Harmonizing the Tripartite Mission in Academic Family Medicine: A Longitudinal Case Example.

Academic practices and departments are defined by a tripartite mission of care, education, and research, conceived as being mutually reinforcing. But in practice, academic faculty have often experienced these 3 missions as competing rather than complementary priorities. This siloed approach has interfered with innovation as a learning health system in which the tripartite missions reinforce each other in practical ways. This paper presents a longitudinal case example of harmonizing academic missions in a large family medicine department so that missions and people interact in mutually beneficial ways to create value for patients, learners, and faculty. We describe specific experiences, implementation, and examples of harmonizing missions as a feasible strategy and culture. "Harmonized" means that no one mission subordinates or drives out the others; each mission informs and strengthens the others (quickly in practice) while faculty experience the triparate mission as a coherent whole faculty job. Because an academic department is a complex system of work and relationships, concepts for leading a complex adaptive system were employed: (1) a "good enough" vision, (2) frequent and productive interactions, and (3) a few simple rules. These helped people harmonize their work without telling them exactly what to do, when, and how. Our goal here is to highlight concrete examples of harmonizing missions as a feasible operating method, suggesting ways it builds a foundation for a learning health system and potentially improving faculty well-being.

Understanding the relationships between acculturation, food insecurity, and food parenting practices among socioeconomically/racially diverse parents.

Research suggests that acculturation and food insecurity are factors that are separately associated with the use of specific food parenting practices among United States (US) families. Certain food parenting practices, such as coercive control and unstructured food parenting practices, are related to negative health consequences in children, such as disordered eating behaviors. The current study aimed to explore associations between acculturation strategies and food parenting practices in a sample of 577 Latinx, Hmong, Somali/Ethiopian, and Multiracial families. A secondary objective was to understand whether food security status significantly modified the relationships between acculturation strategies and food parenting practices. Results showed that acculturation strategies were significantly related to food parenting practices, and patterns in these relationships differed across race and ethnicity. Further, food security status significantly modified the relationship between acculturation strategies and food parenting practices for Latinx, Hmong, and Somali/Ethiopian families, but not for Multiracial families. These results point to the complex relationships among acculturation strategies, food security status, and food parenting practices in immigrant populations in the US. Longitudinal studies exploring the temporal relationships between acculturation strategies, food security status, and food parenting practices would help tease apart how food parenting practices may evolve upon migrating to the US.

A three-arm randomized controlled trial using ecological momentary intervention, community health workers, and video feedback at family meals to improve child cardiovascular health: the Family Matters study design.

BACKGROUND: Numerous observational studies show associations between family meal frequency and markers of child cardiovascular health including healthful diet quality and lower weight status. Some studies also show the "quality" of family meals, including dietary quality of the food served and the interpersonal atmosphere during meals, is associated with markers of child cardiovascular health. Additionally, prior intervention research indicates that immediate feedback on health behaviors (e.g., ecological momentary intervention (EMI), video feedback) increases the likelihood of behavior change. However, limited studies have tested the combination of these components in a rigorous clinical trial. The main aim of this paper is to describe the Family Matters study design, data collection protocols, measures, intervention components, process evaluation, and analysis plan. METHODS/DESIGN: The Family Matters intervention utilizes state-of-the-art intervention methods including EMI, video feedback, and home visiting by Community Health Workers (CHWs) to examine whether increasing the quantity (i.e., frequency) and quality of family meals (i.e., diet quality, interpersonal atmosphere) improves child cardiovascular health. Family Matters is an individual randomized controlled trial that tests combinations of the above factors across three study Arms: (1) EMI; (2) EMI + Virtual Home Visiting with CHW + Video Feedback; and (3) EMI + Hybrid Home Visiting with CHW + Video Feedback. The intervention will be carried out across 6 months with children ages 5-10 (n = 525) with increased risk for cardiovascular disease (i.e., BMI ≥ 75%ile) from low income and racially/ethnically diverse households and their families. Data collection will occur at baseline, post-intervention, and 6 months post-intervention. Primary outcomes include child weight, diet quality, and neck circumference. DISCUSSION: This study will be the first to our knowledge to use multiple innovative methods simultaneously including ecological momentary intervention, video feedback, and home visiting with CHWs within the novel intervention context of family meals to evaluate which combination of intervention components are most effective in improving child cardiovascular health. The Family Matters intervention has high potential public health impact as it aims to change clinical practice by creating a new model of care for child cardiovascular health in primary care. TRIAL REGISTRATION: This trial is registered in clinicaltrials.gov (Trial ID: NCT02669797). Date recorded 5/02/22.

Impacts of COVID-19 on the home food environment and eating related behaviors of families with young children based on food security status.

This mixed-methods study endeavored to expand the current understanding of how early pandemic related disruptions impacted the home food environment and parent feeding practices of families with young children. Data for this study are taken from the Kids EAT! Study, a racially/ethnically diverse cohort of families with 2-5 year old children. Individual interviews were conducted by phone and video conference with mothers (n = 25) during August/September of 2020 and were coded using a hybrid deductive/inductive analysis approach. Parents also reported on their family's food insecurity status enabling qualitative findings to be stratified by family-level food security status. Two overarching themes were identified related to how families in this sample describe the COVID-19 pandemic's impact on their home food environment. Themes included 1) Impacts on obtaining food for one's family, and 2) Specific changes in parent feeding practices. Findings indicated variation within each theme by family food security status. Overall, families experiencing food insecurity more frequently discussed using various coping strategies, including stocking up, rationing food, and use of supplemental food resources, to overcome challenges associated with obtaining food brought on by COVID-19. Families with food insecurity also reported having more time for home cooked meals and more frequently discussed enforcing less structure (timing of meal, place) related to meals/snacks consumed at home during the pandemic. The impacts of the COVID-19 persist, ranging from ongoing economic challenges, inconsistent access to childcare for families, and the emergence of new, more contagious, variants. With this, interventions to address food insecurity amongst families with young children should consider how to optimize the home food environment and promote healthful parent feeding practices within the families they serve in the face of an evolving public health crisis.

The interplay between food insecurity and family factors in relation to disordered eating in adolescence.

This study examined the association between food insecurity and both binge eating and unhealthy weight-control behaviors (UWCBs) and assessed whether such associations differ by factors within the family environment. Data were collected from a diverse sample of adolescents (Mage = 14.5 years; 54.1% female) and their parents/guardians (N = 2137 dyads) participating in EAT 2010 (Eating and Activity over Time). Food-insecure adolescents were more likely to report binge eating (prevalence ratio [PR] = 1.94; 95% confidence interval [CI]: 1.41-2.69) and UWCBs (PR = 1.34; 95% CI: 1.21-1.49) than food-secure adolescents. Family meal importance (p = .03) and family communication (p < .001) significantly moderated the association between food insecurity and UWCBs, such that the association was weaker at lower levels of these factors. Significant interactions with parental weight talk/concern (p < .001) and weight teasing (p = .04) indicated a weaker association between food insecurity and UWCBs in the presence of these factors. Findings indicate that the association between food insecurity and UWCBs among youth is less salient in the absence of family protective factors and in the presence of family risk factors for UWCBs, indicating the importance of targeting food insecurity itself, regardless of the presence of family risk or protective factors for UWCBs.

Relative food abundance predicts greater binge-eating symptoms in subsequent hours among young adults experiencing food insecurity: Support for the "feast-or-famine" cycle hypothesis from an ecological momentary assessment study.

Food insecurity (FI) may increase risk for binge eating through a "feast-or-famine" cycle, where fluctuations in food availability correspond to alternating periods of food restriction and opportunities for binge eating, but research on this topic is limited. To clarify the relationship between food availability and binge eating in the context of FI, this study examined the association between momentary food security level and subsequent binge-eating symptoms among individuals in food-insecure households and investigated how this association differs by factors that may modify the extent to which food availability fluctuates. Ecological momentary assessment data were collected in 2020-2021 from 75 young adults (Mage = 25.3 ± 1.8 years; 72% female; 72% Black, Indigenous, or a Person of Color) in the United States who had experienced past-month household FI. For 14 days, participants reported four times per day on food security and eating episodes, and binge-eating symptoms were assessed for each reported eating episode. About 35% of the variance in momentary food security ratings was accounted for by within-person variability over time. A significant within-person association was observed in multilevel analyses, indicating that instances of greater food security relative to one's average level predicted greater subsequent binge-eating symptoms. Moderation analyses revealed that this association was significant only among individuals reporting use of food assistance programs, high engagement in resource trade-off coping strategies (e.g., skipping bill payments to buy food), or low food security-related self-efficacy. Overall, findings offer support for the "feast-or-famine" cycle hypothesis as an explanation for the link between FI and binge eating, emphasize the importance of identifying approaches to promote more stable access to adequate food, and suggest potential intervention targets to reduce risk for binge eating in populations experiencing FI.

Adverse childhood experiences and disordered eating among middle-aged adults: Findings from the coronary artery risk development in young adults study.

Adverse childhood experiences (ACEs) include childhood abuse, neglect, and household substance abuse. Childhood abuse is a risk factor for disordered eating (DEB). Less well established are associations of childhood neglect and household substance abuse with DEB, and little research has examined ACE associations with DEB in middle adulthood. The objective of this study was to examine associations between ACEs and DEBs among middle-aged adults and examine sex differences. ACEs prior to age 18 were retrospectively assessed in the Coronary Artery Risk Development in Young Adults study in 2000-2001 (N = 3340, ages 32 to 46). DEB outcomes (i.e., concerns about weight and shape, anxiety about eating or food, unhealthy weight control behaviors, chronic dieting, overeating, and binge eating) were assessed in 1995-1996 (ages 27 to 41). Modified Poisson regressions estimated risk ratios (RRs) for associations of a history of any ACE, each ACE, and cumulative ACEs with DEB outcomes. Among women, emotional abuse, physical neglect, and emotional neglect were each modestly associated with most DEBs (RRs = 1.21-1.35, 1.21-1.45, and 1.23-1.41 across DEBs, respectively) after adjustment for sociodemographic variables, BMI, and depressive symptoms. A cumulative ACE score was associated with all DEBs in a stepwise manner (p for trend ≤0.05) except concerns about weight and shape and overeating. Among men, emotional abuse was most consistently related to the majority of DEBs (RRs = 1.23-1.92); household substance abuse was modestly associated with overeating (RR = 1.26, 95% CI = 1.04-1.53). ACEs were cumulatively associated with unhealthy weight control behaviors, overeating, and binge eating (p for trend <0.01).

Using apps to self-monitor diet and physical activity is linked to greater use of disordered eating behaviors among emerging adults.

Use of weight-related self-monitoring (WRSM) apps is common among emerging adults, as are weight and shape concerns. The present study aimed to examine (1) whether emerging adult use of dietary-focused (e.g., MyFitnessPal) and physical activity-focused (e.g., Fitbit) WRSM apps was associated with weight-control and muscle-building behaviors, including commonly recommended/conventional behaviors and disordered behaviors and (2) whether prior use of weight-control and muscle-building behaviors in adolescence might explain such relationships. Data were collected as part of the EAT (Eating and Activity over Time) 2010-2018 study (n = 1446) and analyzed using gender-stratified logistic regression models adjusted for demographic characteristics and body mass index. Among women and men, physical activity- and dietary-focused app use were associated with greater adjusted prevalence of disordered weight-control behaviors (e.g., fasting, purging), and disordered muscle-building behaviors (e.g., using steroids). Physical activity- and dietary-focused app use were also associated with a higher adjusted prevalence of commonly recommended weight-control and conventional muscle-building behaviors (e.g., exercising, changing eating habits), but only among those who were also engaging in disordered behaviors. The observed associations remained statistically significant in models that further adjusted for adolescent use of the respective behaviors. Findings suggest that emerging adults who use physical activity- and dietary-focused WRSM apps are more likely to engage in disordered weight-control and muscle-building behaviors and that associations are not explained by engagement in these behaviors during adolescence. Future research is needed to examine if there are aspects of WRSM apps that could be modified to reduce potential harm.

Associations between severe food insecurity and disordered eating behaviors from adolescence to young adulthood: Findings from a 10-year longitudinal study.

Emerging evidence suggests a cross-sectional association between food insecurity (FI) and disordered eating among adults, while evidence among adolescents is limited. Longitudinal research is needed to elucidate the temporality of this relationship and clarify whether the association differs by age. Three waves of prospective data came from 1813 participants in the Project EAT (Eating and Activity in Teens and Young Adults) cohort study. Data were collected at five-year intervals, with the baseline survey in 1998-1999 (EAT-I; Mage = 14.9 years) and follow-up surveys in 2003-2004 (EAT-II; Mage = 19.5 years) and 2008-2009 (EAT-III; Mage = 24.9 years). Severe FI was assessed as any past-year hunger with one item from the U.S. Household Food Security Survey Module, and a range of disordered eating behaviors were self-reported. Associations adjusted for sociodemographic characteristics were examined with generalized estimating equations. Effect modification by age was also tested. Cross-sectionally, severe FI was significantly associated with greater prevalence of all disordered eating behaviors examined, with the strongest associations observed for extreme weight-control behaviors (prevalence ratio [PR] = 1.49, 95% confidence interval [CI]: 1.13-1.95) and binge eating (PR = 1.49, 95% CI: 1.04-2.12). Longitudinally, severe FI significantly predicted 1.41 (95% CI: 1.05-1.90) times greater prevalence of binge eating five years later after accounting for prior binge eating. Effect modification by age indicated a stronger cross-sectional association between severe FI and unhealthy weight-control behaviors among younger participants. Results support a cross-sectional link between severe FI and disordered eating and provide longitudinal evidence suggesting severe FI is a risk factor for binge eating.

Changes to the home food environment and parent feeding practices during the COVID-19 pandemic: A qualitative exploration.

The COVID-19 pandemic brought about many changes that potentially altered the home food environment, which has been associated with child eating patterns and dietary intake. There is also some evidence that changes due to the COVID-19 pandemic are associated with health behaviors in children, such as an increased intake of high-calorie snack food. The current study aimed to more deeply understand how the COVID-19 pandemic affected the home food environment of meal and snack time routines and parent feeding practices within families of young children. Data for this study are taken from the Kids EAT! Study, a racially/ethnically diverse cohort of families with 2-5 year old children. Qualitative interviews were conducted by phone and video conference with mothers (n = 25) during August/September 2020 and were coded using a hybrid deductive/inductive analysis approach. This allowed coders to identify themes using the interview questions as an organizational template (deductive) while also allowing unique themes to emerge from the qualitative data (inductive). Three overarching themes emerged with multiple sub-themes: 1) Mothers were more directive in the types of food and amounts of food eaten by children; 2) Mothers had less rules around mealtimes; 3) Mothers had increased meal responsibilities. When faced with a change in a structured schedule and increased stress-such as occurred with the COVID-19 pandemic, parents may benefit from advice on how to manage parent feeding practices, including tips on appropriate limit setting, establishing a schedule and routines, and improving accessibility of healthful snacks. Lessons learned during the COVID-19 pandemic may have relevance to other time periods when families face disruptions to routine and during other times of transition.

Participant characteristics and dietary correlates of SNAP and other assistance programs among families with children from racially and ethnically diverse households.

The objective of this study was to describe food purchasing behaviors and the home food environment across families simultaneously receiving SNAP (Supplemental Nutrition Assistance Program) and other cash and food assistance benefits, and assess how child dietary intake varied across three distinct categories of assistance (i.e., SNAP and other assistance programs, assistance programs other than SNAP, and not enrolled in any assistance program). This cross-sectional study was conducted with parents of children aged 5-9 years (N = 1033) from low-income and racially and ethnically diverse households, living in Minneapolis and Saint Paul, Minnesota, metropolitan areas. In an online survey, parents reported enrollment in seven assistance programs (SNAP, WIC [Special Supplemental Nutrition Program for Women, Infants and Children Program], free or reduced-cost school breakfast, free or reduced-cost school lunch, SSI [Supplemental Security Income Program], MFIP [Minnesota Family Investment Program], daycare assistance), food purchasing behaviors, the home food environment, and child dietary and fast-food intake. Descriptive statistics were computed to describe food purchasing behaviors and the home food environment. Multivariable linear regressions were used to evaluate the association between assistance categories and child dietary intake factors. Models were adjusted for child age, parent and child sex, race and ethnicity, household income, primary caregiver's educational attainment, employment status, and place of birth. Relative to families participating in assistance programs other than SNAP and not enrolled in any assistance program, families participating in SNAP and other assistance programs had less reliable modes of transportation to go food shopping (use 'my own car or vehicle' 57% vs. 90% and 83%, respectively), shopped less frequently during the month ('1 big trip a month and small trips in between' 35% vs. 19% and 24%, respectively], had a somewhat higher presence of energy-dense (e.g., 'French fries' 60% vs. 35% and 25%, respectively) and high-sodium food items in the home (e.g., 'canned pasta' meals 48% vs. 35% and 20%, respectively), and some aspects of children's dietary intake that were not congruent with current dietary recommendations (e.g., consumption of 'fried vegetables' 3.9 times/week [95% CI 3.4, 4.4] vs. 2.9 [2.3, 3.5] and 2.8 [2.1, 3.6], respectively). Findings could inform targeted strategies to maximize the impact of simultaneous programs' benefits on improving child dietary intake and reaching eligible households not enrolled in assistance programs.

Identification of positive parenting practices among parents of young children living in low-income and racially, ethnically, and culturally diverse households.

Using the positive deviance approach, the purpose of this study was to identify parent feeding practices that might be protective against early childhood obesity among children with lower weight status (BMI percentile ≥5th-<85th) relative to higher weight status (BMI percentile ≥85th). Qualitative interviews were conducted with 71 parents of children aged 2-5 years old (48% girls) enrolled in the Minnesota Special Supplemental Nutrition Program for Women Infants and Children (WIC). Children were identified as having lower weight status (defined as 'positive deviants') (n = 36) or 'higher weight status' (n = 35), and were African American [n = 22], Hispanic [n = 23], or Hmong [n = 26]). Parents were asked about approaches to child feeding and health- and weight-related practices. Findings indicated that relative to caregivers of children with higher weight status, parents of children identified as positive deviant were more likely to report having a consistent routine for providing meals, using a guided choices approach, serving small portions of food during mealtimes, and trusting their child hunger and satiety cues. Moreover, parents of children identified as positive deviant were more likely to promote healthful eating and physical activity engagement and implement clear rules and limits for screen time than parents of children with higher weight status. Results suggest specific parent feeding behaviors and health-related practices that may influence child weight status among children living in low-income and racialized households. The findings of this study also provide research evidence and support the tenets of the Satter Division of Responsibility in Feeding framework. Parenting practices and strategies among parents of children identified as positive deviant are expected to be feasible and should be explored and communicated in future interventions to support age- and sex-recommended weight and health-related outcomes among young children to promote health equity.

Change that Matters: A Health Behavior Change and Behavioral Health Curriculum for Primary Care.

Although primary care is an ideal setting in which to address behavioral influences on health, clinicians spend little time discussing preventive care, including lifestyle counseling. There is a dearth of comprehensive training and evidence-based resources to educate clinicians in how to effectively engage with patients about these topics. This study describes and evaluates the acceptability of Change that Matters: Promoting Healthy Behaviors, a ten-module curriculum to train clinicians in brief, evidence-based interventions. Each module includes three parts: interactive patient handouts, didactic training, and electronic health record templates to guide the discussion and after visit summary. A two-part, mixed-methods pilot study was used to evaluate the acceptability of the curriculum in a family medicine residency clinic. In Study 1, external family medicine faculty experts (N = 11) provided written feedback on the patient handouts. In Study 2, 20 residents and 20 patients completed qualitative interviews regarding their experience with curricular materials. Content analysis was used to extract qualitative themes. Experts rated the patient handouts as highly understandable and actionable. Resident themes indicated that the curriculum provided concrete tools to address health behavior change, helped structure patient discussions, and increased confidence. Patients felt empowered to make behavior changes. This new curriculum addresses a gap in existing resources, and is available for free download online which can facilitate dissemination ( https://changethatmatters.umn.edu/ ). Research has found the curriculum to be acceptable to experts, residents, and patients. Future studies need to explore its impact on the behavior of both clinicians and patients.

Correlates of weight-related self-monitoring application use during emerging adulthood in a population-based sample.

PURPOSE: This study was designed to examine (1) the types of technologies or other applications (apps) emerging adults use to track their eating, physical activity, or weight; (2) who uses these apps and (3) whether eating and weight-related concerns during adolescence predict app use in emerging adulthood. METHODS: Longitudinal survey data were obtained from EAT 2010-2018 (Eating and Activity over Time study, N = 1428), a population-based sample of ethnically/racially and socioeconomically diverse adolescents (mean age: 14.5 ± 2.0 years), who were followed into emerging adulthood (mean age: 22.0 ± 2.0 years). Data were used to examine sociodemographic correlates of physical activity- and dietary-focused app use. Adjusted, gender-stratified logistic regressions were used to investigate longitudinal relationships between eating and weight-related concerns in adolescence and app use in emerging adulthood. RESULTS: Compared to men, women were more likely to use physical activity- (23.2 versus 12.5%, p < 0.001) and dietary-focused apps (16.1 versus 5.5%, p < 0.001). Among women, eating and weight-related concerns in adolescence, particularly unhealthy muscle-building behaviors (OR = 1.73, 95% CI 1.03-2.92), were associated with later dietary-focused app use. Among men, use of other muscle-building behaviors and body dissatisfaction in adolescence predicted use of physical activity- (ORother muscle-building = 1.60, 95% CI 1.03-2.49 and ORbody dissatisfaction = 1.67, 95% CI 1.06-2.65) and dietary-focused (ORother muscle-building = 2.18, 95% CI 1.07-4.47 and ORbody dissatisfaction = 2.35, 95% CI 1.12-4.92) apps 8 years later. CONCLUSIONS: Eating and weight-related concerns may predict later use of physical activity- and dietary-focused apps; future research is needed to understand whether use of such apps further increases eating and weight-related concerns. LEVEL OF EVIDENCE: III, well-designed longitudinal cohort study.

Kitchen Adequacy and Child Diet Quality in a Racially/Ethnically Diverse Sample.

This study examined kitchen adequacy in a racially/ethnically diverse low-income sample and associations with child diet quality. Families with children age five to seven years old (n = 150) from non-Hispanic white, non-Hispanic Black, Hispanic, Native American, Hmong, and Somali families were recruited through primary care clinics. More than 85% of families had 15 of the 20 kitchen items queried, indicating that the sample had adequate kitchen facilities. Only one item (a kitchen table) was associated with higher overall diet quality of children. In contrast, children living in households with can openers and measuring spoons consumed more sodium and added sugars, respectively.

The longitudinal relationship between family and peer teasing in young adulthood and later unhealthy weight control behaviors: The mediating role of body image.

OBJECTIVE: Sociocultural theories hold that family and peer weight-related teasing increases the risk for unhealthy weight control behaviors (UWCBs) by negatively impacting body image. Although much cross-sectional support exists for these pathways, longitudinal data are lacking. This study tested the longitudinal relationships among peer and family teasing (occurrence and perceived impact) in early adolescence, body satisfaction in late adolescence, and UWCBs in young adulthood among a racially/ethnically and socioeconomically diverse population. METHOD: Data were drawn from three waves of Project EAT over a 15-year period (Eating and Activity in Teens and Young Adults), and included responses from 1,902 young adults (57% female). RESULTS: Among female participants, a mediated indirect pathway emerged with family weight-related teasing predicting increased engagement in UWCBs in early adulthood via poorer body image in late adolescence. In contrast, peer teasing did not predict body image or UWCBs. Among boys, the mediated indirect pathways were not significant. However, poor body image in late adolescent males predicted higher likelihood of engaging in UCWBs in early adulthood. DISCUSSION: These findings support the long-term impact of family weight-related teasing on greater risk for UWCBs among girls and young women, and poor body image as a mechanism accounting for this relationship. Moreover, the results highlight the poor body image among adolescent boys as a factor for increased risk of engaging in UWCBs in early adulthood. Pending replication in current cohorts, health promotion and prevention involving family members of early adolescents that address family weight teasing and body image are needed.

Primary care providers' perspectives on initiating childhood obesity conversations: a qualitative study.

BACKGROUND: Primary care physicians (PCPs) are in a critical position for identifying, preventing and treating childhood obesity. However, a one-size-fits-all approach does not exist for having conversations about weight with families. A better understanding of how PCPs can address paediatric patients' weight concerns is needed in order to develop effective guidelines and trainings. OBJECTIVE: To describe PCPs preferences and behaviours regarding weight-related conversations with paediatric patients' and their families. METHODS: Twenty PCPs affiliated with the University of Minnesota, USA, were recruited to participate in semi-structured interviews. Transcripts were analysed using inductive thematic analysis. RESULTS: PCP's identified well-child visits as the most appropriate time for weight-related discussions with families. Physicians described what approaches/elements they perceived to work best during conversations: collaboration, empathy, health-focused and objective measures. CONCLUSIONS: Overall, PCPs were more comfortable with weight-related discussions during annual well-child visits and rarely initiated them during an acute visit or the first encounter with a patient. Objective measures, such as growth charts, were often utilized to start discussions. Considering a large proportion of well-child visits are missed, alternative opportunities to have discussions about healthy lifestyle behaviours should be explored. The integral role PCPs play in paediatric obesity warrants further research.

Concordance of children's intake of selected food groups as reported by parents via 24-h dietary recall and ecological momentary assessment.

OBJECTIVE: To understand how dietary intake data collected via a brief ecological momentary assessment (EMA) measure compares to that of data collected via interviewer-administered 24-h dietary recalls, and explore differences in level of concordance between these two assessment types by individual- and meal-level characteristics. DESIGN: Parents completed three 24-h dietary recalls and 8 d of brief EMA surveys on behalf of their child; in total, there were 185 d where dietary intake data from both EMA and 24-h recall were available. The EMA measure asked parents to indicate whether (yes/no) their child had consumed any of the nine total food items (e.g. fruit, vegetable, etc.) at eating occasions where both the child and parent were present. SETTING: Twenty-four-hour dietary recalls were completed in person in the study participant's home; participants completed EMA surveys using a study provided in iPad or their personal cell phone. PARTICIPANTS: A diverse, population-based sample of parent-child dyads (n 150). RESULTS: Among meals reported in both the EMA and dietary recalls, concordance of reporting of specific types of food ranged from moderate agreement for meat (kappa = 0·55); fair agreement for sweets (kappa = 0·38), beans/nuts (kappa = 0·37), dairy (kappa = 0·31), fruit (kappa = 0·31) and vegetables (kappa = 0·27); and little to no agreement for refined grains, whole grains and sweetened beverages (73 % overall agreement; kappa = 0·14). Concordance of reporting was highest for breakfast and snacks, as compared with other eating occasions. Higher concordance was observed between the two measures if the meal occurred at home. CONCLUSIONS: Data suggest that among meals reported in both the EMA and dietary recalls, concordance in reporting was reasonably good for some types of food but only fair or poor for others.

Associations between parental perception of- and concern about-child weight and use of specific food-related parenting practices.

Little is known about the association between parental perception of their child's weight as well as parent's current and future concerns regarding their child's weight and a broad range of food-related parenting practices. This study used the first wave of cross-sectional data from the longitudinal Family Matters study to examine the relationships between parental perception of child weight status, parent concern for child's current and future weight and parent use of different types of food-related practices. Parent/child dyads (n = 150) were recruited from primary care clinics. Multiple regression models were fit to examine cross-sectional relationships between parental perception and concern for their child's weight and food-related parenting practices (food restriction, pressure-to-eat, food control, food monitoring, nutrition education, and parent modeling). Parents who perceived their child to be underweight had lower scores for food restriction than parents who perceived their child to be overweight. Parents who reported concern about their child's current weight reported higher scores for food restriction and monitoring than parents who were not currently concerned. Parents who reported concern about their child's future weight status reported higher scores for pressure-to-eat and monitoring than parents who were not at all concerned about their child's future weight status. The relationship between parental perception of child's current weight status and parent use of food restriction, pressure-to-eat, and overall food control was modified by child sex. Overall, results suggest that parent's perceptions of and concerns about their child's current and future weight status were correlated with their feeding approaches. Health care providers may want to consider providing anticipatory guidance for parents that have concerns about their child's weight by teaching them about positive, evidence-based ways they can engage in healthy food-related parenting practices.

Family meal characteristics in racially/ethnically diverse and immigrant/refugee households by household food security status: A mixed methods study.

While there is some research examining frequency of family meals by food insecurity (FI) status, there is little research examining other family meal characteristics (e.g., type of food served at meal, emotional atmosphere) or parent feeding practices by FI status. If food and money is scarce, it may be that the broader family meal environment looks different in families with continuous access to food (food secure, FS) compared to families with FI. Using ecological momentary assessment (EMA) and qualitative data, this study explores meal characteristics and parent feeding practices at nearly 4000 family meals in a low-income, racially/ethnically diverse and immigrant/refugee sample. For 8 days, participants (i.e., parents of 5-7-year-old children) completed a survey every time they shared a meal with their child. Additionally, parents completed a qualitative interview regarding family meals. There were many meal characteristics statistically correlated with a family being FI, including: who prepared the meal and how the meal was prepared, the makeup of people at the meal, the meal location and meal atmosphere, and the food served at the meal. Qualitative data illuminated many of these findings from EMA meal surveys. Quantitatively, families with FI and FS reported similar parent feeding practices during family meals. Qualitatively, families with FI and FS reported differences in (1) parent feeding practices; (2) food served at family meals; (3) challenges to having family meals; and 4) adults' role in the family meal. This study provides suggestions for interventionists working with families, including helping families identify time management strategies, including fruits and vegetables into family meals on a budget, reducing screen time at family meals while improving the meal's emotional atmosphere, and developing positive parent feeding practice strategies.