Food Insecurity and Health Outcomes of Children With Intellectual and Developmental Disabilities in the United States.

We aimed to (a) provide nationally representative estimates of food insecurity (FI) among children with intellectual and developmental disabilities (IDD), and (b) determine the association between FI and four health outcomes (overall health, problem behavior, activities of daily living, functional limitations) in 5,657 children with IDD compared to 1:1 propensity score matched children without IDD. Mixed-effects ordered logistic regression models were used. Children with IDD were more likely to experience FI than children without IDD (43.3% vs. 30.0%, p < 0.001). FI and IDD were independently associated with worse scores on all four health outcomes. Having both FI and IDD further exacerbated the adverse impacts on these health outcomes. The association was stronger among children with moderate-to-severe FI than those with mild FI.

Remembered childhood mealtime experiences influence on early childcare and education staff.

Parent feeding styles, behaviors, beliefs, and practices are associated with developing children's eating behaviors. However, many children spend considerable time in childcare; thus, are exposed to child-feeding practices of other adults, e.g., early care and education (ECE) staff. Limited research exists on how and whether current classroom feeding practices of ECE staff associate with their own childhood experiences. The About Feeding Children survey, conducted in 2005, examined self-reported feeding practices and beliefs and personal characteristics of ECE staff in Western United States. An exploratory factor analysis of questions related to childhood experiences (N = 1189), revealed two Mealtime Factors: Remembered Adult Control and Remembered Child Autonomy Support. Structural equation modeling was conducted to examine the hypothesis that these remembered experiences would be associated with current feeding practices (Structural Mealtime Strategies, Verbal Mealtime Strategies, and Beliefs about Mealtimes). For each outcome, models had good to moderate fit. Across models, Remembered Autonomy Support was associated with less control, bribing, autonomy undermining, and concern-based control beliefs and greater support at meals and autonomy promoting beliefs in teachers' classroom feeding practices. More research is called for to consider whether reflection on remembered childhood experiences might be beneficial to consider during ECE staff training related to feeding young children.

Evidence-Based Quality Improvement (EBQI) in the pre-implementation phase: key steps and activities.

Background: Evidence-Based Quality Improvement (EBQI) involves researchers and local partners working collaboratively to support the uptake of an evidence-based intervention (EBI). To date, EBQI has not been consistently included in community-engaged dissemination and implementation literature. The purpose of this paper is to illustrate the steps, activities, and outputs of EBQI in the pre-implementation phase. Methods: The research team applied comparative case study methods to describe key steps, activities, and outputs of EBQI across seven projects. Our approach included: (1) specification of research questions, (2) selection of cases, (3) construction of a case codebook, (4) coding of cases using the codebook, and (5) comparison of cases. Results: The cases selected included five distinct settings (e.g., correction facilities, community pharmacies), seven EBIs (e.g., nutrition promotion curriculum, cognitive processing therapy) and five unique lead authors. Case examples include both community-embedded and clinically-oriented projects. Key steps in the EBQI process included: (1) forming a local team of partners and experts, (2) prioritizing implementation determinants based on existing literature/data, (3) selecting strategies and/or adaptations in the context of key determinants, (4) specifying selected strategies/adaptations, and (5) refining strategies/adaptations. Examples of activities are included to illustrate how each step was achieved. Outputs included prioritized determinants, EBI adaptations, and implementation strategies. Conclusions: A primary contribution of our comparative case study is the delineation of various steps and activities of EBQI, which may contribute to the replicability of the EBQI process across other implementation research projects.

Integration of Food-based Learning With Science in the Preschool Classroom: Implementation Gaps and Opportunities.

OBJECTIVE: To explore Head Start teachers' use and integration of food-based learning (FBL) with science learning in the Head Start classroom. DESIGN: Phenomenological approach using in-depth semistructured telephone interviews. SETTING: North Carolina Head Start preschools. PARTICIPANTS: Thirty-five Head Start lead and assistant teachers. PHENOMENON OF INTEREST: All interviews were transcribed verbatim. Authors coded interview data for emergent themes. ANALYSIS: Eleven primary themes were identified during analysis and inductively organized using the Systems Thinking Iceberg Model. RESULTS: Teachers described most frequently using FBL during mealtimes. Teachers stated they felt successful when children were engaged and willing to try a new food. However, they struggled to connect food to science concepts. Teachers reported several motivators (eg, improving health) and barriers (eg, food waste) to integrating FBL. Teachers prioritized preparing children for kindergarten, but most teachers did not see how FBL could help them achieve this goal. CONCLUSIONS AND IMPLICATIONS: Head Start teacher professional development programs could impact all 4 levels of the Systems Thinking Model to improve teachers' perceptions, underlying structures, and mental models regarding integrative FBL. Additional research is warranted to investigate the adoption, implementation, and potential impact of FBL on academic outcomes.

Systematic Review of Reflection Spectroscopy-Based Skin Carotenoid Assessment in Children.

Assessing children's skin carotenoid score (SCS) using reflection spectroscopy (RS) is a non-invasive, widely used method to approximate fruit and vegetable consumption (FVC). The aims for the current review were to (1) identify distributions of SCS across demographic groups, (2) identify potential non-dietary correlates for RS-based SCS, (3) summarize the validity and reliability of RS-based SCS assessment, and (4) conduct meta-analyses of studies examining the correlation between RS-based SCS with FVC. A literature search in eight databases in June 2021 resulted in 4880 citations and peer-reviewed publications written in English that investigated children's (2-10 years old) SCS using RS. We included 11 studies (intervention = 3, observational = 8). Potential covariates included weight status, ethnicity, seasonal variation, age, sex, and income. Studies reported criterion validity with children's FVC but not with plasma carotenoid. Additionally, no studies reported the reliability of RS-based SCS in children. Among the 726 children included in the meta-analysis, the correlation between RS-based SCS and FVC was r = 0.2 (p < 0.0001). RS-based SCS is a valid method to quantify skin carotenoids for children's FVC estimation with the potential for evaluating nutrition policies and interventions. However, future research should use standardized protocol for using RS and establish how RS-based SCS can translate to the amount of daily FVC in children.

Cultivating informatics capacity for multimorbidity: A learning health systems use case.

Background: The aim of this study was to characterize patterns of multimorbidity across patients and identify opportunities to strengthen the informatics capacity of learning health systems that are used to characterize multimorbidity across patients. Methods: Electronic health record (EHR) data on 225,710 multimorbidity patients were extracted from the Arkansas Clinical Data Repository as a use case. Hierarchical cluster analysis identified the most frequently occurring combinations of chronic conditions within the learning health system's captured data. Results: Results revealed multimorbidity was highest among patients ages 60 to 74, Caucasians, females, and Medicare payors. The largest numbers of chronic conditions occurred in the smallest numbers of patients (i.e., 70,262 (31%) patients with two conditions, two (<1%) patients with 22 chronic conditions). The results revealed urgent needs to improve EHR systems and processes that collect and manage multimorbidity data (e.g., creating new, multimorbidity-centric data elements in EHR systems, detailed longitudinal tracking of compounding disease diagnoses). Conclusions: Without additional capacity to collect and aggregate large-scale data, multimorbidity patients cannot benefit from the recent advancements in informatics (i.e., clinical data registries, emerging data standards) that are abundantly working to improve the outcomes of patients with single chronic conditions. Additionally, robust socio-technical system studies of clinical workflows are needed to assess the feasibility of integrating the collection of risk factor data elements (i.e., psycho-social, cultural, ethnic, and socioeconomic attributes of populations) into primary care encounters. These approaches to advancing learning health systems for multimorbidity could substantially reduce the constraints of current technologies, data, and data-capturing processes.

De-Implementation of Detrimental Feeding Practices in Childcare: Mixed Methods Evaluation of Community Partner Selected Strategies.

This pilot evaluated strategies to decrease detrimental feeding practices in early care and education, which are hypothesized to compete with evidence-based feeding and obesity prevention practices. This study made two key comparisons: (1) a between-site comparison of sites receiving (a) no implementation or de-implementation strategies (i.e., Basic Support; B), (b) implementation strategies only (i.e., Enhanced Support; E), and (c) implementation and de-implementation strategies (i.e., De-implementation + Enhanced Support; D + E) and (2) a within-site pre-post comparison among sites with D + E. At nutrition lessons, the D + E group had more Positive Comments (Hedege's g = 0.60) and higher Role Model fidelity (Hedege's g = 1.34) compared to the E group. At meals, assistant teachers in the D + E group had higher Positive Comments than in the B group (g = 0.72). For within-group comparisons, the D + E group decreased Negative Comments (t(19) = 2.842, p = 0.01), increased Positive Comments (t(20) = 2.314, p = 0.031), and improved use of the program mascot at nutrition lessons (t(21) = 3.899, p = 0.001). At meals, lead teachers' Negative Comments decreased (t(22) = 2.73, p = 0.01). Qualitative data identified strengths and opportunities for iteration. Despite a COVID interruption, mid-point comparisons and qualitative feedback suggest promise of the de-implementation strategy package.

Implementation fidelity, attitudes, and influence: a novel approach to classifying implementer behavior.

BACKGROUND: The current study sought to (1) describe a new classification approach for types of implementer behavior and (2) explore the implementer behavior change in response to tailored implementation facilitation based on the classifications. METHODS: A small-scale, cluster-randomized hybrid type III implementation trial was conducted in 38 early care and education classrooms that were part of the Together, We Inspire Smart Eating (WISE) program. WISE focuses on 4 evidence-based practices (EBPs), which are implemented by teachers to promote nutrition. External facilitators (N = 3) used a modified Rapid Assessment Procedure Informed Clinical Ethnography (RAPICE) to complete immersion (i.e., observations) and thematic content analyses of interviews to identify the characteristics of teachers' behavior at varying levels of implementation fidelity. Three key factors-attitudes toward the innovation, fidelity/adaptations, and influence-were identified that the research team used to classify teachers' implementation behavior. This process resulted in a novel classification approach. To assess the reliability of applying the classification approach, we assessed the percent agreement between the facilitators. Based on the teachers' classification, the research team developed a tailored facilitation response. To explore behavior change related to the tailored facilitation, change in fidelity and classification across the school year were evaluated. RESULTS: The classifications include (1) enthusiastic adopters (positive attitude, meeting fidelity targets, active influence), (2) over-adapting adopters (positive attitude, not meeting fidelity targets, active influence), (3) passive non-adopters (negative attitude, not meeting fidelity targets, passive influence), and (4) active non-adopters (negative attitudes, not meeting fidelity targets, active influence). The average percent agreement among the three facilitators for classification was 75%. Qualitative data support distinct patterns of perceptions across the classifications. A positive shift in classification was observed for 67% of cases between the mid-point and final classification. Finally, we generated an expanded classification approach to consider additional combinations of the three factors beyond those observed in this study. CONCLUSIONS: Data from this study support the ability to apply the classification approach with moderate to high reliability and to use the approach to tailor facilitation toward improved implementation. Findings suggest the potential of our approach for wider application and potential to improve tailoring of implementation strategies such as facilitation.

Obesity prevention practices in early care and education settings: an adaptive implementation trial.

BACKGROUND: Despite the potential for Early Care and Education (ECE) settings to promote healthy habits, a gap exists between current practices and evidence-based practices (EBPs) for obesity prevention in childhood. METHODS: We will use an enhanced non-responder trial design to determine the effectiveness and incremental cost-effectiveness of an adaptive implementation strategy for Together, We Inspire Smart Eating (WISE), while examining moderators and mediators of the strategy effect. WISE is a curriculum that aims to increase children's intake of carotenoid-rich fruits and vegetables through four evidence-based practices in the early care and education setting. In this trial, we will randomize sites that do not respond to low-intensity strategies to either (a) continue receiving low-intensity strategies or (b) receive high-intensity strategies. This design will determine the effect of an adaptive implementation strategy that adds high-intensity versus one that continues with low-intensity among non-responder sites. We will also apply explanatory, sequential mixed methods to provide a nuanced understanding of implementation mechanisms, contextual factors, and characteristics of sites that respond to differing intensities of implementation strategies. Finally, we will conduct a cost effectiveness analysis to estimate the incremental effect of augmenting implementation with high-intensity strategies compared to continuing low-intensity strategies on costs, fidelity, and child health outcomes. DISCUSSION: We expect our study to contribute to an evidence base for structuring implementation support in real-world ECE contexts, ultimately providing a guide for applying the adaptive implementation strategy in ECE for WISE scale-up. Our work will also provide data to guide implementation decisions of other interventions in ECE. Finally, we will provide the first estimate of relative value for different implementation strategies in this setting. TRIAL REGISTRATION: NCT05050539 ; 9/20/21.

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.

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.

BMI Data Collection and Communication Practices in a Multistate Sample of Head Start Programs.

Background: Although there is a federal mandate to collect anthropometric data in Head Start (HS), little is currently known about the processes used to collect the height and weight measurements across programs and how the results are communicated to parents/guardians. The goal of this study was to understand anthropometric data collection and dissemination procedures in a sample of HS programs serving children 3-5 years. Methods: A convenience sample of HS Health or Nutrition managers were recruited via personal contacts and HS state directors to complete an electronic survey. Quantitative data were analyzed using descriptive statistics (means, standard deviations and frequencies). Open-ended questions were coded using thematic analysis. All protocols and procedures were approved by the Institutional Review Board at Miami University. Results: Approximately half of the programs reported that they have a protocol in place to guide measurements (57.1%) and those measurements are primarily taken by HS staff (64.5%). Most programs explain measurements to parents (82.3%) and report that collecting height/weight data is helpful in supporting children's health (76.0%). Most programs (80.3%) provide resources to parents of children with overweight or obesity. Four themes emerged from open-ended responses: (1) Role of Community Partners (e.g., providing information that conflicts with others); (2) Communicating Children's Weight Status with Families (e.g., using sensitive communication methods); (3) Challenges Measuring Children's Weight Status (e.g., accuracy of data, children's awareness); and (4) Family Reaction to Weight Status Communication (e.g., positive or negative experiences). Conclusion: Opportunities for quality improvement include wider use of standardized, written protocols and policies on data collection and enhanced communication practices to share information with parents.

Hungry is not safe: A mixed methods study to explore food insecurity in early care and education.

The early care and education (ECE) environment has the potential to affect both children and their families. Food insecurity in ECE and its management may be an important influence. Objectives of this mixed methods study were to (1) elicit prominent themes relating to teacher experiences with food insecurity (in the classroom) through qualitative interviews; (2) translate interview themes into survey items and analyze survey data to explore generalizability of the qualitative findings; and (3) provide preliminary data on properties of a new tool to study the influence of food insecurity in the ECE setting. An exploratory sequential mixed methods design (QUAL → quant) was used. Twenty-eight interviews about teacher experiences with food insecurity were followed by 781 surveys to assess generalizability of interview findings. Qualitative themes highlighted that ECE teachers are concerned about children's food insecurity in their classroom; ECE teachers have developed their own set of strategies to manage their concern; and teachers often struggle with what to do. Quantitative results demonstrated many teachers had the same concerns and used the strategies described in the interviews. Further, in exploratory analyses, ECE teachers with Food Insecurity scored significantly higher on all scales (e.g., Food Insecurity Concerns, Struggle with Addressing Food Security) in both adjusted and unadjusted analyses. ECE teachers with Food Acquisition Stress had higher scores on Strategies to Address Food Insecurity with Families in adjusted analyses.

The Families and Schools for Health Project: A Longitudinal Cluster Randomized Controlled Trial Targeting Children with Overweight and Obesity.

This cluster randomized controlled trial aimed at overweight and obese children compared three treatments. Two psychoeducation interventions for parents and children were conducted: Family Lifestyle (FL) focused on food and physical activity; Family Dynamics (FD) added parenting and healthy emotion management. A third Peer Group (PG) intervention taught social acceptance to children. Crossing interventions yielded four conditions: FL, FL + PG, FL + FD, and FL + FD + PG-compared with the control. Longitudinal BMI data were collected to determine if family- and peer-based psychosocial components enhanced the Family Lifestyle approach. Participants were 1st graders with BMI%ile >75 (n = 538: 278 boys, 260 girls). Schools were randomly assigned to condition after stratifying for community size and percent American Indian. Anthropometric data were collected pre- and post-intervention in 1st grade and annually through 4th grade. Using a two-level random intercept growth model, intervention status predicted differences in growth in BMI or BMI-M% over three years. Children with obesity who received the FL + FD + PG intervention had lower BMI gains compared to controls for both raw BMI (B = -0.05) and BMI-M% (B = -2.36). Interventions to simultaneously improve parent, child, and peer-group behaviors related to physical and socioemotional health offer promise for long-term positive impact on child obesity.

Stakeholder selected strategies for obesity prevention in childcare: results from a small-scale cluster randomized hybrid type III trial.

BACKGROUND: Together, We Inspire Smart Eating (WISE) is an intervention for the early care and education setting to support children's exposure to and intake of fruits and vegetables. WISE emphasizes 4 evidence-based practices (EBPs): (1) use of a mascot; (2) educators' role modeling; (3) positive feeding practices; and (4) hands-on exposures. The current study reports on a small-scale implementation trial aimed at improving the use of WISE EBPs by teachers. METHODS: A Hybrid Type III Cluster Randomized Design compared a Basic and Enhanced implementation strategy. The Basic Strategy included training and reminders only; the Enhanced strategy was a multi-faceted package of stakeholder-selected strategies including a leadership commitment, an implementation blueprint, a local champion, an environmental reminder of the EBPs, facilitation, and tailored educational resources and incentives. All study sites were Head Starts. Sites were randomized using a balancing technique that considered site characteristics; 4 sites (20 classrooms, 39 educators, 305 children) received Enhanced support; 5 sites (18 classrooms, 36 educators, 316 children) received Basic support. RE-AIM guided the evaluation, and implementation fidelity was the primary outcome. Strategies were assessed using examination of data distributions and unadjusted comparisons (t tests) as well as general linear and mixed effects models controlling for covariates. RESULTS: For the primary outcome of fidelity, the Enhanced group had significantly higher means for 3 of 4 EBPs. Multivariate models explained a significant portion of variance for both mascot use and hands-on exposure with a significant positive effect observed for treatment condition. The Enhanced group also had higher rates of Appropriateness and Organizational Readiness for Implementing Change (as indicators of implementation and adoption, respectively). There was no significant difference between groups for indicators of Reach, Effectiveness or Maintenance. Formative interviews indicated key targets for iteration and potential mechanisms. Key events were catalogued to provide context for interpretation (e.g., 61% of classrooms with turnover). CONCLUSIONS: Findings were mixed but suggested promise for the Enhanced strategy, especially considering key events of the study. Implementation fidelity improvements occurred mainly in the last 3 months of the school year; additional time may be needed to translate to improvements in child outcomes. TRIAL REGISTRATION: NCT03075085 Registered 20 February 2017.

An Overview of Research Opportunities to Increase the Impact of Nutrition Intervention Research in Early Childhood and Education Care Settings According to the RE-AIM Framework.

Objective: To highlight opportunities for future nutrition intervention research within early childhood and education care (ECEC) settings, with a focus on generating evidence that has applicability to real-world policy and practice. Methods: An overview of opportunities to progress the field was developed by the authors using a collaborative writing approach and informed by recent research in the field. The group developed a list of recommendations aligned with the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) framework. Pairs of authors drafted individual sections of the manuscript, which were then reviewed by a separate pair. The first and senior author consolidated all sections of the manuscript and sought critical input on the draft iterations of the manuscript. Results: Interventions that employ digital platforms (reach) in ECEC settings, as well as research in the family day care setting (effectiveness) were identified as areas of opportunities. Research understanding the determinants of and effective strategies for dissemination (adoption), the implementation of nutrition programs, in addition to de-implementation (implementation) of inappropriate nutrition practices, is warranted. For maintenance, there is a need to better understand sustainability and the sustainment of interventions, in addition to undertaking policy-relevant research. Conclusions: The ECEC setting is prime for innovative and practical nutrition intervention research.

Identifying a Fine Line between Food Insecurity and Food Acquisition Stress: A Mixed Methods Exploration.

This study introduces the concept of Food Acquisition Stress (FAS), stress associated with food acquisition among those who do not necessarily screen positive for food insecurity.. This study used an exploratory sequential mixed methods approach among a sample of predominantly early childhood educators to develop a 7-item tool for measuring current and retrospective FAS. Using this tool, we identified that 61% of individuals who had FAS did not meet criteria for food insecurity. Capturing FAS, even among those categorized as food secure, has the potential to identify individuals who may need supportive interventions. Future research can explore how FAS is related to health behaviors.

Bidirectional Associations between Restrained Eating and Body Mass Index in Middle Childhood.

The nature of the association between dietary restraint and weight has been examined in adult samples, but much less is known about this relationship among children. The current study examined the transactional associations among restrained eating behavior and weight among boys and girls during middle childhood. Data for this study came from 263 children participating in the Families and Schools for Health Project (FiSH), a longitudinal study of the psychosocial correlates of childhood obesity. Participants were interviewed by trained researchers in their third- and fourth-grade year when they completed questionnaires and anthropometric assessments. Dietary restraint was assessed using the restrained eating subscale of the Dutch Eating Behavior Questionnaire (DEBQ), and weight was assessed using Body Mass Index z-scores (BMIz). Bidirectional associations between variables were examined using cross-lagged models controlling for children's sex, ethnicity, and weight in first grade. Results indicated that weight in grade 3 was related to greater dietary restraint in grade 4 (B = 0.20, p = 0.001), but dietary restraint in grade 3 was not associated with weight in grade 4 (B = 0.01, p = 0.64). Neither child sex nor race/ethnicity were associated with BMIz or dietary restraint at either time point. Findings from this study advance the existing limited understanding of eating behavior development among children and show that weight predicts increases in children's dietary restraint in middle childhood.

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.

Table Talk: revision of an observational tool to characterize the feeding environment in early care and education settings.

OBJECTIVE: The Table Talk tool is an observational assessment of early care and education teacher (ECET) mealtime practices. The Table Talk Revised (TT-R) tool incorporates new constructs that emerged from qualitative research and teases apart existing categories to improve nuance of data capture. The objective of this study was to evaluate the TT-R, document interrater reliability for the TT-R, and report on ECET feeding communications in broader settings than previously studied (i.e., beyond a single Lunch and Head Start only). METHODS: Trained observers conducted mealtime observations in classrooms (Nclassroms = 63, 10 sites) during Breakfast and two Lunches for both Lead and Assistant ECETs (N = 126). Classrooms were spread across Head Start in an urban area (60%), Head Starts in a rural area (24%), and a state-funded preschool (16%). RESULTS: On average, there were 22.17 (SD = 10.92) total verbal feeding communications at Breakfast, 37.72 (SD = 15.83) at Lunch1, and 34.39 (SD = 15.05) at Lunch2 with meals averaging 25 min. The most commonly observed supportive statement category was Exploring Foods for Lead (Breakfast = 1.61, Lunch1 = 3.23, Lunch2 = 2.70) and Assistant ECETs (Breakfast = .89, Lunch1 = 2.03) except for Lunch2 which was Encourages Trying in a Positive Way (Lunch2 = 1.30). The most commonly observed unsupportive statement category was Firm Behavioral Control for both Lead (Breakfast = 3.61, Lunch1 = 5.84, Lunch2 = 5.51) and Assistants ECETs (Breakfast = 3.11, Lunch1 = 6.38, Lunch2 = 4.32). The majority of Interclass Correlation Coefficients indicating interrater reliability were in the excellent range (64%) for commonly occurring statement categories, and 14 of the 19 low frequency statement categories had > 80% agreement. CONCLUSIONS AND IMPLICATIONS: Overall, items added to the Table Talk tool performed well, and interrater reliability was favorable. Our study also documented differences between Lead and Assistant teachers in mealtime practices and illustrated differing patterns of interaction between lunches and breakfast, important findings to inform future research and practice. The TT-R may be a useful measurement tool for monitoring and evaluating ECET practices in mealtime environments as well as informing intervention.