentile) was the dependent variable. Result: The prevalence of obesity slightly increased from 11.31% before the pandemic to 12.48% during it; the odds of obesity were 1.12 times (95% confidence interval [CI] = 1.08-1.16) as high during the pandemic compared to before it. Several individual factors (e.g., age, gender, fast-food consumption) and perceived family economic status were commonly associated with obesity before and during the COVID-19 pandemic. Physical activity and city type were related to obesity only before the pandemic. Downgraded economic status owing to COVID-19 was adversely related to obesity during the pandemic. Conclusion: Inclusive multilevel support is needed to combat obesity in adolescence during the pandemic and those economically impacted require additional support.

Investigation of non-National Immunization Program vaccination intentions in rural areas of China

BACKGROUND

China's current immunization program was revised in 2007. Some common childhood vaccines such as those for influenza, pediatric pneumonia, Haemophilus influenzae, varicella, and rotavirus have not been included in the National Immunization Program (NIP) and need to be purchased by children's guardians at their own expense. Rural areas, constrained by economic development and vaccine awareness, have a low non-NIP vaccination rate and more family medical expenses and social burden. This study aims to examine the awareness and attitude of rural parents about non-NIP vaccines and relevant factors influencing their vaccination intention to provide strategic suggestions for expanding and improving the Chinese government's NIP policy.

METHODS

A qualitative method of in-depth interviews were conducted for this study. We interviewed 30 rural parents in a central Chinese village to investigate their awareness of non-NIP vaccines and their vaccination intention and behavior. All the interview data were analyzed through the Colaizzi seven-step data analysis method.

RESULTS

This study summarized the individual and social level factors influencing the non-NIP vaccination intention of rural parents. The individual level factors include four themes: perceived severity with physical harm, treatment consumption (cost of the treatment of the subject diseases), psychological burden, and social consequences being subthemes; perceived vulnerability with age vulnerability, medical history, immune quality (children's underlying immune status), and environmental vulnerability (sanitary condition of the rural environment) as subthemes; perceived efficacy with effect perception, psychological comfort, protective strength, and functional compensation (functions of non-NIP vaccines unreplaceable by NIP vaccines) being subthemes; and perceived cost consisting of two subthemes cost burden and adverse reaction. The social level influencing factors include the vaccination opinions in rural social networks, the accessibility of health services and vaccine products, and the guidance and promotion of vaccination policies. These factors act outside of individuals' subjective awareness and influence decisions regarding non-NIP vaccination in rural areas.

CONCLUSION

Based on these influencing factors, this study constructs a structural model for non-NIP vaccination decision-making process in rural areas of China. The results play a guiding role in directing attention to children's health, promoting non-NIP vaccination, facilitating the dissemination of vaccine knowledge in rural areas, and improving NIP policies and practices in China.

Early childhood eating behaviors associated with risk of overweight and its socio-ecological determinants in Korean preschool children

BACKGROUND/OBJECTIVES

This study aimed to identify preschool children's eating behaviors associated with early childhood obesity and its multi-level, socio-ecological determinants.

SUBJECTS/METHODS

In a cross-sectional study of 364 mothers of preschool children aged 3-5 years, these children's healthy eating behaviors were assessed using a validated preschool nutrition quotient (NQ-P) questionnaire. The children's overweight or obesity statuses were determined based on body mass index percentiles from the 2017 Korean National Growth Chart. The associations between the NQ-P score and risk of overweight or obesity were examined using multivariable logistic regression. The associations of individual, maternal, physical, and media environmental factors with the NQ-P score were also examined using multivariable linear regression.

RESULTS

Preschool children with greater NQ-P scores were at a significantly lower risk of overweight or obesity (P < 0.01). The NQ-P score had a significantly positive association with maternal body mass index and an inverse association with household income (all P < 0.05). Maternal parenting and feeding practices exhibited associations with the NQ-P score. Positive associations were observed with "warm," "structured," and "autonomy-supportive" parenting as well as monitoring feeding practices (all P < 0.05). In addition, the NQ-P score had a significantly positive association with the childcare center's anti-obesogenic environment, such as the provision of nutritional and physical-activity support and vicinity of the built food environment to the home, including access to good-quality food, fruits and vegetables, and low-fat foods (all P < 0.05). Regarding media environments, the NQ-P score demonstrated more significant associations with viewing and eating and/or cooking content displayed on online video platforms (all P < 0.05) than with that on television.

CONCLUSIONS

Our findings confirm the significance of healthy eating behaviors in early-childhood-obesity prevention and underscore the importance of multilevel maternal, physical, and media environmental interventions that effectively guide eating behaviors in preschool children.

Examining the Long-term Association Between Neighborhood Socioeconomic Status and Obesity and Obesity-related Unhealthy Behaviors Among Children: Results From the Fragile Families and Child Wellbeing Study

BACKGROUND

Literature has focused on neighborhood environments and their possible impacts on obesity and obesity-related behaviors. However, few longitudinal studies have examined the effect of neighborhood socioeconomic status (nSES) on childhood obesity.

PURPOSE

Investigate the longitudinal association between nSES and obesity and obesity-related unhealthy behaviors.

METHODS

We obtained data from the Fragile Families and Child Wellbeing Study (N = 2,072). The main exposure was nSES (measured using an index of five variables representing wealth, income, education, and occupation from the Decennial Census 2000) at ages 3, 5, and 9. The outcome was children's body mass index z-score (BMIz) at ages 5, 9, and 15. Three measures of obesity-related behaviors (i.e., child- or caregiver-reported soda/snack food intake, fast-food intake, and sedentary behaviors) at ages 5, 9, and 15 were included as mediators and outcomes. Cross-lagged path analyses were conducted.

RESULTS

Higher nSES at a previous wave was associated with consuming less soda/snack foods (βs = -0.15 to -0.11 [varying by ages], p < .05) and fast-food intake (βs = -0.21 to -0.14 [varying by ages], p < .01), and less frequent sedentary behaviors (βs = -0.14 to -0.06 [varying by ages], p < .01), but not with BMIz (βs = -0.08 to 0.05 [varying by ages], p > .05). Unhealthy behaviors did not mediate the nSES-BMIz association at alpha .05.

CONCLUSION

Health policies need to target low-socioeconomic neighborhoods to shape healthy lifestyles in children. To develop effective interventions, future research needs to examine comprehensive potential mediators like obesity-related parenting skills, home environments, and built and social environments on the risk of childhood obesity and obesity-related behaviors.

Point of Decision Design to Address Adolescent Overweight and Obesity

OBJECTIVES

This study aims to utilize the point of decision design framework to understand how, where, and why adolescents and families make decisions about diet and physical activity and to explore how modifications to the environment can help to promote healthier choices and reduce obesity.

BACKGROUND

Child and adolescent obesity is a critical public health problem. As environmental factors are a primary contributor, understanding the role of design in our surrounding environment highlights an important area of interdisciplinary study. Design strategies have been used successfully to increase stair use and reduce sedentary behavior and can be used to further promote healthier diet and activity choices among adolescents and families.

METHODS

We leveraged the human-centered design-thinking process through (1) qualitative interviews and survey instruments, (2) persona and prompt development, and (3) a design workshop with multidisciplinary stakeholders.

RESULTS

Five personas were developed from the qualitative data and used in a design-thinking workshop. During the workshop, participants generated 12 influential factors and nine points of decision which were used to generate 33 solutions spanning the design continuum (from information and policy design to the design of urban, architectural, and interior environments) aimed at improving nutrition and physical activity among adolescents. Additionally, a tool kit was prototyped, which includes interview guides, a persona framework, and a workshop facilitation guide.

CONCLUSIONS

Our novel process led to the generation of design solutions that can be implemented to expand and improve upon existing interventions for childhood obesity and create environments that encourage positive health outcomes.

Motivational Interviewing in Pediatric Obesity: A Meta-analysis of the Effects on Behavioral Outcomes

BACKGROUND

Currently, the effects of motivational interviewing (MI) on children's behavioral changes remain obscure.

PURPOSE

This systematic review and meta-analysis examined the effects of MI on children's lifestyle behavioral changes (fruits and vegetables [F/V], dairy, sugary beverages, calories, snacks, fat intake, moderate vigorous physical activity [MVPA], and screen time).

METHODS

Six databases (CINAHL, Cochrane, Embase, PsycINFO, PubMed, and Web of Sciences) from 2005 to 2022 were searched. Thirty-one intervention studies with a comparison group met the criteria. Random-effects models were performed to estimate the pooled effects; exploratory moderation analyses with mixed-effects models were used to explore potential intervention moderators.

RESULTS

The pooled effect size was 0.10 (p = .334) on ↑F/V, 0.02 (p = .724) on ↑dairy, -0.29 (p < .001) on ↓calories, -0.16 (p = .054) on ↓sugary beverages, -0.22 (p = .002) on ↓snacks, -0.20 (p = .044) on ↓fat, 0.22 (p = .001) on ↑MVPA, and -0.06 (p = .176) on ↓screen time. The effects of MIs were moderated by ↑MI sessions regarding ↓snacks (B = -0.04, p = .010). Multicomponent and clinical programs had greater effects on dairy intake than their counterparts (0.09 vs. -0.21, p = .034; 0.12 vs. -0.14, p = .027, respectively). Similarly, interventions with a fidelity check resulted in greater dairy intake than those without a check (0.29 vs. -0.15, p = .014). A few long-term follow-up assessments revealed effects on ↓F/V (-0.18; p = .143, k = 2), ↓dairy (-0.13, p = .399, k = 4), ↓MVPA (-0.04; p = .611, k = 6), and ↑screen time (0.12; p = .242, k = 4).

CONCLUSIONS

Our findings support the short-term effects of MI on improving children's lifestyle behaviors. Additional investigations are needed to better sustain children's long-term behavioral changes.

Parenting a Toddler in the Era of Pervasive Screens: Interviews with Low-Income Mexican American Parents

Screen media use starts in early childhood, despite recommendations to limit use. This study explored low-income Mexican American mothers' and fathers' beliefs, parenting practices, and perceived contextual contributors related to toddler screen use. We conducted interviews with 32 low-income Mexican American parents. Transcripts of audio recordings were analyzed to identify themes. Parents perceived numerous benefits to screen use, including learning and enjoyment, as well as seeing it as a helpful tool for parents. Reported risks included harmful mental and physical effects and a risk of use being all-consuming. Parents managed screen use with a variety of practices, including giving close attention to content, monitoring duration, and engaging in co-use. They also used screens for behavior management and in specific situations, such as to prepare for sleep. Some differences in beliefs and parenting practices exist by screen device type. Parents also reported that contextual factors, such as weather and neighborhood safety, influenced screen use. This study extends the current literature regarding child screen use, with its focus on low-income Mexican American toddlers. The findings offer interventionists and providers insight into the management of screens in the lives of this population.

Understanding drivers of micro-level disparities in childhood body mass index, overweight, and obesity within low-income, minority communities

The focus of childhood obesity disparities has been mainly on macro-level disparities, such as, between lower versus higher socioeconomic groups. But, less is known about micro-level disparities, that is disparities within minority and low-income populations. The present study examines individual and family level predictors of micro-level obesity disparities. We analyze data on 497 parent-child dyads living in public housing communities in Watts, Los Angeles. Cross-sectional multivariable linear and logistic regression models were estimated to examine whether individual and family level factors predict children's BMI z-scores, overweight, and obesity in the sample overall and separately by child's gender and age group. Child characteristics of our study sample included mean age 10.9 years, 74.3% Hispanic, 25.7% Non-Hispanic Black, 53.1% female, 47.5% with household income below $10,000, 53.3% with overweight or obesity, and 34.6% with obesity. Parental BMI was the strongest and most consistent predictor of child zBMI, overweight, and obesity, even after controlling for parent's diet and activity behaviors and home environment. The parenting practice of limiting children's screentime was also protective of unhealthy BMI in younger children and females. Home environment, parental diet and activity behaviors, and parenting practices related to food and bedtime routines were not significant predictors. Overall, our findings show that there is considerable heterogeneity in child BMI, overweight, and obesity even within low-income communities with similar socioeconomic and built environments in their neighborhoods. Parental factors play an important role in explaining micro-level disparities and should be an integral part of obesity prevention strategies in low-income minority communities.

Discerning conversational context in online health communities for personalized digital behavior change solutions using Pragmatics to Reveal Intent in Social Media (PRISM) framework

BACKGROUND

Online health communities (OHCs) have emerged as prominent platforms for behavior modification, and the digitization of online peer interactions has afforded researchers with unique opportunities to model multilevel mechanisms that drive behavior change. Existing studies, however, have been limited by a lack of methods that allow the capture of conversational context and socio-behavioral dynamics at scale, as manifested in these digital platforms.

OBJECTIVE

We develop, evaluate, and apply a novel methodological framework, Pragmatics to Reveal Intent in Social Media (PRISM), to facilitate granular characterization of peer interactions by combining multidimensional facets of human communication.

METHODS

We developed and applied PRISM to analyze peer interactions (N = 2.23 million) in QuitNet, an OHC for tobacco cessation. First, we generated a labeled set of peer interactions (n = 2,005) through manual annotation along three dimensions: communication themes (CTs), behavior change techniques (BCTs), and speech acts (SAs). Second, we used deep learning models to apply our qualitative codes at scale. Third, we applied our validated model to perform a retrospective analysis. Finally, using social network analysis (SNA), we portrayed large-scale patterns and relationships among the aforementioned communication dimensions embedded in peer interactions in QuitNet.

RESULTS

Qualitative analysis showed that the themes of social support and behavioral progress were common. The most used BCTs were feedback and monitoring and comparison of behavior, and users most commonly expressed their intentions using SAs-expressive and emotion. With additional in-domain pre-training, bidirectional encoder representations from Transformers (BERT) outperformed other deep learning models on the classification tasks. Content-specific SNA revealed that users' engagement or abstinence status is associated with the prevalence of various categories of BCTs and SAs, which also was evident from the visualization of network structures.

CONCLUSIONS

Our study describes the interplay of multilevel characteristics of online communication and their association with individual health behaviors.

Association of fast-food restaurants with overweight and obesity in school-aged children and adolescents: A systematic review and meta-analysis

We aimed to explore associations between the accessibility of fast-food restaurants (FFRs) and weight-related outcomes in children and adolescents through a systematic review and meta-analysis of studies. We searched three databases for studies published before October 21, 2022. Study quality was assessed using the National Institutes of Health's Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Meta-analysis was performed, and the leave-one-out method was used for sensitivity analysis. A total of 60 studies were included. According to our analysis, FFRs within a smaller buffer radius from residences or that provide unhealthy foods may have a more significant influence on children's and adolescents' weight. Children of younger ages and girls may have a higher possibility of being overweight due to FFRs. Though we could hardly avoid bias, the estimates in low-and middle-income countries (only six studies) are much higher than those in high-income countries (54 studies). More research analyses based on microscope data and individual economic levels are needed. This study yields quantitative results, provides policymakers and urban planners with a theoretical support for building resilient and sustainable human settlements, and promotes the translation of research findings from public health to environmental planning.

Child health and development in the course of the COVID-19 pandemic: are there social inequalities?

COVID-19 pandemic lockdowns and closures have influenced all children's health and development (HAD). We aimed to examine whether this differs by social circumstances. We hypothesised that socially disadvantaged children experienced more pronounced deterioration in their HAD compared with better-off children. In our trend study, we included five cohorts of school enrolment medical screening (school entrance 2018-2022) in the city of Dusseldorf, Germany. To compensate for selection bias due to the limited number of examinations in pandemic months, we chose the first 800 examinations of each cohort. We computed predicted prevalences of overweight, coordination and language problems as indicators of HAD. Neighbourhood deprivation, single-parent families and non-German nationality were used as indicators of social disadvantage. All groups of children experienced a deterioration in their HAD. Its magnitude is comparable between children with different social circumstances. For instance, between 2018 and 2021, prevalence of overweight increased from 19.2 to 24.2% in children from deprived neighbourhoods, and from 8.1 to 16.5% in children from well-off neighbourhoods. Prevalence of language problems (prepositions) increased from 49.9 to 72.1% among non-German children, and from 14.4 to 39.1% among German children.   Conclusion: Results only partly confirmed our hypothesis. However, since the pre-pandemic prevalences of HAD problems among disadvantaged children were already higher, further deterioration - regardless of its magnitude - has led to their particularly poor situation. For those children, overweight and language development should be priorities of prevention. Generally, important settings for child HAD such as kindergartens or leisure facilities should remain open in future pandemics. What is known: • The COVID-19 pandemic has had a negative impact on general child health and development. • Before the pandemic, social inequalities in child health and development were a common phenomenon. What is new: • Children in all social groups experienced a deterioration in their health and development over the course of the pandemic. • Over the course of the pandemic, children from deprived neighbourhoods have demonstrated a particularly high prevalence of overweight. Language problems are particularly prevalent among non-German children.

George SM. The Effects of Parent-Adolescent Acculturation Gaps on Adolescent Lifestyle Behaviors: Moderating Role of Family Communication

Objectives

This study examined 1) associations between parent-adolescent acculturation gaps in Americanism and Hispanicism and adolescents' lifestyle behaviors (fruit and vegetable intake and physical activity), and 2) the moderating roles of adolescent- and parent-reported family communication on these associations.

Methods

Hispanic adolescents who have overweight or obesity (n=280; 52% female, 13.0±0.8 years old) and their parents (88% female, 44.9±6.5 years old) completed baseline measures on acculturation, family communication, weekly physical activity, and daily fruit and vegetable intake as part of their participation in a family-based health promotion efficacy trial. Acculturation gaps were calculated by taking the product of adolescent and parent scores for each subscale (Americanism and Hispanicism). We conducted multiple linear regression analyses with three-way interaction terms (e.g., parent Americanism x adolescent Americanism x family communication) to assess for moderation.

Results

Family communication significantly moderated the association between parent-adolescent acculturation gaps in Americanism and adolescent fruit and vegetable intake. For families with low adolescent-reported family communication, parent-adolescent discrepancies in Americanism were associated with lower adolescent fruit and vegetable intake whereas there were no significant associations for families with high family communication. There were no effects on weekly minutes of physical activity. Acculturation gaps in Hispanicism were not significantly associated with either outcome.

Conclusions

Findings highlight the importance of parent-adolescent acculturation gaps and family communication on fruit and vegetable intake for Hispanic adolescents. Targeting parent-adolescent acculturation gaps for families with low levels of communication may be important to improve dietary behaviors in Hispanic adolescents, who are already disproportionately affected by obesity.

"It's about being healthy"; a novel approach to the socio-ecological model using family perspectives within the Latinx community

BACKGROUND

The Latinx community is at risk for obesity, type 2 diabetes, and other chronic illnesses. Culturally appropriate, community facing physical activity (P.A.) and nutrition programs may provide the basis for families to improve their health status. Our objectives are as follows: 1. To investigate synergistic factors within this type of program that play a role in creating an environment for participants to learn and practice healthy behaviors. 2. To apply factors into a novel model of components that support health and wellness. 3. To design an intervention for future implementation and evaluation.

METHODS

A two-year P.A. and nutrition program, Families Inspired Together 4 Youth Empowered to Succeed (FIT 4 YES), took place in Milwaukee, WI. with Hispanic families from 2018 to 2020 through a community-academic partnership. A pair of interviewers spoke with families who provided insight into the impact of the program. A grounded theory qualitative approach to code the transcripts guided the team to identify overarching themes.

RESULTS

Twenty-four interviews were conducted. Common themes indicated that children had a stronger belief in their abilities and confidence in peer support. Parents noticed their children increasing self-directed healthy behaviors. All families grew in their implementation of health and wellness.

CONCLUSIONS

Three main components of FIT 4 YES contributed to its success: opportunities for engagement, supportive relationships, and the interplay of components that emerged from the interviews. Effective programs could include these components to make their outcomes more cohesive within the family. A novel model emerged that builds on the social-ecological model that emphasizes the dynamic interactions between these main components. Additional research is needed to evaluate the long-term effects and response by the community.

The impact of social determinants of health on obesity and diabetes disparities among Latino communities in Southern California

BACKGROUND

Social determinants of health (SDoH) describe the complex network of circumstances that impact an individual before birth and across the lifespan. SDoH contextualize factors in a community that are associated with chronic disease risk and certain health disparities. The main objective of this study was to explore the impact of SDoH on the prevalence of obesity and diabetes, and whether these factors explain disparities in these health outcomes among Latinos in Southern California.

METHODS

We utilized three composite indices that encompass different SDoH: the Healthy Places Index (HPI), Social Vulnerability Index (SVI), and CalEnviroScreen (CES). Univariate linear regression models explored the associations between index scores with adult obesity, adult diabetes, and childhood obesity.

RESULTS

Communities with lower HPI scores were associated with higher prevalence of metabolic disease and a greater proportion of Latino residents. Cities in the lowest decile of HPI scores had 71% of the population identifying as Latino compared to 12% in the highest decile. HPI scores explained 61% of the variability in adult obesity (p < 0.001), 41% of the variability in childhood obesity (p < 0.001), and 47% of the variability in adult diabetes (p < 0.001). Similar results were observed when examining SVI and CES with these health outcomes.

CONCLUSIONS

These results suggest that Latinos in Southern California live in communities with adverse SDoH and face a greater burden of adult obesity, diabetes, and childhood obesity.

Senior food insecurity in the USA: a systematic literature review

OBJECTIVE

Understanding the factors associated with senior food insecurity is key to understanding senior-specific needs to develop targeted interventions and ultimately lower the prevalence and the incidence of food insecurity. We aimed to systematically review published literature and summarise the associated factors of food insecurity in older adults in the USA.

DESIGN

We searched PubMed, Scopus, Web of science, EconLit and JSTOR databases for peer-reviewed articles published in English between January 2005 and September 2019 that assessed food security or its associated factors for US adults aged 60 years and older. After a two-step screening process, twenty articles were retained and included in the review.

SETTING

NA.

PARTICIPANTS

NA.

RESULTS

The majority of studies were cross-sectional (70 %), consisted of data from one state (60 %), and had large sample sizes. Food-insecure individuals were more likely to be younger, less educated, Black or African American, female, a current smoker, low income, and self-report fair/poor health, have chronic conditions, and utilise government assistance programmes. Food insecurity was associated with medication non-adherence, poor mental health outcomes and limitations in physical functioning. Results were mixed for overweight/obesity status. There was no discernable pattern related to the consistency of findings by the assessed quality of the included studies.

CONCLUSIONS

Food insecurity is a prevalent and pervasive issue for older adults. The numerous correlates identified suggest that interventions aimed at enhancing food and nutrition safety net and medication assistance programmes are warranted, and upstream, systemic-level interventions may be best suited to deal with the correlates of food insecurity.

Autism Spectrum Disorder Diagnosis and Other Child, Family, and Community Risk Factors for Obesity among Children and Adolescents Aged Ten to Seventeen Years in the United States: A Mediation Analysis

Background: This study explored whether there are mediated effects of child and family risk in the association between community and organizational risk and obesity among children and adolescents aged 10-17 years using 2017-2018 National Survey of Children's Health (NSCH) data, addressing autism spectrum disorder (ASD) and co-occurring conditions. Methods: This cross-sectional study (N = 27,157) used 2017-2018 NSCH data. Frequency distributions and chi-square tests were used to describe participants with and without ASD. Cumulative risk indices were created for child, family, community, and organizational level risk, and mediation analyses were conducted in a two-mediator model (X1: community risk, X2: organizational risk, M1: child risk, M2: family risk) for the dichotomous outcome (Y: obesity). Path analyses were performed using generalized structural equation modeling in Stata 16.0. Results: Direct effects for all four risk indices were associated with obesity in single index models (all p < 0.001); only child and family risk indices were associated with obesity in a full model with all four risk indices (both p < 0.001). When child and family risk indices were assessed as mediators, the indirect effects of community and organizational risk were significant (all p < 0.0001). The total effect of community risk on obesity was significant with family risk as a mediator (p = 0.002). The total effect of organizational risk was not significant with either mediator. Conclusion: Findings suggest that child and family factors play a strong role in obesity risk and that ASD contributes to this risk. Community risk may be another strong predictor of obesity, mediated by family risk. Additional research on social-ecological risk factors for obesity is needed to identify leverage points to improve obesity risk in children and adolescents with and without ASD.

Adolescents' Nutrition: The Role of Health Literacy, Family and Socio-Demographic Variables

Adolescent obesity rates are increasing on an epidemic level and food intake is one of the most important causes of this condition. From an ecological perspective, food intake is, in turn, influenced by many factors that need to be considered. This study aims to evaluate the associations between socio-demographic factors (gender, family origin, socio-economic status, parent's education level), which consist of social stratifiers, health literacy and family context, as independent variables, and food intake (consumption of fruits, vegetables, soft drinks and sweets and breakfast frequency) and outcomes (Body Mass Index category), as dependent variables. Data were retrieved from 2145 students (13 and 15 years old) from the Lombardy region (Italy) who participated in the 2018 edition of Health Behaviour in School-Aged Children (HBSC). Six multiple binary logistic regression models were used in this study. Fruit, vegetable and soft drinks consumption models were related to all three-factor levels. Breakfast consumption frequency was associated with socio-demographic variables. BMI category was associated with socio-demographic and family variables. The results confirmed the existence of social inequalities, the importance of health literacy in predicting healthy behaviours and the relevance of the family context. The study confirms the importance of the ecological approach to understanding food intake and overweight/obesity status in adolescents.

A Social-Ecological Approach to Modeling Sense of Virtual Community (SOVC) in Livestreaming Communities

Participation in communities is essential to individual mental and physical health and can yield further benefits for members. With a growing amount of time spent participating in virtual communities, it's increasingly important that we understand how the community experience manifests in and varies across these online spaces. In this paper, we investigate Sense of Virtual Community (SOVC) in the context of live-streaming communities. Through a survey of 1,944 Twitch viewers, we identify that community experiences on Twitch vary along two primary dimensions: belonging, a feeling of membership and support within the group, and cohesion, a feeling that the group is a well-run collective with standards for behavior. Leveraging the Social-Ecological Model, we map behavioral trace data from usage logs to various levels of the social ecology surrounding an individual user's participation within a community, in order to identify which of these can be associated with lower or higher SOVC. We find that features describing activity at the individual and community levels, but not features describing the community member's dyadic relationships, aid in predicting the SOVC that community members feel within channels. We consider implications for the design of live-streaming communities and for fostering the well-being of their members, and we consider theoretical implications for the study of SOVC in modern, interactive online contexts, particularly those fostering large-scale or pseudonymized interactions. We also explore how the Social-Ecological Model can be leveraged in other contexts relevant to Computer-Supported Cooperative Work (CSCW), with implications for future work.

Toward Systems Models for Obesity Prevention: A Big Role for Big Data

The relation among the various causal factors of obesity is not well understood, and there remains a lack of viable data to advance integrated, systems models of its etiology. The collection of big data has begun to allow the exploration of causal associations between behavior, built environment, and obesity-relevant health outcomes. Here, the traditional epidemiologic and emerging big data approaches used in obesity research are compared, describing the research questions, needs, and outcomes of 3 broad research domains: eating behavior, social food environments, and the built environment. Taking tangible steps at the intersection of these domains, the recent European Union project "BigO: Big data against childhood obesity" used a mobile health tool to link objective measurements of health, physical activity, and the built environment. BigO provided learning on the limitations of big data, such as privacy concerns, study sampling, and the balancing of epidemiologic domain expertise with the required technical expertise. Adopting big data approaches will facilitate the exploitation of data concerning obesity-relevant behaviors of a greater variety, which are also processed at speed, facilitated by mobile-based data collection and monitoring systems, citizen science, and artificial intelligence. These approaches will allow the field to expand from causal inference to more complex, systems-level predictive models, stimulating ambitious and effective policy interventions.

Sustainability via Active Garden Education: The Sustainability Action Plan Model and Process

Sustainability of intervention programming is challenging to achieve under real world conditions, since few models exist and many studies do not plan far beyond the funding period. Programming content in early care and education centers (ECECs) is often driven by guidelines. However, implementation is very sensitive to contextual factors, such as the setting and implementer (teacher) characteristics. This paper presents the model, definitions, and methodology used for the sustainability action plan capitalizing on a community-based participatory research (CBPR) approach, developed for a multi-site, multi-level garden-based childhood obesity prevention study, Sustainability via Active Garden Education (SAGE). The Ecologic Model of Obesity is applied to develop a sustainability action plan (SAP) and accompanying measures to link early care and education (ECE) environment, the community, policies, and classroom practices to an early childhood obesity prevention program. The SAGE SAP provides an example of how to iteratively evaluate and refine sustainability processes for an obesity prevention intervention utilizing CBPR approaches and will be applied to assess the sustainability of SAGE in a cluster randomized controlled trial. This SAP model can also help inform intervention delivery and scalability within ECECs.

Information seeking of French parents regarding infant and young child feeding: practices, needs and determinants

OBJECTIVE

As part of an update of feeding benchmarks targeting children aged 0-3 years, this study aimed to explore parental perceptions, information-seeking practices and needs concerning infant and young child feeding (IYCF) to design an efficient communication strategy.

DESIGN

Participants were recruited using the quota sampling to complete an online survey. Effects of parity, child age, prematurity, parental education and financial situation on parents' responses were evaluated separately.

SETTING

France.

PARTICIPANTS

A nationally representative sample of 1001 parents of children <4 years.

RESULTS

Parents whose child had any medical condition affecting feeding (children with medical condition (CMC), 17 %) were considered separately from healthy children's parents. All the healthy children's parents recognised the importance of IYCF for children's health and growth; however, one-third considered the available advice contradictory and not guilt-free. The most used information sources were healthcare professionals (HCP, 81 %), internet (72 %) and parental networks (63 %). The most influential sources (mean influence ± sd) included HCP (7·7 ± 1·7/10), childcare professionals (7·3 ± 1·8/10) and parental networks (6·9 ± 1·8/10). Parents searched for practical tips for implementing IYCF starting when their child was 5 months old. Differences regarding the type of source used by parents with higher v. lower educations were small. Search strategies differed according to parity or child age but not to prematurity. The CMC parents reported slightly different practices and needs.

CONCLUSIONS

Parents receive information from multiple sources, which can lead to confusion when deciding which advice to follow. A public health communication strategy adapted to the current parental needs should target these various sources.

Physical (in)activity, and its predictors, among Brazilian adolescents: a multilevel analysis

Background

Physical activity is a multifactorial trait, determined by both individual and environmental characteristics, it seems relevant to understand the determinants related to youth guidelines accomplishment. The present study aimed to verify the differences between the Brazilian federative units regarding to the prevalence of youth physical activity guidelines accomplishment and to investigate the determinants related to the inter-individual differences in this accomplishment.

Methods

Sample comes from the 2015 Brazilian National School Health Survey (PeNSE), comprising 99,570 adolescents (51,527 girls, 13-17y), enrolled in 3039 schools. Adolescents reported the time they spend in moderate-to-vigorous physical activity daily, and they were categorized as active or inactive, if the guidelines were achieved, or not, respectively, and multilevel statistical analyses were used, including both child and school-level variables. Multilevel Binomial model was computed in the SuperMix software.

Results

The majority of the adolescents did not comply with the physical activity guidelines daily, where Bahian children complied the least, while those from Amazonas, Tocantins, and Mato Grosso do Sul complied the most. Boys (OR: 2.305; 95%CI: 2.277-2.334), older adolescents (OR: 1.044; 95%CI: 1.036-1.051), and those who spent more time in active travelling to/from school (OR: 1.001; 95%CI: 1.001-1.001) complied more the physical activity guidelines. At the school level, adolescents from larger schools (OR: 0.957; 95%CI: 0.928-0.986) tended to comply less with the guidelines.

Conclusion

Significant differences between Brazilian federative units in youth daily physical activity guidelines compliance were observed, highlighting the role of individual but also environmental constraints in the Brazilian adolescents’ engagement in physical activity.

Prevention of Pediatric Overweight and Obesity: Position of the Academy of Nutrition and Dietetics Based on an Umbrella Review of Systematic Reviews

This Academy of Nutrition and Dietetics Position Paper reports current evidence on pediatric overweight and obesity prevention interventions and discusses implications for registered dietitian nutritionists (RDNs). An overview of current systematic reviews provided evidence-based results from a range of nutrition interventions according to developmental age group (ages 2 to 5, 6 to 12, and 13 to 17 years). Twenty-one current systematic reviews of nutrition interventions demonstrated a beneficial effect of nutrition and physical activity interventions on body mass index measures and no adverse events were identified. RDNs impart nutrition expertise in a wide range of settings to provide comprehensive care for children and adolescents as their nutrition and developmental needs change over time. This Position Paper outlines the current roles of, and proposed directions for, RDNs engaged in pediatric overweight and obesity prevention. Prevention of pediatric overweight and obesity requires comprehensive strategies ranging from policy-level to individual-level interventions in settings that will have the most beneficial impact for children according to their developmental stage. This Position Paper advocates for increased availability of nutrition and food access programs and interventions to reduce risk of pediatric obesity and associated adverse health outcomes both now and for future generations.

Outcomes of a Multi-Component School-Based Nutrition Program

BACKGROUND

This paper presents the effectiveness of a multi-component elementary school-based nutrition education program, the Integrated Nutrition Education Program (INEP), which has been in existence for over 25 years. INEP includes components to address multiple layers of influence: hands-on nutrition education lessons in the classroom (student-level), parent education, and outreach (home-level), and facilitation of a planning process to implement policy, system, and environmental (PSE) school changes (school-level).

METHODS

Three evaluation tools assessed the effectiveness of the program: (1) classroom plate waste measurement in intervention (N = 149 students) and demographically-matched comparison schools (N = 131 students), (2) pre/post classroom surveys completed by students who participated in INEP (N = 204), and (3) PSE change data from participating schools (N = 47 schools).

RESULTS

Students who participated in the nutrition education program were more likely to consume vegetable-based recipes and vegetables included in classroom nutrition lessons compared to students in comparison classrooms (Chinese vegetable salad: p < .001; couscous salad: p < .001; snap peas: p = .001). Classroom survey analyses showed improvements in student self-efficacy (p < .001), preference for vegetables (p = .005), and knowledge (p < .001). In addition, through a wellness planning process, schools implemented an average of 3.7 PSE changes per school.

CONCLUSIONS

Results demonstrate a multi-component school-based nutrition education program improves student nutrition-related outcomes.

Designing an adolescent physical activity and nutrition intervention before and after COVID-19: A formative research study

BACKGROUND

With rates of childhood obesity continually increasing, effective physical activity (PA) and nutrition interventions are needed. Formative research is used to tailor interventions to different cultural and geographic contexts and can also be vital in adapting intervention strategies in the face of significant disruptive circumstances (like COVID-19).

OBJECTIVE

We conducted formative research via in-person and online focus groups among middle schoolers and parents to better understand barriers and facilitators to PA and fruit and vegetable (FV) consumption and inform the design of a large intervention for a low-income, urban setting in the U.S. Midwest.

METHODS

We conducted two phases of qualitative focus groups with parents (n=20) and 6-9 grade middle schoolers (n=22). Phase 1 was conducted prior to the COVID-19 pandemic in late 2019, and phase 2 was conducted during the COVID-19 pandemic in the summer of 2020. Focus groups were transcribed and thematically coded using Dedoose software.

RESULTS

Main facilitators to PA prior to the pandemic included the opportunity to have fun, peer influence, competition (for some), and incentives, while main barriers to PA were time constraints and social discomfort. Main facilitators to eating FV included parental influence, preparation technique, and convenience, while barriers included dislike of vegetables, time constraints, and preparation or freshness. During the pandemic, facilitators to PA remained the same, while additional barriers to PA such as lack of motivation and limited time spent outside of the home were reported during the pandemic. For FV consumption, both facilitators and barriers remained the same for both time periods. Additionally, for some participants, the pandemic offered an opportunity to offer more FV to middle schoolers throughout the day.

CONCLUSIONS

Some themes identified were common to those reported in previous studies, such as peer influence on PA and parental influence on FV consumption. Novel themes, such as lack of motivation to be active and limited time outside the home, helped improve intervention adaptation, specifically during the COVID-19 pandemic. The continuity of formative research after a major, unexpected change in intervention context can be essential in targeting areas of an intervention that can be retained and those that need to be adjusted.

CLINICALTRIAL

Effects of social participation and physical activity on all-cause mortality among older adults in Norfolk, England: an investigation of the EPIC-Norfolk study

OBJECTIVES

There is growing evidence of an association between social participation and improved physical and mental health among older individuals. The aims of this study were to explore the relationship between self-reported participation in groups, clubs, or organizations and all-cause mortality among older adults and examine the role of physical activity as a potential modifier of the health effects of social participation.

STUDY DESIGN

EPIC-Norfolk is a prospective cohort study that recruited 25,639 individuals between the ages of 40 and 79 in Norfolk County, England. This study involved a retrospective analysis of 8623 participants who had returned for the third health check between 2004 and 2011.

METHODS

Participants were categorized into those who reported participating socially and those who did not and were stratified by involvement in 0, 1, or 2 or more groups. Cox Proportional Hazards models were constructed to compare all-cause mortality between the groups. Stratum-specific hazard ratios were calculated by physical activity level to assess for effect modification.

RESULTS

Of the participants, 861 (9.98%) died during the follow-up period. After adjustment for confounding, social participation was associated with lower all-cause mortality (HR 0.84, 95% CI 0.73-0.97). Involvement in 2 or more groups was associated with lower all-cause mortality (hazard ratio [HR] 0.83, 95% confidence interval [CI] 0.70-0.97), but the association was not statistically significant for people involved in only 1 group (HR 0.86, 95% CI 0.73-1.03). Physical activity appeared to modify the effect of social participation on mortality.

CONCLUSIONS

This study's findings provide evidence of an association between social participation and lower all-cause mortality for older adults. They also suggest that the effect of social participation on health is greater for people who are more physically active. Population-level interventions to facilitate social participation may contribute to improving health and wellbeing among older individuals.

Current Systems-Level Evidence on Nutrition Interventions to Prevent and Treat Cardiometabolic Risk in the Pediatric Population: An Evidence Analysis Center Scoping Review

Improving and maintaining cardiometabolic health remains a major focus of health efforts for the pediatric population. Recent research contributes understanding of the systems-level nutrition factors influencing cardiometabolic health in pediatric individuals. This scoping review examines current evidence on interventions and exposures influencing pediatric cardiometabolic health to inform registered dietitian nutritionists working at each systems level, ranging from individual counseling to public policy. A literature search of MEDLINE, CINAHL, Cochrane Databases of Systematic Reviews, and other databases was conducted to identify evidence-based practice guidelines, systematic reviews, and position statements published in English from January 2017 until April 2020. Included studies addressed nutrition interventions or longitudinal exposures for participants 2 to 17 years of age who were healthy or had cardiometabolic risk factors. Studies were categorized according level of the social-ecological framework addressed. The databases and hand searches identified 2614 individual articles, and 169 articles were included in this scoping review, including 6 evidence-based practice guidelines, 141 systematic reviews, and 22 organization position statements. The highest density of systematic reviews focused on the effects of dietary intake (n = 58) and interventions with an individual child or family through counseling or education (n = 54). The least frequently examined levels of interventions or exposures were at the policy level (n = 12). Registered dietitian nutritionists can leverage this considerable body of recent systematic reviews to inform a systems-level, collaborative approach to prevention and treatment of pediatric cardiometabolic risk factors.

Associations between Child and Family Level Correlates and Behavioural Patterns in School-Aged Children

Identifying correlates of behavioural patterns are important to target population sub-groups at increased health risk. The aim was to investigate correlates of behavioural patterns comprising four behavioural domains in children. Data were from the HAPPY study when children were 6–8 years (n = 335) and 9–11 years (n = 339). Parents reported correlate and behavioural data (dietary intake, physical activity, sedentary behaviour, and sleep). Behavioural data were additionally captured using accelerometers. Latent profile analysis was used to derive patterns. Patterns were identified as healthy, unhealthy, and mixed at both time points. Multinomial logistic regression tested for associations. Girls were more likely to display healthy patterns at 6–8 years and display unhealthy and mixed patterns at 9–11 years than boys, compared to other patterns at the corresponding ages. Increased risk of displaying the unhealthy pattern with higher age was observed at both timepoints. At 9–11 years, higher parental working hours were associated with lower risk of displaying mixed patterns compared to the healthy pattern. Associations observed revealed girls and older children to be at risk for unhealthy patterns, warranting customisation of health efforts to these groups. The number of behaviours included when deriving patterns and the individual behaviours that dominate each pattern appear to be drivers of the associations for child level, but not for family level, correlates.