Assessing the scale and spread of an experiential teaching kitchen in after-school programming among school-age children.

OBJECTIVE: To scale-out an experiential teaching kitchen in Parks and Recreation centres' after-school programming in a large urban setting among predominantly low-income, minority children. DESIGN: We evaluated the implementation of a skills-based, experiential teaching kitchen to gauge programme success. Effectiveness outcomes included pre-post measures of child-reported cooking self-efficacy, attitudes towards cooking, fruit and vegetable preference, intention to eat fruits and vegetables and willingness to try new fruits and vegetables. Process outcomes included attendance (i.e., intervention dose delivered), cost, fidelity and adaptations to the intervention. SETTING: After-school programming in Parks and Recreation Community centres in Nashville, TN. PARTICIPANTS: Predominantly low-income minority children aged 6-14 years. RESULTS: Of the twenty-five city community centres, twenty-one successfully implemented the programme, and nineteen of twenty-five implemented seven or more of the eight planned sessions. Among children with pre-post data (n 369), mean age was 8·8 (sd 1·9) years, and 53·7 % were female. All five effectiveness measures significantly improved (P < 0·001). Attendance at sessions ranged from 36·3 % of children not attending any sessions to 36·6 % of children attending at least four sessions. Across all centres, fidelity was 97·5 %. The average food cost per serving was $1·37. CONCLUSIONS: This type of nutritional education and skills building experiential teaching kitchen can be successfully implemented in a community setting with high fidelity, effectiveness and organisational alignment, while also expanding reach to low-income, underserved children.

Salivary epigenetic biomarkers as predictors of emerging childhood obesity.

BACKGROUND: Epigenetics could facilitate greater understanding of disparities in the emergence of childhood obesity. While blood is a common tissue used in human epigenetic studies, saliva is a promising tissue. Our prior findings in non-obese preschool-aged Hispanic children identified 17 CpG dinucleotides for which differential methylation in saliva at baseline was associated with maternal obesity status. The current study investigated to what extent baseline DNA methylation in salivary samples in these 3-5-year-old Hispanic children predicted the incidence of childhood obesity in a 3-year prospective cohort. METHODS: We examined a subsample (n = 92) of Growing Right Onto Wellness (GROW) trial participants who were randomly selected at baseline, prior to randomization, based on maternal phenotype (obese or non-obese). Baseline saliva samples were collected using the Oragene DNA saliva kit. Objective data were collected on child height and weight at baseline and 36 months later. Methylation arrays were processed using standard protocol. Associations between child obesity at 36 months and baseline salivary methylation at the previously identified 17 CpG dinucleotides were evaluated using multivariable logistic regression models. RESULTS: Among the n = 75 children eligible for analysis, baseline methylation of Cg1307483 (NRF1) was significantly associated with emerging childhood obesity at 36-month follow-up (OR = 2.98, p = 0.04), after adjusting for child age, gender, child baseline BMI-Z, and adult baseline BMI. This translates to a model-estimated 48% chance of child obesity at 36-month follow-up for a child at the 75th percentile of NRF1 baseline methylation versus only a 30% chance of obesity for a similar child at the 25th percentile. Consistent with other studies, a higher baseline child BMI-Z during the preschool period was associated with the emergence of obesity 3 years later, but baseline methylation of NRF1 was associated with later obesity even after adjusting for child baseline BMI-Z. CONCLUSIONS: Saliva offers a non-invasive means of DNA collection and epigenetic analysis. Our proof of principle study provides sound empirical evidence supporting DNA methylation in salivary tissue as a potential predictor of subsequent childhood obesity for Hispanic children. NFR1 could be a target for further exploration of obesity in this population.

Evaluating dose delivered of a behavioral intervention for childhood obesity prevention: a secondary analysis.

BACKGROUND: Current recommendations for intensive behavioral interventions for childhood obesity treatment do not account for variable participant attendance, optimal duration of the intervention, mode of delivery (phone vs. face-to-face), or address obesity prevention among young children. A secondary analysis of an active one-year behavioral intervention for childhood obesity prevention was conducted to test how "dose delivered" was associated with body mass index z-score (BMI-Z) across 3 years of follow-up. METHODS: Parent-child pairs were eligible if they qualified for government assistance and spoke English or Spanish. Children were between three and 5 years old and were at risk for but not yet obese (BMI percentiles ≥50th and < 95th). The intended intervention dose was 18 h over 3-months via 12 face-to-face "intensive sessions" (90 min each) and 6.75 h over the next 9 months via 9 "maintenance phone calls" (45 min each). Ordinary least-squares multivariable regression was utilized to test for associations between dose delivered and child BMI-Z immediately after the 1-year intervention, and at 2-, and 3-year follow-up, including participants who were initially randomized to the control group as having "zero" dose. RESULTS: Among 610 parent-child pairs (intervention n = 304, control n = 306), mean child age was 4.3 (SD = 0.9) years and 51.8% were female. Mean dose delivered was 10.9 (SD = 2.5) of 12 intensive sessions and 7.7 (SD = 2.4) of 9 maintenance calls. Multivariable linear regression models indicated statistically significant associations of intensive face-to-face contacts (B = -0.011; 95% CI [- 0.021, - 0.001]; p = 0.029) and maintenance calls (B = -0.015; 95% CI [- 0.026, - 0.004]; p = 0.006) with lower BMI-Z immediately following the 1-year intervention. Their interaction was also significant (p = 0.04), such that parent-child pairs who received higher numbers of both face-to-face intensive sessions (> 6) and maintenance calls (> 8) were predicted to have lower BMI-Z. Sustained impacts were not statistically significant at 2- or 3-year follow-up. CONCLUSIONS: In a behavioral intervention for childhood obesity prevention, the combination of a modest dose of face-to-face sessions (> 6 h over 3 months) with sustained maintenance calls (> 8 calls over 9 months) was associated with improved BMI-Z at 1-year for underserved preschool aged children, but sustained impacts were not statistically significant at 2 or 3 year follow-up. CLINICAL TRIAL REGISTRATION: The trial was registered on ClinicalTrials.gov (NCT01316653) on March 16, 2011, which was prior to participant enrollment.

The Effect of a General Healthy Lifestyle Intervention Delivered Around Pregnancy on Gestational Weight Gain and Infant Growth.

OBJECTIVES: A life-course perspective emphasizes healthy behaviors before, during, and after pregnancy to support a multi-generational risk reduction in obesity for mothers and infants. Optimal timing, content, and dose of such interventions is not well defined. METHODS: We conducted a nested cohort within a randomized trial to evaluate whether a healthy lifestyle intervention around pregnancy led to a "spill-over effect," including a healthier rate (kg/week) of maternal gestational weight gain, and infant growth during the first year. Study enrollment began in 2012, follow-up data collection completed in 2018, and the data were analyzed in 2019. The intervention focused on healthy maternal diet and physical activity but not pregnancy weight or infant feeding. Outcome data were abstracted from electronic medical records. RESULTS: Of the 165 women who became pregnant, 114 enrolled in the nested cohort. The average pre-pregnancy BMI was 29.6 (SD 5.1) kg/m2. Mixed effects models suggested clinically insignificant differences in both the rate of gestational weight gain (-0.02 kg/week; 95% CI -0.09, 0.06) and the rate of infant growth (difference at 1 year: -0.002 kg/cm; 95% CI -0.009, 0.005). CONCLUSIONS FOR PRACTICE: A behavioral intervention that focused on overall maternal health delivered in the time around pregnancy did not result in a "spill-over effect" on healthy gestational weight gain or healthy infant growth during the first year of life. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT01316653.

Predicting Early Emergence of Childhood Obesity in Underserved Preschoolers.

OBJECTIVE: To determine the magnitude of risk of factors that contribute to the emergence of childhood obesity among low-income minority children. STUDY DESIGN: We conducted a prospective cohort analysis of parent-child pairs with children aged 3-5 years who were nonobese (n = 605 pairs) who participated in a 3-year randomized controlled trial of a healthy lifestyle behavioral intervention. After baseline, height and weight were measured 5 times over 3 years to calculate body mass index (BMI) percentiles and classify children as normal, overweight, or obese. Multivariable logistic regression was used to estimate the odds of obesity after 36 months. Predictors included age, sex, birth weight, gestational age, months of breastfeeding, ethnicity, baseline child BMI, energy intake, physical activity, food security, parent baseline BMI, and parental depression. RESULTS: Among this predominantly low-income minority population, 66% (398/605) of children were normal weight at baseline and 34% (n = 207/605) were overweight. Among normal weight children at baseline, 24% (85/359) were obese after 36 months; among overweight children at baseline, 55% (n = 103/186) were obese after 36 months. Age at enrollment (OR 2.11, 95% CI 1.64-2.72), child baseline BMI (OR 3.37, 95% CI 2.51-4.54), and parent baseline BMI (OR for a 6-unit change 1.36, 95% CI 1.09-1.70) were significantly associated with the odds of becoming obese for children. CONCLUSIONS: The combination of child age, parent BMI, and child overweight as predictors of child obesity suggest a paradigm of family-centered obesity prevention beginning in early childhood, emphasizing the relevance of child overweight as a phenotype highly predictive of child obesity. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01316653.

Designing and Assessing Multilevel Interventions to Improve Minority Health and Reduce Health Disparities.

Multilevel interventions can be uniquely effective at addressing minority health and health disparities, but they pose substantial methodological, data analytic, and assessment challenges that must be considered when designing and applying interventions and assessment. To facilitate the adoption of multilevel interventions to reduce health disparities, we outline areas of need in filling existing operational challenges to the design and assessment of multilevel interventions. We discuss areas of development that address overarching constructs inherent in multilevel interventions, with a particular focus on their application to minority health and health disparities. Our approach will prove useful to researchers, as it allows them to integrate information related to health disparities research into the framework of broader constructs with which they are familiar. We urge researchers to prioritize building transdisciplinary teams and the skills needed to overcome the challenges in designing and assessing multilevel interventions, as even small contributions can accelerate progress toward improving minority health and reducing health disparities. To make substantial progress, however, a concerted and strategic effort, including work to advance analytic techniques and measures, is needed.

Scale-out of a community-based behavioral intervention for childhood obesity: pilot implementation evaluation.

BACKGROUND: Expanding the use of evidence-based behavioral interventions in community settings has met with limited success in various health outcomes as fidelity and dose of clinical interventions are often diluted when translated to communities. We conducted a pilot implementation study to examine adoption of the rigorously evaluated Healthier Families Program by Parks and Recreation centers in 3 cities across the country (MI, GA, NV) with diverse socio-cultural environments. METHODS: Using the RE-AIM framework, we evaluated the program both quantitatively (pre/post surveys of health behavior change; attendance & fidelity) and qualitatively (interviews with Parks and Recreation staff and participants following the program). RESULTS: The 3 partner sites recruited a total of 26 parent-child pairs. REACH: Among the 24 participants who completed pre/post surveys, 62.5% were 25-34 years old, and average child age was 3.6 (SD 0.7) years. The distribution of self-reported race/ethnicity was 54% non-Hispanic White, 38% non-Hispanic Black, and 8% Latino. EFFECTIVENESS: Qualitative interviews with participants demonstrated increased use of the built environment for physical activity and continued use of key strategies for health behavior change. ADOPTION: Three of five (60%) collaborating sites proceeded with implementation of the program. IMPLEMENTATION: The average attendance for the 12-week program was 7.6 (SD 3.9) sessions, with 71% attending > 50% of sessions. Average fidelity for the 12 weekly sessions was 25.2 (SD 1.2; possible range 9-27). MAINTENANCE: All 3 partner sites continued offering the program after grant funding was complete. CONCLUSIONS: This pilot is among the first attempts to scale-out an evidence-based childhood obesity intervention in community Parks and Recreation centers. While this pilot was not intended to confirm the efficacy of the original trial on Body Mass Index (BMI) reduction, the effective and sustained behavior change among a geographically and ethnically diverse population with high attendance and fidelity demonstrates an effective approach on which to base future large-scale implementation efforts to reduce childhood obesity in community settings.

Novel patterns of physical activity in a large sample of preschool-aged children.

BACKGROUND: Moderate-to-vigorous physical activity (MVPA), shown to be associated with health benefits, is not well-characterized in preschool-aged children. MVPA is commonly described as a threshold amount to achieve. We examined a novel way to characterize MVPA patterns in preschool-aged children by gender and age. METHODS: Preschool-aged children from Nashville, TN and Minneapolis, MN wore triaxial accelerometers. Four distinct MVPA patterns were identified: isolated spurt (IS), isolated sustained activity (ISA), clustered spurt (CS), and clustered sustained activity (CSA). Multivariable linear regression models were used to test associations of gender and age with each pattern. RESULTS: One thousand one hundred thirty-one children (3.9 years old, 51% girls, 30% overweight, 11% obese, and 76% Hispanic) wore accelerometers for 12.9 (SD = 1.4) hours/day for 6.7 (SD = 0.7) days. Children spent 53% of wear time in sedentary behavior and 13% in MVPA. On average, boys and girls achieved > 90 min/day of MVPA (98.2 min, SD = 32.3). Most MVPA (80%) was obtained in spurt-like (IS and CS) MVPA; however, girls spent a higher proportion of MVPA in IS and CS, and lower proportion of time in CSA (all p < 0.001). Controlling for gender, an increase of 1-year in age corresponded to a 1.5% increase in CSA (p < 0.05). CONCLUSIONS: How MVPA was obtained varied depending on the gender and age of the child. On average, boys spent more time in sustained MVPA than girls and MVPA was more sustained in older children. Utilizing these patterns could inform PA practice and policy guidelines. TRIAL REGISTRATION: NCT01316653 , date of registration: March 3, 2011; NCT01606891, date of registration: May 23, 2012.

Community readiness assessment for obesity research: pilot implementation of the Healthier Families programme.

BACKGROUND: This article reports on the development of a systematic approach to assess for community readiness prior to implementation of a behavioural intervention for childhood obesity. Using the Consolidated Framework for Implementation Research (CFIR), we developed research tools to evaluate local community centres' organisational readiness and their capacity to implement the intervention. METHODS: Four community Parks and Recreation centres from different states expressed interest in piloting an approach for dissemination and implementation of an evidence-based obesity prevention program for families with young children (Healthier Families). We conducted a mixed methods pre-implementation evaluation using the CFIR to evaluate the alignment of organisational priorities with the Healthier Families programme. Written surveys assessed organisational readiness for change amongst organisational leaders, recreation programmers, and staff (N = 25). Key informant interviews were conducted among staff to assess organisational readiness and with community members to assess community readiness (N = 64). Surveys were analysed with univariate statistics. Interviews were transcribed, coded and analysed using inductive and deductive methods of analysis. RESULTS: Mixed-methods analysis led to the identification of three key domains on which to assess the organisational readiness to adopt a childhood obesity intervention, namely the physical infrastructure, the knowledge infrastructure, and the social infrastructure. The most critical measure of compatibility was the social infrastructure, since obstacles in the knowledge and physical infrastructures could be overcome by the strength of social resources, including the staff's ingenuity and commitment to a healthier community. This approach guided an assessment of organisational readiness prior to community organisations adopting and preparing to disseminate an obesity prevention community-based program in a wide-range of social and environmental contexts. CONCLUSIONS: Using a comprehensive pre-implementation assessment of the knowledge, physical and social infrastructures in a community is an essential step in effective dissemination for community-based behavioural interventions. Our research found that, when evaluating readiness and alignment, a responsive social infrastructure could provide the capacity to overcome potential barriers to implementation in either the knowledge or physical infrastructures.

Effect of a Behavioral Intervention for Underserved Preschool-Age Children on Change in Body Mass Index: A Randomized Clinical Trial.

Importance: Prevention of obesity during childhood is critical for children in underserved populations, for whom obesity prevalence and risk of chronic disease are highest. Objective: To test the effect of a multicomponent behavioral intervention on child body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) growth trajectories over 36 months among preschool-age children at risk for obesity. Design, Setting, and Participants: A randomized clinical trial assigned 610 parent-child pairs from underserved communities in Nashville, Tennessee, to a 36-month intervention targeting health behaviors or a school-readiness control. Eligible children were between ages 3 and 5 years and at risk for obesity but not yet obese. Enrollment occurred from August 2012 to May 2014; 36-month follow-up occurred from October 2015 to June 2017. Interventions: The intervention (n = 304 pairs) was a 36-month family-based, community-centered program, consisting of 12 weekly skills-building sessions, followed by monthly coaching telephone calls for 9 months, and a 24-month sustainability phase providing cues to action. The control (n = 306 pairs) consisted of 6 school-readiness sessions delivered over the 36-month study, conducted by the Nashville Public Library. Main Outcomes and Measures: The primary outcome was child BMI trajectory over 36 months. Seven prespecified secondary outcomes included parent-reported child dietary intake and community center use. The Benjamini-Hochberg procedure corrected for multiple comparisons. Results: Participants were predominantly Latino (91.4%). At baseline, the mean (SD) child age was 4.3 (0.9) years; 51.9% were female. Household income was below $25 000 for 56.7% of families. Retention was 90.2%. At 36 months, the mean (SD) child BMI was 17.8 (2.2) in the intervention group and 17.8 (2.1) in the control group. No significant difference existed in the primary outcome of BMI trajectory over 36 months (P = .39). The intervention group children had a lower mean caloric intake (1227 kcal/d) compared with control group children (1323 kcal/d) (adjusted difference, -99.4 kcal [95% CI, -160.7 to -38.0]; corrected P = .003). Intervention group parents used community centers with their children more than control group parents (56.8% in intervention; 44.4% in control) (risk ratio, 1.29 [95% CI, 1.08 to 1.53]; corrected P = .006). Conclusions and Relevance: A 36-month multicomponent behavioral intervention did not change BMI trajectory among underserved preschool-age children in Nashville, Tennessee, compared with a control program. Whether there would be effectiveness for other types of behavioral interventions or implementation in other cities would require further research. Trial Registration: ClinicalTrials.gov Identifier: NCT01316653.

Maternal BMI as a predictor of methylation of obesity-related genes in saliva samples from preschool-age Hispanic children at-risk for obesity.

BACKGROUND: The study of epigenetic processes and mechanisms present a dynamic approach to assess complex individual variation in obesity susceptibility. However, few studies have examined epigenetic patterns in preschool-age children at-risk for obesity despite the relevance of this developmental stage to trajectories of weight gain. We hypothesized that salivary DNA methylation patterns of key obesogenic genes in Hispanic children would 1) correlate with maternal BMI and 2) allow for identification of pathways associated with children at-risk for obesity. RESULTS: Genome-wide DNA methylation was conducted on 92 saliva samples collected from Hispanic preschool children using the Infinium Illumina HumanMethylation 450 K BeadChip (Illumina, San Diego, CA, USA), which interrogates >484,000 CpG sites associated with ~24,000 genes. The analysis was limited to 936 genes that have been associated with obesity in a prior GWAS Study. Child DNA methylation at 17 CpG sites was found to be significantly associated with maternal BMI, with increased methylation at 12 CpG sites and decreased methylation at 5 CpG sites. Pathway analysis revealed methylation at these sites related to homocysteine and methionine degradation as well as cysteine biosynthesis and circadian rhythm. Furthermore, eight of the 17 CpG sites reside in genes (FSTL1, SORCS2, NRF1, DLC1, PPARGC1B, CHN2, NXPH1) that have prior known associations with obesity, diabetes, and the insulin pathway. CONCLUSIONS: Our study confirms that saliva is a practical human tissue to obtain in community settings and in pediatric populations. These salivary findings indicate potential epigenetic differences in Hispanic preschool children at risk for pediatric obesity. Identifying early biomarkers and understanding pathways that are epigenetically regulated during this critical stage of child development may present an opportunity for prevention or early intervention for addressing childhood obesity. TRIAL REGISTRATION: The clinical trial protocol is available at ClinicalTrials.gov ( NCT01316653 ). Registered 3 March 2011.

The dose of behavioral interventions to prevent and treat childhood obesity: a systematic review and meta-regression.

BACKGROUND: A better understanding of the optimal "dose" of behavioral interventions to affect change in weight-related outcomes is a critical topic for childhood obesity intervention research. The objective of this review was to quantify the relationship between dose and outcome in behavioral trials targeting childhood obesity to guide future intervention development. METHODS: A systematic review and meta-regression included randomized controlled trials published between 1990 and June 2017 that tested a behavioral intervention for obesity among children 2-18 years old. Searches were conducted among PubMed (Web-based), Cumulative Index to Nursing and Allied Health Literature (EBSCO platform), PsycINFO (Ovid platform) and EMBASE (Ovid Platform). Two coders independently reviewed and abstracted each included study. Dose was extracted as intended intervention duration, number of sessions, and length of sessions. Standardized effect sizes were calculated from change in weight-related outcome (e.g., BMI-Z score). RESULTS: Of the 258 studies identified, 133 had sufficient data to be included in the meta-regression. Average intended total contact (# sessions x length of sessions) was 27.7 (SD 32.2) hours and average duration was 26.0 (SD 23.4) weeks. When controlling for study covariates, a random-effects meta-regression revealed no significant association between contact hours, intended duration or their interaction and effect size. CONCLUSIONS: This systematic review identified wide variation in the dose of behavioral interventions to prevent and treat pediatric obesity, but was unable to detect a clear relationship between dose and weight-related outcomes. There is insufficient evidence to provide quantitative guidance for future intervention development. One limitation of this review was the ability to uniformly quantify dose due to a wide range of reporting strategies. Future trials should report dose intended, delivered, and received to facilitate quantitative evaluation of optimal dose. TRIAL REGISTRATIONS: The protocol was registered on PROSPERO (Registration # CRD42016036124 ).

Objective reports versus subjective perceptions of crime and their relationships to accelerometer-measured physical activity in Hispanic caretaker-child dyads.

Crime and safety are commonly cited barriers to physical activity (PA). We had three objectives, 1) describe the association between objective crime measures and perceptions of crime, 2) analyze the relationships between each type of crime and accelerometer-measured physical activity in caretakers and young children (ages 3-5years), and 3) explore for early gender differences in the relationship between crime and physical activity in young children. Data are from the cross-sectional baseline data of an ongoing randomized controlled trial in Nashville, Tennessee spanning September 2012 through May 2014. Data was analyzed from 480 Hispanic dyads (adult caretaker and 3-5year old child). Objective crime rate was assessed in ArcGIS and perception of crime was measured by caretaker agreement with the statement "The crime rate in my neighborhood makes it unsafe to go on walks." The primary outcome was accelerometer-measured physical activity over seven consecutive days. Objective and perceived crime were significantly positively correlated. Caretaker vigorous PA was significantly related to perceptions of crime; however, its relationship to objective crime was not significant. Child PA was not significantly related to caretaker perceptions of crime. However, interactions suggested that the relationship between crime rate and PA was significantly more negative for girls than for boys. Objective and subjective measures of crime rate are expected to be important correlates of PA, but they appear to have complex relationships that are different for adults than they are for young children, as well as for young girls compared to boys, and research has produced conflicting findings.

Parenting Self-Efficacy, Parent Depression, and Healthy Childhood Behaviors in a Low-Income Minority Population: A Cross-Sectional Analysis.

Objectives Childhood obesity prevention and treatment depends, in part, on parents acting as agents of change for their children. Our objective was to measure the associations between parenting self-efficacy, parent depressive symptoms, and preschool child behaviors that support healthy growth. Methods We performed a cross-sectional analysis of baseline data from a randomized controlled trial. Parenting self-efficacy was measured using a 5-item version of the Parenting Sense of Competence (PSOC-5) scale (α= 0.8). Parent depressive symptoms were measured using the Center for Epidemiological Studies-Depression (CESD) scale. Child outcomes included diet (24 h diet recall), physical activity (accelerometry), sleep (parent-report), and media use during meals (parent-report). We performed separate multiple linear regressions for each outcome controlling for other covariates. Results The sample consisted of 601 parent-child pairs. Median child age was 4.3 (IQR 3.6-5.1) years; median child body mass index (BMI) percentile was 79.1% (IQR 66.8-88.5%); 90% of children were Hispanic/Latino, and 6% of children were non-Hispanic Black. Median parent age was 31.5 (IQR 27.6-36.0) years; 22% of parents met criteria for depression. Parenting self-efficacy (median PSOC-5 25; IQR 24-28) was negatively correlated with depressive symptoms (ρ = -0.16; p < 0.001). In adjusted models, higher parenting self-efficacy was associated with duration of child's sleep and fewer meals eaten in front of a TV (p < 0.001). There was a significant interaction of parenting self-efficacy and parental depressive symptoms on child sleep duration (p < 0.001). Parenting self-efficacy and depressive symptoms were not significantly associated with child physical activity or child diet. Conclusions In this minority population, higher parenting self-efficacy was associated with longer child sleep and fewer meals in front the TV, but parent depressive symptoms mitigated that protective effect for child sleep duration.

Parental perception of built environment characteristics and built environment use among Latino families: a cross-sectional study.

BACKGROUND: Perception of undesirable features may inhibit built environment use for physical activity among underserved families with children at risk for obesity. METHODS: To examine the association of perceived availability, condition, and safety of the built environment with its self-reported use for physical activity, we conducted a cross-sectional analysis on baseline data from a randomized controlled trial. Adjusted Poisson regression was used to test the association between the primary independent variables (perceived availability, physical condition, and safety) with the primary outcome of self-reported use of built environment structures. RESULTS: Among 610 parents (90% Latino) of preschool-age children, 158 (26%) reported that there were no available built environment structures for physical activity in the neighborhood. The use of built environment structures was associated with the perceived number of available structures (B = 0.34, 95% CI 0.31, 0.37, p < 0.001) and their perceived condition (B = 0.19, 95% CI 0.12, 0.27, p = 0.001), but not with perceived safety (B = 0.00, 95% CI -0.01, 0.01, p = 0.7). CONCLUSIONS: In this sample of underserved families, perceived availability and condition of built environment structures were associated with use rather than perceived safety. To encourage physical activity among underserved families, communities need to invest in the condition and availability of built environment structures. TRIAL REGISTRATION: Registered at ClinicalTrials.gov ( NCT01316653 ) on March 11, 2011.

Strategies to identify and stratify children with special health care needs in outpatient general pediatrics settings.

Developing improved systems of care for children with special health care needs (CSHCN) requires accurate identification and stratification of this population. This study was designed to assess the ability of a brief screener to identify and stratify CSHCN in a primary care clinic to focus future quality improvement initiatives and allocate resources. All families presenting for health maintenance visits or acute care appointments at an academic primary care clinic between September 5, 2012 and September 28, 2012 were asked to complete the CSHCN Screener(©). This panel of patients was compared to registries previously created by: (1) retrospective chart reviews using published lists of International Statistical Classification of Diseases and Related Health Problems (ICD9) codes for CSHCN and (2) direct physician referral to a clinic case manager providing care coordination services to CSHCN. Screeners identified 246 CSHCN (16.8 % of unique completed screeners). Scores ranged from 0 to 5; higher scores indicate higher levels of complexity. Patients with positive screens had a mean score of 2.4. Patients previously identified by retrospective ICD9 search who completed a screener had a mean score of 1.6 with nearly one-half having negative screens. Patients previously identified by physician referral who completed a screener had a mean score of 2.7 with nearly one-half having scores of 4 or 5. The CSHCN Screener(©) can be utilized in an academic primary care clinic to prospectively identify CSHCN and potentially offers a more clinically meaningful method of identification given its inherent ability to stratify this population based on complexity of medical needs.

The Injury Prevention Program to Reduce Early Childhood Injuries: A Cluster Randomized Trial.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics designed The Injury Prevention Program (TIPP) in 1983 to help pediatricians prevent unintentional injuries, but TIPP's effectiveness has never been formally evaluated. We sought to evaluate the impact of TIPP on reported injuries in the first 2 years of life. METHODS: We conducted a stratified, cluster-randomized trial at 4 academic medical centers: 2 centers trained their pediatric residents and implemented TIPP screening and counseling materials at all well-child checks (WCCs) for ages 2 to 24 months, and 2 centers implemented obesity prevention. At each WCC, parents reported the number of child injuries since the previous WCC. Proportional odds logistic regression analyses with generalized estimating equation examined the extent to which the number of injuries reported were reduced at TIPP intervention sites compared with control sites, adjusting for baseline child, parent, and household factors. RESULTS: A total of 781 parent-infant dyads (349 TIPP; 432 control) were enrolled and had sufficient data to qualify for analyses: 51% Hispanic, 28% non-Hispanic Black, and 87% insured by Medicaid. Those at TIPP sites had significant reduction in the adjusted odds of reported injuries compared with non-TIPP sites throughout the follow-up (P = .005), with adjusted odds ratios (95% CI) of 0.77 (0.66-0.91), 0.60 (0.44-0.82), 0.32 (0.16-0.62), 0.26 (0.12-0.53), and 0.27 (0.14-0.52) at 4, 6, 12, 18, and 24 months, respectively. CONCLUSIONS: In this cluster-randomized trial with predominantly low-income, Hispanic, and non-Hispanic Black families, TIPP resulted in a significant reduction in parent-reported injuries. Our study provides evidence for implementing the American Academy of Pediatrics' TIPP in routine well-child care.