One Step Closer to Safer: Counseling Outcomes from American Academy of Pediatrics Firearm Safe Storage Education Training.

OBJECTIVE: To assess pre and postself-reported counseling outcomes for Safer: Storing Firearms Prevents Harm, an American Academy of Pediatrics universal firearm safe storage counseling training for pediatric clinicians providing health maintenance in outpatient settings. STUDY DESIGN: Safer was developed by a national multidisciplinary committee of firearm injury prevention experts with input from firearm-owning families and launched in June 2021. Pediatric clinicians completed baseline and 1-month posttraining surveys after signing up for the Pedialink course from February through June 2022. Primary outcomes included self-reported measures of counseling self-efficacy and frequency. Wilcoxon matched-pairs signed-rank tests compared outcome distributions at baseline and follow-up. Two adjusted, multilevel mixed-effects regression models were conducted. RESULTS: Of 230 clinicians who completed baseline surveys, 146 (64%) completed 1-month postsurveys. Regional representation included Southeast = 67 (46%), Northeast = 24 (16%), Midwest = 21 (14%), Pacific = 15 (10%), Southwest = 11 (8%), and Rocky Mountain = 8 (5%). At follow-up, there was significant improvement in both the distribution of self-efficacy (median [first Quartile-third Quartile = 50 [20-70] at baseline and 80 [60-85] at follow-up; P < .001) and self-reported counseling frequency (median [first Quartile-third Quartile] = 10 [0-50] at baseline and 50 [10-80] at follow-up; P < .001). Adjusted regression model results suggested that self-efficacy significantly improved from baseline to follow-up (time coefficient 25.3; 95% CI = [21.0, 29.5]; P < .001) as did counseling frequency (time coefficient 13.6; 95% CI = [9.2, 18.0]; P < .001). CONCLUSIONS: Significant improvement in self-reported counseling self-efficacy and frequency was demonstrated 1 month following Safer training.

Ultra-processed food consumption and BMI-Z among children at risk for obesity from low-income households.

OBJECTIVE: To evaluate the association between baseline ultra-processed food consumption in early childhood and child BMI Z-score over 36 months. METHODS: We conducted a prospective cohort analysis as a secondary data analysis of the Growing Right Onto Wellness randomised trial. Dietary intake was measured via 24-h diet recalls. The primary outcome was child BMI-Z, measured at baseline and at 3-, 9-, 12-, 24- and 36-month timepoints. Child BMI-Z was modelled using a longitudinal mixed-effects model, adjusting for covariates and stratifying by age. RESULTS: Among 595 children, median (Q1-Q3) baseline age was 4.3 (3.6-5.0) years, 52.3% of the children were female, 65.4% had normal weight, 33.8% were overweight, 0.8% were obese and 91.3% of parents identified as Hispanic. Model-based estimates suggest that, compared with low ultra-processed consumption (300 kcals/day), high ultra-processed intake (1300 kcals/day) was associated with a 1.2 higher BMI-Z at 36 months for 3-year-olds (95% CI = 0.5, 1.9; p < 0.001) and a 0.6 higher BMI-Z for 4-year-olds (95% CI = 0.2, 1.0; p = 0.007). The difference was not statistically significant for 5-year-olds or overall. CONCLUSIONS: In 3- and 4-year-old children, but not in 5-year-old children, high ultra-processed food intake at baseline was significantly associated with higher BMI-Z at 36-month follow-up, adjusting for total daily kcals. This suggests that it might not be only the total number of calories in a child's daily intake that influences child weight status, but also the number of calories from ultra-processed foods.

Reliability and validity of assigning ultraprocessed food categories to 24-h dietary recall data.

BACKGROUND: The Nova classification system categorizes foods into 4 processing levels, including ultraprocessed foods (UPFs). Consumption of UPFs is extensive in the United States, and high UPF consumption is associated with chronic disease risk. A reliable and valid method to Nova-categorize foods would advance understanding of UPF consumption and its relationship to health outcomes. OBJECTIVES: Test the reliability and validity of training coders and assigning Nova categories to individual foods collected via 24-h dietary recalls. DESIGN: A secondary analysis of 24-h dietary recalls from 610 children who participated in a randomized controlled trial and were 3-5 y old at baseline was conducted. The Nutrition Data System for Research (NDSR) software was used to collect 2-3 dietary recalls at baseline and yearly for 3 y. Trained and certified coder pairs independently categorized foods into one of 4 Nova categories (minimally processed, processed culinary ingredients, processed, and ultraprocessed). Interrater reliability was assessed by percent concordance between coder pairs and by Cohen's κ coefficient. Construct validity was evaluated by comparing the average daily macronutrient content of foods between Nova categories. RESULTS: In 5546 valid recall days, 3099 unique foods were categorized: minimally processed (18%), processed culinary ingredients (0.4%), processed (15%), and ultraprocessed (67%). Coder concordance = 88.3%, and κ coefficient = 0.75. Descriptive comparisons of macronutrient content across 66,531 diet recall food entries were consistent with expectations. On average, UPFs were 62% (SD 19) of daily calories, and a disproportionally high percentage of daily added sugar (94%; SD 16) and low percentage of daily protein (47%; SD 24). Minimally processed foods were 30% (SD 17) of daily calories, and a disproportionally low percentage of daily added sugar (1%; SD 8) and high percentage of daily protein (43%; SD 24). CONCLUSIONS: This method of Nova classifying NDSR-based 24-h dietary recalls was reliable and valid for identifying individual intake of processed foods, including UPFs.

Diet Quality and School Attendance: Cost Analysis Informing Absence-Reduction Strategies in Schools With Underserved Students.

BACKGROUND: As school districts across the nation evaluate strategies and implement programs to reduce absenteeism, health-related interventions remain largely underutilized. This study provides the estimated cost of improving students' diet quality as a means to increase attendance. Then, it compares the costs and efficacy of improving diet quality to those of other absence-reduction interventions. METHODS: This study used child-level diet quality data from the Growing Right Onto Wellness (GROW) randomized control trial merged with Metro Nashville Public Schools (MNPS) absences data, as well as food cost estimates from Rose et al. to study the cost effectiveness of improving underserved elementary student attendance through improved diet quality. RESULTS: The results suggest that improving diet quality might be a cost-efficient way of improving attendance among elementary students in underserved areas. Further, improving diet quality compares favorably to other absence-reduction strategies, in terms of cost and effectiveness. CONCLUSIONS: Investments in school food programs to improve diet quality may be a cost-effective strategy to reduce student absenteeism, especially for schools with higher concentrations of students with lower diet quality. These results may assist decision-makers who allocate scarce resources aimed at improving school attendance.

Direct-to-patient telehealth equity: Reaching diverse pediatric populations in primary care.

INTRODUCTION: Telehealth is the use of electronic information and technology for long-distance clinical care. In direct-to-patient (DTP) telehealth, the patient initiates care from a personal computer or mobile device to a medical provider. While information on standard clinic-to-clinic telehealth exists, less is known about DTP telehealth in pediatric populations. Using quantitative and qualitative data, we examined DTP telehealth for low-income pediatric patient-families and compared the experience of English and non-English speakers. METHOD: Telehealth visits for acute and preventive care took place from April 2020 to May 2020 at a pediatric primary care clinic (80% Medicaid-insured, 40% non-English-speaking). Patients and primary care providers conducted the visit through the clinic's portal or other platforms (WhatsApp, FaceTime, Zoom). Providers completed an electronic survey with patient feedback about the telehealth experience and their own observations. An iterative inductive/deductive approach informed a coding scheme for free-text survey responses consisting of five domains. RESULTS: REDCap surveys were completed for 258 (52%) of telehealth visits. There was an overrepresentation of English visits compared to the overall clinic population and the majority of visits were via mobile phone. Visits with English speakers utilized the patient portal and had positive process ease ratings more often than those with non-English speakers. Providers rated most telehealth visits as satisfactory, with contributing elements including family call environment, technology process and experience, value added, and barriers. DISCUSSION: Expanding telehealth in pediatrics without worsening health disparities requires building digital health that is user-friendly on mobile technology, facilitating patient preferred language, and simplifying logistical processes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Effect of a Virtual Home-Based Behavioral Intervention on Family Health and Resilience During the COVID-19 Pandemic: A Randomized Clinical Trial.

Importance: Virtual home-based interventions may bolster protective factors, such as family health and resilience, during stressors such as the COVID-19 pandemic; however, their effectiveness is unknown. Objective: To examine the effectiveness of a virtual health coaching intervention on family health and resilience during the pandemic. Design, Setting, and Participants: In this parallel-group, single-site randomized clinical trial, 123 parents and their 2- to 8-year-old children were enrolled at a pediatric clinic or community partner site in Tennessee from March 10 to August 11, 2021. Follow-up surveys were completed between June 29 and November 11, 2021. Interventions: All participants received 11 weekly cooking videos and associated home-delivered groceries. The intervention group also received 12 weekly, 30-minute virtual health coach sessions. Main Outcomes and Measures: The primary outcome was the validated 6-item (range, 6-30) Family Healthy Lifestyle Subscale (FHLS) scores. The secondary outcome was the validated 6-item (range, 0-6) Family Resilience and Connection Index (FRCI) scores. Outcomes were determined a priori and evaluated at baseline and 12-week follow-up. A priori independent t tests and multivariable tobit regression models assessed intervention effects, and post hoc, secondary interaction models assessed whether effects differed over baseline outcomes. Results: Among the 123 enrolled families, 110 (89%) were included in the primary analyses (parent mean [SD] age, 35.1 [8.2] years; 104 [95%] female; 55 [50%] non-Hispanic Black; child mean [SD] age, 5.2 [1.7] years; 62 [56%] male). Intervention-control group mean differences were nonsignificant for follow-up FHLS scores (0.7; 95% CI, -0.6 to 2.0; P = .17) and FRCI scores (0.1; 95% CI, -0.5 to 0.6; P = .74). Tobit regression model intervention effects were nonsignificant for FHLS scores (0.9; 95% CI, -0.3 to 2.2; P = .15) and FRCI scores (0.4; 95% CI, -0.2 to 1.1; P = .17). Post hoc, secondary models found no significant interaction for FHLS scores (1.3 increase per 5-point decrease; 95% CI, -0.2 to 2.7; P = .09), with significant intervention associations for baseline scores of 6 to 23. The interaction was significant for FRCI scores (0.4 increase per 1-point decrease; 95% CI, 0.01 to 0.8; P = .047), with significant intervention associations for baseline scores of 0 to 3. Conclusions and Relevance: In this randomized clinical trial of families with young children, weekly virtual health coaching did not detectably improve family health and resilience. Post hoc, secondary results provided preliminary evidence of potential effectiveness among families with low baseline scores. Trial Registration: ClinicalTrials.gov Identifier: NCT05328193.

Validation of a new scoring approach of a child dietary questionnaire for use in early childhood among low-income, Latino populations.

BACKGROUND: Measuring diet quality in early childhood requires time-intensive and costly measurements (e.g., 24-hour diet recall) that are especially burdensome for low-income, minority populations. This study aimed to validate a new method for calculating overall diet quality among low-income, Latino preschoolers. METHODS: This study was an observational study using data from a randomized controlled trial. Participants included parents of Latino preschoolers who reported child diet quality at baseline, 4-month, 7-month, 12-month, and 13-month follow-up. At each timepoint parents responded to a 28-item child dietary questionnaire (CDQ), based on the National Health and Nutrition Examination Survey (NHANES) dietary module, which generated the number of times/day that a child ate each of 28 foods in the past month. These 28 items were then used to create a total standardized child diet quality index (possible range 0-100), using a percent of maximum method. Parents were asked to complete three 24-hour diet recalls at the 13-month follow-up, from which the 2015 Healthy Eating Index (HEI) was derived. Construct validity was evaluated by Spearman's rank correlations between the new child diet quality index and the 2015 HEI at the 13-month follow-up. Test-retest reliability was assessed by intraclass correlation coefficients (ICC) for sequential pairs of time points. RESULTS: Among 71 eligible parent-child pairs, mean child age was 4.2 (SD = 0.8) years, 50.7% of children were female, and mean child body mass index (BMI) was 17.8 (SD = 2.0) kg/m2. Mean Child Diet Quality Index was 45.2 (SD = 3.2) and mean HEI was 68.4 (SD = 10.5). Child Diet Quality Index and HEI total scores were significantly correlated (r = 0.37; p = 0.001). Test-retest ICCs were statistically significant between all sequential pairs of time points. CONCLUSION: The new approach for calculating a measure of overall diet quality from the previously-validated 28-item dietary questionnaire demonstrated modest construct validity. When time and resources are limited, this new measure of overall diet quality may be an appropriate choice among low-income, Latino preschoolers. TRIAL REGISTRATION: This reports presents observational data collected as a part of a clinical trial, which was registered on clinicaltrials.gov prior to participant enrollment (NCT03141151).

The Utility of the Brokamp Area Deprivation Index as a Prescreen for Social Risk in Primary Care.

OBJECTIVES: To assess the relationship between an Area Deprivation Index (ADI) and a Social Determinant of Health (SDoH) measure within a diverse sample. A prescreening tool based on routinely collected information could reduce clinical burden by identifying patients impacted by SDoH for comprehensive assessment. STUDY DESIGN: In total, 499 consented pediatric patient-families who spoke English, Spanish, or Arabic and had a child ≤12 years receiving primary care at a large academic institution were enrolled. Participants completed the Health Leads Social Needs (HLSN) survey. Residential address was extracted from the electronic health record to calculate Brokamp ADI at the census-tract level. The main outcome was the correlations between the total HLSN score and Brokamp ADI, overall and in each language subgroup. ADI distributions were also compared between participants with/without need for each of the 8 HLSN survey SDoH domains, using 2-sample t-tests and Pearson χ2 tests. RESULTS: In total, 54.9% of participants were English-speaking, 30.9% were Spanish-speaking, and 14.2% were Arabic-speaking. Spearman correlations between Brokamp ADI and total HLSN score were overall (rs = 0.15; P = .001), English (rs = 0.12; P = .04), Spanish (rs = 0.03; P = .7), and Arabic (rs = 0.24; P = .04). SDoH domain analyses found significant ADI differences between those with/without need in housing instability, childcare, transportation, and health literacy. CONCLUSIONS: There were small but statistically significant associations between the Brokamp ADI and total HLSN score and SDoH domains of housing instability, childcare, transportation, and health literacy. These findings support testing the Brokamp ADI as a prescreening tool to help identify patients with social needs in an outpatient clinical setting.

A 3-Item Measure of Digital Health Care Literacy: Development and Validation Study.

BACKGROUND: With increased reliance on digital health care, including telehealth, efficient and effective ways are needed to assess patients' comfort and confidence with using these services. OBJECTIVE: The goal of this study was to develop and validate a brief scale that assesses digital health care literacy. METHODS: We first developed an item pool using existing literature and expert review. We then administered the items to participants as part of a larger study. Participants were caregivers of children receiving care at a pediatric clinic who completed a survey either on the web or over the telephone. We randomized participants into development and confirmatory samples, stratifying by language so that exploratory factor analysis and confirmatory factor analysis could be performed with separate samples of participants. We assessed the scale's validity by examining its associations with participants' demographics, digital access, and prior digital health care use. RESULTS: Participants (N=508) were, on average, aged 34.7 (SD 7.7) years, and 89.4% (454/508) were women. Of the 508 participants, 280 (55.1%) preferred English as their primary language, 157 (30.9%) preferred Spanish, and 71 (14%) preferred Arabic; 228 (45%) had a high school degree or less; and 230 (45.3%) had an annual household income of

A longitudinal analysis of relationships between neighborhood context and underserved children's physical activity in a rapidly growing city.

Neighborhood context, which may be impacted by urban growth or residential mobility, is associated with childhood physical activity. This secondary analysis examined associations of objectively measured neighborhood characteristics with young children's moderate-to-vigorous physical activity (MVPA) and sedentary/rest time (SRT) over a period of rapid infrastructure change. Underserved preschoolers (n = 426) from a 36-month obesity prevention intervention were included in a secondary analysis (2019-2020). Based on household addresses, participants were coded as movers or non-movers and linked to four neighborhood variables: 1) distance to recreation sites, 2) annual crimes, 3) annual stray dogs, and 4) Gini index of income inequality. Accelerometry captured MVPA and SRT at baseline and 36 months. Baseline-to-follow-up neighborhood variables within moved and non-moved groups were compared. Multivariable regression assessed associations between follow-up MVPA/SRT and neighborhood variables. 45.3% of participants (n = 193) moved. Distance to the closest recreation site decreased significantly for non-movers (0.75 to 0.72 mi, p < 0.001). Nearby crimes significantly decreased for both groups (movers: 90 to 80, p < 0.001; non-movers: 77 to 74, p < 0.001) as did stray dogs (movers: 36 to 15, p < 0.001; non-movers: 36 to 18, p < 0.001). Neighborhood income inequality decreased significantly for movers (0.41 to 0.38, p = 0.03). Child MVPA minutes/day significantly decreased over time from median = 84.7 [Q1 = 64.1, Q3 = 103.9] to median = 73.6 [Q1 = 56.1, Q3 = 96.0], p < 0.001). No significant associations were detected between neighborhood variables and child physical activity. In a rapidly growing county, neighborhood context generally improved over time regardless of move status. Within this context, no associations between neighborhood characteristics and MVPA/SRT were detected in children.

Improving Vaccination for Young Children (IVY): A Stepped-Wedge Cluster Randomized Trial.

BACKGROUND: High childhood vaccination rates are critical for public health. We hypothesized that implementation of a vaccine education and quality improvement (QI) program, Improving Vaccinations for Young Children (IVY), would improve childhood vaccine rates. METHODS: Eight pediatric practices (3 academic-based, 5 community-based) were randomized to implement IVY within a stepped-wedge cluster randomized trial (SWCRT) in middle Tennessee. Two educational modules on vaccines were developed using best practices in instructional design. Modules were provided electronically and were tailored to providers or office staff. Practices completed in-person QI coaching sessions and selected at least 2 vaccination-related QI changes. Data were collected monthly. The primary analysis examined intervention effect on the primary outcome of Combination 10 vaccination status for children who turned 2 in the previous month. Combination 10 status without influenza vaccine was a secondary outcome, and exploratory analyses assessed intervention effects after adjusting for time and practice type. RESULTS: Data from 4041 patients (1788 control; 2253 intervention) were collected. The intervention effect was not significant on the primary outcome (OR = 1.01; 95% CI [0.76, 1.34]; P > .9), however there were positive intervention effects in secondary and exploratory models analyzing Combination10 rates without flu, including models adjusting for variation over time (0.20; 95% CI [0.04,0.35]; P = .01) and practice type (higher vaccination rate in academic practices, 0.23; 95% CI [0.03,0.42]; P = .03). CONCLUSIONS: Combination 10 rates were not significantly improved with IVY, yet evidence of beneficial effect on rates without flu vaccine was found. Future studies could evaluate effects over a longer time period and within a larger practice sample.

Identifying bedrest using waist-worn triaxial accelerometers in preschool children.

PURPOSE: To adapt and validate a previously developed decision tree for youth to identify bedrest for use in preschool children. METHODS: Parents of healthy preschool (3-6-year-old) children (n = 610; 294 males) were asked to help them to wear an accelerometer for 7 to 10 days and 24 hours/day on their waist. Children with ≥3 nights of valid recordings were randomly allocated to the development (n = 200) and validation (n = 200) groups. Wear periods from accelerometer recordings were identified minute-by-minute as bedrest or wake using visual identification by two independent raters. To automate visual identification, chosen decision tree (DT) parameters (block length, threshold, bedrest-start trigger, and bedrest-end trigger) were optimized in the development group using a Nelder-Mead simplex optimization method, which maximized the accuracy of DT-identified bedrest in 1-min epochs against synchronized visually identified bedrest (n = 4,730,734). DT's performance with optimized parameters was compared with the visual identification, commonly used Sadeh's sleep detection algorithm, DT for youth (10-18-years-old), and parental survey of sleep duration in the validation group. RESULTS: On average, children wore an accelerometer for 8.3 days and 20.8 hours/day. Comparing the DT-identified bedrest with visual identification in the validation group yielded sensitivity = 0.941, specificity = 0.974, and accuracy = 0.956. The optimal block length was 36 min, the threshold 230 counts/min, the bedrest-start trigger 305 counts/min, and the bedrest-end trigger 1,129 counts/min. In the validation group, DT identified bedrest with greater accuracy than Sadeh's algorithm (0.956 and 0.902) and DT for youth (0.956 and 0.861) (both P<0.001). Both DT (564±77 min/day) and Sadeh's algorithm (604±80 min/day) identified significantly less bedrest/sleep than parental survey (650±81 min/day) (both P<0.001). CONCLUSIONS: The DT-based algorithm initially developed for youth was adapted for preschool children to identify time spent in bedrest with high accuracy. The DT is available as a package for the R open-source software environment ("PhysActBedRest").

Identifying meaningful dietary intake and physical activity questions for individual and population health.

We aimed to identify valid screening questions for adults regarding physical activity and dietary behaviours that (a) were correlated with BMI, (b) were deemed by patients and providers to be relevant to clinical care, and (c) have utility for longitudinal understanding of health behaviours in populations. The goal was to identify screening questions that could be implemented at annual health care visits. First, we identified dietary behaviour questions and solicited patient input. Next, we tested both physical activity and dietary behaviour questions in a large sample to test their potential utility. Finally, we used cognitive interviews with patients and physicians to narrow our assessment for clinical settings. We present a parsimonious and reliable six-question scale of physical activity and dietary behaviours for research settings, as well as a three-question scale for clinical settings. We demonstrate a robust relationship between these measures and obesity. Additionally, we present evidence that these measures may serve as a useful red flag for patients before they develop obesity. We provide a concise and useful tool for assessing patients' physical activity and dietary behaviours in a variety of research settings. We also highlight the importance of incorporating this tool into the clinical intake flow for inclusion in patients' Electronic Health Record.

Leveraging Emergent Social Networks to Reduce Sedentary Behavior in Low-Income Parents With Preschool-Aged Children.

This study tested the hypothesis that parents participating in a pediatric obesity intervention who formed social network ties with a parent in the intervention arm would engage in more daily physical activity and less sedentary behavior (after controlling for participant covariates). Data were collected at baseline, 12 months, and 36 months from 610 low-income parent-child pairs participating in an obesity prevention intervention for 3- to 5-year-old children. A network survey was used to identify social network ties among parents and accelerometers were used to measure parental physical activity and sedentary time. Longitudinal regression analyses tested effects of social network ties on parents' physical activity and sedentary behavior. Compared with parents without a social network tie, having a tie with an intervention group participant was associated with a clinically meaningful 11.04 min/day decrease in parental sedentary behavior that approached statistical significance (95% confidence interval [Cl] = [-22.71, 0.63], p = .06). Social network ties among parents in a pediatric obesity prevention intervention were not clearly associated with reduced sedentary behavior among those parents at the traditional level of p = .05. The large effect size (over 77min per week improvement) suggests there might be potential importance of promoting new social networks in community-based health promotion interventions to elicit and support behavior change, but further examination is needed.

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.

Development of Brief Child Nutrition and Physical Activity Screening Questions for Electronic Health Record Use.

Background: To develop and test brief nutrition and physical activity screening questions for children ages 2-11 years that could be used as a pragmatic screening tool to tailor counseling, track behavior change, and improve population health. Methods: A literature review identified existing validated questions for nutrition and physical activity behaviors in children ages 2-11 years. Response variation and concurrent validity was then assessed using a mechanical Turk (MTurk) crowdsourcing survey employed in 2018. Additionally, cognitive interviews were conducted with both providers and parents of 2- to 11-year-old children to assess screening question priorities and perceived added value. Results: The literature review identified 260 questions, and 20 items were selected with expert guidance based on prespecified criteria (simplicity and potential utility for both clinical interactions during a well-child exam and population health). MTurk surveys yielded 1147 records that met eligibility criteria and revealed 6 items that had adequate response variation and were significantly correlated with parent-reported child BMI or BMI percentile, exhibiting concurrent validity. Cognitive interviews with 10 providers and 20 parents uncovered themes regarding suggestions and usability of the questions, eliminating 3 items due to parent and provider concerns. Combining quantitative and qualitative results, 3 nutrition and physical activity screening items remained for inclusion into the electronic health record (EHR). Conclusions: The three-pronged validation methodology produced a brief, 3-item child nutrition and physical activity screener to incorporate in the EHR, where it can inform tailored counseling for well-child care and be used to test associations with population health outcomes.

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.

Identifying Social Network Conditions that Facilitate Sedentary Behavior Change: The Benefit of Being a "Bridge" in a Group-based Intervention.

Using data from one of the first trials to try to leverage social networks as a mechanism for obesity intervention, we examined which social network conditions amplified behavior change. Data were collected as part of a community-based healthy lifestyle intervention in Nashville, USA, between June 2014 and July 2017. Adults randomized to the intervention arm were assigned to a small group of 10 participants that met in person for 12 weekly sessions. Intervention small group social networks were measured three times; sedentary behavior was measured by accelerometry at baseline and 12 months. Multivariate hidden Markov models classified people into distinct social network trajectories over time, based on the structure of the emergent network and where the individual was embedded. A multilevel regression analysis assessed the relationship between network trajectory and sedentary behavior (N = 261). Being a person that connected clusters of intervention participants at any point during the intervention predicted an average reduction of 31.3 min/day of sedentary behavior at 12 months, versus being isolated [95% CI: (-61.4, -1.07), p = 0.04]. Certain social network conditions may make it easier to reduce adult sedentary behavior in group-based interventions. While further research will be necessary to establish causality, the implications for intervention design are discussed.

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.

Competency-Based Approaches to Community Health: A Randomized Controlled Trial to Reduce Childhood Obesity among Latino Preschool-Aged Children.

Background: Health behavior change interventions that target childhood obesity in minority populations have led to inconsistent and short-lived results. The purpose of this study was to test a novel intervention that was personalized and family-based in a Latino population to reduce childhood obesity. Methods: Competency-Based Approaches to Community Health (COACH) was a randomized controlled trial. Latino parent-child pairs were recruited from community settings in Nashville, TN. Child eligibility criteria included age 3-5 years and a BMI ≥50th percentile. The intervention included 15 weekly, 90-minute sessions followed by 3 months of twice-monthly health coaching calls. The control group was a twice-monthly school readiness curriculum for 3 months. Sessions were conducted by a health coach in local community centers, with groups of 8-11 parent-child pairs. The primary outcome was child BMI trajectory across 12 months, measured at four times. The intervention's effect was assessed by using a longitudinal, linear mixed-effects growth model, adjusting for child gender, baseline child and parent age, and baseline parent BMI and education. Results: Of the 305 parent-child pairs assessed for eligibility, 117 were randomized (59 intervention, 58 control). Child BMI was available for 91.5% at 1-year follow-up. Mean baseline child age was 4.2 [standard deviation (SD) = 0.8] years, and 53.8% of children were female. Mean baseline child BMI was 18.1 (SD = 2.6) kg/m2. After adjusting for covariates, the intervention's effect on linear child BMI growth was -0.41 kg/m2 per year (95% confidence interval -0.82 to 0.01; p = 0.05). Conclusions: Over 1-year follow-up, the intervention resulted in slower linear BMI growth for Latino preschool-aged children from poverty.