Maternal and Paternal Adverse Childhood Experiences (ACEs) and Offspring Health and Wellbeing: A Scoping Review.

BACKGROUND: Adverse childhood experiences (ACEs) are common, often co-occur, and are associated with poor health outcomes across the life course. Emerging research has emphasized the lasting consequences of ACEs across generations, suggesting parental ACEs are associated with poor physical and mental health outcomes in children. However, the individual effects of fathers' ACEs and pathways of transmission remain unclear. A scoping review was conducted to summarize the current knowledgebase of the intergenerational consequences of parental ACEs on offspring health, clarify pathways of transmission, understand how ACEs are operationalized in the intergenerational literature, and identify gaps in knowledge. METHODS: Six electronic databases were searched for articles published in English from 1995 to 2022 relating to the long-term consequences of parental ACEs on offspring physical and mental health. Articles underwent title, abstract, and full-text review by two investigators. Content analysis was performed to integrate findings across the included studies. RESULTS: The search yielded 14,542 unique articles; 49 met the inclusion criteria. Thirty-six articles focused exclusively on mothers, one solely on fathers, and 12 included both mothers and fathers in their analyses. Six studies used an expanded definition of ACEs. Both direct and indirect associations between parental ACEs and poor offspring outcomes were identified, primarily through biological and psychosocial pathways. CONCLUSIONS: Findings underscore the importance and oversight of fathers and the need to solidify a unified definition and measure of ACEs. This review identified modifiable protective factors (social support, father involvement) and pathways of transmission (parental mental health, parenting); both having important implications for intervention development.

What is known on this subject? Recently, research has highlighted the intergenerational consequences of parental ACEs on offspring physical and mental health outcomes with a primary focus on mothers. Maternal exposure to ACEs is associated with poor offspring behavioral, mental and physical health, and developmental outcomes.What the study adds? This review extends prior literature by summarizing the nascent research on paternal ACEs, pathways of transmission, and suggesting the transmission of maternal ACEs to offspring outcomes is observed across a wide range of health outcomes and ACEs.

Evaluation of a cluster-randomized controlled trial: Communities for Healthy Living, family-centered obesity prevention program for Head Start parents and children.

BACKGROUND: This study reports the outcomes of Communities for Healthy Living (CHL), a cluster randomized obesity prevention trial implemented in partnership with Head Start, a federally-funded preschool program for low-income families. METHODS: Using a stepped wedge design, Head Start programs (n = 16; Boston, MA, USA) were randomly assigned to one of three intervention start times. CHL involved a media campaign and enhanced nutrition support. Parents were invited to join Parents Connect for Healthy Living (PConnect), a 10-week wellness program. At the beginning and end of each school year (2017-2019), data were collected on the primary outcome of child Body Mass Index z-score (BMIz) and modified BMIz, and secondary outcomes of child weight-related behaviors (diet, physical activity, sleep, media use) and parents' weight-related parenting practices and empowerment. Data from 2 years, rather than three, were utilized to evaluate CHL due to the COVID-19 pandemic. We used mixed effects linear regression to compare relative differences during intervention vs. control periods (n = 1274 vs. 2476 children) in (1) mean change in child BMIz and modified BMIz, (2) the odds of meeting child health behavior recommendations, (3) mean change in parenting practices, and (4) mean change in parent empowerment. We also compared outcomes among parents who chose post-randomization to participate in PConnect vs. not (n = 55 vs. 443). RESULTS: During intervention periods (vs. control), children experienced greater increases in BMIz and modified BMIz (b = 0.06, 95% CI = 0.02,0.10; b = 0.07, 95% CI = 0.03, 0.12), yet were more likely to meet recommendations related to three of eight measured behaviors: sugar-sweetened beverage consumption (i.e., rarely consume; Odds Ratio (OR) = 1.5, 95% CI = 1.2,2.3), water consumption (i.e., multiple times per day; OR = 1.6, 95% CI = 1.2,2.3), and screen time (i.e., ≤1 hour/day; OR = 1.4, 95% CI = 1.0,1.8). No statistically significant differences for intervention (vs. control) periods were observed in parent empowerment or parenting practices. However, parents who enrolled in PConnect (vs. not) demonstrated greater increases in empowerment (b = 0.17, 95% CI = 0.04,0.31). CONCLUSIONS: Interventions that emphasize parent engagement may increase parental empowerment. Intervention exposure was associated with statistically, but not clinically, significant increases in BMIz and increased odds of meeting recommendations for three child behaviors; premature trial suspension may explain mixed results. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03334669 , Registered October 2017.

Development and Psychometric Properties of the Sleep Parenting Scale for Infants.

Although infants' sleep behaviors are shaped by their interactions with parents at bedtime, few tools exist to capture parents' sleep parenting practices. This study developed a Sleep Parenting Scale for Infants (SPS-I) and aimed to (1) explore and validate its factorial structure, (2) examine its measurement invariance across mothers and fathers, and (3) investigate its reliability and concurrent and convergent validity. SPS-I was developed via a combination of items modified from existing scales and the development of novel items. Participants included 188 mothers and 152 mother-father dyads resulting in 340 mothers and 152 fathers; about half were non-Hispanic white. Mothers and fathers completed a 14-item SPS-I for their 12-month-old infant. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to explore and validate SPS-I's underlying structure. Multigroup CFA was used to examine measurement invariance across mothers and fathers. Reliability was examined using Cronbach's alpha. Concurrent validity was assessed using linear regressions examining associations between SPS-I factors and parent-reported infants nighttime sleep duration. Convergent validity was assessed using paired-sample t-tests to test whether the SPS-I subscale scores were similar between mothers and fathers in the same household. EFA and CFA confirmed a 3-factor, 12-item model: sleep routines, sleep autonomy, and screen media in the sleep environment. SPS-I was invariant across mothers and fathers and was reliable. Concurrent and convergent validity were established. SPS-I has good psychometric properties, supporting its use for characterizing sleep routines, sleep autonomy, and screen media in the sleep environment by mothers and fathers.Supplemental data for this article is available online at https://doi.org/10.1080/08964289.2021.2002799 .

Caregivers Systematically Overestimate Their Child's Height-for-Age Relative to Other Children in Rural Ethiopia.

BACKGROUND: Stunting affects one-quarter of children <5 y of age, yet little is known about the accuracy of caregivers' perceptions regarding their child's linear growth. Most existing quantitative research on this topic has been conducted in high-income countries and has examined perceptions of children's weight rather than height. OBJECTIVES: In rural Ethiopia where linear growth faltering is highly prevalent, this study aimed to better understand how caregivers perceive their child's growth. The objectives of this analysis were to 1) assess caregivers' perceptions of their child's height; 2) investigate whether there is a discrepancy between a child's actual height and caregivers' perceptions of their child's height; and 3) examine the factors that influence discrepancies in estimating a child's height (secondary outcomes), including the role of the average height in the community (primary outcome). METHODS: We conducted a cross-sectional analysis using data from 808 woman caregivers of children ages 6-35 mo in the Oromia region of Ethiopia. We assessed caregivers' rankings (from 1 to 10) of their child's height relative to other children their age in their village. We then converted these rankings to z scores based on an age- and region-specific distribution in order to calculate their difference with the child's actual height-for-age z score and to determine the degree of overestimation. Lastly, we used multivariate log Poisson regressions to determine factors associated with overestimating a child's height. RESULTS: Forty-three percent of caregivers scored their child's height as the median; 37% overestimated their child's height relative to other children. Regression results showed caregivers who were poorer, and had children who were female, older, and stunted, were more likely to overestimate. CONCLUSIONS: Our findings suggest that caregivers of young children in Oromia systematically overestimated their children's height, which could adversely affect child health if these misperceptions translate to insufficient care-seeking behavior or feeding choices for children.

Associations of Healthy Infant Feeding Practices and Early Childhood Adiposity in the Rise & SHINE Cohort.

We studied healthy infant feeding practices among 308 mother-infant pairs, including exclusive breastmilk, satiety cues, complementary food introduction, sugary beverage intake, and bottle use in bed. We examined associations of individual and cumulative infant feeding practices through 12 months of age with body mass index (BMI) z -score at 2 years. Exclusive breastmilk and avoidance of bottle use in bed were associated with lower BMI z -score (ß -0.29 units; 95% CI, -0.56, -0.02 units and ß -0.32 units; 95% CI, -0.57, -0.07, respectively), when accounting for maternal pre-pregnancy BMI, household income, infant sex, race, and ethnicity. Adherence to 4--5 practices, compared to ≤ 2 practices, was associated with lower BMI z -score (ß -0.84 units; 95% CI, -1.35, -0.34 units). Adherence to healthy infant feeding practices may reduce risk of excessive adiposity in early childhood. Targeting multiple infant feeding practices may be a more effective way to prevent childhood adiposity.

Changes in Fathers' Body Mass Index, Sleep, and Diet From Prebirth to 12 Months Postbirth: Exploring the Moderating Roles of Parenthood Experience and Coparenting Support.

BACKGROUND: While research has examined prenatal to postnatal changes in women's weight, sleep, and diet, much less is known about these changes among fathers. PURPOSE: This study aimed to (a) examine changes in fathers' body mass index (BMI), sleep, and diet from 1 month before birth to 5-6 months following birth, and from 5-6 months to 11-12 months following birth and (b) explore the moderating roles of parenthood experience and coparenting support. METHODS: 169 fathers (mean age 35.5 years, 58.9% White) participated. Fathers completed an intake survey shortly after their infant's birth to recall their height and weight, nighttime sleep hours, fruit and vegetable intake, soda intake, and fast food intake for the month prior to birth. When their child was 6 and 12 months old, fathers reported their weight, sleep, and diet again for the past 4 weeks (i.e., 4 week periods spanning 5-6 months and 11-12 months following birth). Generalized estimating equations were used to answer our research questions. RESULTS: Fathers reported higher BMI (Δ = 0.22 kg/m2; 95% confidence interval [CI] = 0.06, 0.38; p = .008) and less nighttime sleep duration (Δ = -0.21 hr; 95% CI = -0.38, -0.05; p = .012) at 5-6 months following birth compared to 1 month prior to birth. Fathers' diet remained stable over the three timepoints. No evidence was found to support the moderating roles of parenthood experience and coparenting support on fathers' weight and behavior changes. CONCLUSIONS: 5-6 months following birth may be an important point of intervention for fathers to promote a return to prebirth BMI and sleep levels.

Acceptability and appropriateness of a novel parent-staff co-leadership model for childhood obesity prevention in Head Start: a qualitative interview study.

BACKGROUND: Peer leadership can be an effective strategy for implementing health programs, benefiting both program participants and peer leaders. To realize such benefits, the peer leader role must be appropriate for the community context. Also, peer leaders must find their role acceptable (i.e., satisfactory) to ensure their successful recruitment and retention. To date, parent peer leaders have seldom been part of early childhood obesity prevention efforts. Moreover, parents at Head Start preschools have rarely been engaged as peer leaders. The aim of this study is to evaluate the appropriateness and acceptability of an innovative model for engaging parents as peer leaders for this novel content area (early childhood obesity prevention) and setting (Head Start). METHODS: Parents Connect for Healthy Living (PConnect) is a 10-session parent program being implemented in Head Start preschools as part of the Communities for Healthy Living early childhood obesity prevention trial. PConnect is co-led by a parent peer facilitator who is paired with a Head Start staff facilitator. In the spring of 2019, 10 PConnect facilitators participated in a semi-structured interview about their experience. Interview transcripts were analyzed by two coders using an inductive-deductive hybrid analysis. Themes were identified and member-checked with two interviewees. RESULTS: Themes identified applied equally to parent and staff facilitators. Acceptability was high because PConnect facilitators were able to learn and teach, establish meaningful relationships, and positively impact the parents participating in their groups, although facilitators did express frustration when low attendance limited their reach. Appropriateness was also high, as PConnect provided adequate structure and support without being overly rigid, and facilitators were able to overcome most challenges they encountered. CONCLUSIONS: The PConnect co-facilitation model was highly acceptable and appropriate for both the parent facilitators (peer leaders) and the staff facilitators. Including parents as peer leaders aligns to Head Start's emphasis on parent engagement, making it a strong candidate for sustained implementation in Head Start. The insights gained about the drivers of peer leadership appropriateness and acceptability in this particular context may be used to inform the design and implementation of peer-led health programs elsewhere. TRIAL REGISTRATION: clinicaltrials.gov, NCT03334669 (7-11-17).

Occasions, purposes, and contexts for offering snacks to preschool-aged children: Schemas of caregivers with low-income backgrounds.

OBJECTIVE: Snacking among preschool aged children is nearly universal and has been associated with overconsumed nutrients, particularly solid fats and added sugars (SoFAS). This research examined caregivers' schemas, or cognitive frameworks, for offering snacks to preschool-aged children. METHODS: A qualitative design utilizing card sort methods was employed. Participants were 59 Black, Hispanic, and White caregivers of children aged 3-5 years with low-income backgrounds. Caregivers sorted 63 cards with images of commonly consumed foods/beverages by preschool-aged children in three separate card sorts to characterize snacking occasions, purposes, and contexts. The mean SoFAS content (kcal/100 g) of foods/beverages was evaluated by snacking occasions (snacks vs. not-snacks), purposes, and contexts. RESULTS: Just under two-thirds (38/63 food cards) of foods/beverages were classified as snacks with moderate to high agreement. Snacks were offered for non-nutritive (e.g., requests, rewards) and nutritive (e.g., hunger/thirst) purposes in routine (e.g., home, school) and social contexts (e.g., with grandparents). Snacks offered for non-nutritive purposes and in social contexts were higher in SoFAS than those offered for nutritive reasons and in routine contexts. CONCLUSIONS: Caregivers of young children offered various types of foods/beverages as snacks, with higher SoFAS snacks given for non-nutritive purposes and in social contexts. Understanding of caregivers' schemas for offering snacks to young children may inform targets for obesity prevention and anticipatory guidance to promote the development of healthful eating behaviors.

Summer Weight Gain Among Preschool-Aged Children With Obesity: An Observational Study in Head Start.

School-aged children gain weight most rapidly in summer, but few studies have investigated summer weight gain among preschool-aged children. We fit continuous linear spline mixed models to test for accelerated summer weight gain among 2,044 children attending 16 Boston-area Head Start programs between fall 2016 and spring 2019. Academic year and summer rates of change in modified body mass index z-score differed (P < .001), with accelerated summer weight gain most pronounced among children with obesity. As with school-aged children, increased focus on the summer is warranted for promoting healthy weight among children in Head Start.

Antenatal dietary concordance among mothers and fathers and gestational weight gain: a longitudinal study.

BACKGROUND: Parent-child dietary concordance is associated with child diet, but the clinical implications of mother-father dietary concordance during pregnancy are unknown. This study evaluates antenatal mother-father dietary concordance and associations with gestational weight gain (GWG). METHODS: Mother-father (n = 111) dyads with low income reported their fruit/vegetable (FV), fast food (FF), and sugar-sweetened beverage (SSB) consumption frequency during the first trimester of pregnancy. From electronic health records, we collected height and self-reported pre-pregnancy weight and calculated pre-pregnancy body mass index (BMI). The primary outcome was excessive GWG for pre-pregnancy BMI. Dyads were categorized as healthy or unhealthy concordant (consuming similarly high or low amounts of FV, FF, or SSB), or mother-healthy or father-healthy discordant (consuming different amounts of FV, FF, or SSB). Multivariable and logistic regressions analyzed associations between dietary concordance and GWG. RESULTS: Mothers were Hispanic (25%), 43% White, 6% Black, and 23% Asian or Other. Most mothers were employed (62%) making <$50,000/year (64%). Average maternal GWG was 11.6 kg (SD = 6.40), and 36% had excessive GWG. Mothers in the mother-healthy discordant FV group (OR = 4.84; 95% CI = 1.29, 18.22) and the unhealthy concordant FF group (OR = 7.08; 95% CI = 2.08, 24.12) had higher odds for excessive GWG, compared to healthy concordant dyads. SSB concordance was associated with higher GWG in unadjusted, but not adjusted models. CONCLUSIONS: Mothers had higher risk for excessive GWG when both partners had unhealthy FF consumption frequency, and when fathers had unhealthy FV consumption frequency. These findings imply that fathers should be involved in educational opportunities regarding dietary intake during pregnancy.

Shaping healthy habits in children with neurodevelopmental and mental health disorders: parent perceptions of barriers, facilitators and promising strategies.

OBJECTIVE: Prevalence of pediatric neurodevelopmental and mental health disorders (ND/MHD) is increasing in the United States and globally. ND/MHD are associated with higher risk of poor dietary, physical activity (PA), screen, and sleep habits in youth, contributing to elevated lifetime chronic disease risk. ND/MHD symptoms can present unique challenges to parenting, create competing parenting priorities, and may decrease parental capacity to instill healthy habits. Unfortunately, literature characterizing parenting of health habits in youth with ND/MHD is sparse. The objective of this study was to describe barriers to, facilitators of, and practical strategies for parenting healthy lifestyle habits in children and teens with ND/MHD. METHODS: We conducted semi-structured interviews with parents whose children with diagnosed ND/MHD were attending a Boston-area therapeutic day school serving K-10th grade. Interviews allowed parents to focus on parenting PA, diet, sleep, and/or screen habits as context for questions. Interviews were transcribed, double-coded using constant comparative methods, and summarized into themes using NVivo 11. RESULTS: We interviewed 24 parents; average age of their child with ND/MHD was 11.2 years (range: 8-15). Most had a son (75%) with multiple ND/MHD (88%); diagnoses included autism spectrum disorder (50%), attention deficit-hyperactivity disorder (67%), anxiety (67%), and other mood disorders (58%). Major barriers to parenting all types of health habits included depleted parent resources, child dysregulation, lack of supportive programming available to children with ND/MHD, and medication side effects. Major facilitators included participation in specialized therapeutic options, adaptive community programs and schools, as well as parents' social capital. Effective parenting strategies included setting clear, often structural boundaries, using positive reinforcement, allowing agency by presenting healthy choices, and use of role modeling to promote healthy habits. Almost one third of parents extensively discussed the role of pets or therapy animals as key to establishing and maintaining healthy routines, particularly PA and screen-time management. CONCLUSIONS: Parenting healthy habits in children with ND/MHD is difficult and is undermined by competing demands on parenting resources. To reduce chronic disease disparities and promote health in this population, future research must better adapt existing health promotion materials and programs to more practically support parents in multiple settings including home, schools and community organizations.

Autonomous motivation, sugar-sweetened beverage consumption and healthy beverage intake in US families: differences between mother-adolescent and father-adolescent dyads.

OBJECTIVE: To assess interdependent effects of autonomous motivation to limit sugar-sweetened beverage (SSB) consumption in relation to SSB and healthy beverage (HB) intake in mother-adolescent and father-adolescent dyads. DESIGN: Adopting a dyadic cross-sectional design, the actor-partner interdependence modelling (APIM) approach was used to construct and analyse two APIM for mother-adolescent and father-adolescent dyads. The first model assessed actor effects (individual's autonomous motivation associated with his/her own beverage intake) and partner effects (individual's autonomous motivation associated with another family member's beverage consumption) of autonomous motivation on SSB consumption. The second model assessed actor and partner effects of autonomous motivation on HB intake. SETTING: Two Internet-based surveys were completed in participant households.ParticipantsData from a demographically representative US sample of parent-adolescent dyads (1225 mother-adolescent dyads, 424 father-adolescent dyads) were used. RESULTS: In the first model (autonomous motivation on SSB consumption), actor effects were significant for adolescents, but not for parents. Partner effects were significant for mother-adolescent, but not father-adolescent dyads. In the second model (autonomous motivation on HB intake), actor effects were significant for adolescents and parents in all dyadic combinations. Regarding partner effects, adolescent autonomous motivation had a significant effect on HB intake for mothers and fathers. In addition, maternal autonomous motivation had a significant effect on adolescent HB intake. No partner effects for HB were identified for fathers. CONCLUSIONS: We found significant interdependent effects of autonomous motivation in relation to SSB and HB intake in mother-adolescent and father-adolescent dyads for eleven out of sixteen pathways modelled.

Changes in the nutritional quality of fast-food items marketed at restaurants, 2010 v. 2013.

OBJECTIVE: To examine the nutritional quality of menu items promoted in four (US) fast-food restaurant chains (McDonald's, Burger King, Wendy's, Taco Bell) in 2010 and 2013. DESIGN: Menu items pictured on signs and menu boards were recorded at 400 fast-food restaurants across the USA. The Nutrient Profile Index (NPI) was used to calculate overall nutrition scores for items (higher scores indicate greater nutritional quality) and was dichotomized to denote healthier v. less healthy items. Changes over time in NPI scores and energy of promoted foods and beverages were analysed using linear regression. SETTING: Four hundred fast-food restaurants (McDonald's, Burger King, Wendy's, Taco Bell; 100 locations per chain). SUBJECTS: NPI of fast-food items marketed at fast-food restaurants. RESULTS: Promoted foods and beverages on general menu boards and signs remained below the 'healthier' cut-off at both time points. On general menu boards, pictured items became modestly healthier from 2010 to 2013, increasing (mean (se)) by 3·08 (0·16) NPI score points (P<0·001) and decreasing (mean (se)) by 130 (15) kJ (31·1 (3·65) kcal; P<0·001). This pattern was evident in all chains except Taco Bell, where pictured items increased in energy. Foods and beverages pictured on the kids' section showed the greatest nutritional improvements. Although promoted foods on general menu boards and signs improved in nutritional quality, beverages remained the same or became worse. CONCLUSIONS: Foods, and to a lesser extent, beverages, promoted on menu boards and signs in fast-food restaurants showed limited improvements in nutritional quality in 2013 v. 2010.

Family-based childhood obesity prevention interventions: a systematic review and quantitative content analysis.

BACKGROUND: A wide range of interventions has been implemented and tested to prevent obesity in children. Given parents' influence and control over children's energy-balance behaviors, including diet, physical activity, media use, and sleep, family interventions are a key strategy in this effort. The objective of this study was to profile the field of recent family-based childhood obesity prevention interventions by employing systematic review and quantitative content analysis methods to identify gaps in the knowledge base. METHODS: Using a comprehensive search strategy, we searched the PubMed, PsycIFO, and CINAHL databases to identify eligible interventions aimed at preventing childhood obesity with an active family component published between 2008 and 2015. Characteristics of study design, behavioral domains targeted, and sample demographics were extracted from eligible articles using a comprehensive codebook. RESULTS: More than 90% of the 119 eligible interventions were based in the United States, Europe, or Australia. Most interventions targeted children 2-5 years of age (43%) or 6-10 years of age (35%), with few studies targeting the prenatal period (8%) or children 14-17 years of age (7%). The home (28%), primary health care (27%), and community (33%) were the most common intervention settings. Diet (90%) and physical activity (82%) were more frequently targeted in interventions than media use (55%) and sleep (20%). Only 16% of interventions targeted all four behavioral domains. In addition to studies in developing countries, racial minorities and non-traditional families were also underrepresented. Hispanic/Latino and families of low socioeconomic status were highly represented. CONCLUSIONS: The limited number of interventions targeting diverse populations and obesity risk behaviors beyond diet and physical activity inhibit the development of comprehensive, tailored interventions. To ensure a broad evidence base, more interventions implemented in developing countries and targeting racial minorities, children at both ends of the age spectrum, and media and sleep behaviors would be beneficial. This study can help inform future decision-making around the design and funding of family-based interventions to prevent childhood obesity.

Food parenting and child snacking: a systematic review.

BACKGROUND: While the role of parenting in children's eating behaviors has been studied extensively, less attention has been given to its potential association with children's snacking habits. To address this gap, we conducted a systematic review to describe associations between food parenting and child snacking, or consuming energy dense foods/foods in between meals. METHODS: Six electronic databases were searched using standardized language to identify quantitative studies describing associations of general and feeding-specific parenting styles as well as food parenting practices with snacking behaviors of children aged 2-18 years. Eligible peer-reviewed journal articles published between 1980 and 2017 were included. Data were extracted using a standard protocol by three coders; all items were double coded to ensure consistency. RESULTS: Forty-seven studies met inclusion criteria. Few studies focused on general feeding (n = 3) or parenting styles (n = 10). Most studies focused on controlling food parenting practices (n = 39) that were not specific to snacking. Parental restriction of food was positively associated with child snack intake in 13/23 studies, while pressure to eat and monitoring yielded inconsistent results. Home availability of unhealthy foods was positively associated with snack intake in 10/11 studies. Findings related to positive parent behaviors (e.g. role modeling) were limited and yielded mixed results (n = 9). Snacking was often assessed using food frequency items and defined post-hoc based on nutritional characteristics (e.g. energy-dense, sugary foods, unhealthy, etc.). Timing was rarely included in the definition of a snack (i.e. chips eaten between meals vs. with lunch). CONCLUSIONS: Restrictive feeding and home access to unhealthy foods were most consistently associated with snacking among young children. Research is needed to identify positive parenting behaviors around child snacking that may be used as targets for health promotion. Detailed definitions of snacking that address food type, context, and purpose are needed to advance findings within the field. We provide suggested standardized terminology for future research.

The influence of fathers on children's physical activity: A review of the literature from 2009 to 2015.

Parents are influential in promoting children's physical activity. Yet, most research has focused on how mothers influence children's activity, while little empirical attention has been devoted to understanding how fathers may influence children's activity. The purpose of this review was to summarize observational studies from 2009 to 2015 examining the influence of fathers on children's physical activity. A publicly available database, from a prior systematic review, containing information on 667 studies of parenting and childhood obesity from 2009 to 2015 was searched for potential studies. Studies were eligible if: 1) fathers were included as participants, 2) results were presented for fathers separate from mothers, 3) fathers' physical activity or physical activity parenting was assessed, and 4) child physical activity was measured. Ten studies met eligibility criteria. All studies were rated as fair quality. The majority of studies (n=8) assessed the relationship between father and child physical activity. Of 27 associations tested, 14 (52%) were significant, indicating a modest, positive relationship between father and child activity. Of the studies examining fathers' physical activity parenting (n=3), there were three significant associations out of 15 tested (20%) and no consistency among measured constructs. No differences were observed in the influence of mothers vs. fathers on children's physical activity. Limited evidence was available to examine moderating effects of child sex or age. Few studies have examined the effect of fathers on child physical activity and this relationship remains unclear. Future studies should target fathers for research and investigate specific pathways through which fathers can influence child activity.

Fathers' Perceived Reasons for Their Underrepresentation in Child Health Research and Strategies to Increase Their Involvement.

Purpose Examine fathers' perceived reasons for their lack of inclusion in pediatric research and strategies to increase their participation. Description We conducted expert interviews with researchers and practitioners (N = 13) working with fathers to inform the development of an online survey. The survey-which measured fathers' perceived reasons for their underrepresentation in pediatric research, recommended recruitment venues, and research personnel and study characteristics valued by fathers-was distributed online and in-person to fathers. Assessment Respondents included 303 fathers. Over 80 % of respondents reported that fathers are underrepresented in pediatric research because they have not been asked to participate. Frequently recommended recruitment venues included community sports events (52 %), social service programs (48 %) and the internet (60 %). Compared with white fathers, more non-white fathers recommended public transit (19 % vs. 10 %, p = .02), playgrounds (16 % vs. 6 %, p = .007) and barber shops (34 % vs. 14 %, p < .0001) and fewer recommended doctors' offices (31 % vs. 43 %, p = .046) as recruitment venues. Compared with residential fathers (100 % resident with the target child), more non-residential fathers recommended social services programs (45 % vs. 63 %, p = .03) and public transit (10 % vs. 27 %, p = .001) and fewer recommended the workplace (17 % vs. 40 %, p = .002) as recruitment venues. Study brevity, perceived benefits for fathers and their families, and the credibility of the lead organization were valued by fathers. Conclusion Fathers' participation in pediatric research may increase if researchers explicitly invite father to participate, target father-focused recruitment venues, clearly communicate the benefits of the research for fathers and their families and adopt streamlined study procedures.

Lessons Learned by Community Stakeholders in the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) Project, 2013-2014.

INTRODUCTION: Childhood obesity is a multifaceted disease that requires sustainable, multidimensional approaches that support change at the individual, community, and systems levels. The Massachusetts Childhood Obesity Research Demonstration project addressed this need by using clinical and public health evidence-based methods to prevent childhood obesity. To date, little information is known about successes and lessons learned from implementing such large-scale interventions. To address this gap, we examined perspectives of community stakeholders from various sectors on successes achieved and lessons learned during the implementation process. METHODS: We conducted 39 semistructured interviews with key stakeholders from 6 community sectors in 2 low-income communities from November 2013 through April 2014, during project implementation. Interviews were audio-recorded, transcribed, and analyzed by using the constant comparative method. Data were analyzed by using QSR NVivo 10. RESULTS: Successes included increased parental involvement in children's health and education, increased connections within participating organizations and within the broader community, changes in organizational policies and environments to better support healthy living, and improvements in health behaviors in children, parents, and stakeholders. Lessons learned included the importance of obtaining administrative and leadership support, involving key stakeholders early in the program planning process, creating buffers that allow for unexpected changes, and establishing opportunities for regular communication within and across sectors. CONCLUSION: Study findings indicate that multidisciplinary approaches support health behavior change and provide insight into key issues to consider in developing and implementing such approaches in low-income communities.

Using School Staff Members to Implement a Childhood Obesity Prevention Intervention in Low-Income School Districts: the Massachusetts Childhood Obesity Research Demonstration (MA-CORD Project), 2012-2014.

INTRODUCTION: Although evidence-based interventions to prevent childhood obesity in school settings exist, few studies have identified factors that enhance school districts' capacity to undertake such efforts. We describe the implementation of a school-based intervention using classroom lessons based on existing "Eat Well and Keep Moving" and "Planet Health" behavior change interventions and schoolwide activities to target 5,144 children in 4th through 7th grade in 2 low-income school districts. METHODS: The intervention was part of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) project, a multisector community-based intervention implemented from 2012 through 2014. Using mixed methods, we operationalized key implementation outcomes, including acceptability, adoption, appropriateness, feasibility, implementation fidelity, perceived implementation cost, reach, and sustainability. RESULTS: MA-CORD was adopted in 2 school districts that were facing resource limitations and competing priorities. Although strong leadership support existed in both communities at baseline, one district's staff reported less schoolwide readiness and commitment. Consequently, fewer teachers reported engaging in training, teaching lessons, or planning to sustain the lessons after MA-CORD. Interviews showed that principal and superintendent turnover, statewide testing, and teacher burnout limited implementation; passionate wellness champions in schools appeared to offset implementation barriers. CONCLUSION: Future interventions should assess adoption readiness at both leadership and staff levels, offer curriculum training sessions during school hours, use school nurses or health teachers as wellness champions to support teachers, and offer incentives such as staff stipends or play equipment to encourage school participation and sustained intervention activities.

Fathers' Representation in Observational Studies on Parenting and Childhood Obesity: A Systematic Review and Content Analysis.

BACKGROUND: The involvement of fathers in caregiving has increased substantially over the past 30 years. Yet in child and adolescent psychopathology, few studies include fathers as research participants and few present results for fathers separate from those for mothers. We test for the first time whether a similar pattern exists in research on parenting and childhood obesity. OBJECTIVES: To conduct a systematic review and quantitative content analysis of observational studies on parenting and childhood obesity to (1) document the inclusion of fathers, relative to mothers, as research participants and (2) examine characteristics of studies that did and did not include fathers. This study presents new data on the number and gender of parent research participants. SEARCH METHODS: We searched title, abstract, and Medical Subject Headings term fields in 5 research databases (PubMed, EMBASE, Academic Search Premier, PsycINFO, and CINAHL) using terms combining parents or parenting (e.g., mother, father, caregiver, parenting style, food parenting) and obesity (e.g., obesity, body weight, overweight) or obesity-related lifestyle behaviors (e.g., diet, snacking, physical activity, outdoor play, exercise, media use). SELECTION CRITERIA: We identified and screened studies as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) published between January 2009 and December 2015, examining links between parenting and childhood obesity, including parents or caregivers as research participants, and written in English. We excluded interventions, nonhuman studies, dissertations, conference abstracts, and studies on youths with specific medical conditions. Of 5557 unique studies, 667 studies were eligible. DATA COLLECTION AND ANALYSIS: For each of the 667 studies, 4 coders were trained to code characteristics of the study (e.g., publication year, geographic region, journal, study focus) and parent research participants (e.g., parent gender, demographic background, biological relationship with child, and residential status). We established intercoder reliability before coding the full sample of studies (mean Krippendorf's alpha = .79; average percentage agreement = 94%). MAIN RESULTS: Of the studies, 1% included only fathers. By contrast, 36% included only mothers. Although slightly more than 50% of studies (n = 347) included at least 1 father, only 57 studies reported results for fathers separate from those for mothers. When we combined them with studies including only fathers, 10% of studies overall reported results for fathers. Samples sizes of fathers were small compared with mothers. Of studies with fathers, 59% included 50 or fewer fathers, whereas 22% of studies with mothers included 50 or fewer mothers. The mean sample size for fathers across all eligible studies was 139, compared with 672 for mothers. Overall, fathers represented 17% of parent participants across all eligible studies. CONCLUSIONS: This study unequivocally demonstrates that fathers are underrepresented in recent observational research on parenting and childhood obesity. Public health implications. The underrepresentation of fathers in obesity research compromises the development of effective family interventions for childhood obesity prevention. Targeted opportunities and incentives are needed to support research with fathers.