Momentary Factors and Study Characteristics Associated With Participant Burden and Protocol Adherence: Ecological Momentary Assessment.

BACKGROUND: Ecological momentary assessment (EMA) has become a popular mobile health study design to understand the lived experiences of dynamic environments. The numerous study design choices available to EMA researchers, however, may quickly increase participant burden and could affect overall adherence, which could limit the usability of the collected data. OBJECTIVE: This study quantifies what study design, participant attributes, and momentary factors may affect self-reported burden and adherence. METHODS: The EMA from the Phase 1 Family Matters Study (n=150 adult Black, Hmong, Latino or Latina, Native American, Somali, and White caregivers; n=1392 observation days) was examined to understand how participant self-reported survey burden was related to both design and momentary antecedents of adherence. The daily burden was measured by the question "Overall, how difficult was it for you to fill out the surveys today?" on a 5-item Likert scale (0=not at all and 4=extremely). Daily protocol adherence was defined as completing at least 2 signal-contingent surveys, 1 event-contingent survey, and 1 end-of-day survey each. Stress and mood were measured earlier in the day, sociodemographic and psychosocial characteristics were reported using a comprehensive cross-sectional survey, and EMA timestamps for weekends and weekdays were used to parameterize time-series models to evaluate prospective correlates of end-of-day study burden. RESULTS: The burden was low at 1.2 (SD 1.14) indicating "a little" burden on average. Participants with elevated previous 30-day chronic stress levels (mean burden difference: 0.8; P=.04), 1 in 5 more immigrant households (P=.02), and the language primarily spoken in the home (P=.04; 3 in 20 more non-English-speaking households) were found to be population attributes of elevated moderate-high burden. Current and 1-day lagged nonadherence were correlated with elevated 0.39 and 0.36 burdens, respectively (P=.001), and the association decayed by the second day (ß=0.08; P=.47). Unit increases in momentary antecedents, including daily depressed mood (P=.002) and across-day change in stress (P=.008), were positively associated with 0.15 and 0.07 higher end-of-day burdens after controlling for current-day adherence. CONCLUSIONS: The 8-day EMA implementation appeared to capture momentary sources of stress and depressed mood without substantial burden to a racially or ethnically diverse and immigrant or refugee sample of parents. Attention to sociodemographic attributes (eg, EMA in the primary language of the caregiver) was important for minimizing participant burden and improving data quality. Momentary stress and depressed mood were strong determinants of participant-experienced EMA burden and may affect adherence to mobile health study protocols. There were no strong indicators of EMA design attributes that created a persistent burden for caregivers. EMA stands to be an important observational design to address dynamic public health challenges related to human-environment interactions when the design is carefully tailored to the study population and to study research objectives.

Young Adult Physical Activity Trajectories and Midlife Nonalcoholic Fatty Liver Disease.

Importance: Physical activity (PA) is recommended for preventing and treating nonalcoholic fatty liver disease (NAFLD). Yet, how long-term patterns of intensity-based physical activity, including moderate-intensity PA (MPA) and vigorous-intensity PA (VPA), might affect the prevalence of NAFLD in middle age remains unclear. Objective: To identify distinct intensity-based PA trajectories from young to middle adulthood and examine the associations between PA trajectories and NAFLD prevalence in midlife. Design, Setting, and Participants: This population-based cohort of 2833 participants used the Coronary Artery Risk Development in Young Adults study data. The setting included field clinics in Birmingham, Alabama; Chicago, Illinois; Minneapolis, Minnesota; and Oakland, California. Data analysis was completed in March 2023. Exposures: PA was self-reported at 8 examinations over 25 years (1985-1986 to 2010-2011) and separately scored for MPA and VPA. Main Outcomes and Measures: NAFLD was defined as liver attenuation values less than 51 Hounsfield units after exclusion of other causes of liver fat, measured using computed tomography in year 25 (2010-2011). Results: Among a total of 2833 participants included in the sample, 1379 (48.7%) self-identified as Black, 1454 (51.3%) as White, 1206 (42.6%) as male, and 1627 (57.4%) as female from baseline (1985-1986) (mean [SD] age, 25.0 [3.6] years) to year 25 (2010-2011) (mean [SD] age, 50.1 [3.6] years). Three MPA trajectories were identified: very low stable (1514 participants [53.4%]), low increasing (1096 [38.7%]), and moderate increasing (223 [7.9%]); and 3 VPA trajectories: low stable (1649 [58.2%]), moderate decreasing (1015 [35.8%]), and high decreasing (169 [6.0%]). After adjustment for covariates (sex, age, race, study center, education, smoking status, and alcohol consumption), participants in the moderate decreasing (risk ratio [RR], 0.74; 95% CI, 0.54-0.85) and the high decreasing (RR, 0.59; 95% CI, 0.44-0.80) VPA trajectories had a lower risk of NAFLD in middle age, relative to participants in the low stable VPA trajectory. Adjustments for baseline body mass index and waist circumference attenuated these estimates, but the results remained statistically significant. The adjusted RRs across the MPA trajectories were close to null and not statistically significant. Conclusions and Relevance: This cohort study of Black and White participants found a reduced risk of NAFLD in middle age for individuals with higher levels of VPA throughout young to middle adulthood compared with those with lower VPA levels. These results suggest the need for promoting sustainable and equitable prevention programs focused on VPA over the life course to aid in lowering NAFLD risk.

Adapting a US dietary analysis software and nutrient database for use in Brazil.

In many countries, assessing food and nutrient intake for research and surveillance purposes is difficult due to the lack of comprehensive, country-specific food and nutrient databases and/or a dietary analysis software program. In this case study, we describe the approach used to adapt a United States (US) dietary analysis software and nutrient database (Nutrition Data System for Research [NDSR]) for use in analyzing 24-hour dietary recalls collected for the Brazil Kids Nutrition and Health Study (KNHS). A team of experts that included individuals knowledgeable about Brazil and US eating traditions was assembled to devise solutions for between-country differences in eating habits, food supply, food nomenclature, and language. Solutions devised relied on several key resources, including the Brazilian Food Composition Table (TBCA) and a list of 200 foods commonly consumed in Brazil. These solutions included creating data entry rules that specified how each reported food should be entered into NDSR, creation of User Recipes for foods lacking a close nutritionally matching food in the NDSR database, and adjustment for food fortification differences as part of the analysis of study data. This case study illustrates that NDSR can be adapted for use outside of the United States through a structured process.

Real-time predictors of food parenting practices and child eating behaviors in racially/ethnically diverse families.

BACKGROUND: Prior research has shown associations between controlling food parenting practices (e.g., pressure-to-eat, restriction) and factors that increase risk for cardiovascular disease in children (e.g., low diet quality, obesity). This study aimed to examine associations between real-time parental stress and depressed mood, food parenting practices, and child eating behaviors in a longitudinal cohort study. METHODS: Children ages 5-9 years and their families (n = 631) from six racial/ethnic groups (African American, Hispanic, Hmong, Native American, Somali/Ethiopian, White) were recruited for this study through primary care clinics in a large metromolitan area in the US (Minneapolis/St. Paul, MN) in 2016-2019. Ecological momentary assessment was carried out over seven days with parents at two time points, 18 months apart. Adjusted associations between morning stress and depressed mood of parents on food parenting practices and child eating behaviors at the evening meal were examined. Interactions tested whether food security, race/ethnicity and child sex moderated associations. RESULTS: High levels of parental stress and depressed mood experienced earlier in the day were associated with controlling food parenting practices and child food fussiness at dinner the same night. Results were dependent on food security status, race/ethnicity, and child sex. CONCLUSIONS: Health care professionals may want to consider, or continue, screening parents for stress, depression, and food insecurity during well-child visits and discuss the influence these factors may have on food parenting practices and child eating behaviors. Future research should use real-time interventions such as ecological momentary intervention to reduce parental stress and depressed mood to promote healthy food parenting practices and child eating behaviors.

Body Mass Index Trajectories and Biomarkers of Cardiometabolic Risk in Children from Low-Income and Racially and Ethnically Diverse Households.

Background: This study examined the associations between BMI trajectories and emerging cardiometabolic risk (CMR) in children living in low-income and racially and ethnically diverse households in the United States. Methods: Data were drawn from NET-Works randomized intervention trial and NET-Works 2 prospective follow-up study (N = 338). BMI was measured across 6 follow-up visits and biomarkers of cardiometabolic risk (CMR) at the sixth visit. Group-based trajectory modeling identified child BMI trajectories. Adjusted multivariable linear regressions evaluated the associations between BMI trajectories and CMR. Results: We identified two BMI trajectories: 25% followed a trajectory of steep BMI increase, and 75% followed a moderate decreasing BMI trajectory over time. Relative to children in the moderate decreasing trajectory, children in the increasing trajectory had higher adjusted mean levels of C-reactive protein [CRP; 3.3; 95% confidence interval (CI): 1.6 to 5.0], leptin (63.1; 95% CI: 44.3 to 81.8), triglycerides (35.4; 95% CI: 22.1 to 48.6), triglyceride/high-density lipoprotein (HDL) ratio (1.2; 95% CI: 0.8 to 1.6), hemoglobin A1c (HbA1C; 0.1; 95% CI: 0.03 to 0.2), fasting glucose (1.8; 0.1 to 3.5) and insulin (8.8; 95% CI: 6.5 to 11.0), overall CMR score (0.7; 95% CI: 0.5 to 0.9), and lower adiponectin (-1.3; 95% CI: -2.5 to -0.1) and HDL (-10.8; 95% CI: -14.3 to -7.4). Conclusions: Children with high BMIs early in childhood were more likely to maintain an accelerated BMI trajectory throughout childhood, which was associated with adverse CMR in pre-adolescence. To advance health equity and support children's healthy weight and cardiovascular health trajectories, public health efforts are needed to address persistent disparities in childhood obesity and CMR.

Household food insecurity is associated with greater prevalence and 18-month incidence of a range of disordered eating behaviors in a racially and ethnically diverse sample of parents.

This study examined cross-sectional and longitudinal associations between household food insecurity (FI) and a range of disordered eating behaviors (DEBs) and explored whether associations differ by Supplemental Nutrition Assistance Program (SNAP)/Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation. Data came from 1120 racially/ethnically diverse parents (Mage = 35.7 ± 7.8 years at baseline) in the Family Matters longitudinal cohort study. Parents reported on household FI and SNAP/WIC participation at baseline, and on past-year restrictive weight-control behaviors (WCBs; e.g., fasting), compensatory WCBs (e.g., self-induced vomiting), and binge eating at baseline and 18-month follow-up. Sociodemographics-adjusted modified Poisson regressions examined baseline household FI in relation to baseline prevalence and 18-month incidence (i.e., new onset) of each type of DEB. Moderation by SNAP/WIC participation was also tested. Household FI affected 29.6 % of participants and was associated with significantly greater baseline prevalence (prevalence ratios ranging from 1.38 to 2.69) and 18-month incidence (risk ratios ranging from 1.63 to 2.93) of each type of DEB examined. The association between household FI and incident compensatory WCBs differed significantly by SNAP/WIC participation, such that household FI significantly predicted new-onset compensatory WCBs at follow-up only among those participating in SNAP/WIC. Results from this study are the first, to our knowledge, to demonstrate that FI is longitudinally associated with restrictive and compensatory DEBs, thereby highlighting FI as a risk factor not only for binge eating, but for a range of DEBs. These findings emphasize the importance of screening for FI in clinical settings and the need to address structural barriers to food security.

Effect of Weight Goals on Sitting and Moving During a Worksite Sedentary Time Reduction Intervention.

Introduction/Purpose: Although many US adults report trying to lose weight, little research has examined weight loss goals as a motivator for reducing workplace sitting and increasing physical activity. This exploratory analysis examined weight goals and the association with changes in workplace sitting, physical activity, and weight. Methods: Employees (N = 605) were drawn from worksites participating in Stand and Move at Work. Worksites (N = 24) were randomized to a multilevel behavioral intervention with (STAND+) or without (MOVE+) sit-stand workstations for 12 months; MOVE+ worksites received sit-stand workstations from 12 to 24 months. At each assessment (baseline and 3, 12, and 24 months), participants were weighed and wore activPAL monitors. Participants self-reported baseline weight goals and were categorized into the "Lose Weight Goal" (LWG) group if they reported trying to lose weight or into the "Other Weight Goal" (OWG) group if they did not. Results: Generalized linear mixed models revealed that within STAND+, LWG and OWG had similar sitting time through 12 months. However, LWG sat significantly more than OWG at 24 months. Within MOVE+, sitting time decreased after introduction of sit-stand workstations for LWG and OWG, although LWG sat more than OWG. Change in physical activity was minimal and weight remained stable in all groups. Conclusions: Patterns of change in workplace sitting were more favorable in OWG relative to LWG, even in the absence of notable weight change. Expectations of weight loss might be detrimental for reductions in workplace sitting. Interventionists may want to emphasize non-weight health benefits of reducing workplace sitting.

Maternal employment and child weight-related health.

Several studies have documented a link between maternal employment and childhood obesity, but the mechanisms are not clear. This study investigated the association of maternal employment with children's weight status and detailed weight-related behaviors using data from Phase I of Family Matters, a cross-sectional, observational study of 150 children aged 5-8 from six racial/ethnic groups (White, Black, Latinx, Native American, Hmong, and Somali) and their families from the Minneapolis/St. Paul, MN metropolitan area recruited in 2015-2016. Weight status (objectively measured), child dietary intake (three 24-h dietary recalls), physical activity (eight days of hip-mounted accelerometer data on children), and sleep (eight daily parent reports on children's sleep hours) were examined across four categories of maternal employment status: stay-at-home caregivers, working part-time, working full-time, and unemployed/unable to work. This study found that children's weight status and physical activity levels were similar across all categories of maternal employment. However, there were significant differences in aspects of children's diets by maternal employment status and, compared to children with stay-at-home mothers, children's sleep was significantly lower if their mother worked full-time. These findings highlight that dietary and sleep interventions tailored to the mother's employment status may be fruitful.

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

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

Exploring associations between social determinants of health and mental health outcomes in families from socioeconomically and racially and ethnically diverse households.

This cross-sectional study investigated the associations between Social Determinants of Health (SDOH) and mental health outcomes of parents and children (n = 1307) from the Latinx, Native American, Somali/Ethiopian, White, Hmong, and African American communities. Logistic regression models were used to estimate the adjusted associations between five parent and child mental health measures and 25 measures of SDOH. False discovery rate q-values were computed to account for multiple comparisons. Families of color reported 5.3-7.8 SDOH barriers while White families reported 1.7 SDOH barriers on average. Adjusted analyses indicated that low family functioning and high perceived discrimination were associated with low resiliency among parents and increased behavioral difficulties among children. Other SDOH that were adversely associated with parent or child mental health included lack of social support, recent stressful life events, and adverse childhood experiences among parents. SDOH in the social and community context were most likely to be associated with mental health problems. Community-engaged evidence-based interventions are needed to improve population mental health.

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

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

Ecological Momentary Assessment of Weight-Related Behaviors in the Home Environment of Children From Low-Income and Racially and Ethnically Diverse Households: Development and Usability Study.

BACKGROUND: Ecological momentary assessment (EMA) is an innovative tool for capturing in-the-moment health behaviors as people go about their daily lives. EMA is an ideal tool to measure weight-related behaviors, such as parental feeding practices, stress, and dietary intake, as these occur on a daily basis and vary across time and context. A recent systematic review recommended standardized reporting of EMA design for studies that address weight-related behaviors. OBJECTIVE: To answer the call for reporting study designs using EMA, this paper describes in detail the EMA design of the Family Matters study and how it was adapted over time to improve functionality and meet the needs of a racially, ethnically, and socioeconomically diverse sample. METHODS: Family Matters is an incremental, 2-phased, mixed methods study, conducted with a racially and ethnically diverse, immigrant and refugee sample from largely low-income households, designed to examine risk and protective factors for child weight and weight-related behaviors in the home environment. The Family Matters study intentionally recruited White, Black, Hmong, Latino, Native American, and Somali parents with young children. Parents in phase 1 of the study completed 8 days of EMA on their smartphones, which included signal-contingent surveys (eg, asking about the parent's stress at the time of the survey), event-contingent surveys (eg, descriptions of the meal the child ate), and end-of-day surveys (eg, overall assessment of the child's day). RESULTS: A detailed description of EMA strategies, protocols, and methods used in phase 1 of the Family Matters study is provided. Compliance with EMA surveys and participants' time spent completing EMA surveys are presented and stratified by race and ethnicity. In addition, lessons learned while conducting phase 1 EMA are shared to document how EMA methods were improved and expanded upon for phase 2 of the Family Matters study. CONCLUSIONS: The results from this study provided an important next step in identifying best practices for EMA use in assessing weight-related behaviors in the home environment. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/30525.

Changes in Physical Activity and Sedentary Behaviors During COVID-19: Associations with Psychological Distress Among Mothers.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic increased mothers' caregiving demands, potentially placing them at increased risk for reduced engagement in healthful behaviors and high psychological distress. PURPOSE: The purpose of this study was to describe perceived changes in moderate-vigorous physical activity (MVPA) and sedentary behaviors and the prevalence of different measures of psychological distress (depressive and anxiety symptoms, perceived stress, and positive and negative affect) among mothers. We also evaluated the associations of perceived change in MVPA and sedentary behaviors with measures of psychological distress. METHODS: We conducted a cross-sectional survey with 317 mothers living with children (0-20 years old) at home. Mothers self-reported perceived changes in MVPA and sedentary behaviors from before the pandemic to during COVID-19 stay-at-home orders and early reopening, and levels of depression and anxiety symptomatology, perceived stress, and positive and negative affect during the pandemic. RESULTS: Compared to pre-pandemic levels, 39% of mothers reported engaging less in MVPA, and 63% reported engaging in more sedentary activities. One-quarter and 31% of mothers reported moderate/severe depressive and anxiety symptoms, respectively, and 78% medium/high levels of perceived stress. Adjusted linear regression analyses revealed that reduced MVPA and increased sedentary behaviors were associated with high average scores of depressive and anxiety symptoms, perceived stress, negative affect, and low scores of positive affect. CONCLUSION: A large proportion of mothers reported being less physically active and more engaged in sedentary behaviors, which were associated with increases in psychological distress. Clinical and public health intervention efforts should consider how to improve mothers' physical and mental health as the country emerges from this crisis.

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

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

Efficacy of the 'Stand and Move at Work' multicomponent workplace intervention to reduce sedentary time and improve cardiometabolic risk: a group randomized clinical trial.

BACKGROUND: Sedentary time is associated with chronic disease and premature mortality. We tested a multilevel workplace intervention with and without sit-stand workstations to reduce sedentary time and lower cardiometabolic risk. METHODS: Stand and Move at Work was a group (cluster) randomized trial conducted between January 2016 and December 2017 among full-time employees; ≥18 years; and in academic, industry/healthcare, and government worksites in Phoenix, Arizona and Minneapolis/St. Paul, Minnesota, USA. Eligible worksites were randomized to (a) MOVE+, a multilevel intervention targeting reduction in sedentary time and increases in light physical activity (LPA); or (b) STAND+, the MOVE+ intervention along with sit-stand workstations to allow employees to sit or stand while working. The primary endpoints were objectively-measured workplace sitting and LPA at 12 months. The secondary endpoint was a clustered cardiometabolic risk score (blood pressure, glucose, insulin, triglycerides, and HDL-cholesterol) at 12 months. RESULTS: Worksites (N = 24; academic [n = 8], industry/healthcare [n = 8], and government [n = 8] sectors) and employees (N = 630; 27 ± 8 per worksite; 45 ± 11 years of age, 74% female) were enrolled. All worksites were retained and 487 participants completed the intervention and provided data for the primary endpoint. The adjusted between arm difference in sitting at 12 months was - 59.2 (CI: - 74.6,-43.8) min per 8 h workday, favoring STAND+, and in LPA at 12 months was + 2.2 (- 0.9,5.4) min per 8 h workday. Change in the clustered metabolic risk score was small and not statistically significant, but favored STAND+. In an exploratory subgroup of 95 participants with prediabetes or diabetes, the effect sizes were larger and clinically meaningful, all favoring STAND+, including blood glucose, triglycerides, systolic blood pressure, glycated hemoglobin, LDL-cholesterol, body weight, and body fat. CONCLUSIONS: Multilevel workplace interventions that include the use of sit-stand workstations are effective for large reductions in sitting time over 12 months. Among those with prediabetes or diabetes, clinical improvements in cardiometabolic risk factors and body weight may be realized. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02566317 . Registered 2 October 2015, first participant enrolled 11 January 2016.

Associations Between Parent Self-Reported and Accelerometer-Measured Physical Activity and Sedentary Time in Children: Ecological Momentary Assessment Study.

BACKGROUND: Retrospective self-report questionnaires are the most common method for assessing physical activity (PA) and sedentary behavior (SB) in children when the use of objective assessment methods (eg, accelerometry) is cost prohibitive. However, self-report measures have limitations (eg, recall bias). The use of real-time, mobile ecological momentary assessment (EMA) has been proposed to address these shortcomings. The study findings will provide useful information for researchers interested in using EMA surveys for measuring PA and SB in children, particularly when reported by a parent or caregiver. OBJECTIVE: This study aimed to examine the associations between the parent's EMA report of their child's PA and SB and accelerometer-measured sedentary time (ST), light-intensity PA (LPA), and moderate-to-vigorous-intensity PA (MVPA) and to examine if these associations differed by day of week, sex, and season. METHODS: A total of 140 parent-child dyads (mean child age 6.4 years, SD 0.8; n=66 girls; n=21 African American; n=24 American Indian; n=25 Hispanic/Latino; n=24 Hmong; n=22 Somali; and n=24 white) participated in this study. During an 8-day period, parents reported child PA and SB via multiple daily signal contingent EMA surveys, and children wore a hip-mounted accelerometer to objectively measure ST, LPA, and MVPA. Accelerometer data was matched to the time period occurring before parent EMA-report of child PA and SB. Generalized estimating equations with interaction-term analyses were performed to determine whether the relationship between parent-EMA report of child PA and SB and accelerometer-measured ST and LPA and MVPA outcomes differed by day of the week, sex and season. RESULTS: The parent's EMA report of their child's PA and SB was strongly associated with accelerometer-measured ST, LPA, and MVPA. The parent's EMA report of their child's PA was stronger during the weekend than on weekdays for accelerometer-measured ST (P≤.001) and LPA (P<.001). For the parent's EMA report of their child's SB, strong associations were observed with accelerometer-measured ST (P<.001), LPA (P=.005), and MVPA (P=.008). The findings related to sex-interaction terms indicated that the association between the parent-reported child's PA via EMA and the accelerometer-measured MVPA was stronger for boys than girls (P=.02). The association between the parent's EMA report of their child's PA and SB and accelerometer-measured ST and PA was similar across seasons in this sample (all P values >.31). CONCLUSIONS: When the use of accelerometry-based methods is not feasible and in contexts where the parent is able to spend more proximate time observing the child's PA and SB, the parent's EMA report might be a superior method for measuring PA and SB in young children relative to self-report, given the EMA's strong associations with accelerometer-measured PA and ST.

The effect of green walking on heart rate variability: A pilot crossover study.

We investigated the effects of regular walking in green and suburban environments on heart rate variability (HRV) and blood pressure (BP) in middle-aged adults. Twenty-three adults participated in a non-randomized crossover experiment comprised of once-weekly 50-min moderate-intensity walking sessions. Separated by a two-week washout period, participants walked for three weeks in each of two treatment conditions (green and suburban) in a local arboretum and suburban sidewalks of Chaska, MN. Eleven participants completed green walking first and 12 suburban walking first. Walks were split into 15-min intra-walk phases, with phases representing each walk's beginning, middle, and final 15-min. Repeated measures linear mixed models evaluated (1) HRV phase differences between treatments and HRV change within treatments, and (2) pre- and post-walk BP differences between treatments and pre-to post-walk BP changes. Intra-walk phase analyses revealed higher HRV during green walking vs. suburban walking during phase 2 (p < 0.0001) and phase 3 (p = 0.02). Less HRV reduction was seen between intra-walk phases 1 and 2 during green vs. suburban walking (p = 0.02). Pre-to post-walk changes revealed decreased mean systolic BP for both green (p = 0.0002) and suburban (p = 0.003) walking conditions, but not for diastolic BP. Post-walk BP results were similar after both green walking and suburban walking. In summary, walking sessions in a green environment elicited greater beneficial HRV responses compared to a suburban environment. Additionally, walking in either environment, green or suburban, promoted reductions in systolic BP.

Walking Green: Developing an Evidence Base for Nature Prescriptions.

Although the health benefits of exercise and exposure to nature are well established, most evidence of their interaction comes from acute observations of single sessions of activity. However, documenting improved health outcomes requires ongoing interventions, measurement of multiple outcomes, and longitudinal analyses. We conducted a pilot study to guide the development of a protocol for future longitudinal studies that would assess multiple physiological and psychological outcomes. Herein, we report psychological outcomes measured from thirty-eight participants before and after three conditions: a 50 min walk on a forest path, a 50 min walk along a busy road, and a period of activities of daily living. Changes in positive and negative affect, anxiety, perceived stress, and working memory are reported. We benchmark these results to existing studies that used similar protocols and also identify elements of the protocol that might impair recruitment or retention of subjects in longer-term studies. Linear mixed-models regression revealed that walking improved psychological state when compared to activities of daily living, regardless of walk environment (p < 0.05). Comparison of mean differences showed that forest walks yielded the largest and most consistent improvements in psychological state. Thus, despite a protocol that required a 3.5 h time commitment per laboratory visit, the beneficial effects of walking and exposure to a forested environment were observed.

Changes in Psychological and Cognitive Outcomes after Green versus Suburban Walking: A Pilot Crossover Study.

This study investigated the acute effects of repeated walking sessions within green and suburban environments on participants' psychological (anxiety and mood) and cognitive (directed-attention) outcomes. Twenty-three middle-aged adults (19 female) participated in a non-randomized crossover study comprised of once-weekly 50-min moderate-intensity walking sessions. Participants walked for three weeks in each of two treatment conditions: green and suburban, separated by a two-week washout period. Eleven participants completed green walking first and 12 suburban walking first. For each walk, we used validated psychological questionnaires to measure pre- and post-walk scores for: (1) mood, evaluated via the Positive and Negative Affect Schedule (PANAS); (2) anxiety, assessed by the State-Trait Anxiety Inventory (STAI-S); and (3) directed-attention, measured using the visual Backwards Digit Span test (BDS). Repeated measures linear mixed models assessed pre- to post-walk changes within-treatment conditions and post-walk contrasts between-treatment conditions. Results indicated that anxiety decreased after green walking and increased after suburban walking (-1.8 vs. +1.1 units, respectively; p = 0.001). For mood, positive affect improved after green walking and decreased after suburban walking (+2.3 vs. -0.3 units, respectively; p = 0.004), and negative affect decreased after green walking and remained similar after suburban walking (-0.5 vs. 0 units, respectively; p = 0.06). Directed-attention did not improve from pre- to post-walk for either condition. Our results suggested that green walking may be more effective at reducing state anxiety and increasing positive affect compared to suburban walking.