Self-Reported Food Security in Adolescents with Type 1 Diabetes: Association with Hemoglobin A1c and Mental Health Symptoms Independent of Household Food Security.

BACKGROUND: Typically, child exposure to food insecurity is assessed by caregiver reports of household food security. Child report has the potential for greater accuracy because it pertains only to the child whose experiences may differ from caregiver reports. OBJECTIVE: We assessed if adolescent-reported food insecurity was associated with levels of hemoglobin A1c (HbA1c), acute diabetes-related complications, depressive symptoms, and disordered eating behaviors in adolescents with type 1 diabetes, independently from household food security. METHODS: In a cross-sectional analysis of the multicenter SEARCH for Diabetes in Youth Cohort Study (phase 4, 2016-2019) including 601 adolescents aged 10-17 y with type 1 diabetes and their caregivers, household food security, and adolescent-reported food security were assessed using the 18-item Household Food Security Survey Module and the 6-item Child Food Security Assessment questionnaire. Age-stratified (10-13 and 14-17) regression models were performed to estimate independent associations, adjusting for sociodemographics, clinical factors, and household food security. RESULTS: Food insecurity was reported by 13.1% (n = 79) of adolescents and 15.6% (n = 94) of caregivers. Among adolescent-caregiver dyads, 82.5% (n = 496) of reports were concordant and 17.5% (n = 105) discordant, Cohen's κ= 0.3. Adolescent-reported food insecurity was not independently associated with HbA1c, diabetic ketoacidosis, and severe hypoglycemia, including in age-stratified analyses. Adolescent-reported food insecurity was independently associated with elevated odds of depressive symptoms [odds ratio (OR): 3.6; 95% confidence interval (CI): 1.3, 10.3] and disordered eating behaviors (OR: 2.5, 95% CI: 1.4, 4.6) compared with adolescents reporting food security; these associations remained in both age groups for disordered eating behaviors and in the older group for depressive symptoms. CONCLUSIONS: Adolescents with type 1 diabetes may experience food insecurity differently than caregivers. Adolescent-reported food insecurity was independently associated with depressive symptoms and disordered eating behaviors and thus may be an important attribute to assess in addition to household food security in adolescents with type 1 diabetes.

Properties of the Household Food Security Survey Module Scale in Young Adults with Diabetes.

BACKGROUND: The Household Food Security Survey Module (HFSSM) was not tailored to people with chronic diseases or young adults (YAs). OBJECTIVES: We aim to evaluate whether the 18-item HFSSM meets assumptions underlying the scale among YAs with diabetes. METHODS: Data from 1887 YAs with youth-onset type 1 diabetes or type 2 diabetes were used from the SEARCH for Diabetes in Youth Study, 2016-2019, and on 925 who returned for the SEARCH Food Security Cohort Study, 2018-2021, all of whom had completed the HFSSM. Guttman scaling properties (affirmation of preceding less severe items) and Rasch model properties (probability to answer an item based on difficulty level) were assessed. RESULTS: Items 3 (balanced meals) and 6 (eating less than one should) were affirmed more frequently than expected (nonmonotonic response pattern). At 1.2%-3.5%, item nonresponse was rare among type 1 diabetes but higher among type 2 diabetes (range: 3.1%-10.6%). Items 9 (not eating the whole day) and 3 did not meet the Guttman scaling properties. Rasch modeling revealed that item 3 had the smallest difficulty parameter. INFIT indices suggested that some responses to item 3 did not match the pattern in the rest of the sample. Classifying household food insecurity (HFI) based on items 1 and 2 compared with other 2-item combinations, including item 3, revealed a substantial undercount of HFI ranging from 5% to 8% points. CONCLUSIONS: Use of the HFSSM among YAs with diabetes could potentially result in biased HFI reporting and affect estimates of HFI prevalence in this population.

Evaluation of a walking school bus program: a cluster randomized controlled trial.

BACKGROUND: The purpose of this study was to investigate the effects of a walking school bus intervention on children's active commuting to school. METHODS: We conducted a randomized controlled trial (RCT) in Houston, Texas (Year 1) and Seattle, Washington (Years 2-4) from 2012 to 2016. The study had a two-arm, cluster randomized design comparing the intervention (walking school bus and education materials) to the control (education materials) over one school year October/November - May/June). Twenty-two schools that served lower income families participated. Outcomes included percentage of days students' active commuting to school (primary, measured via survey) and moderate-to-vigorous physical activity (MVPA, measured via accelerometry). Follow-up took place in May or June. We used linear mixed-effects models to estimate the association between the intervention and outcomes of interest. RESULTS: Total sample was 418 students [Mage=9.2 (SD = 0.9) years; 46% female], 197 (47%) in the intervention group. The intervention group showed a significant increase compared with the control group over time in percentage of days active commuting (ß = 9.04; 95% CI: 1.10, 16.98; p = 0.015) and MVPA minutes/day (ß = 4.31; 95% CI: 0.70, 7.91; p = 0.02). CONCLUSIONS: These findings support implementation of walking school bus programs that are inclusive of school-age children from lower income families to support active commuting to school and improve physical activity. TRAIL REGISTRATION: This RCT is registered at clinicaltrials.gov (NCT01626807).

Household Food Insecurity and Cognition in Youth and Young Adults with Youth-Onset Diabetes.

Objective: We evaluated the association of household food insecurity (FI) with cognition in youth and young adults with type 1 diabetes (T1D) or type 2 diabetes (T2D). Design: In this cross-sectional study, age-adjusted scores for composite Fluid Cognition, and sub-domain scores for Receptive Language and Inhibitory Control and Attention, were modeled stratified by diabetes-type using linear regression, with FI in the past year as the predictor, controlling for covariates. Tests for processing speed, inhibitory control/attention, working memory, episodic memory, and cognitive flexibility were administered to measure composite Fluid Cognition score. The NIHT-CB Picture Vocabulary Test was used to assess Crystallized Cognition score and rapid identification of congruent versus noncongruent items were used to assess Inhibitory Control and Attention score. Setting: The SEARCH for Diabetes in Youth study, representative of 5 U.S. states. Participants: Included 1574 youth and young adults with T1D or T2D, mean age of 21 years, mean diabetes duration of 11 years, 51% non-Hispanic white, and 47% had higher HbA1c levels (>9% HbA1c). Results: Approximately 18% of the 1,240 participants with T1D and 31% of the 334 with T2D experienced FI. The food-insecure group with T1D had a lower composite Fluid Cognition score (ß= -2.5, 95% confidence interval (CI)= -4.8, -0.1) and a lower Crystallized Cognition score (ß= -3.4, CI= -5.6, -1.3) than food-secure peers. Findings were attenuated to non-significance after adjustment for demographics. Among T2D participants, no associations were observed. In participants with T1D effect modification by glycemic levels were found in the association between FI and composite Fluid Cognition score but adjustment for socioeconomic characteristics attenuated the interaction (p=0.0531). Conclusions: Food-insecure youth and young adults with T1D or T2D did not have different cognition compared to those who were food-secure after adjustment for confounders. Longitudinal research is needed to further understand relations amongst these factors.

Inequalities in Glycemic Control in Youth with Type 1 Diabetes Over Time: Intersectionality Between Socioeconomic Position and Race and Ethnicity.

BACKGROUND: Racial/ethnic health inequities have been well-documented among youth and young adults with type 1 diabetes (T1D), yet little is known about how socioeconomic position (SEP) intersects with the risk marker of race/ethnicity to predict inequities in longitudinal glycemic control. PURPOSE: To identify patterns of SEP, race/ethnicity, and clinical characteristics that differentiate hemoglobin A1c (HbA1c) trajectories among youth and young adults after T1D diagnosis. METHODS: The SEARCH for Diabetes in Youth cohort includes youth with diabetes diagnosed from 2002 to 2006 and 2008 who were followed through 2015. We analyzed data from 1,313 youth and young adults with T1D with ≥3 HbA1c measures. Classification tree analysis identified patterns of baseline demographic, SEP, and clinical characteristic that best predicted HbA1c trajectories over an average of 8.3 years using group-based trajectory modeling. RESULTS: Two HbA1c trajectories were identified: Trajectory 1 (77%) with lower baseline HbA1c and mild increases (from mean 7.4% to 8.4%) and Trajectory 2 (23%) with higher baseline HbA1c and major increases (from 8.5% to 11.2%). Race/ethnicity intersected with different SEP characteristics among non-Hispanic white (NHW) than in non-whites. Public health insurance predicted high-risk Trajectory 2 membership in non-whites, whereas parental education, household structure, diagnosis age and glucose checking frequency predicted membership for NHW youth and young adults. Two characteristics, race/ethnicity and parental education alone identified 80% of the Trajectory 2 members. CONCLUSIONS: Race/ethnicity intersects with multiple SEP and clinical characteristics among youth and young adults with T1D, which is associated with particularly high risk of poor long-term glycemic control.

Household food insecurity is associated with diabetic ketoacidosis but not severe hypoglycemia or glycemic control in youth and young adults with youth-onset type 2 diabetes.

OBJECTIVE: To examine the association between household food insecurity (HFI), glycemic control, severe hypoglycemia and diabetic ketoacidosis (DKA) among youth and young adults (YYA) with youth-onset type 2 diabetes. RESEARCH DESIGN AND METHODS: This cross-sectional study included 395 YYA with type 2 diabetes from the SEARCH for Diabetes in Youth Study (2015-2019). HFI was reported by young adult participants or parents of minor participants via the US Household Food Security Survey Module. Glycemic control was assessed by HbA1c and analyzed as a continuous and categorical variable (optimal: <7.0%, suboptimal: ≥7.0%-9.0%, poor: >9.0%). Acute complications included self-reported severe hypoglycemia or DKA in the last 12 months. Adjusted logistic and linear regression were used for binary and continuous outcomes, respectively. RESULTS: Approximately 31% reported HFI in the past 12 months. Mean HbA1c among those with HFI was 9.2% compared to 9.5% without HFI. Of those with HFI, 56% had an HbA1c >9.0% compared to 55% without HFI. Adjusted models showed no associations between HFI and glycemic control. Of those with HFI, 14.4% reported experiencing DKA and 4.7% reported severe hypoglycemia. YYA with HFI had 3.08 times (95% CI: 1.18-8.06) the odds of experiencing DKA as those without HFI. There was no association between HFI and severe hypoglycemia. CONCLUSIONS: HFI was associated with markedly increased odds of DKA but not with glycemic control or severe hypoglycemia. Future research among YYA with type 2 diabetes should evaluate longitudinally whether alleviating HFI reduces DKA.

PM2.5 air pollution exposure and nonalcoholic fatty liver disease in the Nationwide Inpatient Sample.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease. Particulate matter air pollution <2.5 µm in diameter (PM2.5) is a ubiquitous exposure primarily produced from fossil fuel combustion. Previous epidemiologic studies have been mixed. The objective of this study was to examine the association between ambient PM2.5 exposure and NAFLD among hospitalized patients in the Nationwide Inpatient Sample (NIS). METHODS: We conducted a cross-sectional analysis of hospitalizations from 2001 to 2011 using the NIS, the largest nationally representative all-payer inpatient care administrative database in the United States. Average annual PM2.5 exposure was estimated by linking census tracts (based on NIS-provided hospital ZIP Codes) with a spatiotemporal exposure model. Clinical conditions were identified using hospital discharge diagnosis codes. Multivariable logistic regression incorporating discharge weights was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between PM2.5 exposure and odds of NAFLD among hospitalized patients adjusting for age, sex, race/ethnicity, year, individual- and area-level socioeconomic status, urbanicity, region, obesity, diabetes, metabolic syndrome, impaired fasting glucose, dyslipidemia, hypertension, obstructive sleep apnea, and smoking. RESULTS: There were 269,705 hospitalized patients with NAFLD from 2001 to 2011 (total unweighted n = 45,433,392 hospitalizations). Higher ambient PM2.5 exposure was associated with increased odds of NAFLD among hospitalized patients (adjusted OR: 1.24 per 10 µg/m3 increase, 95% CI 1.15-1.33, p < 0.01). There were statistically significant interactions between PM2.5 exposure and age, race/ethnicity, diabetes, smoking, and region, with stronger positive associations among patients who were aged ≥45 years, non-Hispanic White or Asian/Pacific Islander, non-diabetics, non-smokers, or in the Midwest and West regions, respectively. CONCLUSIONS: In this nationwide cross-sectional analysis of the NIS database, there was a positive association between ambient PM2.5 exposure and odds of NAFLD among hospitalized patients. Future research should examine the effects of long-term historical PM2.5 exposure and incident NAFLD cases.

Parent-perceived neighbourhood environment, parenting practices and preschool-aged children physical activity and screen time: a cross-sectional study of two culturally and geographically diverse cities.

BACKGROUND: Preschool-aged children's physical activity (PA) and screen time (ST) are important health-related behaviours likely influenced by PA opportunities, parental perceptions of neighbourhood safety and parenting practices pertaining to PA and ST. How these factors interact to impact on young children's PA and ST, and whether their effects are generalisable across cultures and geographical location is not known. This study addressed these knowledge gaps by conducting pooled analyses of comparable data from two culturally and geographically diverse samples - Chinese parent-child dyads from an ultra-dense city (Hong Kong, China) and Latino parent-child dyads from a low-density city (Houston, USA). METHODS: The analytical sample consisted of 164 Hong Kong Chinese and 84 US Latino parent-child dyads with data on socio-demographic characteristics, parent-perceived neighbourhood destinations and facilities for children's PA, physical and social safety-related neighbourhood attributes, PA-related parenting practices and child's ST and accelerometer-assessed PA. Generalised linear models with robust standard errors accounting for neighbourhood-level clustering were used to estimate associations and interaction effects. RESULTS: Hong Kong Chinese children accumulated less PA than US Latino children, although the latter had more ST. Hong Kong Chinese parents reported more parenting practices promoting inactivity. Neighbourhood PA opportunities were positively related to children's PA only if parental perceptions of neighbourhood safety were favourable, and the associations of physical neighbourhood environment characteristics with children's PA and ST depended on PA-related parenting practices. Community cohesion was positively related to children's PA and negatively related to ST, while parental promotion of ST was positively associated with children's ST. Correlates of children's PA and ST did not differ by city. CONCLUSIONS: The substantial differences in activity patterns between Hong Kong Chinese and US Latino preschool-aged children observed in this study are likely due to a combination of cultural and built environmental factors. However, the fact that no between-city differences in correlates of PA and ST were detected indicates that both populations of children are equally affected by parent-perceived neighbourhood environmental characteristics and parenting practices. Overall, this study highlights the importance of considering how various individual-, home- and neighbourhood physical and social factors interact to influence young children's health-promoting activity levels.

Evaluating the Feasibility and Acceptability of the Lifestyle Enhancement for ADHD Program.

OBJECTIVE: To evaluate the feasibility and acceptability of the Lifestyle Enhancement for Attention Deficit Hyperactivity Disorder (ADHD) Program (LEAP), a novel parent behavior management training program that promotes physical activity (PA) and positive health behaviors and is enhanced with mobile health technology (Garmin) and a social media (Facebook) curriculum for parents of children with ADHD. METHODS: The study included parents of children ages 5-10 years diagnosed with ADHD who did not engage in the recommended >60 min/day of moderate to vigorous PA based on parent report at baseline. Parents participated in the 8-week LEAP group and joined a private Facebook group. Children and one parent wore wrist-worn Garmin activity trackers daily. Parents completed the Treatment Adherence Inventory, Client Satisfaction Questionnaire, and participated in a structured focus group about their experiences with various aspects of the program. RESULTS: Of 31 children enrolled, 51.5% had ADHD combined presentation, 36.3% with ADHD, predominately inattentive presentation, and 12.1% had unspecified ADHD (age 5-10; M = 7.6; 48.4% female). Parents attended an average of 86% of group sessions. On average, parents wore their Garmins for 5.1 days/week (average step count 7,092 steps/day) and children for 6.0 days/week (average step count 9,823 steps/day). Overall, parents and children were adherent to intervention components and acceptability of the program was high. CONCLUSIONS: Findings indicate that the LEAP program is an acceptable and feasible intervention model for promoting PA among parents and their children with ADHD. Implications for improving ADHD symptoms and enhancing evidence-based parent training programs are discussed.

Participation and engagement of a rural community in Ciclovía: progressing from research intervention to community adoption.

BACKGROUND: Open streets events, where roads are temporarily closed to motorized vehicles, can provide safe spaces for physical activity (PA) and become sustainable community infrastructure. Since 2016, we have collaborated with a rural community to implement an open streets event, named ciclovía. In 2019, ciclovía was adopted as a community-wide program. This paper describes the process of building and progressing a ciclovía from a research intervention to a community-adopted program and participation of a rural community in ciclovía. METHODS: We used community-based participatory research to foster bidirectional learning on how to optimize the content and implementation of ciclovía to be feasible and acceptable for rural communities. The community-academic partnership focused on: 1) understanding the science of ciclovía; 2) learning the implementation process; 3) creating tools to facilitate planning, implementation, and evaluation of ciclovía; and 4) developing transition steps from a research intervention to a community-adopted program. RESULTS: The progression of the research intervention to community adoption spanned 2 years. First, the partnership met quarterly to discuss the science of ciclovía, its utility, and its adaptation for rural communities. Second, the partnership studied processes that facilitated ciclovía implementation. Third, the partnership created the ciclovía planning guide and tools for communities to establish their own ciclovía. The guide included forming a planning committee, setting meeting and communication plans, marketing and promotion, and selecting evaluation tools. Fourth, the transition steps from research intervention to community adoption included creating roles and responsibilities, implementing ciclovía using the planning guide, and convening listening sessions for improvement on implementation. Community attendance at ciclovía doubled from 189 individuals (126 children and 63 adults) when it was a research intervention to 394 individuals (277 children and 117 adults) when it was a community program. CONCLUSIONS: The progression from a research intervention to a community-adopted program encompasses multiple steps that involve bidirectional learning and partnership with the community. Lessons learned from this study are integrated into a disseminatable ciclovía planning guide.

Socioeconomic position is associated with glycemic control in youth and young adults with type 1 diabetes.

OBJECTIVE: Health inequities persist in youth and young adults (YYA) with type 1diabetes in achieving optimal glycemic control. The purpose of this study was to assess the contribution of multiple indicators of social need to these inequities. RESEARCH DESIGN AND METHODS: Two hundred and twenty two YYA withtype 1 diabetes enrolled in the SEARCH Food Insecurity Study in South Carolina and Washington between the years 2013 and 2015 were included. Latent class analysis was used to identify socioeconomic profiles based on household income, parental education, health insurance, household food insecurity, and food assistance. Profiles were evaluated in relation to glycemic control using multivariable linear and logistic regression, with HbA1c > 9%(75 mmol/mol) defined as high-risk glycemic control. RESULTS: Two profiles were identified: a lower socioeconomic profile included YYA whose parents had lower income and/or education, and were more likely to be uninsured, receive food assistance, and be food insecure. A higher socioeconomic profile included YYA whose circumstances were opposite to those in the lower socioeconomic profile. Those with a lower socioeconomic profile were more likely to have high-risk glycemic control relative to those with a higher socioeconomic profile (OR = 2.24, 95%CI = 1.16-4.33). CONCLUSIONS: Lower socioeconomic profiles are associated with high-risk glycemic control among YYA with type 1 diabetes. This supports recommendations that care providers of YYA with type 1 diabetes assess individual social needs in tailoring diabetes management plans to the social context of the patient.

Model of goal directed behavior for limiting Latino preschoolers' television viewing: validity and reliability.

BACKGROUND: Accurately measuring parents' attitudes and beliefs regarding limiting their children's TV viewing is important to inform the design and evaluation of effective interventions. This manuscript assesses the internal consistency reliability, test-retest reliability, convergent validity, and construct validity of the Model of Goal Directed Behavior (MGDB) scales among parents of Latino preschoolers to characterize Latino parents' attitudes and beliefs toward limiting their preschoolers' TV viewing. METHOD: Participants included parents of Latino preschoolers in the United States, 3-5 years old (n = 186). Parents completed a socio-demographic survey and the 105-item MGDB questionnaire (Attitudes, Perceived Positive/Negative Behavioral Control, Subjective Norms, Positive and Negative Anticipated Emotions, Habits, Self-Efficacy, Desires, and Intentions surrounding their child's TV viewing) which was used to measure internal consistency reliability and construct validity. A subsample of participants completed the questionnaire twice to measure test-retest reliability. Further, parents completed a 7-day TV viewing diary for their preschooler, and a TV parenting practices questionnaire as measures of convergent validity. RESULTS: Internal consistency reliability was generally acceptable for the MGDB scales (Cronbach's alphas> 0.7), except for the Desires scale, which was revealed to have two factors and the Attitudes and Perceived Behavioral Control scales. Test-retest reliability over 2 months had negligible to moderate correlations (r's = 0.28 to 0.61). Two structural equation models were conducted. One yielded acceptable model fit (x2 (97) = 113.65, p = .119) and the other had questionable model fit (x2 (97) = 125.39; p = .028). Testing convergent validity, only two MGDB scales (Habits and Self-Efficacy) were positively correlated with the TV parenting practices questionnaire (r's = 0.33 to 0.51), and none were meaningfully correlated with preschoolers' mean daily TV viewing. CONCLUSIONS: Initial reliability and validity for some of the MGDB scales appear acceptable among parents of Latino preschoolers. Refinement of the instrument and testing among larger samples is necessary to fully evaluate psychometric properties. This instrument may be useful for characterizing Latino parents' attitudes and beliefs toward limiting their preschoolers' TV viewing and informing future TV reduction interventions. TRIAL REGISTRATION: Clinical Trials NCT01216306 Registered October 6, 2010.

Keys to academic success for under-represented minority young investigators: recommendations from the Research in Academic Pediatrics Initiative on Diversity (RAPID) National Advisory Committee.

BACKGROUND: Although Latinos, African-Americans, and American Indians/Alaska Natives comprise 34% of Americans, these under-represented minorities (URMs) account for only 7% of US medical-school faculty. Even when URMs become faculty, they face many substantial challenges to success. Little has been published, however, on keys to academic success for URM young faculty investigators. METHODS: The Research in Academic Pediatrics Initiative on Diversity (RAPID) goal is to enhance the professional advancement of URM junior faculty pursuing research careers in general academic pediatrics. One important RAPID component is the annual mentoring/career-development conference, which targets URM residents, fellows, and junior faculty, and has included 62 URM participants since its 2013 inception. A conference highlight is the panel discussion on keys to academic success for URM young investigators, conducted by the RAPID National Advisory Committee, a diverse group of leading senior researchers. The article aim was to provide a guide to academic success for URM young investigators using the 2018 RAPID Conference panel discussion. A modified Delphi technique was used to provide a systematic approach to obtaining answers to six key questions using an expert panel: the single most important key to success for URM young investigators; ensuring optimal mentorship; how to respond when patients/families say, "I don't want you to see my child because you are ____"; best strategies for maximizing funding success; how to balance serving on time-consuming committees with enough time to advance research/career objectives; and the single thing you wish someone had told you which would have substantially enhanced your success early on. RESULTS/CONCLUSIONS: This is the first published practical guide on keys to academic success for URM young investigators. Identified keys to success included having multiple mentors, writing prolifically, being tenaciously persistent, having mentors who are invested in you, dealing with families who do not want you to care for their child because of your race/ethnicity by seeking to understand the reasons and debriefing with colleagues, seeking non-traditional funding streams, balancing committee work with having enough time to advance one's research and career by using these opportunities to generate scholarly products, and asking for all needed resources when negotiating for new jobs.

Lifestyle factors and subsequent ischemic heart disease risk after hematopoietic cell transplantation.

BACKGROUND: The objective of this study was to evaluate whether modifiable cardiovascular risk conditions and lifestyle factors were temporally associated with an increased risk for ischemic heart disease and overall mortality in a cohort of hematopoietic cell transplantation (HCT) survivors. METHODS: HCT recipients who had survived for ≥1 year, were ≥20 years old, and had undergone transplantation between 1970 and 2010 at a transplant referral center were surveyed in 2010-2011 about cardiovascular health and lifestyle factors (n = 3833). Respondents (n = 2360 [61.6%]) were followed to 2016 for incident ischemic heart disease and overall mortality. RESULTS: Among the 2360 transplant survivors (median age at the baseline survey, 55.9 years; median time since transplantation, 10.8 years), 162 (6.9%) reported ischemic heart disease at the baseline survey. Among those without ischemic heart disease at the baseline survey (n = 2198), the 5-year cumulative incidence of subsequent ischemic heart disease was 4.3%. Obesity, dyslipidemia, diabetes, and physical inactivity at baseline were associated with an increased risk for subsequent ischemic heart disease (hazard ratio [HRs] ≥ 1.8). Greater physical activity and fruit/vegetable intake at baseline were associated with subsequent lower overall mortality (HRs ≤ 0.7). When jointly considered, each additional cardiovascular risk condition and each adverse lifestyle factor were independently associated with subsequent ischemic heart disease (HR for risk conditions, 1.4; 95% confidence interval [CI], 1.0-1.9; HR for lifestyle factors, 1.9; 95% CI, 1.2-2.9), and adverse lifestyle factors remained associated with overall mortality (HR, 1.8; 95% CI, 1.5-2.3). CONCLUSIONS: These results support strong efforts to promote healthy lifestyle behaviors and to treat cardiovascular risk factors aggressively in HCT survivors. This may reduce future ischemic heart disease and overall mortality in this high-risk population. Cancer 2018;124:1507-15. © 2018 American Cancer Society.

A Fitbit and Facebook mHealth intervention for promoting physical activity among adolescent and young adult childhood cancer survivors: A pilot study.

BACKGROUND: Physical activity (PA) may be important for preventing chronic diseases for adolescent and young adult (AYA) childhood cancer survivors. Randomized controlled trials (RCTs) of PA interventions for AYA survivors are sparse, but necessary to determine effective programs for increasing PA among this population. Thus, we conducted a pilot RCT, testing the feasibility of a mobile health (mHealth) intervention to promote PA among AYA survivors. PROCEDURE: We recruited 14- to 18-year-olds who were ≥1-year post cancer therapy from Seattle Children's Hospital. The 10-week intervention consisted of a wearable PA-tracking device (Fitbit Flex) and a peer-based virtual support group (Facebook group). Research staff helped set step goals and awarded badges weekly. Controls received usual care. Baseline assessments occurred before randomization and follow-up assessments occurred during weeks 8-10 of the intervention period. Feasibility criteria are defined below. Qualitative interviews assessed acceptability. Exploratory outcomes included PA, quality of life, and motivation for PA. RESULTS: All feasibility criteria were met: we recruited 60 survivors, intervention participants wore the Fitbit on the majority (71.5%) of intervention days, and ≥90% of all participants completed questionnaires. Qualitative data confirmed intervention acceptability. Exploratory analyses found no significant adjusted group differences for change in moderate-to-vigorous PA (4.4 vs. 5.0 min/day; P = 0.92) or sedentary time (-4.5 vs. 1.0 min/day; P = 0.73), comparing intervention subjects to controls. Some modest differences were found for select subscales of quality of life and motivation for PA. CONCLUSIONS: This mHealth PA intervention was feasible and acceptable to AYA childhood cancer survivors and warrants a fully powered RCT.

Effects of a school-based intervention on active commuting to school and health-related fitness.

BACKGROUND: Active commuting to school has declined over time, and interventions are needed to reverse this trend. The main objective was to investigate the effects of a school-based intervention on active commuting to school and health-related fitness in school-age children of Southern Spain. METHODS: A total of 494 children aged 8 to 11 years were invited to participate in the study. The schools were non-randomly allocated (i.e., school level allocation) into the experimental group (EG) or the control group (CG). The EG received an intervention program for 6 months (a monthly activity) focused on increasing the level of active commuting to school and mainly targeting children's perceptions and attitudes. Active commuting to school and health-related fitness (i.e., cardiorespiratory fitness, muscular fitness and speed-agility), were measured at baseline and at the end of the intervention. Children with valid data on commuting to school at baseline and follow-up, sex, age and distance from home to school were included in the final analysis (n = 251). Data was analyzed through a factorial ANOVA and the Bonferroni post-hoc test. RESULTS: At follow up, the EG had higher rates of cycling to school than CG for boys only (p = 0.04), but not for walking to school for boys or girls. The EG avoided increases in the rates of passive commuting at follow up, which increased in the CG among girls for car (MD = 1.77; SE = 0.714; p = 0.010) and bus (MD = 1.77; SE = 0.714; p = 0.010) modes. Moreover, we observed significant interactions and main effects between independent variables (study group, sex and assessment time point) on health-related fitness (p < 0.05) over the 6-month period between groups, with higher values in the control group (mainly in boys). CONCLUSION: A school-based intervention focused on increasing active commuting to school was associated with increases in rates of cycling to school among boys, but not for walking to school or health-related fitness. However, the school-based intervention avoided increases in rates of passive commuting in the experimental group, which were significantly increased in girls of the control group.

Places where preschoolers are (in)active: an observational study on Latino preschoolers and their parents using objective measures.

BACKGROUND: To combat the disproportionately higher risk of childhood obesity in Latino preschool-aged children, multilevel interventions targeting physical (in) activity are needed. These require the identification of environmental and psychosocial determinants of physical (in) activity for this ethnic group. The objectives were to examine differences in objectively-measured physical activity and sedentary behavior across objectively-determined types of locations in Latino preschool-aged children; and determine whether the differences in physical activity by location were greater in children of parents with higher neighborhood-safety perceptions and physical activity-supportive parenting practices. METHODS: An observational field study was conducted in Houston (Texas, USA) from August 2011 to April 2012. A purposive sample of Latino children aged 3-5 years and one of their parents (n = 84) were recruited from Census block groups in Houston (Texas) stratified by objectively-assessed high vs. low traffic and crime safety. Seventy-three children provided valid data. Time spent outdoors/indoors tagged with geographic locations was coded into location types based on objective data collected using Global Positioning Systems units that children wore >8 hr/day for a week. Physical activity parenting practices, perceived neighborhood-safety, and demographics were reported by parents. Time spent in sedentary behavior and moderate-to-vigorous physical activity was measured based on objective data collected using accelerometers (motion sensors) that children wore >8 hr/day for a week. RESULTS: The odds of children engaging in moderate-to-vigorous physical activity were 43% higher when outdoors than indoors (95% confidence interval: 1.30, 1.58), and the odds of being sedentary were 14% lower when outdoors compared to indoors (95% confidence intervals: 0.81, 0.91). This difference depended on parental neighborhood-safety perceptions and parenting practices. Children were most active in parks/playgrounds (30% of the time spent in moderate-to-vigorous physical activity) and least active in childcare/school settings (8% of the time spent in moderate-to-vigorous physical activity). CONCLUSIONS: Objectively-assessed time spent in specific locations is correlated with physical activity and sedentary behavior in Latino preschoolers. Interventions and policies should identify ways to engage Latino preschool-aged children in more physical activity and less sedentary behavior while in childcare, and encourage parents to spend more time with their young children in parks/playgrounds and other safe outdoor places.

Hot topics, urgent priorities, and ensuring success for racial/ethnic minority young investigators in academic pediatrics.

BACKGROUND: The number of racial/ethnic minority children will exceed the number of white children in the USA by 2018. Although 38% of Americans are minorities, only 12% of pediatricians, 5% of medical-school faculty, and 3% of medical-school professors are minorities. Furthermore, only 5% of all R01 applications for National Institutes of Health grants are from African-American, Latino, and American Indian investigators. Prompted by the persistent lack of diversity in the pediatric and biomedical research workforces, the Academic Pediatric Association Research in Academic Pediatrics Initiative on Diversity (RAPID) was initiated in 2012. RAPID targets applicants who are members of an underrepresented minority group (URM), disabled, or from a socially, culturally, economically, or educationally disadvantaged background. The program, which consists of both a research project and career and leadership development activities, includes an annual career-development and leadership conference which is open to any resident, fellow, or junior faculty member from an URM, disabled, or disadvantaged background who is interested in a career in academic general pediatrics. METHODS: As part of the annual RAPID conference, a Hot Topic Session is held in which the young investigators spend several hours developing a list of hot topics on the most useful faculty and career-development issues. These hot topics are then posed in the form of six "burning questions" to the RAPID National Advisory Committee (comprised of accomplished, nationally recognized senior investigators who are seasoned mentors), the RAPID Director and Co-Director, and the keynote speaker. RESULTS/CONCLUSIONS: The six compelling questions posed by the 10 young investigators-along with the responses of the senior conference leadership-provide a unique resource and "survival guide" for ensuring the academic success and optimal career development of young investigators in academic pediatrics from diverse backgrounds. A rich conversation ensued on the topics addressed, consisting of negotiating for protected research time, career trajectories as academic institutions move away from an emphasis on tenure-track positions, how "non-academic" products fit into career development, racism and discrimination in academic medicine and how to address them, coping with isolation as a minority faculty member, and how best to mentor the next generation of academic physicians.

Correlates of Physical Activity in Latino Preschool Children Attending Head Start.

BACKGROUND: Physical activity is associated with long-term benefits for health and tracks from early childhood into later adolescence. Limited information exists about factors influencing physical activity among Latino preschoolers. We aimed to identify correlates of objectively measured light-to-vigorous-intensity physical activity as a proportion of wear time (% PA) in Latino 3-5 year olds. METHODS: Latino preschoolers (n = 96) were recruited from Head Start centers in Houston, TX, USA, from 2009 to 2010. Sociodemographics, anthropometrics, acculturation, neighborhood disorder, and TV viewing were measured. Actigraph GT1M accelerometers measured physical activity. Block linear regression was used with % PA as the dependent variable. RESULTS: Children achieved 285.7 ± 58.0 min/day of PA. In the final adjusted-model, child age, parental education and neighborhood disorder were positively associated with % PA (beta = 0.33, p = .002; beta = 0.25, p = .038; beta = 0.22, p = .039, respectively). TV viewing was inversely associated with % PA (beta=-0.23, p = .027). CONCLUSION: The majority of Latino preschoolers in our study exceeded US national and international guidelines of physical activity duration. Future interventions to sustain physical activity should focus on the influence of age, socioeconomic status, neighborhood disorder, and TV viewing on Latino preschoolers' attainment of physical activity.

Psychometrics of the preschooler physical activity parenting practices instrument among a Latino sample.

BACKGROUND: Latino preschoolers (3-5 year old children) have among the highest rates of obesity. Low levels of physical activity (PA) are a risk factor for obesity. Characterizing what Latino parents do to encourage or discourage their preschooler to be physically active can help inform interventions to increase their PA. The objective was therefore to develop and assess the psychometrics of a new instrument: the Preschooler Physical Activity Parenting Practices (PPAPP) among a Latino sample, to assess parenting practices used to encourage or discourage PA among preschool-aged children. METHODS: Cross-sectional study of 240 Latino parents who reported the frequency of using PA parenting practices. 95% of respondents were mothers; 42% had more than a high school education. Child mean age was 4.5 (±0.9) years (52% male). Test-retest reliability was assessed in 20%, 2 weeks later. We assessed the fit of a priori models using Confirmatory factor analyses (CFA). In a separate sub-sample (35%), preschool-aged children wore accelerometers to assess associations with their PA and PPAPP subscales. RESULTS: The a-priori models showed poor fit to the data. A modified factor structure for encouraging PPAPP had one multiple-item scale: engagement (15 items), and two single-items (have outdoor toys; not enroll in sport-reverse coded). The final factor structure for discouraging PPAPP had 4 subscales: promote inactive transport (3 items), promote screen time (3 items), psychological control (4 items) and restricting for safety (4 items). Test-retest reliability (ICC) for the two scales ranged from 0.56-0.85. Cronbach's alphas ranged from 0.5-0.9. Several sub-factors correlated in the expected direction with children's objectively measured PA. CONCLUSION: The final models for encouraging and discouraging PPAPP had moderate to good fit, with moderate to excellent test-retest reliabilities. The PPAPP should be further evaluated to better assess its associations with children's PA and offers a new tool for measuring PPAPP among Latino families with preschool-aged children.