Changes in leukocyte telomere length among children with obesity participating in a behavioural weight control program.

OBJECTIVE: To examine changes in leukocyte telomere length (LTL) during and after a behavioural weight control program for children with obesity. METHODS: We measured LTL among a cohort of 158 children 8-12 years of age with a body mass index greater than or equal to the 95th percentile for age and sex. Children were 55% female, 29% white, 52% Latinx, 8% Asian and 11% Pacific Islander, other or multiethnic. All children participated in a 6-month, family-based, group behavioural weight control program and were assessed before treatment, after treatment and 1 year after the end of treatment. To test the sample population slope of LTL over the intervention and maintenance time periods, we fit spline mixed-effect regression models. RESULTS: LTL increased an average of 0.09 T/S units per year (95% confidence interval [CI] 0.04 to 0.13; p = 0.0001) during the weight control program intervention period, followed by an average decline of -0.05 T/S units per year (95% CI -0.08 to -0.03; p < 0.0001) during the 1 year of follow-up after the completion of the intervention. Among 26 social, psychological, behavioural and physiological factors we examined, we did not find any predictors of these changes. CONCLUSIONS: LTL increased in response to a behavioural weight control program among children with obesity, suggesting an impact on biological health and cellular aging from participation in a behavioural weight control intervention. LTL may be a useful biomarker for assessing changes in response to behavioural interventions.

Are mobile phone ownership and age of acquisition associated with child adjustment? A 5-year prospective study among low-income Latinx children.

This prospective, longitudinal study examined associations between whether and when children first acquire a mobile phone and their adjustment measures, among low-income Latinx children. Children (N = 263; 55% female; baseline Mage  = 9.5) and their parents were assessed annually for 5 years from 2012. Children first acquired a mobile phone at a mean (SD) age of 11.62 (1.41) years. Pre-registered multilevel models tested associations linking phone ownership, phone acquisition age, and the interaction between ownership and acquisition age to levels and changing trends of depressive symptoms, school grades, and reported and objectively assessed sleep. Results showed no statistically significant associations, controlling the False Discovery Rate. Findings suggest an absence of meaningful links from mobile phone ownership and acquisition age to child adjustment.

Packaging and Scaling the Stanford Pediatric Weight Control Program: A Family-Based, Group, Behavioral Weight Management Program for Children with Obesity and Their Families: Background, Rationale, and Design of the Stanford CORD 3.0 Project.

Efficacious treatments for children with obesity have not been broadly disseminated. The Stanford Pediatric Weight Control Program (SPWCP) is grounded in behavioral theory and prior observations, follows a proven treatment model, and is consistent with the US Preventive Services Task Force (USPSTF) recommendations. It has shown high levels of participation and retention and reductions in BMI and percent of median BMI for age and sex comparable to many studied programs, as well as improvements in physiological risk factors, psychological measures, and diet, activity, and screen time behaviors in children with obesity when delivered as a real-world clinical program with sociodemographically diverse families in multiple clinic and community settings. The Stanford CORD 3.0 Project proposes to use technology, design, behavioral theory, and biomedical business innovation strategies to package and scale the SPWCP to reach low-income children throughout the United States. Efficacy and success of implementation of the new packaged program will be tested in a one-arm pilot implementation study when delivered by community partners.

A community-based, multi-level, multi-setting, multi-component intervention to reduce weight gain among low socioeconomic status Latinx children with overweight or obesity: The Stanford GOALS randomised controlled trial.

BACKGROUND: There are few long-term studies of interventions to reduce in low socioeconomic status children with overweight or obesity. The Stanford GOALS trial evaluated a 3-year, community-based, multi-level, multi-setting, multi-component (MMM) systems intervention, to reduce weight gain among low socioeconomic status, Latinx children with overweight or obesity. METHODS: We did a two-arm, parallel group, randomised, open-label, active placebo-controlled trial with masked assessment over 3 years. Families from low-income, primarily Latinx communities in Northern California, CA, USA, with 7-11-year-old children with overweight or obesity were randomly assigned to a MMM intervention or a Health Education (HE) comparison intervention. The MMM intervention included home environment changes and behavioural counselling, community after school team sports, and reports to primary health-care providers. The primary outcome was child BMI trajectory over three years. Secondary outcomes included one- and two-year changes in BMI. This trial is registered with ClinicalTrials.govNCT01642836. FINDINGS: Between July 13, 2012, and Oct 3, 2013, 241 families were recruited and randomly assigned to MMM (n=120) or HE (n=121). Children's mean age was 9·5 (SD 1·4) years, 134 (56%) were female and 107 (44%) were male, and 236 (98%) were Latinx. 238 (99%) children participated in year 1, 233 (97%) in year 2, and 227 (94%) in year 3 of follow-up assessments. In intention-to-treat analysis, over 3 years, the difference between intervention groups in BMI trajectory was not significant (mean adjusted difference -0·25 [95% CI -0·90 to 0·40] kg/m2; Cohen's d=0.10; p=0·45). Children in the MMM intervention group gained less BMI over 1 year than did children in the HE intervention group (-0·73 [-1·07 to -0·39] kg/m2, d=0.55); the same was true over 2 years (-0·63 [-1·13 to -0·14] kg/m2; d =0.33). No differential adverse events were observed. INTERPRETATION: The MMM intervention did not reduce BMI gain versus HE over 3 years but the effects over 1 and 2 years in this rigorous trial show the promise of this systems intervention approach for reducing weight gain and cardiometabolic risk factors in low socioeconomic status communities. FUNDING: US National Institutes of Health.

Potential corner case cautions regarding publicly available implementations of the National Cancer Institute's nonwear/wear classification algorithm for accelerometer data.

The National Cancer Institute's (NCI) wear time classification algorithm uses a rule based on the occurrence of physical activity data counts-a cumulative measure of movement, influenced by both magnitude and duration of acceleration-to differentiate between when a physical activity monitoring (PAM) device (ActiGraph accelerometer) is being worn by a participant (wear) from when it is not (nonwear). It was applied to PAM data generated from the 2003-2004 National Health and Nutrition Examination Survey (NHANES 2003-2004). We discuss two corner case conditions that can produce unexpected, and perhaps unintended results when the algorithm is applied. We show, using simulated data of two special cases, how this algorithm classifies a 24-hour period with only 72 total counts as 100% wear in one case, and classifies a 24-hour period with 96,000 counts as 0.1% wear in another. The prevalence of like scenarios in the NHANES 2003-2004 PAM dataset is presented with corresponding summary statistics for varying degrees of the algorithm's nonwear classification threshold (T). The number of participants with valid days, defined as 10 or more hours classified as wear time in a 24-hour day, increased while the mean counts-per-minute (CPM) decreased as the threshold for excluding non-wear was reduced from the allowed 4,000 counts in an hour. The number of participants with four or more valid days increased 2.29% (n = 113) and mean CPM dropped 2.45% (9.5 CPM) when adjusting the nonwear classification threshold to 50 counts an hour. Applying the most liberal criteria, only excluding hours as nonwear which contained 1 count or less, resulted in a 397 more participants (7.83% increase) and 26.5 fewer CPM (6.98% decrease) in NHANES 2003-2004 participants with four or more valid days. The algorithm should be used with caution due to the potential influence of these corner cases.

Effects of Varying Epoch Lengths, Wear Time Algorithms, and Activity Cut-Points on Estimates of Child Sedentary Behavior and Physical Activity from Accelerometer Data.

OBJECTIVE: To examine the effects of accelerometer epoch lengths, wear time (WT) algorithms, and activity cut-points on estimates of WT, sedentary behavior (SB), and physical activity (PA). METHODS: 268 7-11 year-olds with BMI ≥ 85th percentile for age and sex wore accelerometers on their right hips for 4-7 days. Data were processed and analyzed at epoch lengths of 1-, 5-, 10-, 15-, 30-, and 60-seconds. For each epoch length, WT minutes/day was determined using three common WT algorithms, and minutes/day and percent time spent in SB, light (LPA), moderate (MPA), and vigorous (VPA) PA were determined using five common activity cut-points. ANOVA tested differences in WT, SB, LPA, MPA, VPA, and MVPA when using the different epoch lengths, WT algorithms, and activity cut-points. RESULTS: WT minutes/day varied significantly by epoch length when using the NHANES WT algorithm (p < .0001), but did not vary significantly by epoch length when using the ≥ 20 minute consecutive zero or Choi WT algorithms. Minutes/day and percent time spent in SB, LPA, MPA, VPA, and MVPA varied significantly by epoch length for all sets of activity cut-points tested with all three WT algorithms (all p < .0001). Across all epoch lengths, minutes/day and percent time spent in SB, LPA, MPA, VPA, and MVPA also varied significantly across all sets of activity cut-points with all three WT algorithms (all p < .0001). CONCLUSIONS: The common practice of converting WT algorithms and activity cut-point definitions to match different epoch lengths may introduce significant errors. Estimates of SB and PA from studies that process and analyze data using different epoch lengths, WT algorithms, and/or activity cut-points are not comparable, potentially leading to very different results, interpretations, and conclusions, misleading research and public policy.

Family, community and clinic collaboration to treat overweight and obese children: Stanford GOALS-A randomized controlled trial of a three-year, multi-component, multi-level, multi-setting intervention.

OBJECTIVE: To test the effects of a three-year, community-based, multi-component, multi-level, multi-setting (MMM) approach for treating overweight and obese children. DESIGN: Two-arm, parallel group, randomized controlled trial with measures at baseline, 12, 24, and 36 months after randomization. PARTICIPANTS: Seven through eleven year old, overweight and obese children (BMI ≥ 85th percentile) and their parents/caregivers recruited from community locations in low-income, primarily Latino neighborhoods in Northern California. INTERVENTIONS: Families are randomized to the MMM intervention versus a community health education active-placebo comparison intervention. Interventions last for three years for each participant. The MMM intervention includes a community-based after school team sports program designed specifically for overweight and obese children, a home-based family intervention to reduce screen time, alter the home food/eating environment, and promote self-regulatory skills for eating and activity behavior change, and a primary care behavioral counseling intervention linked to the community and home interventions. The active-placebo comparison intervention includes semi-annual health education home visits, monthly health education newsletters for children and for parents/guardians, and a series of community-based health education events for families. MAIN OUTCOME MEASURE: Body mass index trajectory over the three-year study. Secondary outcome measures include waist circumference, triceps skinfold thickness, accelerometer-measured physical activity, 24-hour dietary recalls, screen time and other sedentary behaviors, blood pressure, fasting lipids, glucose, insulin, hemoglobin A1c, C-reactive protein, alanine aminotransferase, and psychosocial measures. CONCLUSIONS: The Stanford GOALS trial is testing the efficacy of a novel community-based multi-component, multi-level, multi-setting treatment for childhood overweight and obesity in low-income, Latino families.

Turn off the TV and dance! Participation in culturally tailored health interventions: implications for obesity prevention among Mexican American girls.

Our evaluation study identifies facilitators and barriers to participation among families participating in the treatment arm of Stanford ECHALE. This culturally tailored obesity prevention trial consisted of a combined intervention with two main treatment components: 1) a folkloric dance program; and 2) a screen time reduction curriculum designed for 7-11 year old Latinas and their families. We conducted 83 interviews (40 parents and 43 girls) in participant homes after 6 months of enrollment in the ECHALE trial. The Spradley ethnographic method and NVivo 8.0 were used to code and analyze narrative data. Three domains emerged for understanding participation: 1) family cohesiveness; 2) perceived gains; and 3) culturally relevant program structure. Two domains emerged for non-participation: program requirements and perceived discomforts. Non-parametric, Spearman's rank correlation coefficients were calculated to assess the relationships with participant attendance data. Sustained participation was most strongly influenced by the domain perceived gains when parents reported better self-esteem, confidence, improved attitude, improved grades, etc. (Spearman r = .45, P = .003). Alternatively, under the domain, perceived discomforts, with subthemes such as child bullying, participation in the combined intervention was inversely associated with attendance (Spearman r = -.38, P = .02). Family-centered, school-based, community obesity prevention programs that focus on tangible short-term gains for girls may generate greater participation rates, enhance social capital, and promote community empowerment. These factors can be emphasized in future obesity prevention program design and implementation.

A randomized controlled trial of culturally tailored dance and reducing screen time to prevent weight gain in low-income African American girls: Stanford GEMS.

OBJECTIVE: To test a 2-year community- and family-based obesity prevention program for low-income African American girls: Stanford GEMS (Girls' health Enrichment Multi-site Studies). DESIGN: Randomized controlled trial with follow-up measures scheduled at 6, 12, 18, and 24 months. SETTING: Low-income areas of Oakland, California. PARTICIPANTS: African American girls aged 8 to 10 years (N=261) and their parents or guardians. INTERVENTIONS: Families were randomized to one of two 2-year, culturally tailored interventions: (1) after-school hip-hop, African, and step dance classes and a home/family-based intervention to reduce screen media use or (2) information-based health education. MAIN OUTCOME MEASURE: Changes in body mass index (BMI). RESULTS: Changes in BMI did not differ between groups (adjusted mean difference [95% confidence interval] = 0.04 [-0.18 to 0.27] per year). Among secondary outcomes, fasting total cholesterol level (adjusted mean difference, -3.49 [95% confidence interval, -5.28 to -1.70] mg/dL per year), low-density lipoprotein cholesterol level (-3.02 [-4.74 to -1.31] mg/dL per year), incidence of hyperinsulinemia (relative risk, 0.35 [0.13 to 0.93]), and depressive symptoms (-0.21 [-0.42 to -0.001] per year) decreased more among girls in the dance and screen time reduction intervention. In exploratory moderator analysis, the dance and screen time reduction intervention slowed BMI gain more than health education among girls who watched more television at baseline (P = .02) and/or those whose parents or guardians were unmarried (P = .01). CONCLUSIONS: A culturally tailored after-school dance and screen time reduction intervention for low-income, preadolescent African American girls did not significantly reduce BMI gain compared with health education but did produce potentially clinically important reductions in lipid levels, hyperinsulinemia, and depressive symptoms. There was also evidence for greater effectiveness in high-risk subgroups of girls.

Team sports for overweight children: the Stanford Sports to Prevent Obesity Randomized Trial (SPORT).

OBJECTIVE: To evaluate the feasibility, acceptability, and efficacy of an after-school team sports program for reducing weight gain in low-income overweight children. DESIGN: Six-month, 2-arm, parallel-group, pilot randomized controlled trial. SETTING: Low-income, racial/ethnic minority community. PARTICIPANTS: Twenty-one children in grades 4 and 5 with a body mass index at or above the 85th percentile. INTERVENTIONS: The treatment intervention consisted of an after-school soccer program. The "active placebo" control intervention consisted of an after-school health education program. MAIN OUTCOME MEASURES: Implementation, acceptability, body mass index, physical activity measured using accelerometers, reported television and other screen time, self-esteem, depressive symptoms, and weight concerns. RESULTS: All 21 children completed the study. Compared with children receiving health education, children in the soccer group had significant decreases in body mass index z scores at 3 and 6 months and significant increases in total daily, moderate, and vigorous physical activity at 3 months. CONCLUSION: An after-school team soccer program for overweight children can be a feasible, acceptable, and efficacious intervention for weight control.

Stanford GEMS phase 2 obesity prevention trial for low-income African-American girls: design and sample baseline characteristics.

OBJECTIVE: African-American girls and women are at high risk of obesity and its associated morbidities. Few studies have tested obesity prevention strategies specifically designed for African-American girls. This report describes the design and baseline findings of the Stanford GEMS (Girls health Enrichment Multi-site Studies) trial to test the effect of a two-year community- and family-based intervention to reduce weight gain in low-income, pre-adolescent African-American girls. DESIGN: Randomized controlled trial with measurements scheduled in girls' homes at baseline, 6, 12, 18 and 24 month post-randomization. SETTING: Low-income areas of Oakland, CA. PARTICIPANTS: Eight, nine and ten year old African-American girls and their parents/caregivers. INTERVENTIONS: Girls are randomized to a culturally-tailored after-school dance program and a home/family-based intervention to reduce screen media use versus an information-based community health education Active-Placebo Comparison intervention. Interventions last for 2 years for each participant. MAIN OUTCOME MEASURE: Change in body mass index over the two-year study. RESULTS: Recruitment and enrollment successfully produced a predominately low-socioeconomic status sample. Two-hundred sixty one (261) families were randomized. One girl per family is randomly chosen for the analysis sample. Randomization produced comparable experimental groups with only a few statistically significant differences. The sample had a mean body mass index (BMI) at the 74 th percentile on the 2000 CDC BMI reference, and one-third of the analysis sample had a BMI at the 95th percentile or above. Average fasting total cholesterol and LDL cholesterol were above NCEP thresholds for borderline high classifications. Girls averaged low levels of moderate to vigorous physical activity, more than 3 h per day of screen media use, and diets high in energy from fat. CONCLUSIONS: The Stanford GEMS trial is testing the benefits of culturally-tailored after-school dance and screen-time reduction interventions for obesity prevention in low-income, pre-adolescent African-American girls.

Associations among familism, language preference, and education in Mexican-American mothers and their children.

Latino families who express a higher degree of familism are characterized by positive interpersonal familial relationships, high family unity, social support, interdependence in the completion of daily activities, and close proximity with extended family members. Retention of cultural values, such as familism, may be linked to positive health outcomes; however, little is known about how families retain culture of origin values in the face of acculturation pressures. The current study explores acculturation influences as indexed by language preference and household education on maternal and child familism. Mothers and children of Mexican descent (fourth grade students) (n = 219) completed measures of demographics, household education, language preference, and familism. Three hypotheses were examined. First, we predicted that lower household education would be correlated with higher familism scores. However, contrary to our prediction, a higher familism score was significantly associated with a higher level of household education (p <.05). Second, we predicted that higher child familism would be associated with the preference for speaking Spanish. Children who preferred to use both English and Spanish (p <.01) or English alone (p <.05) had higher familism scores than those who preferred Spanish. Third, we predicted that lower child familism scores would be associated with greater differences in mother and child language preferences. There were no significant differences in child familism based on differences between parent and child language. Protective influences of cultural maintenance deserve further attention in longitudinal studies and in relation to the physical and mental health of youth.