Acculturation and Health Status in the Children's Healthy Living Program in the Pacific Region.

Acculturation/enculturation has been found to impact childhood health and obesity status. The objective of this study is to use cross-sectional data to examine the association between proxies of adult/caregiver acculturation/enculturation and child health status (Body Mass Index [BMI], waist circumference [WC], and acanthosis nigricans [AN]) in the U.S.-Affiliated Pacific Islands (USAPI), Alaska, and Hawai'i. Study participants were from the Children's Healthy Living (CHL) Program, an environmental intervention trial and obesity prevalence survey. Anthropometric data from 2-8 year olds and parent/caregiver questionnaires were used in this analysis. The results of this study (n = 4121) saw that those parents/caregivers who identified as traditional had children who were protected against overweight/obesity (OWOB) status and WC > 75th percentile (compared to the integrated culture identity) when adjusted for significant variables from the descriptive analysis. AN did not have a significant association with cultural classification. Future interventions in the USAPI, Alaska, and Hawai'i may want to focus efforts on parents/caregivers who associated with an integrated cultural group as an opportunity to improve health and reduce child OWOB prevalence.

Proportion and Correlates of Children in the US-Affiliated Pacific Region Meeting Sleep, Screen Time, and Physical Activity Guidelines.

INTRODUCTION: Limited data on 24-hour movement behaviors of children aged 5-8 years exist globally. We describe the prevalence and sociodemographic associations of meeting physical activity (PA), sedentary recreational screen time (ST), and sleep guidelines among children from 11 jurisdictions in the US-Affiliated Pacific region. METHODS: Cross-sectional representative data from 1192 children aged 5-8 years living in the US-Affiliated Pacific region were drawn from the baseline 2012-2014 Children's Healthy Living Program. Sleep and moderate- to vigorous-intensity PA were calculated from accelerometry. ST and sociodemographic data were collected from caregiver surveys. The percentage of children meeting the Asia-Pacific 24-hour movement guidelines for PA (≥60 min/d of moderate- to vigorous-intensity PA), sleep (≥9 and ≤ 11 h/d) and ST (≤2 h/d) were calculated. Generalized linear mixed models were used to examine associations with adiposity and sociodemographic variables. RESULTS: Twenty-seven percent (95% confidence interval, 24.6-30.0) of children met integrated guidelines; 98% (96.2-98.0) met PA, 78% (75.4-80.0) met sleep, and 35% (32.6-38.0) met ST guidelines. Females (adjusted odds ratio = 1.40 [95% confidence interval, 1.03-1.91]) and those living in lower-middle-income jurisdictions (2.29 [1.49-3.54]) were more likely to meet ST guidelines. Overweight children (0.62 [0.40-0.96]), those aged 8 years (0.39 [0.22-0.69]), and children with caregivers of an education level of high school or beyond (0.44 [0.29-0.68]) were less likely to achieve ST guidelines. Children from midrange annual household incomes were less likely to meet combined guidelines (0.60 [0.39-0.92]). CONCLUSIONS: Three-quarters of children are not meeting integrated Asia-Pacific 24-hour movement guidelines. Future strategies for reducing ST and increasing integrated guidelines compliance are needed.

The range of outcomes and outcome measurement instruments collected in multisectoral community-based obesity prevention interventions in children: A systematic review.

Multicomponent and multisectoral community-based interventions (CBIs) have proven potential in preventing overweight and obesity in children. Synthesizing evidence on the outcomes collected and reported in such CBIs is critical for the evidence of effectiveness and cost-effectiveness. This systematic review aimed to identify the range of outcomes and outcome measurement instruments collected and reported in multisectoral and multicomponent CBIs for obesity prevention in children. A systematic search updated an existing review and extended the search to 11 academic databases (2017-2023) and gray literature. Outcomes were classified into outcome domains, and common measurement instruments were summarized. Seventeen outcome domains from 140 unique outcomes were identified from 45 included interventions reported in 120 studies. The most frequently collected outcome domains included anthropometry and body composition (91% of included interventions), physical activity (84%), dietary intake (71%), environmental (71%), and sedentary behavior (62%). The most frequently collected outcomes from each of these domains included body mass index (89%), physical activity (73%), fruit and vegetable intake (58%), school environment (42%), and screen time (58%). Outcome measurement instruments varied, particularly for behavioral outcomes. Standardization of reported outcomes and measurement instruments is recommended to facilitate data harmonization and support quantifying broader benefits of CBIs for obesity prevention.

Social determinants of health literacy among parents and caregivers in the US-Affiliated Pacific.

Health literacy is understudied in the US-Affiliated Pacific (USAP), where local populations have historically experienced social marginalization and disproportionate health inequities caused by the social determinants of health (SDOH). This cross-sectional study analyzed several SDOH indicators-acculturation, use of food assistance programs and demographic characteristics (race and ethnicity, household income, primary language spoken at home and educational attainment)-and their relationship to health literacy among 1305 parents/caregivers of young children ages 2-8 years old who participated in the Children's Healthy Living (CHL) program in Alaska, American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Guam, and Hawai'i. Significantly increased odds of low health literacy were found among parents/caregivers with households where a language other than English was the primary language compared to English-only households (OR = 1.86, 95% CI = 1.22, 2.82), household income of <$35 000 compared to ≥$35 000 (OR = 2.15, 95% CI = 1.13, 4.07), parents/caregivers of Asian children compared to parents/caregivers of White children (OR = 2.68, 95% CI = 1.05, 6.84), parent/caregivers with less than or some high school education compared to high school completion (1st- to 8th-grade OR = 4.46, 95% CI = 2.09, 9.52; 9th- to 11th-grade OR 1.87, 95% CI = 1.06, 3.30) and parent/caregivers with acculturation status defined as marginalized as compared to integrated (OR = 2.31, 95% CI = 1.09, 4.86). This study indicates that some USAP parents/caregivers may lack the capacity to acquire health information, utilize health resources, and navigate health decision making. Future efforts to understand and improve health literacy in the USAP should be population specific, thoroughly assess personal and organizational health literacy, and inventory community health care capacity.

Spillover effects of childhood obesity prevention interventions: A systematic review.

BACKGROUND: Childhood obesity prevention initiatives are complex interventions that aim to improve children's obesity-related behaviors and provide health promoting environments. These interventions often impact individuals, communities, and outcomes not primarily targeted by the intervention or policy. To accurately capture the effectiveness and cost-effectiveness of childhood obesity prevention interventions, an understanding of the broader impacts (or spillover effects) is required. This systematic review aims to assess the spillover effects of childhood obesity prevention interventions. METHODS: Six academic databases and two trial registries were searched (2007-2023) to identify studies reporting quantifiable obesity-related and other outcomes in individuals or communities not primarily targeted by an obesity prevention intervention. Critical appraisal was undertaken for studies that reported statistically significant findings, and a narrative synthesis of the data was undertaken. RESULTS: Twenty academic studies and 41 trial records were included in the synthesis. The most commonly reported spillovers were diet or nutrition-related, followed by BMI and physical activity/sedentary behavior. Spillovers were mostly reported in parents/caregivers followed by other family members. Nine of the 20 academic studies reported statistically significant spillover effects. CONCLUSION: Limited evidence indicates that positive spillover effects of childhood obesity prevention interventions can be observed in parents/caregivers and families of targeted participants.

Prevalence and socio-demographic distributions of meeting RMI Guidelines for Healthy Living among elementary school children in Majuro, Republic of Marshall Islands: a cross-sectional population-based survey.

Background: Childhood obesity is high in Republic of Marshall Islands (RMI). We report the prevalence and socio-demographic distribution of selected obesity-related risk factors among children in Majuro, RMI. Methods: Sixteen elementary schools were approached and students and parents in Grades 1, 3, and 5 invited to participate in this cross-sectional population-based survey. Accelerometry and a questionnaire were used to collect data on children's physical activity (PA), sleep, screen time and dietary behaviours. Descriptive statistics and mixed-effects logistic regression were used to examine differences in the proportions of children meeting selected RMI Healthy Living Guidelines by sex, school grade and school sector. Findings: Thirteen schools and 958 children were recruited, of which 892 (52.2% girls; mean age 9.3 ± 1.8 years) provided useable data. Around 90% met the PA, 29% screen time, 13% sleep, 69% sugar-sweetened beverage and 56% highly processed food guidelines. The proportion meeting individual guidelines was higher among children in Grade 1 compared with Grade 5. Being a girl (0.27; 95% CI 0.16, 0.46) was associated with lower odds of meeting the PA recommendation. Compared with children from Grade 1, those in Grade 5 had lower odds of meeting the PA (0.28; 95% CI 0.15, 0.55), screen time (0.60; 95% CI 0.40, 0.89), sleep duration (0.33; 95% CI 0.18, 0.59), sugar-sweetened beverage (0.35; 95% CI 0.23, 0.53), and consumption of highly processed foods recommendations (0.49; 95% CI 0.33, 0.72). Interpretation: While most children in RMI are adequately active, resources are needed to promote healthier levels of screen time, sleep, sugar-sweetened beverage and highly processed food consumption, especially among older children. Funding: This study was funded by World Diabetes Foundation; Canvasback Missions, RMI; NHMRC Australia (APP1176858); Pacific Community.

Diet Quality of Young Children in the US-Affiliated Pacific's Children's Healthy Living (CHL) Program.

BACKGROUND: Childhood diet can impact health outcomes over the life course. Few studies have assessed dietary quality among infants and children in the US-Affiliated Pacific (USAP) region. OBJECTIVE: The aim of this study was to examine the differences in diet quality among Pacific children in the Children's Healthy Living (CHL) program by Pacific jurisdiction and by their World Bank Income Group (WBIG) level. DESIGN: This cross-sectional study used dietary records collected from 2012 to 2015. PARTICIPANTS/SETTING: Data were collected on 2- to 8-year-old children (n = 3,529) enrolled in the Children's Healthy Living Program for Remote Underserved Minority Populations in the Pacific region, conducted in the USAP jurisdictions of Alaska, Hawai'i, American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Guam, Federated States of Micronesia (FSM islands include Chuuk, Kosrae, Pohnpei, Yap), Republic of the Marshall Islands (RMI), and Republic of Palau. MAIN OUTCOME MEASURE: Diet quality was assessed using the Healthy Eating Index-2005 (HEI-2005). This HEI version was commensurate with the time of dietary data collection for the CHL project and previous studies, thus allowing cross-study comparisons. STATISTICAL ANALYSIS PERFORMED: Means of total HEI-2005 scores between jurisdictions and their WBIG level were compared using linear models, with and without adjustment for age, sex, and dietary energy. RESULTS: Differences in mean HEI-2005 scores among children were found between jurisdictions and their WBIG level. Alaska had the highest adjusted mean score (63.3). RMI had the lowest adjusted mean score (50.1). By WBIG, lower-middle income jurisdictions had the lowest adjusted mean HEI-2005 score (56.0), whereas high income jurisdictions had the highest adjusted mean HEI-2005 score (60.5). CONCLUSIONS: Variation in children's diet quality was found between USAP jurisdictions, notably between jurisdictions of different WBIG levels. Future research is needed to deepen understanding of these differences in diet quality by WBIG level, such as whether differences may be attributable to the jurisdictions' varying food systems, and possibly explained by the nutrition transition. Understanding childhood diet quality in this region can inform approaches for nutrition programs in the Pacific region.

Food Insecurity and Blood Pressure in a Multiethnic Population.

Food insecurity is a social determinant of health and is increasingly recognized as a risk factor for hypertension. Native Hawaiians bear a disproportionate burden of hypertension and known risk factors. Despite this, the relative effects of food insecurity and financial instability on blood pressure have yet to be investigated in this population. This study examines the relative effects of food insecurity and financial instability on blood pressure, controlling for potential confounders in a multiethnic sample. Participants (n = 124) were recruited from a U.S. Department of Agriculture-funded study called the Children's Healthy Living Center of Excellence. Biometrics (i.e., blood pressure, weight, and height) were measured. Demographics, physical activity, diet, psychosocial variables, food insecurity, and financial instability were assessed via self-report questionnaires. Hierarchical linear regression models were conducted. Model 1, which included sociodemographic variables and known biological risk factors, explained a small but significant amount of variance in systolic blood pressure. Model 2 added physical activity and daily intake of fruit, fiber, and whole grains, significantly improving the model. Model 3 added financial instability and food insecurity, further improving the model (R2 = 0.37, F = 2.67, p = 0.031). Food insecurity, female sex, and BMI were significantly and independently associated with increased systolic blood pressure. These results suggest a direct relationship between food insecurity and systolic blood pressure, which persisted after controlling for physical activity, consumption of fruits, fiber, and whole grains, and BMI. Efforts to reduce food insecurity, particularly among Native Hawaiians, may help reduce hypertension in this high-risk population.

Diet and Acanthosis Nigricans over a Two-Year Period in Children of the Pacific Region.

BACKGROUND: The impact that dietary carbohydrates have on children developing type 2 diabetes remains controversial. Furthermore, there are limited pediatric longitudinal studies on changes in body mass index (BMI) and diet related to the development of acanthosis nigricans (AN), a risk factor associated with type 2 diabetes. METHODS: Two 24 h dietary records were collected for 558 children, 2-8 years of age, at baseline and at a 2-year follow-up. Data on age, sex, BMI, and the presence of AN were also collected at each time point from the Children's Healthy Living Program. Logistic regression was used to determine factors associated with the presence of AN at follow-up. Multinominal regression was used to determine factors associated with changes in AN status. Linear regression was used to measure the associations between changes in dietary intake and in the Burke Score for AN. RESULTS: AN was present in 28 children at baseline and 34 children at follow-up. Adjusting for the presence of AN at baseline, age, sex, study group, baseline BMI, change in BMI z-score, time between assessments, and baseline intake, an increase from baseline for each teaspoon of sugar and serving of carbohydrate-rich food increased the risk for having AN at follow-up by 9% and 8%, respectively (p ≤ 0.05). An increased intake of added sugar (teaspoons) increased the risk of developing AN by 13% (p ≤ 0.01) and an increase in servings of foods rich in starch increased the risk of developing AN by 12% (p ≤ 0.01) compared to children who never had AN. Increasing the intake of fruit was also associated with decreased Burke Scores using multiple regression. However, the intake of energy and macronutrients were not associated with AN. CONCLUSIONS: Added sugar and foods rich in starch were independently associated with the occurrence of AN, suggesting the type of carbohydrates consumed is a factor in AN occurrence.

Children's Dietary Intake by Early Care and Education Setting in the US Affiliated Pacific.

OBJECTIVE: Examine differences in dietary intake of children aged 2-5 years in early care and education (ECE) setting in the US Affiliated Pacific (USAP). DESIGN: Secondary analysis of cross-sectional data collected by the Children's Healthy Living program. PARTICIPANTS: Children (n = 1,423) with complete dietary records and information on the ECE setting. MAIN OUTCOME MEASURES: Dietary intake by ECE setting; Head Start (HS), other ECE (OE), and no ECE. ANALYSIS: Comparison of mean dietary intake across ECE settings and multivariate logistic regression to evaluate ECE setting and likelihood for meeting dietary reference intake (DRI). RESULTS: Children in HS and OE settings had a significantly higher intake of several food groups and nutrients, compared with no ECE; vegetables (0.4 cup-equivalents per thousand kcals [CETK] vs 0.3 CETK; P < 0.001), fruits (0.8 CETK vs 0.6 CETK; P = 0.001), milk (0.9 CETK for HS and 1.0 CETK for OE vs 0.8 CETK; P < 0.001). Sixty-five percent of the HS group met DRI and had greater odds of meeting calcium DRI (odds ratio, 1.8; 95% confidence interval, 1.2-2.7) compared with other groups. The OE group had the lowest proportion of children meeting recommended intakes for 19 out of 25 nutrients. CONCLUSIONS AND IMPLICATIONS: Mean intakes of foods and nutrients for children across the USAP meet some, but not all, recommendations and intakes vary across children attending various ECE setting types. Additional research on the clinical importance of these differences and the impact of the complex food systems in the USAP may identify systematic strategies for improving diet among children.

Food Security is Associated with Higher Diet Quality Among Children of the US-Affiliated Pacific Region.

BACKGROUND: The prevalence of food insecurity and its relationship to diet quality are factors impacting the health of persons living across the United States-affiliated Pacific region (USAP). OBJECTIVES: The aim of this study was to describe characterize the relationship between household food security status and diet quality of 2- to 8-y-old children across jurisdictions in the USAP. METHODS: Baseline data from 2- to 8-y-olds (n = 3099) enrolled in the Children's Healthy Living Program for Remote Underserved Minority Populations in the Pacific region, an obesity prevention study conducted in communities across Alaska, American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Guam, and Hawaii, and a concomitant prevalence study in communities across the Freely Associated States (FAS) (the Federated States of Micronesia: Kosrae, Pohnpei, Chuuk, Yap; Republic of Marshall Islands; Republic of Palau) were collected in 2012. Caregivers self-reported sociodemographic data and food insecurity. Assisted by their caregiver, children completed two dietary records on nonconsecutive, randomly assigned days. The Healthy Eating Index 2005 (HEI-2005) was used to assess the diet quality. Data were summarized overall and by jurisdiction. Differences in HEI-2005 and HEI component scores among jurisdictions and by household food security status were tested using 1-factor ANOVA. RESULTS: Half or more of participants from American Samoa, Guam, CNMI, and FAS reported household food insecurity (n = 295, 59.7%; n = 292, 49.9%; n = 267, 54.6%; n = 572, 69.0%, respectively). HEI-2005 scores varied by jurisdiction (P < 0.001) and were significantly lower among FAS participants (54.7 ± 1.2) than among all other jurisdictions (P < 0.05). Total diet quality scores did not differ by food security status (59.9 ± 0.8 food secure compared with 58.3 ± 1.1 food insecure, P = 0.07); however, most diet quality adequacy component scores were significantly higher and moderation component scores significantly lower among participants in food secure households than those in food insecure households. CONCLUSIONS: Significant differences in children's diet quality and household food security existed across USAP jurisdictions.

Asia-Pacific consensus statement on integrated 24-hour activity guidelines for the early years.

Background: Early childhood is a vital period for development and growth. Promoting beneficial lifestyle behaviours in early childhood can help optimise children's health, development and learning, shape their behaviours in adulthood and offer the best protection against future non-communicable diseases (NCDs). In the Asia-Pacific region, NCDs are significant causes of healthcare burden and mortality. Furthermore, there is also a high prevalence of adverse metabolic risk factors and unhealthy lifestyle behaviours among these children. Method: Representatives from 19 Asia-Pacific nations and/or jurisdictions developed a consensus statement on integrated 24-hour activity guidelines for the early years using the GRADE-ADOLOPMENT framework. Findings: These guidelines apply to all infants, toddlers and pre-schoolers below 5 years of age. The guidelines aim to provide a holistic and practical approach to lifestyle activities by framing physical activity, sedentary behaviour and sleep within a 24-hour period. Dietary patterns were included as they play an integral role in metabolic health and energy balance. Interpretation: Aligned with the World Health Organization's Global Action Plan for the Prevention and Control of NCDs through health promotion interventions in early life, through cultivating healthy lifestyle behaviours in the children's early years, we aim to provide children with the best start in life and reduce the burden of future NCDs in the Asia-Pacific region. Funding: Funded by Integrated platform for research in advancing metabolic health outcomes of women and children.

Food and Physical Activity Environment in the US-Affiliated Pacific Region: The Children's Healthy Living Program.

OBJECTIVE: To describe the quality of food and physical activity (PA) environments by World Bank Income level in jurisdictions from the Children's Healthy Living Program. DESIGN: Baseline cross-sectional community data were analyzed from 11 jurisdictions categorized by World Bank Income levels to describe exposure to different food and PA outlets. The Children's Healthy Living Program was a multilevel, multijurisdictional prevalence study and community intervention trial that reduced child obesity in the US-Affiliated Pacific region. SETTING: US-Affiliated Pacific region. PARTICIPANTS: Food (n = 426) and PA (n = 552) Outlets. MAIN OUTCOME MEASURES: Physical activity and food scores that reflect the quality of the outlets that support being physically active and healthy eating options, respectively. ANALYSIS: Descriptive statistics are presented as means ± SD or percentages. RESULTS: High-income-income level jurisdictions had higher food and PA scores than middle-income level jurisdictions. CONCLUSIONS AND IMPLICATIONS: The US-Affiliated Pacific region has limited quality food and PA outlets in underserved communities at risk for obesity. The findings in this paper can be used to develop tools and design interventions to improve the food and PA environment to increase a healthier, active lifestyle.

Food Group, Macronutrient Intake, and Metabolic Status in the US-Affiliated Pacific's Children's Healthy Living (CHL) Program.

BACKGROUND: The Children's Healthy Living study provided dietary intake information for understudied Native Hawaiian and Other Pacific Islander (NHOPI) young children. OBJECTIVES: Our objective was to describe food group and macronutrient intakes of NHOPI children in the US-Affiliated Pacific region (USAP), overall and by jurisdiction, income level, and metabolic status. METHODS: We evaluated 2-8-y-olds (n = 3520) in a cross-sectional cluster sampled study using 2 d of dietary records completed by caregivers using provided tools, quantified by a specially developed food composition table and compared with US dietary recommendations. Overweight and obesity (OWOB) and acanthosis nigricans (AN) assessment (metabolic status) was completed by trained evaluators using standard tools. Demographic data were collected by questionnaire. Regression analysis identified differences in dietary component means by jurisdiction, World Bank income groups (WBIGs), and metabolic status, adjusted for age and sex. RESULTS: Few children met US recommendations for vegetable (2.4%) and milk (4.1%) food groups. US macronutrient recommendations were generally met. Food group and macronutrient intakes were significantly different by jurisdiction and WBIG. Means for food groups, except meats, and macronutrients, except protein, were higher in overweight/obese (OWOB) compared with healthy-weight children. Grain intake of 7.25 (SE: 0.08) oz was higher (P < 0.05) and milk intake of 0.90 (SE: 0.05) cups was lower (P < 0.05) in children with OWOB compared with those without OWOB [grains: 7.17 (SE: 0.07) oz; and milk: 0.96 (SE: 0.04) cups]. Monounsaturated fat intake of 11.68 (SE: 0.10) % energy was higher in those with OWOB, compared with healthy-weight children [11.56 (SE: 0.08) % energy, P < 0.05]. CONCLUSIONS: Young children's diets in the USAP did not meet milk, vegetable, or fruit intake recommendations. There was variability in dietary patterns across the USAP and by WBIG. Grain intake and monounsaturated fat intake were lower and milk intake was higher in children with better metabolic status.

Exploring Foods of the Pacific: Cultural Food Identity in the US Affiliated Pacific Region.

Indigenous peoples of the Pacific have seen major shifts in dietary patterns due to foreign colonization, which introduced an array of new foods. Today, foods considered traditional and acculturated are consumed in various extents. However, the definitions and identity of traditional versus acculturated foods has become unclear as many introduced foods have been incorporated into Pacific cultures. The purpose of this study was to capture culturally relevant definitions of traditional, acculturated, and locally grown foods among 10 jurisdictions of the US-Affiliated Pacific (USAP) region with a focus on fruits and vegetables. Questionnaires were used to capture definitions of these terms, and to identify a list of foods (n=121) as traditional, acculturated, and/or locally grown in addition to classify them into food groups (ie, fruit, vegetable, starch, and/or grain). For the most part, definitions of traditional, acculturated, and locally grown were agreed upon by participating USAP jurisdictions, with some supplementary caveats presented by different jurisdictions. More foods were identified as acculturated (n=75) than traditional (n=37). Fruits (n=55) were the most frequent designation and about a third were vegetables (n=44). The majority of the jurisdictions reported growing at least half of the food items. This is the first study to identify and classify foods of the Pacific from the perspective of those indigenous to the USAP region. Understanding these similarities and differences in how food is classified and identified, through the lens of those from the Pacific, is crucial for nutrition education, and understanding what foods are locally grown is important for future sustainability.

Consumption of Traditional Fruits and Vegetables among Children in the US-Affiliated Pacific Region.

Background: Traditional Pacific diets have many health benefits, including maintenance of a healthy weight and prevention of various diseases. Few studies have evaluated the frequency at which traditional diets are consumed in the Pacific, especially among children. Objectives: This study examined the frequency of traditional and acculturated fruit and vegetable (F&V) intake among children in the US-affiliated Pacific (USAP) region. Methods: Diet records of 3319 children ages 2 to 8 y old were analyzed for frequency of traditional or acculturated F&V intake within USAP jurisdictions of American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Federated States of Micronesia (FSM; FSM island states include Chuuk, Kosrae, Pohnpei, and Yap), Guam, Hawaii, Republic of the Marshall Islands (RMI), and Republic of Palau. Results: Of the 95,304 food items recorded among participating children in the USAP jurisdictions, 15.2% were F&Vs. Of the 10 jurisdictions, children in the islands of Chuuk, Kosrae, Yap, and Pohnpei recorded the highest frequencies of traditional F&V intake relative to their total F&V intake (67.8%, 64.8%, 56.7%, and 52.5%, respectively). American Samoa and RMI recorded moderate frequency of traditional F&V intake (38.9% and 46.4%, respectively), whereas children in Hawaii, Guam, and CNMI recorded the lowest frequencies of traditional F&V intake relative to their total F&V intake (10.4%, 12.4%, and 15.3%, respectively). Children in Hawaii, Guam, Palau, and CNMI recorded high frequencies of acculturated F&V intake (37.8%, 31.2%, 34.5%, and 27.9%, respectively). Conclusions: Overall, children in the USAP jurisdictions participating in this study recorded a low frequency of F&V intake. The differences in traditional F&V intake found between the USAP islands may be due to variation in economic income level and external influences on social and cultural norms among the island populations and variations of cost, accessibility, and convenience of each category of food to each island's population.

Maintenance Outcomes of the Children's Healthy Living Program on Overweight, Obesity, and Acanthosis Nigricans Among Young Children in the US-Affiliated Pacific Region: A Randomized Clinical Trial.

Importance: Few obesity prevention trials among children have demonstrated sustainable outcomes in the long term. Objectives: To sustain a community-wide decrease in the prevalence of overweight and obesity among young children in the US-affiliated Pacific region. Design, Setting, and Participants: In the Children's Healthy Living community-randomized clinical trial, hierarchical modeling comparing the change in intervention and control communities accounted for community randomization (community clustering with jurisdictions), and adjusted for the age and sex distribution of the assessed children in a cross-sectional design. The outcome measures were repeated in communities rather than among individual children. A total of 27 communities in 5 jurisdictions (Hawai'i, Alaska, Commonwealth of the Northern Mariana Islands, American Samoa, and Guam) of the US-affiliated Pacific region were included. Participants included children aged 2 to 8 years in the 27 selected communities from October 1, 2012 (4329 in time 1 [baseline]) to August 31, 2015 (4043 in time 2 [intervention end]) and from January 1, 2019, to April 30, 2020 (1469 in time 3 [maintenance period]). Study analysis was completed March 25, 2022. Interventions: Nineteen activities addressed training, policies, systems, and environments of communities and 6 target behaviors of children (consumption of fruit and vegetables, water, and sugar-sweetened beverages; sleep; physical activity; and screen time) during a 2-year intervention period. Continued partnership with community coalitions, ongoing academic training of community partners, and use of trial data during a 6-year maintenance period. Main Outcomes and Measures: The primary outcome was measured anthropometry; secondary outcomes were the presence of acanthosis nigricans, dietary intake derived from 2 days of food records, and survey questions on screen time and sleep disturbance. Results: Among the 9840 children included in the analysis (4866 girls [49.5%] and 4974 boys [50.5%]; 6334 [64.4%] aged 2-5 years), the intervention group showed significant improvements compared with the control group from times 1 to 3 in prevalence of overweight plus obesity (d = -12.60% [95% CI, -20.92% to -4.28%]), waist circumference (d = -1.64 [95% CI, -2.87 to -0.41] cm), and acanthosis nigricans prevalence (d = -3.55% [95% CI, -6.17% to -0.92%]). Significant improvements were also observed from times 2 to 3 in prevalence of overweight plus obesity (d = -8.73% [95% CI, -15.86% to -1.60%]) but not in waist circumference (d = -0.81 [95% CI, -1.85 to 0.23] cm). Conclusions and Relevance: This randomized clinical trial found that the outcomes of the Children's Healthy Living intervention were maintained and enhanced 6 years after the intervention among young children in the US-affiliated Pacific region. The prevalence of overweight, obesity, and acanthosis nigricans was further reduced in communities, suggesting that multilevel multicomponent interventions may help reduce child overweight and obesity in this region. Trial Registration: ClinicalTrials.gov Identifier: NCT01881373.

Associations between Cultural Identity, Household Membership and Diet Quality among Native Hawaiian, Pacific Islander, and Filipino Infants in Hawai'i.

Public health efforts to reduce diet-related health disparities experienced by indigenous peoples could be enhanced by efforts to improve complementary infant feeding practices. The latter is possible through interventions informed by cultural determinants. This cross-sectional secondary analysis explored possible determinants of the complementary feeding practices of Native Hawaiian, Pacific Islander, and/or Filipino infants (NHPIF) in Hawai'i, ages 3-12 months. The objective was to determine the association between caregiver cultural identity and infant household membership with indicators of infant diet healthfulness. The cultural identities, infant household memberships, early infant feeding practices and additional demographic information (infant age and sex, household income) were assessed via an online questionnaire. Surrogate reporting of the infants' diets over four days was evaluated using an image-based mobile food record (mFR). Data collected by the mFR were evaluated to derive the World Health Organization's minimum dietary diversity (MDD) indicator and food group consumption. Data were summarized by descriptive statistics and analyzed using multivariate linear and logistic regressions. Seventy infant participants, ages 3-12 months, and their primary caregivers completed the study. Of these, there were 56 infant participants between the age of 6-12 months. Approximately 10% of infants, ages 6-12 months, met MDD for all four days. Meeting MDD and the number of food groups consumed were significantly associated with age. Caregiver cultural identity, infant household membership and infant sex had non-significant associations with indicators of infant diet quality. Findings inform the influences shaping dietary patterns of Native Hawaiian, Pacific Islander and Filipino infants in Hawai'i.

Prediction of breast cancer risk among women of the Mariana Islands: the BRISK retrospective case-control study.

OBJECTIVES: To develop a breast cancer risk prediction model for Chamorro and Filipino women of the Mariana Islands and compare its performance to that of the Breast Cancer Risk Assessment Tool (BCRAT). DESIGN: Case-control study. SETTING: Clinics/facilities and other community-based settings on Guam and Saipan (Northern Mariana Islands). PARTICIPANTS: 245 women (87 breast cancer cases and 158 controls) of Chamorro or Filipino ethnicity, age 25-80 years, with no prior history of cancer (other than skin cancer), residing on Guam or Saipan for at least 5 years. PRIMARY AND SECONDARY OUTCOME MEASURES: Breast cancer risk models were constructed using combinations of exposures previously identified to affect breast cancer risk in this population, population breast cancer incidence rates and all-cause mortality rates for Guam. RESULTS: Models using ethnic-specific relative risks performed better than those with relative risks estimated from all women. The model with the best performance among both ethnicities (the Breast Cancer Risk Model (BRISK) model; area under the receiver operating characteristic curve (AUC): 0.64 and 0.67 among Chamorros and Filipinos, respectively) included age at menarche, age at first live birth, number of relatives with breast cancer and waist circumference. The 10-year breast cancer risk predicted by the BRISK model was 1.28% for Chamorros and 0.89% for Filipinos. Performance of the BCRAT was modest among both Chamorros (AUC: 0.60) and Filipinos (AUC: 0.55), possibly due to incomplete information on BCRAT risk factors. CONCLUSIONS: The ability to develop breast cancer risk models for Mariana Islands women is constrained by the small population size and limited availability of health services and data. Nonetheless, we have demonstrated that breast cancer risk prediction models with adequate discriminatory performance can be built for small populations such as in the Mariana Islands. Anthropometry, in particular waist circumference, was important for estimating breast cancer risk in this population.

Dietary and Complementary Feeding Practices of US Infants, 6 to 12 Months: A Narrative Review of the Federal Nutrition Monitoring Data.

Complementary foods and beverages (CFBs) are key components of an infant's diet in the second 6 months of life. This article summarizes nutrition and feeding practices examined by the 2020 Dietary Guidelines Advisory Committees during the CFB life stage. Breastfeeding initiation is high (84%), but exclusive breastfeeding at 6 months (26%) is below the Healthy People 2030 goal (42%). Most infants (51%) are introduced to CFBs sometime before 6 months. The primary mode of feeding (ie, human milk fed [HMF]; infant formula or mixed formula and human milk fed [FMF]) at the initiation of CFBs is associated with the timing of introduction and types of CFBs reported. FMF infants (42%) are more likely to be introduced to CFBs before 4 months compared with HMF infants (19%). Different dietary patterns, such as higher prevalence of consumption and mean amounts, were observed, including fruit, grains, dairy, proteins, and solid fats. Compared with HMF infants of the same age, FMF infants consume more total energy (845 vs 631 kcal) and protein (22 vs 12 g) from all sources, and more energy (345 vs 204 kcal) and protein (11 vs 6 g) from CFBs alone. HMF infants have a higher prevalence of risk of inadequate intakes of iron (77% vs 7%), zinc (54% vs <3%), and protein (27% vs <3%). FMF infants are more likely to have an early introduction (<12 months) to fruit juice (45% vs 20%) and cow's milk (36% vs 24%). Registered dietitian nutritionists and nutritional professionals should consider tailoring their advice to caregivers on dietary and complementary feeding practices, taking into account the primary mode of milk feeding during this life stage to support infants' nutrient adequacy. National studies that address the limitations of this analysis, including small sample sizes and imputed breast milk volume, could refine findings from this analysis.