Incorporating primary and secondary prevention approaches to address childhood obesity prevention and treatment in a low-income, ethnically diverse population: study design and demographic data from the Texas Childhood Obesity Research Demonstration (TX CORD) study

The range of outcomes and outcome measurement instruments collected in multisectoral community-based obesity prevention interventions in children: A systematic review

Multicomponent and multisectoral community-based interventions (CBIs) have proven potential in preventing overweight and obesity in children. Synthesizing evidence on the outcomes collected and reported in such CBIs is critical for the evidence of effectiveness and cost-effectiveness. This systematic review aimed to identify the range of outcomes and outcome measurement instruments collected and reported in multisectoral and multicomponent CBIs for obesity prevention in children. A systematic search updated an existing review and extended the search to 11 academic databases (2017-2023) and gray literature. Outcomes were classified into outcome domains, and common measurement instruments were summarized. Seventeen outcome domains from 140 unique outcomes were identified from 45 included interventions reported in 120 studies. The most frequently collected outcome domains included anthropometry and body composition (91% of included interventions), physical activity (84%), dietary intake (71%), environmental (71%), and sedentary behavior (62%). The most frequently collected outcomes from each of these domains included body mass index (89%), physical activity (73%), fruit and vegetable intake (58%), school environment (42%), and screen time (58%). Outcome measurement instruments varied, particularly for behavioral outcomes. Standardization of reported outcomes and measurement instruments is recommended to facilitate data harmonization and support quantifying broader benefits of CBIs for obesity prevention.

Using Agent-Based Modeling to Extrapolate Community-Wide Impact from a Stakeholder-Driven Childhood Obesity Prevention Intervention: Shape Up Under 5

Objective: Whole-of-community interventions are a promising systems-based approach to childhood obesity prevention. A theorized driver of success is "Stakeholder-Driven Community Diffusion" (SDCD): the spread of knowledge about and engagement with obesity prevention efforts from a committee of stakeholder representatives. We focus on the potential of SDCD to affect the broader community. Methods: We use an agent-based model of SDCD to dynamically represent the interpersonal interactions that drive community diffusion of knowledge and engagement. We test its explanatory power using longitudinal data from a sample of community members and then use simulations to extrapolate from this limited sample to the unobserved community at large. We also consider counterfactual scenarios that show how changes in implementation strategy might have led to different patterns of community change. Results: Our model can reproduce real-world patterns of diffusion. Simulations show a substantial increase in knowledge (an approximate doubling) and a slight increase in engagement throughout the broader community. A relatively small amount of this change in knowledge (∼10%), and all the change in engagement is attributable to direct intervention effects on committee members. Conclusions: SDCD is premised on creating preconditions for sustainable change. Previous work has estimated impact on small samples closely linked to the stakeholder committee, but the degree to which this translates into the much broader diffusion envisioned by SDCD theory is unknown. This analysis demonstrates the potential of interventions to do just that. Additionally, the counterfactual scenarios suggest that simulation can help tailor implementation of SDCD interventions to increase impact.

Residence in a Latinx enclave and end-induction minimal residual disease positivity among children with acute lymphoblastic leukemia

Racial and ethnic inequities in survival persist for children with acute lymphoblastic leukemia (ALL). In the US, there are strong associations between SES, race/ethnicity, and place of residence. This is evidenced by ethnic enclaves: neighborhoods with high concentrations of ethnic residents, immigrants, and language isolation. The Latinx enclave index (LEI) can be used to investigate how residence in a Latinx enclave is associated with health outcomes. We studied the association between LEI score and minimal residual disease (MRD) in 142 pediatric ALL patients treated at Texas Children's Hospital. LEI score was associated with end-induction MRD positivity (OR per unit increase 1.63, CI 1.12-2.46). There was also a significant trend toward increased odds of MRD positivity among children living in areas with the highest enclave index scores. MRD positivity at end of induction is associated with higher incidence of relapse and lower overall survival among children with ALL; future studies are needed to elucidate the exact causes of these findings and to improve ALL outcomes among children residing within Latinx enclaves.Supplemental data for this article is available online at https://doi.org/10.1080/08880018.2022.2047850.

Comparison of Vascular Function, Cardiometabolic Parameters, Hemorheological Function, and Cardiorespiratory Fitness Between Middle-Aged Korean Women With and Without Obesity—A Pilot Study

This study aimed to compare vascular function, cardiometabolic parameters, hemorheological function, and cardiorespiratory fitness in middle-aged Korean women according to obesity defined using body mass index (BMI). A total of 32 Korean women aged between 34 and 60 years (16 without obesity, mean age 46.31 ± 7.49 years and 16 with obesity, mean age 49.68 ± 6.69 years) participated in this study. Obesity was defined as BMI ≥ 25 kg/m2. The body composition, vascular function, cardiometabolic parameters, hemorheological function, and cardiorespiratory fitness of all participants were measured. Statistical differences in the dependent parameters between individuals with and without obesity were analyzed, and the correlations between BMI and the dependent variables were verified. The obese group showed significantly worse results (p < 0.05) for body composition (significantly higher weight, BMI, fat mass, and percent body fat), vascular function [significantly higher branchial ankle pulse wave velocity (baPWV) and lower flow-mediated vasodilation (FMD)], cardiometabolic parameters [significantly higher insulin and homeostatic model assessment for insulin resistance (HOMA-IR)], hemorheological function (significantly lower erythrocyte deformability and higher aggregation), and cardiorespiratory fitness [significantly lower maximal oxygen uptake (VO2max)] compared to the non-obese group. In addition, BMI showed a significant positive correlation (p < 0.05) with baPWV (r = 0.430); total cholesterol (r = 0.376), triglyceride (r = 0.411), low-density lipoprotein cholesterol (r = 0.462), and insulin (r = 0.477) levels; HOMA-IR (r = 0.443); and erythrocyte aggregation (r = 0.406), and a significant negative correlation (p < 0.05) with VO2max (r = −0.482) and FMD (r = −0.412). Our study confirmed that obesity is a major determinant for deterioration of vascular function, cardiometabolic parameters, hemorheological function, and cardiorespiratory fitness.

Harmonizing Ratings From Different School Environment Assessment Methods: A Simplified Approach

BACKGROUND

This study describes a method for harmonizing data collected with different tools to compute a rating of compliance with national recommendations for school physical activity (PA) and nutrition environments.

METHODS

We reviewed questionnaire items from 84 elementary schools that participated in the Childhood Obesity Research Demonstration (CORD) project, which was 3 distinct childhood obesity prevention projects in 7 communities in California, Massachusetts, and Texas. Each project used tools specific to its programs, schools, and communities. While this approach increased the feasibility of data collection, it created a challenge with the need to combine data across projects. We evaluated all questionnaire items and retained only those items that assessed one or more recommendations and constructed several items to indicate compliance or noncompliance with the respective associated recommendations.

RESULTS

Ten constructed items covered 11 of the 20 recommendations. Analysis indicated that the scores detected variability in compliance both among communities and among school within communities.

CONCLUSIONS

The scores captured differences in compliance with the national recommendations at multiple levels. Our method, designed for creating common scores, may be useful in integrated data analysis, systematic reviews, or future studies requiring harmonizing of data collected via different tools.

Implementation of the JOIN for ME Program for Families from Low-Income Backgrounds: The Use of Theory-Driven Formative Evaluation: Rhode Island CORD 3.0

Advances have been made in the development of effective interventions to address pediatric obesity; however, research findings often do not translate into clinical practice and a limited number of programs have been designed toward wide-spread dissemination and implementation. The Rhode Island (RI)-Childhood Obesity Research Demonstration (CORD) 3.0 Project involves adapting and testing an evidence-based pediatric weight management intervention (PWMI), JOIN for ME, for wide-scale dissemination and implementation in communities with a high proportion of families from low-income backgrounds. In this article, we describe the robust developmental formative evaluation (FE) process employed by RI-CORD as a model for the use of FE to drive dissemination of evidence-based PWMIs. The current project was guided by the Consolidated Framework for Implementation Research and Proctor Implementation Outcomes. This article also showcases examples of how the use of key informant interviews from engaged stakeholders in the community during a developmental FE process can drive selection of implementation strategies. The use of FE, driven by evidence-based theory, can help provide a roadmap to successful implementation of a pediatric weight management program, such as JOIN for ME.

Stakeholder perspectives and sustainability of an integrated care model for the prevention and management of obesity: the Childhood Obesity Research Demonstration (CORD) project

Although reliable strategies exist to promote healthy habits that reduce childhood obesity, the sustainability of these strategies remains an ongoing public health challenge. This study aimed to identify factors experienced in a large, multisite project aimed at reducing childhood obesity that might contribute to project sustainability. Hypothesized constructs underpinning sustainability included replicability, continuation of benefits, institutionalization, and community capacity. Key informants (n = 27) completed 60 min, in-depth interviews, which were audio recorded and transcribed. Transcripts were first coded using a combined deductive and inductive approach. Four major themes emerged (with numerous subthemes): developing partnerships, challenges to the sustainability of implemented programming, the importance of intervening in multiple settings, and ongoing implementation and evaluation strategies. Replicability of complex childhood obesity interventions is possible when there are strong partnerships. Benefits can continue to be conferred from programming, particularly when evidence-based strategies are used that employ best practices. Implementation is facilitated by institutionalization and policies that buffer challenges, such as staffing or leadership changes. Community capacity both enhances the sustainability of interventions and develops as a result of strengthening partnerships and policies that support childhood obesity programming.

Expanding Implementation Research to Prevent Chronic Diseases in Community Settings

Chronic disease prevention continues to be inadequate, overall and in achieving health equity, in spite of the many evidence-based practices and policies (EBPPs) available to address risk behaviors such as unhealthful eating, lack of physical activity, and tobacco use. Although clinical settings are needed for EBPPs that involve medical procedures such as immunization or early detection, dissemination of EBPPs can be effective in a variety of settings such as schools and childcare centers, worksites, social service organizations, and religious organizations. More implementation research is needed to meet challenges of effective application of EBPPs in such community settings, in which primary missions, capacity, cultures, and values do not focus on health services delivery. To address health equity, consideration of social and economic contexts of people reached in these settings is essential. This review presents lessons learned from past studies to guide future implementation research and practice across diverse settings and geographies.

Cross-Sectional Relationship between Regular Bedtime and Weight Status and Obesity-Related Behaviors among Preschool and Elementary School Children: TX CORD Study

Background: This study examines the relations between a regular weekday bedtime with weight status, diet quality, physical activity, wellbeing, and parental rules among children 2 to 12 years of age from low-income populations. Methods: The study used baseline data collected in 2012, as part of a larger quasiexperimental study design. A convenience sample of parents of children in preschools, second, or fifth grade attending Head Start centers or elementary schools located in low-income catchment areas, in Houston and Austin, TX, were recruited to participate in the study (n = 32 elementary schools; n = 12 Head Start centers). Regular weekday bedtime was measured with the question "Does your child have a regular weekday bedtime?" Results: The sample of 1467 child-parent dyads were split approximately evenly by sex, and consisted of 44.4% Pre-K, 30.4% second grade, and 25.2% fifth grade students. Six hundred twenty-two (43.6%) children were overweight or obese. Children who had a regular bedtime had 15% lower odds of being overweight or obese (adjusted odds ratio [aOR]: 0.85, 95% confidence interval [CI]: 0.74-0.97, p-value: 0.017). Also, children who had a regular bedtime had 45% higher odds of eating the recommended number of fruits and vegetables (aOR: 1.45, 95% CI: 1.02-2.07, p-value: 0.039) and had physical activity more days of the week (β: 0.42, 95% CI: 0.26-0.57, p-value: <0.001). Conclusions: Having a regular weekday bedtime is associated with better weight status and several obesity-related health behaviors in children. Parental report of regular bedtimes for their children may be an indication of parenting skills related to other health-related behaviors for prevention of childhood obesity.

Motivating Children and Adolescents in Obesity Treatment

Enhancing motivation is a crucial issue in pediatric obesity interventions, as behavioral changes related to food intake and physical exercise are difficult to carry out with an insufficient level of motivation. In the treatment setting, low motivation towards change may lead to early termination or inadequate treatment outcomes. This paper reviews widely-used models of motivation, including the transtheoretical model of change, self-determination theory, and motivational interviewing (MI). We introduce useful strategies based on each theoretical model to enhance motivation, such as an importance and confidence scale and a decisional balance technique. A review of recent MI interventions in children and adolescents is presented to discuss the efficacy of MI-based interventions and considerations for applying MI in pediatric obesity.

Influence of Perception of Family Support and Functioning on Adolescent High-Risk Sexual Behavior

Adolescents often engage in high-risk behaviors which often have lifelong consequences. It is unclear whether an association exists between adolescents' perception of family support and family functioning and sexual risk behavior. We conducted a cross-sectional study of 702 adolescent students (aged 15-19 years) of a university in Nigeria and assessed high-risk sexual behavior (HRSB) and their judgment of family functioning and support. We used multivariable logistic regression analyses to evaluate the relationship between HRSB and the perception of family support and functioning. We found that 114 (16.2%, 95% CI: 13.69-19.16) of the adolescents engaged in HRSB. A higher proportion of boys (22.7%, 95% CI: 17.79-28.47) than girls (12.93, 95% CI: 10.17-16.31) engaged in HRSB (P = 0.001). The prevalence of intimate partner violence in our study was 8% (95% CI: 6.19-10.29). Participants with lower perception scores were more likely to be engaged in HRSB (aOR: 0.920, 95% CI: 0.878-0.965). Likewise, the perception of family functioning was inversely related to HRSB among the participants (aOR: 0.884, 95% CI: 0.813-0.962). There is an association between adolescents' perception of family support and functioning and HRSB. This association may provide a link in the complex interaction between the role of the family and adolescent sexuality. Programs and interventions for preventing HRSB and promoting risk-reducing autonomous decision-making among adolescents should include context- and setting-specific interventions that improve family support and functioning, and those that target in dysfunctional family settings.

Adiposity, cardiovascular, and health-related quality of life indicators and the reallocation of waking movement behaviors in preschool children with overweight and obesity: An isotemporal data analysis

Background

Isotemporal substitution evaluates hypothetical time replacement scenarios of physical movement on health, with few studies conducted among ethnically diverse preschool-aged populations. This study examines the reallocation of waking movement behaviors on adiposity, cardiovascular, and quality of life indicators among low-income, majority Hispanic preschool-aged youth (2–5 years) with overweight.

Methods

Participants wore an ActiGraph monitor (waist) and completed adiposity, cardiovascular, and health-related quality of life health assessments. Covariates included age, sex, ethnicity, and socioeconomic status. The isotemporal substitution approach was employed to address study aims.

Results

Complete data were available for 131 preschoolers. For boys, reallocating 5 minutes of stationary time with light intensity, moderate to vigorous intensity, or total physical activity showed a relation with beneficial reductions in adiposity indicators; for girls, these relations were statistically null. For boys and girls, reallocating 5 minutes of stationary time [-2.2 (95% CI: -3.7, -0.7) mmHg], light intensity [-2.1 (95% CI: -3.7, -0.7) mmHg], or moderate intensity activity [-2.7 (95% CI: -5.0, -0.4) mmHg] to vigorous intensity activity was related to favorable systolic blood pressure. Reallocating 5 minutes of stationary time to moderate to vigorous intensity activity [0.6 (95% CI: -1.0, -0.1) mmHg] or total physical activity [-0.2 (95% CI: -0.3, -0.01) mmHg] was related to lowered systolic blood pressure. Reallocating 5 minutes of stationary time to moderate to vigorous intensity activity [0.6 (95% CI: -1.1, -0.02) bpm] was related to lowered resting heart rate. No significant results for quality of life were found.

Conclusion

Reallocation of time from stationary time to other movement behaviors is associated with several favorable adiposity and cardiovascular health outcomes among preschool children with overweight and obesity.

A Pilot Randomized Controlled Trial of a Nutrition and Dietary Intervention for Early Care and Education Providers

BACKGROUND

The aim of this study is to evaluate the feasibility and preliminary impact of the Create Healthy Futures program, a self-paced, 6-lesson, web-based intervention on promoting healthy eating for Early Care and Education (ECE) providers, using a group-randomized controlled trial design with 3 repeated measurements.

METHODS

Nine ECE facilities in Ohio were recruited and randomly assigned to intervention (N = 4) and comparison (N = 5). The 111 participants are mostly female (97.3%), college graduated (59.5%), and overweight or obese (75.2%). Nutrition-related psychosocial and environmental factors and individual behaviors were assessed at baseline, post-test, and 3-month follow-up. We used mixed model analyses to compare changes between time points, controlling for ethnicity, age, and center effect, and calculated effect size to assess the magnitude of change.

RESULTS

We observed significant between-group changes in improving nutrition knowledge (p = .003), increasing perceived support for staff wellness (p = .038), and reducing perceived barriers to eating fruits and vegetables (p = .004) and promoting nutrition in classrooms (p = .038), with small to medium effect sizes. The study demonstrated high feasibility with 94.1% enrollment rate, 87.5% intervention completion rate, and 83.8% retention rate.

CONCLUSIONS

This pilot study demonstrated high feasibility and acceptability of nutrition intervention programs using an online platform among ECE providers.

Childhood Obesity Evidence Base Project: A Systematic Review and Meta-Analysis of a New Taxonomy of Intervention Components to Improve Weight Status in Children 2-5 Years of Age, 2005-2019

Objective: To evaluate the efficacy of childhood obesity interventions and conduct a taxonomy of intervention components that are most effective in changing obesity-related health outcomes in children 2-5 years of age. Methods: Comprehensive searches located 51 studies from 18,335 unique records. Eligible studies: (1) assessed children aged 2-5, living in the United States; (2) evaluated an intervention to improve weight status; (3) identified a same-aged comparison group; (4) measured BMI; and (5) were available between January 2005 and August 2019. Coders extracted study, sample, and intervention characteristics. Effect sizes [ESs; and 95% confidence intervals (CIs)] were calculated by using random-effects models. Meta-regression was used to determine which intervention components explain variability in ESs. Results: Included were 51 studies evaluating 58 interventions (N = 29,085; mean age = 4 years; 50% girls). Relative to controls, children receiving an intervention had a lower BMI at the end of the intervention (g = 0.10, 95% CI = 0.02-0.18; k = 55) and at the last follow-up (g = 0.17, 95% CI = 0.04-0.30; k = 14; range = 18-143 weeks). Three intervention components moderated efficacy: engage caregivers in praise/encouragement for positive health-related behavior; provide education about the importance of screen time reduction to caregivers; and engage pediatricians/health care providers. Conclusions: Early childhood obesity interventions are effective in reducing BMI in preschool children. Our findings suggest that facilitating caregiver education about the importance of screen time reduction may be an important strategy in reducing early childhood obesity.

Cross-Site Process Evaluation Results for the Early Childhood Education Center Setting: CORD Study

Background: The Childhood Obesity Research Demonstration project aimed to deliver evidence-based obesity prevention interventions to at-risk families at three demonstration sites. The interventions were delivered in multiple settings, including early childhood education centers (ECECs), public schools, and primary care clinics. An evaluation center conducted cross-site process, impact, and sustainability evaluations. Results of the cross-site process evaluation for the ECECs will be described. Methods: Reach (proportion of the target population who participated), dose delivered (materials and interventions that were distributed), and fidelity (proportion of planned intervention components delivered) were assessed at two levels (researcher-to-provider and provider-to-family levels). Standardized data forms were completed by research team members at each demonstration site with assistance from the evaluation center. Results: The Childhood Obesity Research Demonstration project reached 5174 children and 390 teachers in 58 ECECs. The centers delivered an average of 3.9 hours of training to teachers. A total of 1382 different types of materials were distributed to providers, and from 1.3 to 4.3 hours of technical support were delivered to centers monthly. For fidelity at the researcher-to-provider level, 49.5% (n = 370) of eligible teachers completed all training sessions. Considerable variations across demonstration sites in reach, dose delivered, and fidelity across were observed. Conclusion: The Childhood Obesity Research Demonstration project reached large numbers of children, families, teachers, and ECECs. Maintaining intervention fidelity while reaching large numbers of at-risk individuals proved to be a challenge.

Precision Nutrition and Childhood Obesity: A Scoping Review

Environmental exposures such as nutrition during life stages with high developmental plasticity—in particular, the in utero period, infancy, childhood, and puberty—may have long-lasting influences on risk of chronic diseases, including obesity-related conditions that manifest as early as childhood. Yet, specific mechanisms underlying these relationships remain unclear. Here, we consider the study of ‘omics mechanisms, including nutrigenomics, epigenetics/epigenomics, and metabolomics, within a life course epidemiological framework to accomplish three objectives. First, we carried out a scoping review of population-based literature with a focus on studies that include ‘omics analyses during three sensitive periods during early life: in utero, infancy, and childhood. We elected to conduct a scoping review because the application of multi-‘omics and/or precision nutrition in childhood obesity prevention and treatment is relatively recent, and identifying knowledge gaps can expedite future research. Second, concomitant with the literature review, we discuss the relevance and plausibility of biological mechanisms that may underlie early origins of childhood obesity identified by studies to date. Finally, we identify current research limitations and future opportunities for application of multi-‘omics in precision nutrition/health practice.

Prevention of Childhood Obesity: A Position Paper of the Global Federation of International Societies of Paediatric Gastroenterology, Hepatology and Nutrition (FISPGHAN)

Global childhood obesity increased more than 8-fold over 40 years, inducing a very large personal, societal, and economic burden. Effects of available treatments are less than satisfactory; therefore, effective prevention is of high priority. In this narrative review, we explore preventive opportunities. The available evidence indicates large benefits of improving nutrition and lifestyle during early life, such as promoting breast-feeding and improving the quality of infant and early childhood feeding. Promoting healthy eating patterns and limiting sugar-containing beverage consumption from early childhood onwards are of great benefit. Regular physical activity and limited sedentary lifestyle and screen time alone have limited effects but are valuable elements in effective multicomponent strategies. The home environment is important, particularly for young children, and can be improved by educating and empowering families. School- and community-based interventions can be effective, such as installing water fountains, improving cafeteria menus, and facilitating regular physical activity. Reducing obesogenic risk factors through societal standards is essential for effective prevention and limiting socioeconomic disparity; these may comprise food, drink, and physical activity standards for day cares and schools, general food quality standards, front-of-pack food labeling, taxation of unhealthy foods, restriction of food advertisements to children, and others. Effective prevention of childhood obesity is not achieved by single interventions but by integrated multicomponent approaches involving multiple stakeholders that address children, families, and societal standards. Pediatricians and their organizations should be proactive in supporting and empowering families to support their children's health, and in promoting societal measures that protect children.

Who benefits from the intervention? Correlates of successful BMI reduction in the Texas Childhood Obesity Demonstration Project (TX-CORD)

BACKGROUND

Many childhood obesity intervention studies report mean outcomes but do not explore the variation in responses and the characteristics of those who respond well.

OBJECTIVE

To identify child and family characteristics associated with improvement in the primary outcome, %BMI_p95 , of the Texas Childhood Obesity Research Demonstration project (TX-CORD).

METHODS

The 12-month TX-CORD secondary prevention study randomized 549 children, ages 2 to 12 years, with BMI ≥85th percentile to the intensive intervention vs. the comparison program, with measurements at baseline, 3-, and 12-months. A growth mixture model was used to identify mutually exclusive latent %BMI_p95 trajectories. Latent class regression tested associations between baseline characteristics and latent class membership.

RESULTS

A 2-class solution emerged after accounting for the effect of intervention randomization. Latent Class 1 participants (86% of sample) were characterized by mild-to-moderate obesity and demonstrated a significantly greater response to the intensive intervention between 0 and 3 months (slope-on-group = -0.931, p = 0.03). A rebound between 3 and 12 months was not significantly different between arms. Latent Class 2 participants (14%), who had severe obesity, demonstrated no difference in response between intervention groups. Characteristics associated with Class 1 membership included younger age (2-5 years vs. 6-12 years: OR 3.70, p = .035) and lower maternal BMI category (< 35 kg/m² vs. ≥ 35 kg/m² : OR 7.14, p < .0001).

CONCLUSIONS

The optimal target population for the intensive intervention are children who have milder obesity, are younger, and do not have a mother with severe obesity. Children with severe obesity may require different approaches.

Evaluating sustainability in the Childhood Obesity Research Demonstration project: the model and process

Background

In the context of health-related interventions, sustainability is the capacity to maintain the changes resulting from the intervention. These can be improved policies, practices or trends intended to improve population health. The Childhood Obesity Research Demonstration (CORD) project was a multi-site, multi-intervention collaboration testing the Obesity Chronic Care Model with interventions for childhood obesity prevention and management. We present the model, definitions and methodology used for the cross-site sustainability evaluation of CORD.

Methods

We applied the Ecologic Model of Obesity to childhood obesity interventions to operationalize four sustainability constructs: replicability, continuation of benefits, institutionalization, and community capacity. We used a triangulation approach and employed mixed methods to assess sustainability constructs at each level of the Ecologic Model of Obesity: Micro, Meso, Exo and Macro. We constructed checklists to count and code intervention activities, use of evidence-based practices among providers, and environmental factors and policies hypothesized to influence intervention sustainability. We developed in-depth interviews for principal investigators and project leads. We applied the Wilder Collaboration Factors Inventory with key stakeholders.

Results

Lessons learned suggested that sustainability constructs should be clearly identified and operationalized a priori. Constructs must be flexible to account for differences between intervention plans and implementation to obtain robust and informative data.

Conclusion

Strong links are needed among researchers, program implementers and communities to accomplish consistent, robust and valuable data collection efforts to assure sustainable and healthy communities.

Improvement in Primary Care Provider Self-Efficacy and Use of Patient-Centered Counseling To Address Child Overweight and Obesity after Practice-Based Changes: Texas Childhood Obesity Research Demonstration Study

BACKGROUND

The Texas Childhood Obesity Research Demonstration project, a multicenter, multisystem approach to childhood overweight and obesity (OW/OB), included training and materials to support primary care clinics (PCCs) in addressing child OW/OB in the office. This study evaluated the impact over 24 months of brief training and practice-based support on primary care providers' (PCPs) perceived self-efficacy and practice behaviors.

METHODS

The PCPs at five Houston and seven Austin PCCs completed questionnaires at baseline (2012, n = 36), 12 months (2013, n = 30), and 24 months (2014, n = 34) follow-up. Mixed-effects linear regression models were used to compare changes in self-efficacy (15 items, responses 1-4: not at all confident to very confident) and practice behaviors (30 items, responses 0-4: never to always) in obesity-related screening and counseling, and to assess association between prior training and these outcomes.

RESULTS

Self-efficacy items for identification of (2.9 [0.1] vs. 3.3 [0.1]) and counseling about (2.8 [0.1] vs. 3.4 [0.1]) OW/OB-related parenting practices, and setting behavioral goals (2.9 [0.2] vs. 3.3 [0.2]) improved significantly (p < 0.05) between baseline and 24-month follow-up. Self-efficacy items with "confident" mean baseline scores that further improved included determining child OW/OB (3.6 [0.1] vs. 3.9 [0.1]) and interpreting BMI (3.6 [0.1] vs. 3.9 [0.1]). At all measurements, PCPs reported frequently addressing medical problems and lifestyle behaviors. Use of patient-centered counseling techniques, which was low at baseline, increased significantly, including asking permission before discussing lifestyle (1.5 [0.3] vs. 2.4 [0.3]). Prior training was associated with improved self-efficacy.

CONCLUSIONS

The improvement in PCPs' self-efficacy and patient-centered counseling to address childhood OW/OB supports implementation of brief training and practice support in clinics that serve Medicaid-eligible children.

Nurse-Led Telephone Follow-Up to Improve Parent Promotion of Healthy Behaviors in Young Children With Motivational Interviewing Techniques

INTRODUCTION

The American Academy of Pediatrics (AAP) recommends primary care-based health promotion for obesity prevention at all visits, focusing on nutrition and activity.

METHODS

In this quality improvement project, a primary care innovation was developed to support parents in promoting healthy habits in their children ages 2 to 5 years old. Nurse-led telephone support using motivational interviewing was implemented during two follow-up phone calls aimed at helping parent-child dyads reach self-created activity or nutrition goals.

RESULTS

Parent-rated confidence and motivation related to meeting these goals showed significant increases. During the second call, 80% self-reported goal completion and high satisfaction with the visits. Registered nurses reported a significant increase in their self-efficacy of communication with parents.

DISCUSSION

This project showed the feasibility of using nurse telephone visits in an urban low-income primary care setting to improve parental recognition and understanding of healthy habits that align with American Academy of Pediatrics recommendations for obesity prevention.

The role of maternal social networks on the outcomes of a home-based childhood obesity prevention pilot intervention

BACKGROUND

Despite evidence that obesity and related behaviors are influenced by social networks and social systems, few childhood obesity initiatives have focused on social network factors as moderators of intervention outcomes, or targets for intervention strategies.

OBJECTIVES

This pilot study examines associations between maternal social network characteristics hypothesized to influence health behaviors, and the target outcomes of a family-centered childhood obesity prevention initiative. The pilot intervention entailed the provision of healthy eating and activity components as part of an existing home visiting program (HVP) delivered to mothers and infants, to test the feasibility of this approach for improving mother diet, physical activity, and weight status; and infant diet and weight trajectory.

METHODS

Mothers and their infants (N=50 dyads) receiving services from our HVP partner were recruited and randomized to receive the HVP core curriculum with or without a nutrition and physical activity enhancement module for six months. Assessments of mothers' social network characteristics, mother/infant food intake and mother physical activity, and mothers' postpartum weight retention and children's growth velocity were conducted at baseline and post-intervention.

RESULTS

Several features of mothers' social networks, including the receipt of health-related social support, were significantly associated with the focal intervention outcomes (p < .05) at follow-up, controlling for study condition.

CONCLUSIONS

Integrating childhood obesity prevention into HVPs appears promising. Future family-based interventions to prevent childhood obesity may be enhanced by including social network intervention strategies. For example, by addressing family network characteristics that impede healthy behavior change, or enhancing networks by fostering social support for healthy behavior and weight change.

Evidence-based Nutritional Intervention Protocol for Korean Moderate-Severe Obese Children and Adolescents

Diet-related behavioral modification for healthy eating and lifestyle is required to improve childhood obesity. The present study aimed to develop customized nutritional intervention protocol and education program to find barriers to adhere healthy diet and lifestyle for moderate to severe obese children and adolescents and their families. Theoretical framework approaches can be used to change behavior and achieve goals. Previous studies that described the relationship between behavioral modification and nutrition education theory were reviewed. The social cognitive theory and transtheoretical model were employed with behavioral changes to target a healthful diet and lifestyle. The nutrition care process (NCP) model was adopted to customize nutrition care for the participants. Customized nutritional intervention protocol was developed following as the four steps of the NCP. Firstly, nutrition status of the participants was assessed by the nutrition expert. Nutrition problems were described as "inadequate energy intake," "overweight/obesity," or "food and nutrition-related knowledge deficit." All nutrition sessions were designed for nutrition intervention to give nutritional knowledge and a practical mission in real life for individual goal setting and self-control. Meal planning, portion control, healthy snack selection and cooking with fruits and vegetables were consisted of five components of the nutrition education session. During each session, the participants and their families were interviewed by a nutrition expert for monitoring and evaluating diet-related goal setting and achievement. A theoretical and evidence-based nutritional intervention was developed for the secondary to tertiary prevention of childhood obesity. This nutrition intervention protocol and program might be helpful for the further research on childhood obesity.

Trial Registration

Clinical Research Information Service Identifier: KCT0002111.

Design and methods of the Healthy Kids & Families study: a parent-focused community health worker-delivered childhood obesity prevention intervention

Background

One third of U.S. children and two thirds of adults are overweight or obese. Interventions to prevent obesity and thus avert threats to public health are needed. This paper describes the design and methods of the Healthy Kids & Families study, which tested the effect of a parent-focused community health worker (CHW)-delivered lifestyle intervention to prevent childhood obesity.

Methods

Participants were English or Spanish-speaking parent-child dyads (n = 247) from nine elementary schools (grades K-6) located in racial/ethnically diverse low-income communities in Worcester, Massachusetts. Using a quasi-experimental design with the school as the level of allocation, the study compared the lifestyle intervention vs. an attention-control comparison condition. The lifestyle intervention was guided by social cognitive theory and social ecological principles. It targeted the child’s social and physical home environment by intervening with parental weight-related knowledge, beliefs, and skills for managing child obesogenic behaviors; and addressed families’ needs for community resources supportive of a healthy lifestyle. The two-year CHW-delivered intervention was structured based on the 5As model (Agenda, Assess, Advise, Assist, Arrange follow up) and included two in person sessions and two telephone follow-ups per year with the parent, with a personalized letter and print materials sent after each contact. Parents also received quarterly newsletters, Facebook messages, and invitations to community events. The attention-control comparison condition used the same format and contact time as the intervention condition, but targeted positive parenting skills. Measurements occurred at baseline, and at 6-, 12-, 18- and 24-month follow-up. Assessments included anthropometrics, accelerometry, global positioning system (GPS), and self-report surveys. The primary outcome was child body mass index (BMI) z score. Secondary outcomes were parent BMI; and parent and child diet, physical activity, sedentariness, and utilization of community resources supportive of a healthy lifestyle.

Discussion

A CHW-delivered parent-focused lifestyle intervention may provide a translatable model for targeting the high priority public health problem of childhood obesity among low-income diverse communities. If demonstrated effective, this intervention has potential for high impact.

Trial registration

ClinicalTrials NCT03028233. Registered January 23,2017. The trial was retrospectively registered.

Effective Implementation of Culturally Appropriate Tools in Addressing Overweight and Obesity in an Urban Underserved Early Childhood Population in Pediatric Primary Care

Overweight and obese children are at an increased risk of remaining obese. The American Academy of Pediatrics recommends addressing healthy habits at well-child checks, but this poses challenges, especially in low-income populations. A clinical innovation project was designed to adapt recommendations in a busy urban clinic and consisted of motivational interviewing, culturally tailored tools, and standardizing documentation. A quasi-experimental design examined innovation outcomes. Of 137 overweight and obese children aged 24 to 66 months, providers' documentation of weight during well-child check visits improved post-innovation ( P < .01), as did development of healthy habits goals ( P < .001). Families were more likely to return for visits post-innovation ( P = .01). A logistic regression analysis showed that adding body mass index to the problem list and establishing a specific follow-up timeframe most predicted follow-up visits to assess progress ( P < .001). Comprehensive innovations consisting of motivational interviewing, implementation of culturally tailored tools, and standardized documentation can enhance engagement in an urban clinic setting.

Using Process Evaluation for Implementation Success of Preschool-Based Programs for Obesity Prevention: The TX Childhood Obesity Research Demonstration Study

BACKGROUND

Through the Texas Childhood Obesity Research Demonstration study, we implemented and evaluated a system-oriented model of primary and secondary prevention approaches to mitigate obesity among low-income Texas children aged 2 to 12 years. Primary prevention included implementing the Coordinated Approach To Child Health Early Childhood (CATCH EC) program in Head Start preschools. In this paper, we describe the methods and results of CATCH EC program process evaluation over 2 years of implementation.

METHODS

We used a quasi-experimental design with serial cross-sectional data collected from Head Start centers across intervention and comparison catchment areas in Houston and Austin, Texas (intervention: N = 12 centers in 2012-2013 [Year 1], N = 12 in 2013-2014 [Year 2]; comparison: N = 13 centers in Year 1, N = 12 in Year 2). Process evaluation included center director and teacher surveys conducted in both years of implementation. We developed indices for implementation of CATCH EC and non-CATCH health events at the centers.

RESULTS

Implementation scores were higher among intervention centers as compared to comparison centers across both years of implementation, and these differences were statistically significant (p < .01). There was also high variability in program implementation in intervention centers across both years ranging from 55% to 95%.

CONCLUSION

These implementation index strategies may inform future evaluation of preschool-based obesity prevention program implementation.

Dietary Intake, Attitudes toward Healthy Food, and Dental Pain in Low-Income Youth

Few studies have examined the relation between food consumption and related attitudes and dental pain among children. The objective of this study is to examine the associations of healthy and unhealthy food items, attitudes toward healthy food, and self-efficacy of eating healthy with dental pain among children. A cross-sectional analysis was performed using child survey data from the Texas Childhood Obesity Research Demonstration (TX CORD) project. Fifth-grade students ( n = 1,020) attending 33 elementary schools in Austin and Houston, Texas, completed the TX CORD Child Survey, a reliable and valid survey instrument focused on nutrition and physical activity behaviors. All nutrition questions ask about the number of times food and beverage items were consumed on the previous day. Dental pain was reported as mouth or tooth pain in the past 2 wk that made their mouth hurt so much that they could not sleep at night. Mixed-effects logistic regression models were used to test the association between 10 unhealthy food items, 9 healthy food items, 2 health attitudes, and self-efficacy with dental pain. All models controlled for sociodemographic variables. In total, 99 (9.7%) students reported dental pain. Dental pain was associated with intake of the following unhealthy items: soda, fruit juice, diet soda, frozen desserts, sweet rolls, candy, white rice/pasta, starchy vegetables, French fries/chips, and cereal (adjusted odds ratio [AOR], 1.27-1.81, P < 0.01). The intake of other vegetables (AOR, 1.56; P < 0.01), a healthy item, and the attitude that healthy food tastes good (AOR, 1.59; P = 0.04) were also positively associated with dental pain. The attitude of eating healthier leads to fewer health problems (AOR, 0.50) and self-efficacy for healthy eating (AOR, 0.44) were negatively associated with dental pain ( P < 0.01). Interventions should focus on improving oral health by reducing intake of unhealthy foods and educating children and families on the importance of diet as a means of reducing dental caries. Knowledge Transfer Statement: The results of this study can be used to inform researchers on potential food items and psychosocial measures to examine in low-income, minority populations for longitudinal research. These results would also be useful to educators who could incorporate oral health care and nutrition education into school curriculums.

Physical activity, screen time, and outdoor learning environment practices and policy implementation: a cross sectional study of Texas child care centers

Background

Early care and education (ECE) centers are important for combating childhood obesity. Understanding policies and practices of ECE centers is necessary for promotion of healthy behaviors. The purpose of this study is to describe self-reported practices, outdoor environment aspects, and center policies for physical activity and screen time in a statewide convenience sample of non-Head Start Texas ECE centers.

Methods

Licensed home and child care centers in Texas with email addresses publicly available on the Department of Family and Protective Services website (N = 6568) were invited to participate in an online survey. Descriptive statistics of self-reported practices, policies, and outdoor learning environment are described.

Results

827 surveys were collected (response rate = 12.6%). Exclusion criteria yielded a cross-sectional sample of 481 center-only respondents. > 80% of centers meet best practice recommendations for screen time practices for infants and toddlers, although written policies were low (M = 1.4 policies, SD = 1.65, range = 0–6). For physical activity, < 30% meet best practice recommendations with M = 3.9 policies (SD = 3.0, range = 0–10) policies reported. Outdoor learning environment indicators (M = 5.7 policies, SD = 2.5, range = 0–12) and adequate play settings, storage (< 40%), and greenery (< 20%) were reported.

Conclusions

This statewide convenience sample of non-Head Start Texas ECE centers shows numerous opportunities for improvement in practices and policies surrounding outdoor environments, physical activity, and screen time. With less than half of centers meeting the recommendations for physical activity and outdoor learning environments, dedicating resources to help centers enact and modify written policies and to implement programs to improve their outdoor learning environments could promote physical activity and reduce sedentary time of children.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6588-5) contains supplementary material, which is available to authorized users.

Behavior Modification of Diet and Parent Feeding Practices in a Community- Vs Primary Care-Centered Intervention for Childhood Obesity

OBJECTIVE

To evaluate behavior modification of diet and parent feeding practices in childhood obesity interventions.

DESIGN

Secondary analysis of randomized, controlled trial comparing Mind, Exercise, Nutrition … Do It! (MEND2-5 and MEND/Coordinated Approach to Child Health [CATCH6-12]) vs Next Steps at baseline and 3 and 12 months.

SETTING

Austin and Houston, TX.

PARTICIPANTS

A total of 549 Hispanic and black children randomized to programs by age groups (2-5, 6-8, and 9-12 years) INTERVENTIONS: Twelve-month MEND2-5 and MEND/CATCH6-12 vs Next Steps.

MAIN OUTCOME MEASURE(S)

Diet (MEND-friendly/unfriendly food groups and Healthy Eating Index-2010) and parent feeding practices (parental overt control, discipline, limit setting, monitoring, reinforcement, modeling, and covert control; and food neophobia).

ANALYSIS

Mixed-effects linear regression.

RESULTS

Changes in diet quality, consumption of MEND-unfriendly foods, and parent feeding practices did not differ between programs. In both interventions, MEND-unfriendly vegetables, grains, dairy and protein, added fat and desserts/sugar-sweetened beverages declined in 2-5- and 6-8-year-olds (P < .001). Healthy Eating Index-2010 improved in 2-5- (treatment; P = .002) and 6-8-year-olds (P = .001). Parental overt control decreased and limit setting, discipline, monitoring, reinforcement, and covert control increased with both interventions in 2-5- and 6-8-year-olds (P < 0.01-0.001).

CONCLUSIONS

Diet quality, consumption of MEND-unfriendly foods, and parent feeding practices were altered constructively in 2 pediatric obesity interventions, especially in 2-5- and 6-8-year-olds.

Impact of the Coordinated Approach to Child Health Early Childhood Program for Obesity Prevention among Preschool Children: The Texas Childhood Obesity Research Demonstration Study

BACKGROUND

This study presents the impact of a 2-year implementation of Coordinated Approach to Child Health Early Childhood (CATCH EC), a preschool-based healthy nutrition and physical activity program, on child BMI z-scores, BMI percentiles, diet, physical activity, and sedentary behaviors among 3- to 5-year old children across Head Start centers in Houston and Austin, Texas.

METHODS

We used a quasi-experimental study design with serial cross-sectional data collection (Intervention catchment area: n = 12 centers, 353 parent-child dyads in Year 1; n = 12 centers, 365 parent-child dyads; Comparison catchment area: n = 13 centers in year 1, 319 parent child dyads; and n = 12 centers, 483 parent-child dyads in year 2). Child height and weight were measured and parent self-report surveys were conducted at year 1 (fall 2012) and year 2 (spring 2014).

RESULTS

In year 1, 34.8% of the children were overweight or obese, 74% were Hispanic, and >80% reported an annual household income of <$25,000. In year 2, 32.2% were overweight or obese, 72% were Hispanic, and 82.3% reported an annual income of <$25,000. Results demonstrated significantly lower child BMI z-scores [β = -0.26 (95% confidence interval, CI: -0.50 to -0.01), p = 0.041] and BMI percentiles [β = -6.5 (95% CI: -12.4 to -0.69), p = 0.028] from year 1 to 2 follow-up among those in intervention Head Start centers, compared to those in the comparison centers. There were no significant between-group changes in child dietary, physical activity, or screen time behaviors.

CONCLUSION

Implementation of a preschool-based obesity prevention program can be modestly effective in lowering the prevalence of child overweight in low-income populations.

Development and use of an index for measuring implementation of a weight management program in children in primary care clinics in Texas

BACKGROUND

The Texas Childhood Obesity Research Demonstration study was an integrated, systems-oriented intervention that incorporated primary and secondary obesity prevention approaches targeting multiple sectors, including primary care clinics, to address childhood obesity. The primary care clinic component included the American Academy of Pediatrics' Next Steps weight management counseling materials that support brief healthy lifestyle-focused visits. The current study describes the methodology and assesses the implementation of the Next Steps program in the participating primary care clinics, as well as the association of implementation with enrollment of children with overweight and obesity in the secondary prevention intervention.

METHODS

The study used a serial cross-sectional study design to collect data from 11 primary care clinics in Houston (n = 5) and Austin (n = 6), Texas, in 2013-2014. Responses of primary care providers on 42 self-reported survey questions assessing acceptability, adoption, appropriateness, and feasibility of the program were utilized to create a mean standardized clinic implementation index score. Provider scores were aggregated to represent Next Steps implementation scores at the clinic level. A mixed effects logistic regression test was conducted to determine the association between program implementation and the enrollment of children in the secondary prevention.

RESULTS

Mean implementation index score was lower at Year 2 of implementation (2014) than Year 1 (2013) although the decrease was not significant [63.2% (12.2%) in 2013 vs. 55.3% (16.5%) in 2014]. There were no significant associations between levels of implementation of Next Steps and enrollment into TX CORD secondary prevention study.

CONCLUSIONS

The development of an index using process evaluation measures can be used to assess the implementation and evaluation of provider-based obesity prevention tools in primary care clinics.

Childhood obesity prevention cluster randomized trial for Hispanic families: outcomes of the healthy families study

BACKGROUND

Obesity prevalence is disproportionately high among Hispanic children.

OBJECTIVES

The Healthy Families Study assessed the efficacy of a culturally targeted, family-based weight gain prevention intervention for Hispanic immigrant families with children ages 5-7 years.

METHODS

The study used a two-group, cluster randomized trial design, assigning 136 families (clusters) to the active intervention (weight gain prevention) and 136 families to attention control (oral health). The active intervention included a 4-month intensive phase (eight classes) and an 8-month reinforcement phase (monthly mail/telephone contact). Children's body mass index z-score (BMI-Z) was the primary outcome.

RESULTS

The BMI-Z growth rate of the active intervention group did not differ from the attention control group at short-term follow-up (median 6 months; 168 families, 206 children) or long-term follow-up (median 16 months; 142 families, 169 children). Dose response analyses indicated a slower increase in BMI-Z at short term among overweight/obese children who attended more intervention classes. Moderate physical activity on weekends increased at short term. Weekend screen time decreased at short term among those attending at least one class session.

CONCLUSION

Low class attendance likely impacted intention-to-treat results. Future interventions targeting this population should test innovative strategies to maximize intervention engagement to produce and sustain effects on weight gain prevention.

Evaluation of complex community-based childhood obesity prevention interventions

BACKGROUND

Multi-setting, multi-component community-based interventions have shown promise in preventing childhood obesity; however, evaluation of these complex interventions remains a challenge.

OBJECTIVE

The objective of the study is to systematically review published methodological approaches to outcome evaluation for multi-setting community-based childhood obesity prevention interventions and synthesize a set of pragmatic recommendations.

METHODS

MEDLINE, CINAHL and PsycINFO were searched from inception to 6 July 2017. Papers were included if the intervention targeted children ≤18 years, engaged at least two community sectors and described their outcome evaluation methodology. A single reviewer conducted title and abstract scans, full article review and data abstraction. Directed content analysis was performed by three reviewers to identify prevailing themes.

RESULTS

Thirty-three studies were included, and of these, 26 employed a quasi-experimental design; the remaining were randomized control trials. Body mass index was the most commonly measured outcome, followed by health behaviour change and psychosocial outcomes. Six themes emerged, highlighting advantages and disadvantages of active vs. passive consent, quasi-experimental vs. randomized control trials, longitudinal vs. repeat cross-sectional designs and the roles of process evaluation and methodological flexibility in evaluating complex interventions.

CONCLUSIONS

Selection of study designs and outcome measures compatible with community infrastructure, accompanied by process evaluation, may facilitate successful outcome evaluation.

Feasibility of a Clinic-Community Partnership to Treat Childhood Obesity

BACKGROUND

"Bull City Fit" is a childhood obesity treatment partnership between Duke Children's pediatric weight management clinic and Durham Department of Parks and Recreation.

OBJECTIVES

Report on feasibility and implementation, characteristics of participants, and predictors of attendance.

METHODS

Mixed methods study consisting of (1) a retrospective cohort analysis (n = 171) reporting demographic, attendance, and clinical data and (2) structured focus groups among stakeholders to identify implementation facilitators and barriers.

RESULTS

Higher attendance was associated with Spanish language ( P = .07), more clinic visits ( P = .03), shorter time to first attendance ( P = .06), lower child z-body mass index (BMI) at baseline ( P = .08), and lower parent BMI ( P = .02). Associations were mitigated after controlling for demographic characteristics. BMI z-score did not differ between low- and moderate/high attenders at 6 months. Family inclusion and community engagement emerged as positive themes during focus groups.

CONCLUSIONS

Clinic-community partnerships engage diverse populations in fitness and nutrition activities, but no specific patient characteristics appear to predict greater attendance.

Predictors of Severe Obesity in Low-Income, Predominantly Hispanic/Latino Children: The Texas Childhood Obesity Research Demonstration Study

INTRODUCTION

The objective of this study was to identify predictors of severe obesity in a low-income, predominantly Hispanic/Latino sample of children in Texas.

METHODS

This cross-sectional analysis examined baseline data on 517 children from the secondary prevention component of the Texas Childhood Obesity Research Demonstration (TX CORD) study; data were collected from September 2012 through February 2014. Self-administered surveys were used to collect data from parents of children who were aged 2 to 12 years, had a body mass index (BMI) in the 85th percentile or higher, and resided in Austin, Texas, or Houston, Texas. Multivariable logistic regression models adjusted for sociodemographic covariates were used to examine associations of children's early-life and maternal factors (large-for-gestational-age, exclusive breastfeeding for ≥4 months, maternal severe obesity [BMI ≥35.0 kg/m2]) and children's behavioral factors (fruit and vegetable consumption, physical activity, screen time) with severe obesity (BMI ≥120% of 95th percentile), by age group (2-5 y, 6-8 y, and 9-12 y).

RESULTS

Across all ages, 184 (35.6%) children had severe obesity. Among children aged 9 to 12 years, large-for-gestational-age at birth (odds ratio [OR] = 2.31; 95% confidence interval [CI], 1.13-4.73) was significantly associated with severe obesity. Maternal severe obesity was significantly associated with severe obesity among children aged 2 to 5 years (OR = 2.67; 95% CI, 1.10-6.47) and 9 to 12 years (OR = 4.12; 95% CI, 1.84-9.23). No significant association was observed between behavioral factors and severe obesity in any age group.

CONCLUSION

In this low-income, predominantly Hispanic/Latino sample of children, large-for-gestational-age and maternal severe obesity were risk factors for severe obesity among children in certain age groups. Promoting healthy lifestyle practices during preconception and prenatal periods could be an important intervention strategy for addressing childhood obesity.

Strategies to Recruit a Diverse Low-Income Population to Child Weight Management Programs From Primary Care Practices

Purpose and Objectives

Primary care practices can be used to engage children and families in weight management programs. The Texas Childhood Obesity Research Demonstration (TX CORD) study targeted patients at 12 primary care practices in diverse and low-income areas of Houston, Texas, and Austin, Texas for recruitment to a trial of weight management programs. This article describes recruitment strategies developed to benefit both families and health care practices and the modification of electronic health records (EHRs) to reflect recruitment outcomes.

Intervention Approach

To facilitate family participation, materials and programs were provided in English and Spanish, and programs were conducted in convenient locations. To support health care practices, EHRs and print materials were provided to facilitate obesity recognition, screening, and study referral. We provided brief training for providers and their office staffs that covered screening patients for obesity, empathetic communication, obesity billing coding, and use of counseling materials.

Evaluation Methods

We collected EHR data from 2012 through 2014, including demographics, weight, and height, for all patients aged 2 to 12 years who were seen in the 12 provider practices during the study’s recruitment phase. The data of patients with a body mass index (BMI) at or above the 85th percentile were compared with the same data for patients who were referred to the study and patients who enrolled in the study. We also examined reasons that patients referred to the study declined to participate.

Results

Overall, 26% of 7,845 patients with a BMI at or above the 85th percentile were referred to the study, and 27% of referred patients enrolled. Enrollment among patients with a BMI at or above the 85th percentile was associated with being Hispanic and with more severe obesity than with patients of other races/ethnicities or less severe obesity, respectively. Among families of children aged 2 to 5 years who were referred, 20% enrolled, compared with 30% of families of older children (>5 y to 12 y). Referral rates varied widely among the 12 primary care practices, and referral rates were not associated with EHR modifications.

Implications for Public Health

Engagement and recruitment strategies for enrolling families in primary care practice in weight management programs should be strengthened. Further study of factors associated with referral and enrollment, better systems for EHR tools, and data on provider and office adherence to study protocols should be examined. EHRs can track referral and enrollment to capture outcomes of recruitment efforts.

Best Practices and Barriers to Obesity Prevention in Head Start: Differences Between Director and Teacher Perceptions

Introduction

Practices and barriers to promoting healthy eating and physical activity at Head Start centers may influence children’s energy balance behaviors. We examined differences between directors’ and teachers’ perspectives on best practices and barriers to promoting healthy eating and physical activity in Head Start centers.

Methods

We conducted a cross-sectional study of directors (n = 23) and teachers (n = 113) at 23 Head Start centers participating in the baseline assessment of the Texas Childhood Obesity Research Demonstration study. Participants completed surveys about practices and barriers to promoting healthy eating and physical activity. Multilevel regression models examined differences between director and teacher responses.

Results

More than half of directors and teachers reported meeting most best practices related to nutrition and physical activity; few directors or teachers (<25%) reported conducting physical activity for more than 60 minutes a day, and less than 40% of teachers helped children attend to satiety cues. Significantly more directors than teachers reported meeting 2 nutrition-related best practices: “Teachers rarely eat less healthy foods (especially sweets, salty snacks, and sugary drinks) in front of children” and “Teachers talk to children about trying/enjoying new foods” (P < .05). No barrier to healthy eating or physical activity was reported by more than 25% of directors or teachers. Significantly more teachers than directors reported barriers to healthy eating, citing lack of food service staff support, limited time, and insufficient funds (P < .05).

Conclusion

More barriers to healthy eating were reported than were barriers to physical activity indicating that more support may be needed for healthy eating. Differences between responses of directors and teachers may have implications for future assessments of implementation of best practices and barriers to implementation related to nutrition and physical activity in early care and education centers.

Overview of the obesity intervention taxonomy and pooled analysis working group

The National Heart, Lung, and Blood Institute and the National Institutes of Health Office of Disease Prevention convened a meeting on August 29-30, 2013 entitled "Obesity Intervention Taxonomy and Pooled Analysis." The overarching goals of the meeting were to understand how to decompose interventions targeting behavior change, and in particular, those that focus on obesity and to combine data from groups of related intervention studies to supplement what can be learned from the individual studies. This paper summarizes the workshop recommendations and provides an overview of the two other papers that originated from the workshop and that address decomposition of behavioral change interventions and pooling of data across diverse studies within a consortium.

Efficacy of a Community- Versus Primary Care-Centered Program for Childhood Obesity: TX CORD RCT

OBJECTIVE

This randomized controlled trial was conducted to determine comparative efficacy of a 12-month community-centered weight management program (MEND2-5 for ages 2-5 or MEND/CATCH6-12 for ages 6-12) against a primary care-centered program (Next Steps) in low-income children.

METHODS

Five hundred forty-nine Hispanic and black children (BMI ≥ 85th percentile), stratified by age groups (2-5, 6-8, and 9-12 years), were randomly assigned to MEND2-5 (27 contact hours)/MEND/CATCH6-12 (121.5 contact hours) or Next Steps (8 contact hours). Primary (BMI value at the 95th percentile [%BMI_p95 ]) and secondary outcomes were measured at baseline, 3 months (Intensive Phase), and 12 months (Transition Phase).

RESULTS

For age group 6-8, MEND/CATCH6-12 resulted in greater improvement in %BMI_p95 than Next Steps during the Intensive Phase. Effect size (95% CI) was -1.94 (-3.88, -0.01) percentage points (P = 0.05). For age group 9-12, effect size was -1.38 (-2.87, 0.16) percentage points for %BMI_p95 (P = 0.07). MEND2-5 did not differentially affect %BMI_p95 . Attendance averaged 52% and 22% during the Intensive and Transition Phases. Intervention compliance was inversely correlated to change in %BMI_p95 during the Intensive Phase (P < 0.05). In the Transition Phase, %BMI_p95 was maintained or rebounded in both programs (P < 0.05).

CONCLUSIONS

MEND/CATCH6-12 was more efficacious for BMI reduction at 3 months but not 12 months compared to Next Steps in underserved children. Intervention compliance influenced outcomes, emphasizing the need for research in sustaining family engagement in low-income populations.

Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years

BACKGROUND

Child and adolescent overweight and obesity has increased globally, and can be associated with significant short- and long-term health consequences. This is an update of a Cochrane review published first in 2003, and updated previously in 2009. However, the update has now been split into six reviews addressing different childhood obesity treatments at different ages.

OBJECTIVES

To assess the effects of diet, physical activity and behavioural interventions (behaviour-changing interventions) for the treatment of overweight or obese children aged 6 to 11 years.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS as well as trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of studies and systematic reviews. We did not apply any language restrictions. The date of the last search was July 2016 for all databases.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) of diet, physical activity, and behavioural interventions (behaviour-changing interventions) for treating overweight or obese children aged 6 to 11 years, with a minimum of six months' follow-up. We excluded interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened references, extracted data, assessed risk of bias, and evaluated the quality of the evidence using the GRADE instrument. We contacted study authors for additional information. We carried out meta-analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included 70 RCTs with a total of 8461 participants randomised to either the intervention or control groups. The number of participants per trial ranged from 16 to 686. Fifty-five trials compared a behaviour-changing intervention with no treatment/usual care control and 15 evaluated the effectiveness of adding an additional component to a behaviour-changing intervention. Sixty-four trials were parallel RCTs, and four were cluster RCTs. Sixty-four trials were multicomponent, two were diet only and four were physical activity only interventions. Ten trials had more than two arms. The overall quality of the evidence was low or very low and 62 trials had a high risk of bias for at least one criterion. Total duration of trials ranged from six months to three years. The median age of participants was 10 years old and the median BMI z score was 2.2.Primary analyses demonstrated that behaviour-changing interventions compared to no treatment/usual care control at longest follow-up reduced BMI, BMI z score and weight. Mean difference (MD) in BMI was -0.53 kg/m2 (95% confidence interval (CI) -0.82 to -0.24); P < 0.00001; 24 trials; 2785 participants; low-quality evidence. MD in BMI z score was -0.06 units (95% CI -0.10 to -0.02); P = 0.001; 37 trials; 4019 participants; low-quality evidence and MD in weight was -1.45 kg (95% CI -1.88 to -1.02); P < 0.00001; 17 trials; 1774 participants; low-quality evidence.Thirty-one trials reported on serious adverse events, with 29 trials reporting zero occurrences RR 0.57 (95% CI 0.17 to 1.93); P = 0.37; 4/2105 participants in the behaviour-changing intervention groups compared with 7/1991 participants in the comparator groups). Few trials reported health-related quality of life or behaviour change outcomes, and none of the analyses demonstrated a substantial difference in these outcomes between intervention and control. In two trials reporting on minutes per day of TV viewing, a small reduction of 6.6 minutes per day (95% CI -12.88 to -0.31), P = 0.04; 2 trials; 55 participants) was found in favour of the intervention. No trials reported on all-cause mortality, morbidity or socioeconomic effects, and few trials reported on participant views; none of which could be meta-analysed.As the meta-analyses revealed substantial heterogeneity, we conducted subgroup analyses to examine the impact of type of comparator, type of intervention, risk of attrition bias, setting, duration of post-intervention follow-up period, parental involvement and baseline BMI z score. No subgroup effects were shown for any of the subgroups on any of the outcomes. Some data indicated that a reduction in BMI immediately post-intervention was no longer evident at follow-up at less than six months, which has to be investigated in further trials.

AUTHORS' CONCLUSIONS

Multi-component behaviour-changing interventions that incorporate diet, physical activity and behaviour change may be beneficial in achieving small, short-term reductions in BMI, BMI z score and weight in children aged 6 to 11 years. The evidence suggests a very low occurrence of adverse events. The quality of the evidence was low or very low. The heterogeneity observed across all outcomes was not explained by subgrouping. Further research is required of behaviour-changing interventions in lower income countries and in children from different ethnic groups; also on the impact of behaviour-changing interventions on health-related quality of life and comorbidities. The sustainability of reduction in BMI/BMI z score and weight is a key consideration and there is a need for longer-term follow-up and further research on the most appropriate forms of post-intervention maintenance in order to ensure intervention benefits are sustained over the longer term.

Home visitation programs: an untapped opportunity for the delivery of early childhood obesity prevention

BACKGROUND

Extant obesity efforts have had limited impact among low-income underserved children, in part because of limitations inherent to existing programs: (i) short duration and low intensity; (ii) late timing of implementation, when children are already overweight or obese; (iii) intervention delivery limiting their accessibility and sustainability; and (iv) failure to address barriers such as a lack of culturally competent services, poverty and housing instability, which interfere with healthy lifestyle changes.

OBJECTIVE

This concept paper proposes an innovative model of obesity prevention implemented in infancy and sustained throughout early childhood to address the limitations of current obesity prevention efforts. Specifically, we propose to integrate sustained, weekly, in-home obesity prevention as part of the services already delivered by ongoing Home Visitation Programs, which currently do not target obesity prevention.

CONCLUSION

The home visiting structure represents an ideal model for impactful obesity prevention as home visitation programs: (i) already provide comprehensive services to diverse low-income infants and families who are most at risk for obesity and poor health because of socio-economic and structural conditions; (ii) services are initiated in infancy and sustained throughout critical developmental periods for the formation of healthy/unhealthy behaviors; and (iii) have been in place for more than 40 years, with a widespread presence across the United States and nationwide, which is critical for the scalability and sustainability of obesity prevention.

Impact of school-based vegetable garden and physical activity coordinated health interventions on weight status and weight-related behaviors of ethnically diverse, low-income students: Study design and baseline data of the Texas, Grow! Eat! Go! (TGEG) cluster-randomized controlled trial

Background

Coordinated, multi-component school-based interventions can improve health behaviors in children, as well as parents, and impact the weight status of students. By leveraging a unique collaboration between Texas AgriLife Extension (a federal, state and county funded educational outreach organization) and the University of Texas School of Public Health, the Texas Grow! Eat! Go! Study (TGEG) modeled the effectiveness of utilizing existing programs and volunteer infrastructure to disseminate an enhanced Coordinated School Health program. The five-year TGEG study was developed to assess the independent and combined impact of gardening, nutrition and physical activity intervention(s) on the prevalence of healthy eating, physical activity and weight status among low-income elementary students. The purpose of this paper is to report on study design, baseline characteristics, intervention approaches, data collection and baseline data.

Methods

The study design for the TGEG study consisted of a factorial group randomized controlled trial (RCT) in which 28 schools were randomly assigned to one of 4 treatment groups: (1) Coordinated Approach to Child Health (CATCH) only (Comparison), (2) CATCH plus school garden intervention [Learn, Grow, Eat & Go! (LGEG)], (3) CATCH plus physical activity intervention [Walk Across Texas (WAT)], and (4) CATCH plus LGEG plus WAT (Combined). The outcome variables include student’s weight status, vegetable and sugar sweetened beverage consumption, physical activity, and sedentary behavior. Parents were assessed for home environmental variables including availability of certain foods, social support of student health behaviors, parent engagement and behavior modeling.

Results

Descriptive data are presented for students (n = 1369) and parents (n = 1206) at baseline. The sample consisted primarily of Hispanic and African American (53 % and 18 %, respectively) and low-income (i.e., 78 % eligible for Free and Reduced Price School Meals program and 43 % food insecure) students. On average, students did not meet national guidelines for vegetable consumption or physical activity. At baseline, no statistical differences for demographic or key outcome variables among the 4 treatment groups were observed.

Conclusions

The TGEG study targets a population of students and parents at high risk of obesity and related chronic conditions, utilizing a novel and collaborative approach to program formulation and delivery, and a rigorous, randomized study design.

"Whole-of-Community" Obesity Prevention: A Review of Challenges and Opportunities in Multilevel, Multicomponent Interventions

The causes of obesity worldwide are complex and multilevel, including changing food environments, physical activity levels, policies, and food production systems. This intricate context requires multilevel and multicomponent (MLMC) interventions to improve health outcomes. We conducted a literature review of MLMC interventions for obesity prevention and mitigation; 14 studies meeting search criteria were identified. We found examples of successes in preventing obesity, reducing overweight, improving healthful behaviors, and enhancing some psychosocial indicators. Of eight studies that reported health and behavioral results, five showed no significant impact and three showed reductions in obesity. Four studies showed significant improvement in dietary behavior, and five reported significant desirable effects in physical activity or screen time. Five studies reported psychosocial impacts, and three of these showed significant improvements. MLMC approaches show promising results, particularly when they are able to integrate components at the policy, community, and interpersonal levels.

Wildcat wellness coaching feasibility trial: protocol for home-based health behavior mentoring in girls

BACKGROUND

Childhood obesity is a major public health problem, with one third of America's children classified as either overweight or obese. Obesity prevention and health promotion programs using components such as wellness coaching and home-based interventions have shown promise, but there is a lack of published research evaluating the impact of a combined home-based and wellness coaching intervention for obesity prevention and health promotion in young girls. The main objective of this study is to test the feasibility of such an intervention on metrics related to recruitment, intervention delivery, and health-related outcome assessments. The secondary outcome is to evaluate the possibility of change in health-related psychosocial, behavioral, and biomedical outcomes in our sample of participants.

METHODS/DESIGN

Forty girls who are overweight or obese (aged 8-13 years) will be recruited from a Midwestern college town. Participants will be recruited through posted flyers, newspaper advertisements, email, and social media. The volunteer convenience sample of girls will be randomized to one of two home-based wellness coaching interventions: a general health education condition or a healthy eating physical activity skills condition. Trained female wellness coaches will conduct weekly hour-long home visits for 12 consecutive weeks. Assessments will occur at baseline, post-intervention (3 months after baseline), and follow-up (6 months after baseline) and will include height, weight, waist circumference, body composition, pulmonary function, blood pressure, systemic inflammation, physical activity (Actical accelerometer), and self-reported survey measures (relevant to fruit and vegetable consumption, physical activity, and quality of life).

DISCUSSION

This study will evaluate the feasibility of home-based wellness coaching interventions for overweight and obese girls and secondarily assess the preliminary impact on health-related psychosocial, behavioral, and biomedical outcomes. Results will provide information regarding the feasibility of this new model for use in girls as an approach to reduce the burden of overweight and obesity toward the prevention of chronic disease.

TRIAL REGISTRATION

NCT01845480.

Rationale, Design, and Methods for Process Evaluation in the Childhood Obesity Research Demonstration Project

OBJECTIVE

The cross-site process evaluation plan for the Childhood Obesity Research Demonstration (CORD) project is described here.

DESIGN

The CORD project comprises 3 unique demonstration projects designed to integrate multi-level, multi-setting health care and public health interventions over a 4-year funding period.

SETTING

Three different communities in California, Massachusetts, and Texas.

PARTICIPANTS

All CORD demonstration projects targeted 2-12-year-old children whose families are eligible for benefits under Title XXI (CHIP) or Title XIX (Medicaid).

INTERVENTION(S)

The CORD projects were developed independently and consisted of evidence-based interventions that aim to prevent childhood obesity. The interventions promote healthy behaviors in children by applying strategies in 4 key settings (primary care clinics, early care and education centers, public schools, and community institutions).

MAIN OUTCOME MEASURE(S)

The CORD process evaluation outlined 3 main outcome measures: reach, dose, and fidelity, on 2 levels (researcher to provider, and provider to participant).

ANALYSIS

The plan described here provides insight into the complex nature of process evaluation for consortia of independently designed multi-level, multi-setting intervention studies. The process evaluation results will provide contextual information about intervention implementation and delivery with which to interpret other aspects of the program.

Childhood Obesity Research Demonstration project: cross-site evaluation methods

INTRODUCTION

The Childhood Obesity Research Demonstration (CORD) project links public health and primary care interventions in three projects described in detail in accompanying articles in this issue of Childhood Obesity. This article describes a comprehensive evaluation plan to determine the extent to which the CORD model is associated with changes in behavior, body weight, BMI, quality of life, and healthcare satisfaction in children 2-12 years of age.

DESIGN/METHODS

The CORD Evaluation Center (EC-CORD) will analyze the pooled data from three independent demonstration projects that each integrate public health and primary care childhood obesity interventions. An extensive set of common measures at the family, facility, and community levels were defined by consensus among the CORD projects and EC-CORD. Process evaluation will assess reach, dose delivered, and fidelity of intervention components. Impact evaluation will use a mixed linear models approach to account for heterogeneity among project-site populations and interventions. Sustainability evaluation will assess the potential for replicability, continuation of benefits beyond the funding period, institutionalization of the intervention activities, and community capacity to support ongoing program delivery. Finally, cost analyses will assess how much benefit can potentially be gained per dollar invested in programs based on the CORD model.

CONCLUSIONS

The keys to combining and analyzing data across multiple projects include the CORD model framework and common measures for the behavioral and health outcomes along with important covariates at the individual, setting, and community levels. The overall objective of the comprehensive evaluation will develop evidence-based recommendations for replicating and disseminating community-wide, integrated public health and primary care programs based on the CORD model.

Childhood Obesity Research Demonstration (CORD): the cross-site overview and opportunities for interventions addressing obesity community-wide

BACKGROUND

This is the first of a set of articles in this issue on the Childhood Obesity Research Demonstration (CORD) project and provides an overview of the multisite approach and community-wide interventions. Innovative multisetting, multilevel approaches that integrate primary healthcare and public health interventions to improve outcomes for children with obesity need to be evaluated. The CORD project aims to improve BMI and obesity-related behaviors among underserved 2- to 12-year-old children by utilizing these approaches.

METHODS

The CORD consortium, structure, model terminology and key components, and common measures were solidified in year 1 of the CORD project. Demonstration sites applied the CORD model across communities in years 2 and 3. Evaluation plans for year 4 include site-specific analyses as well as cross-site impact, process, and sustainability evaluations.

RESULTS

The CORD approach resulted in commonalities and differences in participant, intervention, comparison, and outcome elements across sites. Products are to include analytic results as well as cost assessment, lessons learned, tools, and materials.

DISCUSSION

Foreseen opportunities and challenges arise from the similarities and unique aspects across sites. Communities adapted interventions to fit their local context and build on strengths, but, in turn, this flexibility makes cross-site evaluation challenging.

CONCLUSION

The CORD project represents an evidence-based approach that integrates primary care and public health strategies and evaluates multisetting multilevel interventions, thus adding to the limited research in this field. CORD products will be disseminated to a variety of stakeholders to aid the understanding, prevention, and management of childhood obesity.