Care groups in an integrated nutrition education intervention improved infant growth among South Sudanese refugees in Uganda's West Nile post-emergency settlements: A cluster randomized trial.

OBJECTIVE: This study examined the effects of a peer-led integrated nutrition education intervention with maternal social support using Care Groups on infant growth among South Sudanese refugees in Uganda. METHODS: A community-based cluster-randomized trial (RCT) was conducted among 390 pregnant women (third trimester). Two intervention study arms were Mothers-only(n = 131) and Parents-combined (n = 142) with a Control (n = 117). WHO infant growth standards defined length-for-age z-scores (LAZ) for stunting, weight-for-age z-scores (WAZ) for underweight and weight-for-length z-scores (WLZ) for wasting. The Medical Outcomes Study (MOS) social support index was a proxy measure for social support. A split-plot ANOVA tested the interaction effects of social support, intervention, and time on infant growth after adjusting for covariates. Further, pairwise comparisons explained mean differences in infant growth among the study arms. RESULTS: The mean infant birth weight was 3.1 ± 0.5 kg. Over the study period, infant stunting was most prevalent in the Control (≥ 14%) compared to Mothers-only (< 9.5%) and Parents-combined (< 7.4%) arms. There were significant interaction effects of the Care Group intervention and social support by time on infant mean LAZ (F (6, 560) = 28.91, p < 0.001), WAZ (F (5.8, 539.4) = 12.70, p = < 0.001) and WLZ (F (5.3, 492.5) = 3.38, p = 0.004). Simple main effects by the end of the study showed that the intervention improved infant mean LAZ (Mothers-only vs. Control (mean difference, MD) = 2.05, p < 0.001; Parents-combined vs. Control, MD = 2.00, p < 0.001) and WAZ (Mothers-only vs. Control, MD = 1.27, p < 0.001; Parents-combined vs. Control, MD = 1.28, p < 0.001). CONCLUSION: Maternal social support with an integrated nutrition education intervention significantly improved infant stunting and underweight. Nutrition-sensitive approaches focused on reducing child undernutrition among post-emergency refugees may benefit from using Care Groups in programs. TRIAL REGISTRATION: Clinicaltrials.gov, NCT05584969.

Relationship between Body Mass Index and Health and Occupational Performance among Law Enforcement Officers, Firefighters, and Military Personnel: A Systematic Review.

The prevalence of overweight and obesity among tactical populations is estimated at 70%-75%, which may negatively impact health and performance. The relationship between BMI and health and performance is well established among the general population, however, literature on such relationships among tactical populations has yet to be reviewed and evaluated. The purpose of this study was to systematically review available literature on the relationship between BMI and health and occupational performance among law enforcement officer, firefighters, and military personnel. After reviewing the literature, 27 articles were included. Nine studies found BMI was positively associated with cardiovascular disease (CVD) risk factors. Studies involving BMI and cancer were lacking. One study found BMI was positively associated with type 2 diabetes (T2DM) risk. Five studies on occupational/physical performance and 12 studies on injury found a higher BMI was often indicative of decreased performance and increased risk of injury in general, but protective against stress fractures. Overall, higher BMI was often associated with negative health and performance outcomes among tactical populations, especially when beyond the overweight classification. Public health practitioners should focus efforts on improving nutrition and physical activity to promote a healthy BMI among these individuals.

A Peer-Led Integrated Nutrition Education Intervention through Care Groups Improved Complementary Feeding of Infants in Postemergency Settlements in the West-Nile Region in Uganda: A Cluster Randomized Trial.

Background: Complementary feeding of infants in refugee settlements remains inadequate. Furthermore, there has been limited evaluation of interventions addressing these nutrition challenges. Objective: This study examined the effects of a peer-led integrated nutrition education intervention on infant complementary feeding by South Sudanese refugee mothers in the West-Nile region in Uganda. Methods: A community-based randomized trial enrolled 390 pregnant women (during third trimester) as the baseline. Two arms [mothers-only and parents-combined (both mothers and fathers)] comprised treatments with a control. Infant feeding was assessed using WHO and UNICEF guidelines. Data were collected at Midline-II and Endline. The medical outcomes study (MOS) social support index was used to measure social support. An overall mean score of >4 was considered optimal social support, a score of ≤2 was none or little support. Adjusted multivariable logistic regression models determined the effects of the intervention on infant complementary feeding. Results: At the end of the study, infant complementary feeding improved significantly in both mothers-only and parents-combined arms. There was a positive effect on the introduction of solid, semisolid, and soft foods (ISSSF) in the mothers-only arm at both Midline-II {adjusted odds ratio (AOR) = 4.0]} and Endline (AOR = 3.8). Likewise, ISSSF was better for the parents-combined arm at both Midline-II (AOR = 4.5) and Endline (AOR = 3.4). Minimum dietary diversity (MDD) was significantly better at the Endline for the parents-combined arm (AOR = 3.0). Minimum acceptable diet (MAD) was significantly better at Endline for both mothers-only (AOR = 2.3) and parents-combined arms (AOR = 2.7). Infant consumption of eggs and flesh foods (EFF) was improved only in the parents-combined arm at both Midline-II (AOR = 3.3) and Endline (AOR = 2.4). Higher maternal social support was associated with better infant MDD (AOR = 3.3), MAD (AOR = 3.6), and EFF (AOR = 4.7). Conclusion: Engaging both fathers and mothers in care groups benefited complementary feeding of infants. Overall, this peer-led integrated nutrition education intervention through care groups improved infant complementary feeding in the West-Nile postemergency settlements in Uganda.This trial was registered at clinicaltrials.gov as NCT05584969.

Breastfeeding among South Sudanese refugees in protracted settlements in Adjumani district, Uganda: facilitators and barriers.

BACKGROUND: Evidence suggests that forced migration and refugee status may adversely impact mothers' breastfeeding choices. Furthermore, suboptimal breastfeeding practices have been reported among vulnerable populations including those living in refugee settlements. Therefore, this study investigated the barriers and facilitators of breastfeeding in protracted settlements in Adjumani district, in the West Nile region in Uganda. METHODS: This study was conducted among refugees living in protracted settlements located in Uganda in July 2019. Participants, originally from South Sudan, included mothers (n = 63) and fathers (n = 32) of children less than 24 months of age. Agojo, Ayilo-I, and Nyumanzi were randomly selected among the 17 refugee settlements in Adjumani. Participants formed a total of six focus group discussions (FGDs); four FGDs for mothers and two FGDs for fathers. Each FGD consisted of 15-16 participants. Data were transcribed verbatim and back-translated into English. Thematic analysis was used and data were analyzed using NVivo, v. 12. RESULTS: Facilitators of breastfeeding included knowledge of breastfeeding benefits, support from husband/father, support from the community, and support from non-governmental organizations. Mothers and fathers noted that breastfeeding protected children from diseases and breastfed children grew well. Fathers, the community, and organizations provided material support for breastfeeding mothers. Four themes were identified as barriers to breastfeeding: physical, socioeconomic, knowledge, and psychosocial. Mothers and fathers described physical barriers such as mothers stop breastfeeding when they are sick or they feel they are not producing enough breastmilk. Mothers reported that working or educated mothers may use other milk to feed their infant. Some mothers and fathers believed infants under six months needed more than breastmilk. Fathers described psychosocial barriers such as mothers' fear of pain during breastfeeding and maternal mental health issues. CONCLUSION: Interventions and policies that aim to improve breastfeeding in protracted settlements should consider addressing the barriers to breastfeeding at each level: physical, socioeconomic, knowledge, and psychosocial. Involving and encouraging support from husbands/fathers, relatives, and the community may increase adherence to breastfeeding recommendations.

The associations between women's empowerment measures, child growth and dietary diversity: Findings from an analysis of demographic and health surveys of seven countries in Eastern Africa.

Evidence on the efficacy of women's empowerment to improve child growth and minimum dietary diversity (MDD) in the Eastern Africa (EA) region is limited. This cross-sectional study used recent Demographic and Health Survey data of mother-child dyads from seven countries in EA to examine the associations between women's empowerment measures, child growth and MDD. Length-for-age z-scores, weight-for-length z-scores and weight-for-age z-scores were used to categorize growth indicators of 6-23 months old children. Multivariable logistic regression was used to identify significant associations. Among all countries, 32%-59% of children experienced growth failure. Children meeting MDD were 18%-45%. Women having self-esteem were associated with lower odds of stunting (adjusted odds ratio [AOR] = 0.62 in Rwanda), wasting (AOR = 0.38 in Uganda), underweight (AORs = 0.60 and 0.57 in Tanzania and Uganda, respectively) and growth failure (AOR = 0.64 in Rwanda). Having health decision control in Burundi was associated with lower odds of stunting (AOR = 0.49) and child growth failure (AOR = 0.52) and higher odds of meeting MDD (AOR = 2.50). Having Legal empowerment among women increased the odds of stunting (AOR = 1.79 in Burundi), underweight (AOR = 1.77 in Uganda) and growth failure (AOR = 1.87 in Burundi). Economic empowerment showed mixed associations with child growth and MDD among some countries. Women's self-esteem and health decision control were associated with better child growth and MDD for some countries in EA. Nutrition-sensitive interventions aimed at improving child growth and MDD should consider local contexts when addressing women's empowerment.

Baseline associations between biomarkers, cognitive function, and self-regulation indices in the Cognitive and Self-regulatory Mechanisms of Obesity Study.

OBJECTIVE: Understanding how biological, cognitive, and self-regulatory factors are related to obesity, and weight regulation is clearly needed to optimize obesity prevention and treatment. The objective of this investigation was to understand how baseline biological, cognitive, and self-regulatory factors are related to adiposity at the initiation of a behavioral weight loss intervention among treatment-seeking adults with overweight/obesity. METHODS: Participants (N = 107) in the Cognitive and Self-regulatory Mechanisms of Obesity Study (Identifier-NCT02786238) completed a baseline assessment with anthropometric, cardiometabolic, inflammatory, cognitive function, and self-regulation measures as part of a larger on-going trial. Data were analyzed with linear regression. RESULTS: At baseline, body mass index, body fat percentage, and waist circumference (WC) were positively associated with fasting insulin and insulin resistance. Higher WC was related to higher fasting glucose and hemoglobin A1c (HbA1c). Higher glucose and insulin resistance levels were related to lower list sorting working memory. Higher glucose and HbA1c levels were negatively associated with reading scores. Cognitive function and self-regulation indices were unrelated. CONCLUSIONS: In adults with overweight/obesity entering a weight loss treatment study: (1) elevated WC and associated glycemic impairment were negatively associated with cognition, (2) poorer executive function and reading abilities were associated with poorer glycemic control, and (3) objectively measured cognitive functions were unrelated to self-reported/behavioral measures of self-regulation. Such findings increase understanding of the relationships between adiposity, biomarkers, cognition, and self-regulation at treatment initiation and may ultimately inform barriers to successful obesity treatment response.

Variability in Dietary Quality of Elementary School Lunch Menus with Changes in National School Lunch Program Nutrition Standards.

National School Lunch Program (NSLP) standards recently changed significantly. The Healthy, Hunger-Free Kids Act (HHFKA) presumably improved the dietary quality (DQ) of meals, whereas Child Nutrition Program (CNP) Flexibilities appear to decrease DQ. This variability has not been quantified. Our objective was to determine differences in DQ between elementary school lunch menus meeting NSLP standards: School Meal Initiative (SMI), HHFKA, CNP Flexibilities, and evidence-based best practices (BP). A base menu was portioned per NSLP standards and analyzed for nutrient content and DQ. Statistical analyses included 1-factor ANOVA, Kruskal-Wallis, and Dunnett's test. The BP menu had higher whole fruit and whole grain Healthy Eating Index scores than SMI (Ps < 0.0083). The BP and HHFKA menus had higher refined grain and added sugars scores than SMI (Ps < 0.0083). The SMI menu had lower total vegetable and saturated fat scores than all menus (Ps < 0.0083). This study informs policy toward improving standards, positively affecting child health and academic performance through higher-DQ lunches.

The Association Between School Health Promotion Programs and School Wellness Policies.

OBJECTIVE: Determine school wellness policy quality and evaluate the association between health promotion programs on school wellness policy quality. METHODS: A descriptive cross-sectional study of 344 school districts in Oklahoma, a south-central region of the US. Secondary data including school districts' participation in health promotion programs for school years 2015 and 2016 and school wellness policy scores were used for this study. Descriptive statistics and Cohen d were used in the analysis. RESULTS: School wellness policies had a mean comprehensiveness score of 43.7% and a mean strength score of 21.8%. The presence of ≥3 health promotion programs had a small effect (Cohen d range = 0.20 to 0.48) on school wellness policy scores. CONCLUSIONS AND IMPLICATIONS: School wellness policies have room for improvement in both comprehensiveness and strength. Engagement in ≥3 health promotion programs may contribute to improved policy quality.

Parents' Perceptions of Childhood Obesity and Support of the School Wellness Policy.

OBJECTIVE: Investigate differences in familiarity of parents of school-aged children with school wellness polices (SWP) and perceptions of the problem of childhood obesity related to support for the SWP and school's role in providing a healthy environment. METHODS: Descriptive, cross-sectional study using telephone surveys conducted in spring, 2016. T test statistics compared differences between parents with high vs low SWP familiarity and agreement vs disagreement of childhood obesity as problematic. RESULTS: Nearly half of parents (49.5%) had low familiarity with SWP. Overall, fewer parents agreed that obesity was a local school problem compared with a statewide problem (P < .001). Differences in agreement about childhood obesity explained some differences in SWP support. CONCLUSIONS AND IMPLICATIONS: Greater awareness is needed among parents of schoolchildren regarding the SWP as well as the prevalence of childhood obesity. This could be achieved through increased development, implementation, and evaluation of communication efforts between schools and families regarding health-promoting environments.

Use of Community Readiness Model to Develop and Evaluate a Pilot Culinary Training Program for School Nutrition Staff.

OBJECTIVE: Use the Community Readiness Model (CRM) to develop and evaluate a contextually appropriate pilot culinary training program for school nutrition staff members. DESIGN: Mixed methods to guide intervention development. SETTINGS: Six school districts in rural and urban areas of a southwestern state. PARTICIPANTS: School nutrition staff (n = 36; female; <1 to >20 years' experience). INTERVENTION: Pre- and post-training assessments used the CRM. Findings from the pre-assessment were used to develop the pilot culinary training intervention. MAIN OUTCOME MEASURE: Readiness to integrate new food preparation methods into existing practices. ANALYSIS: The researchers used t and Wilcoxon tests to compare overall readiness and dimension scores (P ≤ .05). Thematic analysis was used to identify themes from the discussion component of the assessments. RESULTS: Overall readiness increased from vague awareness to preparation (P = .02). Improved dimensions were knowledge of efforts (P = .004), leadership (P = .05), and knowledge of issues (P = .04). Themes included barriers, leadership, and motivation. CONCLUSIONS AND IMPLICATIONS: The CRM was useful for developing and evaluating a contextually appropriate and effective culinary training program for school nutrition staff. Future efforts should address the provision of additional resources such as on-site chefs, small equipment grants, and engaging school stakeholders.

Innovative use of influential prenatal counseling may improve breastfeeding initiation rates among WIC participants.

OBJECTIVE: To determine whether integrating influence strategies (reciprocation, consistency, consensus, feeling liked, authority, and scarcity) throughout Chickasaw Nation Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics (1) changed participants' perception of the WIC experience and (2) affected breastfeeding initiation rates. METHODS: Two-part, quasi-experimental design. SETTING: Four WIC clinics. PARTICIPANTS: Parents and caregivers of children birth to 3 years. INTERVENTION: Behavior change intervention based on Social Cognitive Theory using Caildini's Principles of Influence. Traditional-model groups (control) received services prior to the intervention; influence-model groups (experimental) received services after initiation of the intervention. MAIN OUTCOMES: The preliminary demonstration project surveyed 2 groups to measure changes in their perceptions of the WIC environment. Secondary data analysis measured changes in breastfeeding initiation in 2 groups of postpartum women. ANALYSES: Frequency analysis, independent sample t tests, chi-square for independence, step-wise logistic regression. RESULTS: The demonstration project resulted in 5 improved influence measures (P < .02), aligning with the influence principle of "feeling liked." The model had a small effect (φ = 0.10) in distinguishing breastfeeding initiation; women in the influence model were 1.5 times more likely (95% CI, 1.19-1.86; P < .05) to initiate breastfeeding compared with women in the traditional model, controlling for parity, mother's age, and race. CONCLUSIONS AND IMPLICATIONS: Consistent with Social Cognitive Theory, changing the WIC environment by integrating influence principles may positively affect women's infant feeding decisions and behaviors, specifically breastfeeding initiation rates.

A quantitative and qualitative approach to understanding fruit and vegetable availability in low-income african-american families with children enrolled in an urban head start program.

BACKGROUND: Prior studies have shown low-income African Americans have low intakes of fruits and vegetables, which correlate, in part, to area of residence. To address the dietary problem, behavior-change interventions are most effective when they are theoretically based and compatible with cultural/behavioral characteristics of a given population. OBJECTIVE: To use the Transtheoretical Model of Behavior Change to determine whether low-income African Americans were in proportionately different stages of change for increasing fruits and vegetables to their young children and identify differences in decision making, self-efficacy, and use of cognitive and behavioral strategies related to fruit and vegetable availability. DESIGN: The two-phase, descriptive study utilized a mixed methodology consisting of a fruit and vegetable survey and focus groups. SUBJECTS/SETTING: Convenience sample of low-income African-American parents with children enrolled in an urban area Head Start program. STATISTICAL ANALYSES PERFORMED: chi(2) test was calculated to examine the distribution of parents into stages of change for increasing fruit and vegetable availability. Analysis of variance was used to test differences in fruit and vegetable availability to children and parents' decision making, self-efficacy, and use of cognitive and behavioral strategies. Content analysis of focus group transcripts was used to triangulate quantitative findings and further explore meanings of survey responses. RESULTS: Of 94 participants completing the fruit and vegetable survey, 21% staged as precontemplation/contemplation, 25% staged as preparation, and 54% staged as action/maintenance (P<0.001). Parents in action/maintenance stages served significantly more fruits and vegetables (P=0.006) and used behavioral processes significantly more often (P<0.001) compared to parents in precontemplation/contemplation stages. Content analysis of focus group transcripts provided greater insight into the quantitative findings. CONCLUSIONS: Nutrition education targeting low-income African-American parents in earlier stages of change should address planning and preparing convenient and economical meals and snacks that include fruits and vegetables. Interventions targeting parents in later stages of change should address increasing variety and healthful preparation methods. Interventions for both groups can benefit from social support strategies.

Assessment of stage of change, decisional balance, self-efficacy, and use of processes of change of low-income parents for increasing servings of fruits and vegetables to preschool-aged children.

OBJECTIVE: Use the Transtheoretical Model of Behavior Change (TTM) to determine the proportionate stage of change of low-income parents and primary caregivers (PPC) for increasing accessibility, measured as servings served, of fruits and vegetables (FV) to their preschool-aged children and evaluate response differences for theoretical constructs. DESIGN: Cross-sectional, quantitative survey design consisting of staging algorithm, construct scales, and food frequency questionnaire. SETTING: Rural and urban communities in a southwestern state of the United States. PARTICIPANTS: 238 low-income PPC enrolled in federal nutrition education programs were recruited from group nutrition education sessions. MAIN OUTCOME MEASURES: Stage of change using a staging algorithm, TTM constructs of processes of change, decisional balance, and self-efficacy measured by multiple-item scales using Likert response, and fruit and vegetable servings served using a food frequency questionnaire. ANALYSIS: Descriptive analysis, Pearson's chi-square, analyses of variance with Tukey's Honestly Significant Difference post hoc test, and principal component function analysis. RESULTS: Of the surveyed PPC, 43% were in precontemplation/contemplation stages, and 29% were in the preparation stage for increasing FV accessibility (measured by servings served) to their preschool-aged children. PPC in the action/maintenance stages evidenced greater use of behavioral processes and had higher self-efficacy scores compared to PPC in precontemplation/contemplation and preparation stages. CONCLUSIONS AND IMPLICATIONS: Interventions aimed at increasing FV accessibility for preschool-aged children should be tailored to meet PPCs' stage of change. Interventions targeting PPC in precontemplation/contemplation stages should use methods to share ideas for planning meals and snacks to include FV. Interventions for PPC in the preparation stage should aim to build skills in quick preparation of economical FV, address parental role modeling of FV consumption, and encourage goal setting. Learning formats providing social support may prove effective in prevention of behavior relapse for PPC in action/maintenance stages.