Maternal Risk of Cardiovascular Disease Is Associated With Higher BMI Among Preschool-Aged Children: A Cross-Sectional Study.

Childhood obesity is an ongoing concern in the United States. Higher weight status in early childhood is associated with higher weight status at older ages. The Maternal Obesity Matters (MOMs) Study investigated associations between maternal risk of cardiovascular disease (CVD) and child BMI z-scores (BMIz) among preschool-aged children. This cross-sectional exploratory study included mothers and their 3- to 5-year-old children in Colorado, United States. Maternal nonfasting blood samples, blood pressure, and maternal and child anthropometrics were collected. Maternal CVD risk was assessed on a scale of 0-5 using five health measures. Multivariate regression tested associations between maternal CVD risk and child BMIz. Each 1-point increase in maternal CVD risk was associated with a 0.18 increase in child BMIz, controlling for maternal employment. Intervening upon maternal health may be an important strategy for addressing childhood obesity.

Using Plan, Do, Study, Act Cycles to Improve a Maternal Self-Care Intervention With Audience Input.

Maternal self-care, including healthy eating, physical activity, and stress management behaviors, is influenced by environmental, social, and individual factors. Plan-Do-Study-Act (PDSA) Cycling is an effective quality improvement process using rapid cycling to refine interventions to fit audience-specific contexts and to address socioecological influences on behavior change. To refine components of the Healthy EnviROnmentS Self-Care intervention, a mindful self-care program for mothers of preschool-aged children in rural communities, PDSA cycles were used to examine: (A) acceptability of content, (B) suitability of implementation strategies, and (C) feasibility of digital supports across three stages of program development. Stage 1 included a group discussion with an expert panel (n = 8). Stage 2 used brief interviews and group discussion with a convenience sample (n = 5). Stage 3 included in-depth interviews with the focal population (n = 6). In-depth interviews were transcribed and analyzed using a directed approach, and data were compiled from group discussion notes and assessed for congruence and analyzed for emergent themes. PDSA cycles relating to content led to the addition of activities to introduce mindfulness and foster social support and the revision of handouts. Implementation strategies were refined with respect to workshop duration, activity order, and meeting type. Digital supports resulted in refinement to the study website and tablet applications. Utilization of PDSA cycles allowed for input from the focus population at every point of intervention design and considered socioecological factors that can influence behavior change.

A Narrative Review of Dietary Assessment Tools for Preschool-Aged Children in the Home Environment.

Preschool-aged children in the U.S. have suboptimal diets. Interventions to improve child nutrition focus on parents and their role in shaping social and physical home environments, which influence children's eating behaviors. Dietary assessment tools selected to measure intervention objectives, and how results are interpreted in key findings, are essential when examining children's diets. The objectives of this review were to (1) describe dietary assessment tools used in intervention studies in young children focused within the home environment; and (2) examine how the application of these dietary assessment tools addressed intervention objectives. PubMed and Web of Science were searched for English-language nutrition intervention studies that included children aged 2-5 years, had a home environment component, used a dietary assessment tool, and reported on diet-related outcomes. Seventeen studies were included. Intervention objectives focused on overall diet, specific food groups, eating occasions, and obesity prevention/treatment. Concordance of key findings with intervention objectives, type of tool used, and multiple tools within the same study varied with 8 studies aligning in objective and tool, 1 discordant in both, and 8 partially concordant or too broad to determine. This review highlights current challenges in measuring dietary intake in preschoolers and provides recommendations for alternative applications and strategies.

Digital Intervention Strategies for Increasing Physical Activity Among Preschoolers: Systematic Review.

BACKGROUND: Digital interventions are increasingly used to improve health behaviors. Improved access and lower costs (relative to in-person interventions) make such interventions appealing. Specifically, digital platforms may be a promising approach for increasing physical activity (PA) in young children. OBJECTIVE: The goal of this systematic review was three-pronged: (1) to determine the quality of studies using digital PA intervention strategies with preschool-aged children (ie, 3 to 5 years old); (2) to assess the efficacy of digital interventions and approaches designed to improve PA in preschool-aged children; and (3) to examine theoretical application and implementation outcomes with current approaches to digital PA interventions. METHODS: This review identified and summarized studies on digitally supported interventions for promoting PA in preschool-aged children. We generated 3 lists of relevant search terms that included technology-related terms, PA-related terms, and weight-related terms. The search included Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Study selection was led by a single author and verified by a second; the same 2 authors assessed study quality using a standardized tool, and 3 authors completed data extraction on PA outcomes, theory application, and implementation outcomes. RESULTS: In total, 601 studies were identified; 8 met the inclusion criteria. For study quality, only 2 studies received an overall rating of strong quality and low risk of bias. All but 1 study had a small sample size (<100). Positive and significant changes in child PA outcomes were reported in only 2 studies with weak overall quality, both of which used child-directed approaches. In total, 5 studies applied a behavioral theory for designing the intervention; no patterns of effectiveness were identified based on the application of theory. Finally, no studies reported on the implementation outcomes of adoption, cost, penetration, or sustainability; 1 study did not assess any implementation outcomes, and no single study reported on more than 2 implementation outcomes. Studies measured the implementation outcome of acceptability most frequently (n=4), and researchers assessed fidelity in 3 studies. CONCLUSIONS: The interventions with a significant effect on PA used child-centered activities; parent-directed digital interventions alone were ineffective for improving PA. Future research with rigorous designs, monitoring of implementation outcomes, and testing of the contributions of digital components will advance understanding of the effectiveness of digital interventions for increasing PA in children.

Strengthening Nutrition Education and Behavior Research for Academicians and Practitioners.

Nutrition education and behavior research is essential for translating scientific nutrition-related evidence into actionable strategies at the individual, family, community, and policy levels. To enhance the impact of nutrition educators and researchers' efforts, there is a need for continued and directed support to sustain the rigor of research. It is the perspective of this paper that the field of nutrition education and behavior research address its inherent complexities to meet the diverse investigative strategies used by academicians as well as practitioners. Such strategies could ensure the role of nutrition education and behavior in ongoing nationwide efforts to address emerging and novel nutrition research.

Predictors of sustainment of two distinct nutrition and physical activity programs in early care and education.

Introduction: The goal of the present study was to investigate factors associated with sustainment of two evidence-based programs for nutrition promotion in early care and education (ECE) settings - Food Friends (FF) and Together, We Inspire Smart Eating (WISE). Materials and methods: In a cross-sectional study design, ECE directors (N = 55) from centers that had previously been trained in WISE or FF completed a survey. Program-specific measures included Steckler's Perception of Innovations, the Program Sustainability Assessment Tool (PSAT), and the Organizational Readiness for Change Assessment (ORCA). For our primary outcomes, two measures of sustainment were examined: Nutrition Continued Practice (i.e., the use of or general focus on nutrition programs) and Program Fidelity (i.e., how well centers used specific evidence-based practices of WISE or FF). Multiple regression was used to determine the association of these outcomes with program, years since last implementation, and overall scores on predictors. Follow-up correlation analyses were used to investigate outcome relationships with context submeasures due to high intercorrelations between predictor submeasures. Results: Nutrition Continued Practice was significantly predicted by program and overall PSAT score. WISE programs had significantly higher Nutrition Continued Practice scores than FF program (p = 0.03). All subscales of the PSAT (e.g., environmental support, funding stability, organizational capacity, program adaptation, communications, and strategic planning) were significantly correlated with Nutrition Continued Practice (all rs > 0.30, all ps < 0.03). Program Fidelity was significantly predicted by PSAT and Steckler Perception of Innovation scores. All subscales of the PSAT were strongly positively correlated with Program Fidelity (all rs > 0.48, all ps < 0.001); relative advantage (r = 0.54, p < 0.001) and level of institutionalization (r = 0.61, p < 0.001) were positively correlated with Program Fidelity. Conclusion: This study suggests that factors associated with the continued practice of program principles are partially distinct from those that are associated with the sustainment of specific practices driving program fidelity. Results suggest capacity building strategies may be important for both continued attention to nutrition and physical activity as well as sustaining fidelity to specific evidence-based practices.

Switching up sides: Using choice architecture to alter children's menus in restaurants.

U.S. children's frequent consumption of restaurant foods has been associated with low vegetable consumption. Use of choice architecture in restaurants has been shown to increase children's orders of healthy sides, but what children consume when healthy sides are included is unknown. The purpose of the present study was to investigate whether altering the choice architecture of children's meals by restructuring the menu, using optimal defaults and vice-virtue bundles, would impact ordering of side dishes and consumption of a vegetable side dish during a restaurant meal. Families with a child between 4-8y attended three dinners at a university-based restaurant. Children's meals included choice of entree (macaroni-and-cheese or chicken tenders) and default side: all carrots (150 g; Menu-1), small fries (50 g)/large carrots (100 g; Menu-2), and small carrots (50 g)/large fries (100 g; Menu-3). Participants could opt-out of the default side for: only fries (Menu-1) or only fries or carrots (Menus-2/3). All foods were pre- and post-weighed to determine consumption. Descriptive statistics examined children's ordering behavior. Repeated measures ANOVA examined differences in consumption of study foods. A paired samples t-test examined differences in french fry consumption (Menus-2/3). Forty-eight children (6.2 ± 1.3 years; 25 male) participated. Most children remained with the default side (Meal-1: 90%; Meal-2: 88%; Meal-3: 85%). Significant differences were seen in children's consumption of french fries (t = -2.57, p = .014) where children ate more during meal 3 compared to meal 2. There were no significant differences in carrot consumption. Use of optimal defaults led to increased orders of healthy sides and steady consumption across the meal conditions. However, use of an optimal, vice-virtue bundle led to a decrease in consumption of french fries. Further investigation of optimal default use on children's menus is warranted.

Validation of a Home Food Environment Instrument Assessing Household Food Patterning and Quality.

The home food environment (HFE) is associated with dietary intake; yet measuring HFE quality often requires burdensome collection of detailed inventories. This project evaluated the capacity of the Home Inventory to Describe Eating and Activity, version 2 (Home-IDEA2) to capture HFE quality by measuring the presence or absence of household foods. Validity was tested using a modified application of the Healthy Eating Index-2010 (HEI). Comparative data were drawn from the National Food Acquisition and Purchase Survey (FoodAPS) Food-at-Home Public Use File. HEI scores were calculated for 4202 households in FoodAPS using Home-IDEA2 inventories and full reported inventories. Paired t-tests compared: (1) estimated vs. total edible grams (EEG; TEG); (2) limited vs. all reported foods; and (3) EEG + limited foods vs. TEG + all reported foods. Sensitivity and range of scores were compared. Mean HEI scores for Home-IDEA2 were higher (p < 0.003) than FoodAPS: (1) 51.6 ± 16.1 vs. 49.6 ± 18.1 (food amounts); (2) 53.5 ± 15.8 vs. 49.8 ± 15.4 (food items); (3) 55.5 ± 15.7 vs. 49.8 ± 15.4 (full instrument); differences were small. Scores demonstrated comparable sensitivity and range. The study found that the Home-IDEA2 can capture HFE quality adequately with low data collection burden.

Moving Together: Understanding Parent Perceptions Related to Physical Activity and Motor Skill Development in Preschool Children.

Background: Establishing physical activity (PA) and motor behaviors in early childhood are important for developing healthy activity behaviors. Parents play a central role in shaping young children's PA and fundamental motor skills (FMS). This qualitative study explored parents' attributes, values, perceptions, and practices related to PA and FMS. Methods: Thirty-one parents (26 mothers) of preschool-aged children participated in semi-structured in-person interviews. Interviews were audio-recorded, transcribed verbatim, coded and analyzed using an iterative approach. Results: Four themes related to PA and FMS emerged: (1) parent attributes; (2) parent-child interactions; (3) parent perception of children's attributes; and (4) parenting practices. Although most parents enjoyed playing with their child, some did not realize the importance of engaging in PA with their child and even believed that FMS are naturally developed. Parents indicated that children's temperament may influence their preference for practicing motor skills. Conclusions: Social support and positive parenting practices, including encouragement, monitoring, logistical support, co-participation, and facilitation, are important for the development of PA and FMS. The findings add emphasis to the importance of parents' role in the development of young children's PA and FMS, and they inform future strategies aiming to promote young children's activity behaviors.

Examining Parent Preferences for the Use of Behavioral Economic Strategies on Children's Menus in Restaurants.

BACKGROUND: A majority of children's restaurant meals are nutritionally deficient; use of behavioral economics may improve healthful menu selections. Parents play a role in children's restaurant meal selection, thus understanding parent preferences for potential behavioral economic strategies is warranted. OBJECTIVE: To examine parent-derived and -stated preferences for selected attributes of children's restaurant menus, which included behavioral economic strategies (eg, optimal defaults and vice-virtue bundles). DESIGN: A descriptive, cross-sectional, within-subjects survey integrating a conjoint design was developed along with 8 children's menus. Menus were manipulated by varying levels of attributes (meal price, healthful side dishes, number of side dish items, healthful entrées, and cost for sugar-sweetened beverages [SSB]). Parents rated menus and attributes using Likert scales. PARTICIPANTS/SETTING: A national sample of US parents with children 4 to 10 years (n = 463) were recruited in August of 2019 via Amazon's Mechanical Turk. ANALYSIS: A conjoint (regression) analysis was conducted to derive parent preference for each attribute and overall menu preference. Descriptive statistics (means) described overall stated parent menu preferences and ratings. Cluster analysis segmented parents into groups with similar preferences. RESULTS: Derived preferences showed parents had the strongest preference for choice of side dishes (ß = .73) and low-priced menus (ß = .51), and weak preferences for inclusion of healthful entrées (ß = .04) and added cost for SSB (ß = .18). Parents stated preference was for a menu that included healthful entrées, was low priced, and featured choices for side dishes. Cluster analysis revealed half of parents preferred the low-cost children's menu with the other half of parents split evenly across preferences related to health, choice, and traditional menus. CONCLUSION: Parents stated preference was for a socially desirable menu featuring healthful entrée options and added cost for SSB, which was contrary to the conjoint derived menu preferences. Understanding parent preferences may help guide nutrition professionals working to build a more healthful food environment through the use of behavioral economic strategies.

Picture Perfect: How Attaining the Ideal Meal is Not So Easy for Parents of Young Children.

OBJECTIVE: To explore parental perspectives on the ideals and realities of family mealtimes. DESIGN: Mini-focus groups (n = 7). SETTING: Rural Colorado, US. PARTICIPANTS: Parents (n = 30) were recruited at Head Start/preschool centers. PHENOMENON OF INTEREST: Parent perspectives on mealtimes with preschool-aged children. ANALYSIS: Transcripts were analyzed using thematic analysis. RESULTS: Three categories of themes emerged: participant conceptions of ideal family meals, challenges to achieving their ideal family meal, and parental solutions. The theme of participant conceptions of ideal family meals composed family togetherness, children liking and eating the prepared food, healthfulness of food, and a nonchaotic mealtime. Challenges to achieving their ideal family meal included work schedules, disruptive child behaviors, child pickiness, snacking, and negative role-modeling. Finally, parental solutions to challenges incorporated having flexible meal timings, considering child preferences in premeal preparations, role-modeling, and numerous other parenting strategies. CONCLUSIONS AND IMPLICATIONS: While parents valued many aspects of a version of the ideal meal rooted in historical standards, families faced many challenges in trying to attain that ideal. Although parents employed various strategies to combat mealtime challenges, parental expectations for preschool-aged children's mealtime behaviors may be unrealistic for the developmental stage of early childhood. Future interventions could help parents develop age-appropriate mealtime expectations.

Examining Front-of-Package Product Names and Ingredient Lists of Infant and Toddler Food Containing Vegetables.

OBJECTIVE: To investigate the alignment between vegetables and fruits listed in the ingredients of commercially produced infant and toddler food (ITF) and inclusion in front-of-package product names. DESIGN: A database of commercial ITF containing vegetables (n = 548) was created. Inclusion of each vegetable or fruit in the product name (yes/no), form (ie, whole/puree, juice/juice concentrate, etc), and ingredient list position (ie, first, second) were recorded. Vegetables were classified per US Department of Agriculture categories; fruits were classified into 2 categories. ANALYSIS: Chi-square tests of association tested associations between product name inclusion and (1) vegetable and fruit category, (2) form, and (3) form by category. RESULTS: Associations were observed between vegetable and fruit categories and inclusion in product names [χ2 (6, N = 1,462) = 70.3, P < 0.001]. Vegetables in the US Department of Agriculture dark green category were more likely to appear in product names (94%; standardized residual [SR] = 2.1), as were other vegetables (62%; SR = 4.9). Vegetable and fruit forms were associated with inclusion in product name [χ2 (4, N = 1,462) = 206.6, P < 0.001]. Juice/juice concentrates were less likely to be included in names (32.4%; SR = -5.4). CONCLUSIONS AND IMPLICATIONS: Substantial discrepancies exist between ITF ingredient lists and front-of-package product names. When only front-of-package information informs purchases, caregivers may not be purchasing products that facilitate children's building of vegetable preferences.

A mixed-methods protocol for identifying successful sustainability strategies for nutrition and physical activity interventions in childcare.

BACKGROUND: Despite the importance of sustainability for nutrition and physical activity in public health interventions, limited studies have explored the factors that promote and inhibit evidence-based program sustainment in the childcare setting. This study protocol describes a mixed-methods approach to develop novel sustainability strategies based on real-world settings and stakeholder feedback, with the goal of providing support for future obesity prevention programs and related studies on intervention sustainability. Two interventions, Together, We Inspire Smart Eating (WISE) and The Food Friends' (FF) Fun with New Foods and Get Movin' with Might Moves, are studied to this end. METHODS: The study will deploy an explanatory, sequential mixed-methods design. First, the research team will collect a quantitative survey to assess rates of sustainment among WISE and Food Friends sites. We expect to collect 150 surveys from WISE and FF sites combined. Data from these surveys will be used to purposively sample sites for 12 to 18 site visits. Specifically, we will purposively sample low, partial, and high sustaining sites where we will conduct key informant interviews and focus groups as well as validate self-reports on sustainability. Survey content, qualitative interviews, and coding will be based on the Dynamic Sustainability Framework. We will draw on findings from the quantitative survey on predictors of sustainment and the qualitative site visits to understand varying levels of program sustainment. Then, we will utilize evidence-based quality improvement sessions to engage stakeholders in developing a multi-component sustainability strategy. DISCUSSION: This study will provide a stakeholder-informed sustainability strategy ready for testing in a full-scale trial examining effects on sustainment of evidence-based nutrition and physical activity practices in childcare. We expect this strategy to be relevant for educators and consistent with the views of administrators as a guide for future practice for the targeted nutrition and physical activity interventions and beyond.

Food Photography as a Tool to Assess Type, Quantity, and Quality of Foods in Parent-Packed Lunches for Preschoolers.

OBJECTIVE: Explore using food photography to assess packed lunches in a university-based Early Childhood Center and contextualize these photographs through parent interviews. METHODS: An explanatory sequential design was used. Packed lunches were photographed to assess the type and quantity of foods offered and consumed by Child and Adult Food Care Program components (fruit, vegetable, grain, and protein) and quality of foods offered using the Healthy Meal Index. Parent interviews aimed to understand motivations and behaviors related to packing lunch. RESULTS: Data were collected on 401 lunches. Only 16.2% of lunches met all Child and Adult Food Care Program requirements. Most lunches included fruit (84%) and grains (82%), whereas fewer included vegetables (44%). Portion sizes were large, especially for grains (2.7 ± 1.5 servings). In interviews (n = 24), parents expressed tension between offering healthful items and foods they knew their child would eat, as well as concern about children going hungry. CONCLUSIONS AND IMPLICATIONS: Food photography is a feasible methodology to capture parent-packed lunches for preschoolers and may have utility in nutrition education, particularly related to age-appropriate portion sizes.

Farm to Early Care and Education Programming: A Descriptive Study of Challenges and Opportunities to Promote Healthful Foods to Young Children.

Interest in farm to early care and education (ECE) programming, which consists of gardening, nutrition education, and local food procurement, has been growing in the United States, as it may be a promising technique for promoting healthful foods to young children. However, there is limited information about current farm to ECE efforts in specific states, including Colorado, to support funding and resource needs. An online survey was distributed to licensed Colorado ECE providers in two phases to understand current participation in the farm to ECE as well as provider perspectives on benefits and barriers to programming. A total of 250 surveys were completed. Approximately 60% of ECE facilities participated in gardening and nutrition education with providers almost unanimously agreeing on the child-centric benefits of programming. Fewer facilities (37%) participated in local food procurement likely due to significant time, cost, and knowledge barriers. To increase participation in farm to ECE as a technique for promoting healthful foods to young children, future efforts should focus on innovative solutions to reduce ECE-specific barriers.