Associations between BMI and home, school and route environmental exposures estimated using GPS and GIS: do we see evidence of selective daily mobility bias in children?

BACKGROUND: This study examined whether objective measures of food, physical activity and built environment exposures, in home and non-home settings, contribute to children's body weight. Further, comparing GPS and GIS measures of environmental exposures along routes to and from school, we tested for evidence of selective daily mobility bias when using GPS data. METHODS: This study is a cross-sectional analysis, using objective assessments of body weight in relation to multiple environmental exposures. Data presented are from a sample of 94 school-aged children, aged 5-11 years. Children's heights and weights were measured by trained researchers, and used to calculate BMI z-scores. Participants wore a GPS device for one full week. Environmental exposures were estimated within home and school neighbourhoods, and along GIS (modelled) and GPS (actual) routes from home to school. We directly compared associations between BMI and GIS-modelled versus GPS-derived environmental exposures. The study was conducted in Mebane and Mount Airy, North Carolina, USA, in 2011. RESULTS: In adjusted regression models, greater school walkability was associated with significantly lower mean BMI. Greater home walkability was associated with increased BMI, as was greater school access to green space. Adjusted associations between BMI and route exposure characteristics were null. The use of GPS-actual route exposures did not appear to confound associations between environmental exposures and BMI in this sample. CONCLUSIONS: This study found few associations between environmental exposures in home, school and commuting domains and body weight in children. However, walkability of the school neighbourhood may be important. Of the other significant associations observed, some were in unexpected directions. Importantly, we found no evidence of selective daily mobility bias in this sample, although our study design is in need of replication in a free-living adult sample.

Application of the Intervention Mapping protocol to develop Keys, a family child care home intervention to prevent early childhood obesity.

BACKGROUND: Many families rely on child care outside the home, making these settings important influences on child development. Nearly 1.5 million children in the U.S. spend time in family child care homes (FCCHs), where providers care for children in their own residences. There is some evidence that children in FCCHs are heavier than those cared for in centers. However, few interventions have targeted FCCHs for obesity prevention. This paper will describe the application of the Intervention Mapping (IM) framework to the development of a childhood obesity prevention intervention for FCCHs METHODS: Following the IM protocol, six steps were completed in the planning and development of an intervention targeting FCCHs: needs assessment, formulation of change objectives matrices, selection of theory-based methods and strategies, creation of intervention components and materials, adoption and implementation planning, and evaluation planning RESULTS: Application of the IM process resulted in the creation of the Keys to Healthy Family Child Care Homes program (Keys), which includes three modules: Healthy You, Healthy Home, and Healthy Business. Delivery of each module includes a workshop, educational binder and tool-kit resources, and four coaching contacts. Social Cognitive Theory and Self-Determination Theory helped guide development of change objective matrices, selection of behavior change strategies, and identification of outcome measures. The Keys program is currently being evaluated through a cluster-randomized controlled trial CONCLUSIONS: The IM process, while time-consuming, enabled rigorous and systematic development of intervention components that are directly tied to behavior change theory and may increase the potential for behavior change within the FCCHs.

Watch me grow: a garden-based pilot intervention to increase vegetable and fruit intake in preschoolers.

BACKGROUND: Americans, including children, consume fewer fruit and vegetable servings than is recommended. Given that young children spend large amounts of time in child care centers, this may be an ideal venue for increasing consumption of and enthusiasm for fruits and vegetables. This pilot study aimed to assess the feasibility of a gardening intervention to promote vegetable and fruit intake among preschoolers. METHODS: We enrolled two intervention centers and two control centers. The intervention included a fruit and vegetable garden, monthly curriculum, gardening support, and technical assistance. We measured mean (SD) servings of fruits and vegetables served to and consumed by three children per center before and after the intervention. RESULTS: Post intervention, intervention and control centers served fewer vegetables (mean (standard deviation) difference of -0.18 (0.63) in intervention, -0.37 (0.36) in control), but intervention children consumed more than control children (+0.25 (1.11) vs. -0.18 (0.52). The number of fruits served decreased in all centers (intervention -0.62 (0.58) vs. control -0.10 (0.52)) but consumption was higher in controls (intervention -0.32 (0.58) vs. control 0.15 (0.26)). CONCLUSIONS: The garden-based feasibility study shows promise, but additional testing is needed to assess its ability to increase vegetable and fruit intake in children.

Changes in physical activity among postpartum overweight and obese women: results from the KAN-DO Study.

Few studies have assessed physical activity at multiple time points in the postpartum period or used both self-reported and objective measures of assessment. The purpose of this study was to describe physical activity and sedentary behavior at two time points in a cohort of overweight or obese postpartum women using both self-reported and objective measures. In total, 132 women completed physical activity assessments at a median of 24 weeks postpartum and again approximately 10 months later. At both time points, women wore an Actical accelerometer for one week and completed the Kaiser Physical Activity Survey. Adjusted Poisson regression models were used to determine whether physical activity changed over time for the cohort. Overall counts per minute and moderate to vigorous physical activity increased from baseline to 10 months later, although the absolute levels were modest (median 6.9 to 8.8 minutes/day). A median of 64%-71% at baseline and 63%-67% at follow-up of their monitored times were sedentary. More intensive interventions are needed to help postpartum women integrate physical activity and reduce sedentary behavior. [Supplementary material is available for this article. Go to the publisher's online edition of Women & Health for the following resource: three figures that show the distribution of physical activity and sedentary behavior by study periods among control participants].

Parent-focused change to prevent obesity in preschoolers: results from the KAN-DO study.

OBJECTIVE: The study presents the immediate post-intervention results of Kids and Adults Now - Defeat Obesity!, a randomized controlled trial to enhance healthy lifestyle behaviors in mother-preschooler (2-5 years old) dyads in North Carolina (2007-2011). The outcomes include change from baseline in the child's diet, physical activity and weight, and in the mother's parenting behaviors, diet, physical activity, and weight. METHOD: The intervention targeted parenting through maternal emotion regulation, home environment, feeding practices, and modeling of healthy behaviors. 400 mother-child dyads were randomized. RESULTS: Mothers in the intervention arm, compared to the control arm, reduced instrumental feeding (-0.24 vs. 0.01, p<0.001) and TV snacks (-.069 vs. -0.24, p=0.001). There were also improvements in emotional feeding (p=0.03), mother's sugary beverage (p=0.03) and fruit/vegetable (p=0.04) intake, and dinners eaten in front of TV (p=0.01); these differences were not significant after adjustment for multiple comparisons. CONCLUSION: KAN-DO, designed to maximize the capacity of mothers as agents of change, improved several channels of maternal influence. There were no group differences in the primary outcomes, but differences were observed in the parenting and maternal outcomes and there were trends toward improvement in the preschoolers' diets. Long-term follow-up will address whether these short-term trends ultimately improve weight status.

Can physicians accurately predict which patients will lose weight, improve nutrition and increase physical activity?

BACKGROUND: Physician counselling may help patients increase physical activity, improve nutrition and lose weight. However, physicians have low outcome expectations that patients will change. The aims are to describe the accuracy of physicians' outcome expectations about whether patients will follow weight loss, nutrition and physical activity recommendations. The relationships between physician outcome expectations and patient motivation and confidence also are assessed. METHODS: This was an observational study that audio recorded encounters between 40 primary care physicians and 461 of their overweight or obese patients. We surveyed physicians to assess outcome expectations that patients will lose weight, improve nutrition and increase physical activity after counselling. We assessed actual patient change in behaviours from baseline to 3 months after the encounter and changes in motivation and confidence from baseline to immediately post-encounter. RESULTS: Right after the visit, ~55% of the time physicians were optimistic that their individual patients would improve. Physicians were not very accurate about which patients actually would improve weight, nutrition and physical activity. More patients had higher confidence to lose weight when physicians thought that patients would be likely to follow their weight loss recommendations. CONCLUSIONS: Physicians are moderately optimistic that patients will follow their weight loss, nutrition and physical activity recommendations. Patients might perceive physicians' confidence in them and thus feel more confident themselves. Physicians, however, are not very accurate in predicting which patients will or will not change behaviours. Their optimism, although helpful for patient confidence, might make physicians less receptive to learning effective counselling techniques.

Correlates of sedentary time and physical activity among preschool-aged children.

INTRODUCTION: Few studies have examined the correlates of objectively measured amounts of sedentary time and physical activity in young children. We evaluated the demographic, biological, behavioral, social, and environmental correlates of the amount of sedentary time and moderate-to-vigorous physical activity (MVPA) as measured by accelerometry in preschool-aged children. METHODS: We obtained baseline measurements of physical activity by using an Actical accelerometer among 337 preschool-aged children (aged 2-5) of overweight or obese mothers. For children, we defined sedentary time as less than 12 counts per 15 seconds and MVPA as 715 or more counts per 15 seconds. Body mass index of the mother and child (calculated from measured height and weight) and maternal physical activity as measured by accelerometer were included as potential correlates. Mothers self-reported all other potential correlates. We used multivariable linear regression analyses to examine correlates of the amount of sedentary time and MVPA. RESULTS: Children had an average of 6.1 hours per day of sedentary time and 14.9 minutes per day of MVPA. In multivariable analysis, boys (P <.001) had fewer minutes per day of sedentary time, whereas older children (P <.001), boys (P <.001), children in high-income households (>$60,000/y [P = .005]), and children who spent more time outdoors (P = .001) had more MVPA. CONCLUSION: Both modifiable and nonmodifiable factors were correlated with preschool children's amount of MVPA, which can be helpful when designing interventions for this age group. The lack of correlates for sedentary time indicates the need for further investigation into this behavior.

Leveling the Joint Task Force Core Competencies for Clinical Research Professionals.

Competency standards for clinical research professionals are being developed across the enterprise, based largely on the Core Competency Framework put forth by the Joint Task Force for Clinical Trial Competency (JTF). In late 2016, representatives from organizations around the world convened at a workshop hosted by the Multi-Regional Clinical Trial Center of Brigham and Women's Hospital and Harvard (MRCT Center) to discuss their use of the standards. A number of modifications were suggested that resulted in the publication of JTF Framework 2.0. Another suggested evolution of the Framework was to consider "leveling" the competencies, to reflect the increase in competency that occurs as individuals progress in their careers. This paper describes the process utilized and final outcome of this work. The leveled competencies, defined as the Fundamental, Skilled, and Advanced levels, and the included examples are expected to provide better-defined tools and resources to organizations that are creating educational and training programs, standardized role descriptions, or professional progression planning for clinical research professionals.

Impact of implementing a competency-based job framework for clinical research professionals on employee turnover.

INTRODUCTION: A new competency-based job framework was implemented for clinical research professionals at a large, clinical research-intensive academic medical center. This study evaluates the rates of turnover before and after implementation of the new framework. Turnover in this workforce (as with most) is costly; it contributes to wasted dollars and lost productivity since these are highly specialized positions requiring extensive training, regardless of experience in the field. METHODS: Trends in employee turnover for 3 years prior to and after the implementation of competency-based job framework for clinical research positions were studied using human resources data. Employee demographics, turnover rates, and comparisons to national statistics are summarized. RESULTS: Employee turnover within the clinical research professional jobs has decreased from 23% to 16%, a 45% reduction, since the implementation of competency-based job framework. CONCLUSION: The new jobs and career ladders, both of which are centered on a competency-based framework, have decreased the overall turnover rate in this employee population. Since little is known about the rates of turnover in clinical research, especially in the academic medical setting, the results of this analysis can provide important insights to other academic medical centers on both employee turnover rate in general and the potential impact of implementing large-scale competency-based job changes.

Adherence to nicotine replacement therapy among pregnant smokers.

INTRODUCTION: This secondary analysis examined the association between adherence to nicotine replacement therapy (NRT) and smoking cessation among pregnant smokers enrolled in Baby Steps, an open-label randomized controlled trial testing cognitive-behavioral therapy (CBT) versus CBT plus NRT. METHOD: The analysis included only women who received NRT for whom we had complete data (N = 104). Data came from daily calendars created from recordings of counseling sessions and from telephone surveys at baseline and 38 weeks gestation. RESULTS: Overall, 29% of the 104 women used NRT for the recommended 6 weeks and 41% used NRT as directed in the first 48 hr after a quit attempt. Ordinal logistic regression modeling indicated that using NRT as directed in the first 48 hr and having made a previous quit attempt were the strongest predictors of longer NRT use. Univariate analyses suggested that primigravid women and women who used NRT longer were more likely to report quitting at 38 weeks gestation. DISCUSSION: Findings indicated that adherence to NRT is low among pregnant smokers, but adherence was a predictor of cessation. Future trials should emphasize adherence, particularly more days on NRT, to promote cessation during pregnancy.

Nicotine replacement and behavioral therapy for smoking cessation in pregnancy.

BACKGROUND: This study examines whether adding nicotine replacement therapy (NRT) to cognitive-behavioral therapy (CBT) for pregnant smokers increases rates of smoking cessation. METHODS: An open-label randomized trial (Baby Steps, n=181) of CBT-only versus CBT+NRT (choice of patch, gum, or lozenge; 1:2 randomization) was used. Data were collected from 2003 through 2005; analyses were conducted in 2006 and 2007. Outcomes were biochemically validated self-reported smoking status at 7 weeks post-randomization, 38 weeks gestation, and 3 months postpartum. RESULTS: Women in the CBT+NRT arm were almost three times more likely than women in the CBT-only arm to have biochemically validated cessation at both pregnancy time points (after 7 weeks: 24% vs 8%, p=0.02; at 38 weeks gestation: 18% vs 7%, p=0.04), but not at 3 months postpartum (20% vs 14%, p=0.55). Recruitment was suspended early by an Independent Data and Safety Monitoring Board when an interim analysis found a higher rate of negative birth outcomes in the CBT+NRT arm than in the CBT-only arm. In the final analysis, the difference between the arms in rate of negative birth outcomes was 0.09 (p=0.26), when adjusted for previous history of preterm birth. CONCLUSIONS: The addition of NRT to CBT promoted smoking cessation in pregnant women. This effect did not persist postpartum. More data are needed to determine safety parameters and to confirm the efficacy of NRT use during pregnancy.

Physicians' beliefs about discussing obesity: results from focus groups.

PURPOSE: Physicians are expected to discuss weight loss with overweight and obese patients. Physicians' beliefs, outcome expectancies, and strategies for addressing weight with patients have not been examined. DESIGN: Two focus groups of family physicians and internists included questions about obesity and how physicians discuss weight loss with patients. SETTING/SUBJECTS: Family physicians (n = 11) and internists (n = 6) from Duke University Medical Center's Department of Community and Family Medicine and Department of Medicine. ANALYSIS: Qualitative analysis approach using grounded theory methodology. RESULTS: Physicians' responses centered on five key themes: (1) responsibility, (2) barriers, (3) target populations, (4) introducing topic, and (5) ways to talk about obesity. CONCLUSION: Physicians have many barriers related to discussing weight loss with patients. Given the obesity epidemic, the need to understand how to have these discussions, when to have these discussions, and with whom to have these discussions becomes paramount to providing effective care for patients with obesity. Limited physician training in weight-loss counseling explains why physicians find it challenging to discuss obesity with patients.

Physical activity-related and weather-related practices of child care centers from 2 states.

BACKGROUND: Young children's physical activity (PA) is influenced by their child care environment. This study assessed PA practices in centers from Massachusetts (MA) and Rhode Island (RI), compared them to best practice recommendations, and assessed differences between states and center profit status. We also assessed weather-related practices. METHODS: Sixty percent of MA and 54% of RI directors returned a survey, for a total of 254. Recommendations were 1) daily outdoor play, 2) providing outdoor play area, 3) limiting fixed play structures, 4) variety of portable play equipment, and 5) providing indoor play area. We fit multivariable linear regression models to examine adjusted associations between state, profit status, PA, and weather-related practices. RESULTS: MA did not differ from RI in meeting PA recommendations (ß = 0.03; 0.15, 0.21; P = .72), but MA centers scored higher on weather-related practices (ß = 0.47; 0.16, 0.79; P = .004). For-profit centers had lower PA scores compared with nonprofits (ß = -0.20; 95% CI: -0.38, -0.02; P = .03), but they did not differ for weather (ß = 0.12; -0.19, 0.44; P = .44). CONCLUSIONS: More MA centers allowed children outside in light rain or snow. For-profit centers had more equipment­both fixed and portable. Results from this study may help inform interventions to increase PA in children.

The keys to healthy family child care homes intervention: study design and rationale.

BACKGROUND: Obesity is a major public health problem for which early preventive interventions are needed. Large numbers of young children are enrolled in some form of child care program, making these facilities influential environments in children's development. Family child care homes (FCCH) are a specific type of child care in which children are cared for within the provider's own residence. FCCHs serve approximately 1.5 million children in the U.S.; however, research to date has overlooked FCCH providers and their potential to positively influence children's health-related behaviors. METHODS: Keys to Healthy Family Child Care Homes (Keys) is a cluster-randomized controlled trial testing the efficacy of an intervention designed to help providers become healthy role models, provide quality food- and physical activity-supportive FCCH environments, and implement effective business practices. The intervention is delivered through workshops, home visits, tailored coaching calls, and educational toolkits. Primary outcomes are child physical activity measured via accelerometry data and dietary intake data collected using direct observation at the FCCH. Secondary outcomes include child body mass index, provider weight-related behaviors, and observed obesogenic environmental characteristics. CONCLUSION: Keys is an innovative approach to promoting healthy eating and physical activity in young children. The intervention operates in a novel setting, targets children during a key developmental period, and addresses both provider and child behaviors to synergistically promote health.

Steps to Health employee weight management randomized control trial: short-term follow-up results.

OBJECTIVE: To present the short-term follow-up findings of the Steps to Health study, a randomized trial to evaluate the effectiveness of two employee weight management programs offered within Duke University and the Health System. METHODS: A total of 550 obese (body mass index, ≥30 kg/m2) employees were randomized 1:1 between January 2011 and June 2012 to the education-based Weight Management (WM) or the WM+ arm, which focused on behavior modification. Employees were contacted to complete a follow-up visit approximately 14 months after baseline. RESULTS: There were no clinically, or statistically, meaningful differences between arms, but there were modest reductions in body mass index, and positive, meaningful changes in diet and physical activity for both arms. CONCLUSIONS: The modest positive effects observed in this study may suggest that to achieve weight loss through the workplace more intensive interventions may be required.

A community-based intervention increases physical activity and reduces obesity in school-age children in North Carolina.

BACKGROUND: Community-based interventions are promising approaches to obesity prevention, but few studies have prospectively evaluated them. The aim of this study was to evaluate a natural experiment­a community intervention designed to promote active living and decrease obesity within a small southern town. METHODS: In 2011, community leaders implemented the Mebane on the Move intervention­a community-wide effort to promote physical activity (PA) and decrease obesity among residents of Mebane, North Carolina. We measured child PA and BMI before and after the intervention, using a nearby town not implementing an intervention as the comparison. In total, we assessed 64 children from Mebane and 40 from the comparison community 6 months before, as well as 34 and 18 children 6 months after the intervention. We assessed PA with accelerometers worn for 7 days and calculated BMI z-scores using children's height and weight. We conducted multivariable linear regressions examining pre- to postintervention change in minutes of PA and BMI z-score, adjusting for confounders. RESULTS: At follow-up, children in Mebane modestly increased their moderate-to-vigorous PA (1.3 minutes per hour; 95% confidence interval (CI): 0.2, 2.3; p=0.03) and vigorous activity (0.8 minutes per hour; 95% CI: 0.1, 1.5; p=0.04) more than comparison children. In intervention children, BMI z-scores decreased 0.5 units (kg/m(2); 95% CI: -0.9, -0.02; p=0.045), compared to children in the comparison community. CONCLUSIONS: We observed positive effects on PA level and weight status of children in Mebane, despite high rates of attrition, suggesting that the community-based intervention may have been successful.

Weight and smoking cessation among low-income African Americans.

BACKGROUND: Concerns about weight gain have been a commonly cited barrier to cessation among white, affluent, female populations, but less is known about this relationship among minority smokers and those with low incomes. Although smoking cessation is strongly encouraged for this population, it often leads to weight gain. Cultural differences in weight standards and the high prevalence of weight-related health conditions (e.g., hypertension and diabetes) may influence concerns about smoking cessation-related weight gain. METHODS: A secondary analysis of low-income African-American smokers (n=367) from a randomized intervention trial was conducted to explore the association of weight concerns with comorbidities and smoking cessation. RESULTS: Less than one quarter of participants were considered concerned about weight, defined as having high general concern about weight and high expectation of post-cessation weight gain. Those for whom weight gain could be riskiest--obese participants--were least concerned about gaining weight. Further, weight concerns were not associated with successful smoking cessation, quit attempts, confidence in quitting, or desire or readiness to quit. CONCLUSIONS: Because post-cessation weight gain may be a serious health threat for this population, but weight gain was not a concern for these smokers, smoking-cessation interventions for low-income African-American smokers may need to incorporate weight-gain education and prevention.

Prolonged nicotine patch use in quitters with past abstinence-induced depressed mood.

To test the efficacy of sustained nicotine patch use among at-risk smokers, 55 smokers with a history of abstinence-induced depressed mood were randomly assigned to either Nicotine Maintenance or Standard Treatment following preliminary high-dose patch treatment. The Nicotine Maintenance group received 21 mg transdermal nicotine for 8 additional weeks; the Standard Treatment group followed a tapered dosing regimen. Significant differences favoring the Nicotine Maintenance group were found in self-reported craving but not withdrawal. No difference was observed in continuous abstinence or in relapse rates. When dropouts who did not relapse during patch use were classified as successful, however, the Nicotine Maintenance group had significantly lower relapse rates. Rate of lapse in the Nicotine Maintenance group during post-trial tapering did not differ significantly from that in the Standard Treatment group during tapering in the trial, suggesting that the benefits of sustained dosing may persist only as long as dosing continues.