Environmental, Socioeconomic, Maternal, and Breastfeeding Factors Associated with Childhood Overweight and Obesity in Ceará, Brazil: A Population-Based Study.

Childhood obesity is now an epidemic in many countries worldwide and is known to be a multifactorial condition. We aimed to examine the relationship of environmental, socioeconomic, and nutritional factors with childhood overweight and obesity. We conducted a population-based cross-sectional study of children from 2 to 6 years of age in Ceará, Brazil. Children's nutritional status was assessed by body mass index (BMI) Z scores categorized as overweight and obesity. Ordinal logistic regression models were used to assess the relationship between the factors with overweight and obesity. A total of 2059 children participated, of which 50.4% were male. The mean age was 46 ± 17 months, with a prevalence of overweight and obesity of 12.0% (95% CI 10.7-13.6) and 8.0% (6.7-9.5), respectively. In multivariate analysis, the probability of childhood obesity increased as family income increased (adjusted hazard ratio (aHR) 0.6 (95% CI 0.37-0.95), p-value = 0.03). Moreover, families with fewer children had more than 30% fewer overweight children (aHR 0.68; 95% CI 0.48-0.96). Environmental, socioeconomic, and child nutritional factors were associated with overweight and obesity. The results provided could be used to design integrated interventions spanning from conception, or earlier, through the first years of life and may improve child nutritional outcomes.

Latino parents' perceptions of the eating and physical activity experiences of their pre-school children at home and at family child-care homes: a qualitative study.

OBJECTIVE: Research indicates that healthful eating and physical activity (PA) practices implemented in child-care settings can have a positive effect on children's healthful behaviours in this setting, and this effect on healthful behaviours may possibly transfer to the home environment. While more research is needed to examine whether behaviours learned in family child-care homes (FCCH) transfer, the potential for transferability is especially important given that Latino children's home environment has been characterized by obesogenic parenting practices. We aimed to examine Latino parents' perceptions of their pre-school children's eating and PA experiences at home and at FCCH. DESIGN: Qualitative study. Six focus groups were conducted in Spanish (n 36). Transcripts were analysed using thematic analysis to identify key concepts and themes. RESULTS: Analyses revealed that Latino parents perceive their children have healthier eating and PA experiences at FCCH than at home. Parents attributed this to FCCH providers providing an environment conducive to healthful eating and PA due to providers having more knowledge and skills, time and resources, and being required to follow rules and regulations set by the state that promote healthful eating and PA. CONCLUSIONS: Understanding parental perceptions, attitudes and practices related to establishing and maintaining an environment conducive to children's healthful eating and PA at home and at the FCCH is essential for the design of successful interventions to promote children's healthful behaviours in these two settings. Given that parents perceive their children as having more healthful behaviours while at FCCH, interventions that address both settings jointly may be most effective than those addressing only one environment by itself.

Access and utilization of healthcare services in Massachusetts, United States: a qualitative study of the perspectives and experiences of Brazilian-born immigrant women.

BACKGROUND: Understanding immigrants' interactions with the United States (US) healthcare system will likely make it possible to meet their healthcare needs and improve their quality of life in the US. Although challenges to accessing and utilizing healthcare in the US have been identified, there is little information specific to Brazilian-born immigrants' experiences. Brazilians comprise a fast-growing immigrant population group in the US. The purpose of this study was to explore Brazilian immigrant women's perspectives and experiences with healthcare services in the US to gain insights into factors amenable to interventions that may contribute to disparities in access to and utilization of services. METHODS: Five focus groups were conducted from April to May in 2015 using a purposeful sampling of Brazilian-born immigrant women living in Massachusetts, US. RESULTS: Thirty-five women participated in this study. Although participants expressed their overall satisfaction with the US healthcare system, they noted several barriers to care, including sociocultural differences in delivery of care and communication barriers, including inconsistent quality of interpreting services. CONCLUSIONS: This study provides new information on the experiences and challenges faced by Brazilian immigrant women in accessing and utilizing healthcare services in the US and points out opportunities for improving services and the overall health of this immigrant population. Addressing noted sociocultural differences and communication barriers including inconsistent quality of hospital's interpreting services might enhance Brazilian-born immigrants' experiences with the healthcare system.

Latino family childcare providers' beliefs, attitudes, and practices related to promotion of healthy behaviors among preschool children: a qualitative study.

BACKGROUND: The continuing rise of obesity among Latinos is a public health concern with an immediate need for early prevention. Changes in family structures have increased demand and reliance for child care for young children. Latino children are the fastest-growing segment of the child population in the United States, and research shows that Latino families use preschools and day care centers much less than those of other ethnic groups, apparently because of cultural preferences for family-like care. OBJECTIVES: Given that many low income Latino children attend family child care homes (FCCHs), there is a need to explore the role that FCCH providers may play in establishing and reinforcing children's early healthful eating and physical activity behaviors and consequently in the prevention of childhood obesity. DESIGN: Using purposive sampling, six focus groups were conducted in Spanish with licensed Latino FCCH providers (n = 44). Data was analyzed to identify recurrent themes. RESULTS: Latino FCCH providers described how they play an influential role in promoting healthful eating and physical activity behaviors of preschool children in their care. They also identified many barriers and challenges in establishing and maintaining healthful nutrition and physical activity behaviors, including high cost of healthy foods, cold weather, and physical environment of FCCH. CONCLUSIONS: Latino FCCH providers can have a strong impact in promoting healthful behaviors in low-income, Latino communities. They may be able to effectively deliver interventions targeting low-income, minority families to promote healthful eating and physical activity behaviors and prevent child obesity.

A qualitative study of diverse experts' views about barriers and strategies to improve the diets and health of Supplemental Nutrition Assistance Program (SNAP) beneficiaries.

The Supplemental Nutrition Assistance Program (SNAP), the largest federal food assistance program, currently serves 44.7 million Americans with a budget of $75 billion in 2011. This study engaged leading experts for in-depth, semi-structured interviews to explore their opinions concerning the existing challenges and barriers to eating nutritiously in SNAP. Experts also proposed strategies for improving nutritional status among SNAP recipients. Twenty-seven individuals were interviewed from advocacy, government, industry, and research organizations. Interviews were recorded, transcribed, coded, and analyzed for thematic content. The high cost of nutrient-rich foods, inadequate SNAP benefits, limited access to purchasing healthy foods, and environmental factors associated with poverty were identified as barriers that influence nutrition among low-income households in the United States. Six themes emerged among respondents from diverse sectors about how to address these challenges, including providing SNAP participants with incentives to purchase nutrient-rich food consistent with the 2010 Dietary Guidelines for Americans, restricting the purchase of nutrient-poor foods and beverages with program benefits, modifying the frequency of SNAP benefit distribution, enhancing nutrition education, improving the SNAP retailer environment, and increasing state and federal level coordination and consistency of program implementation. Given the recent dramatic increase in SNAP enrollment, policymakers must address existing barriers as well as consider new strategies to improve nutrition policies in SNAP so that the program can continue to address food insecurity needs as well as provide a healthful diet for SNAP beneficiaries.

Latina mothers' beliefs and practices related to weight status, feeding, and the development of child overweight.

OBJECTIVE: To examine maternal beliefs and practices related to weight status, child feeding, and child overweight in the Latino culture that may contribute to the rising rates of overweight among preschool Latino children in the United States. DESIGN AND SAMPLE: This 2-phase qualitative study relies on data obtained in 6 focus groups with a total of 31 primarily Spanish-speaking, low-income mothers, followed by 20 individual, in-depth interviews with women participating in a health promotion educational program. MEASURES: Child-feeding beliefs, practices, and weight status perceptions were elicited. RESULTS: The findings indicated that most respondents reported personal struggles with weight gain, particularly during and after pregnancy, and were concerned that their children would become obese. Although subjects understood the health and social consequences related to overweight, many discussed the pressures of familial and cultural influences endorsing a "chubby child." CONCLUSIONS: Education and interventions that incorporate "culturally mediated" pathways to address mothers' feeding practices are essential for the prevention and control of childhood overweight among low-income Latinos. Nurses should be aware of the social and cultural influences on Latina mothers' beliefs and practices related to weight status and feeding practices and address these in their education approaches to prevent childhood overweight and obesity with this population group.

The influence of maternal acculturation on child body mass index at age 24 months.

OBJECTIVE: Obesity rates in preschool-aged children are greatest among Latinos. Studies of the relationship of acculturation to obesity among Latino immigrants have primarily focused on adults and adolescents. We examined the influence of maternal acculturation on child body mass index (BMI) at age 24 and 36 months among predominantly Latino, low-income mother-child pairs enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children. DESIGN AND METHODS: Maternal characteristics were obtained from interviewer-administered surveys conducted in English or Spanish at 6 to 20 weeks postpartum among 679 participants in a randomized controlled trial of a health promotion intervention in two urban areas in the Northeast. Acculturation measures included: nativity (born in the United States vs foreign born), parents' nativity, years of US residence (<8 years vs > or =8 years), and exclusive use of native language vs nonexclusive use (mixed or English only). Following repeated mailings and telephone calls requesting permission to obtain their child's height and weight from Special Supplemental Nutrition Program for Women, Infants, and Children records, informed consent was obtained from 108 mothers. Multivariable linear regression models of maternal acculturation and child BMI z score at age 24 months and age 36 months were estimated among all mother-child pairs and within immigrant-only mother-child pairs, adjusting for relevant maternal characteristics. RESULTS: At age 24 months, children of mothers with exclusive use of native language had higher BMI z scores compared to children of mothers with nonexclusive use among 91 mother-child pairs (beta=.74, P=0.02) and within 63 immigrant-only mother-child pairs (beta=.92, P=0.009). CONCLUSIONS: Exclusive use of native language was associated with greater BMI in children as young as age 24 months. Future research should examine the mechanisms by which mothers' language acculturation may affect proximal determinants of energy balance in preschool children, including breastfeeding practices, dietary intake, and physical activity.

Influence of social context on eating, physical activity, and sedentary behaviors of Latina mothers and their preschool-age children.

As more U.S. children grow up in Latino families, understanding how social class, culture, and environment influence feeding practices is key to preventing obesity. The authors conducted six focus groups and 20 in-depth interviews among immigrant, low-income Latina mothers in the Northeast United States and classified 17 emergent themes from content analysis according to ecologic frameworks for behavior change. Respondents related environmental influences to child feeding, diet, and activity, namely, supermarket proximity, food cost, access to recreational facilities, neighborhood safety, and weather. Television watching was seen as integral to family life, including watching during meals and using TV as babysitter and tool to learn English. Participation in the WIC program helped families address food insecurity, and child care provided healthy eating and physical activity opportunities. Health promotion efforts addressing obesity trends in Latino children must account for organizational and environmental influences on the day-to-day social context of young immigrant families.

The influence of immigrant status and acculturation on the development of overweight in Latino families: a qualitative study.

Exposure to obesogenic environments in the U.S. may foster development of overweight in immigrants with greater acculturation. Few studies document mechanisms of the acculturation process from immigrants' own perspectives or describe implications on the children of immigrants. Focus groups and in-depth interviews were conducted with immigrant Latina mothers (N = 51) examining mothers' beliefs, attitudes and practices related to early child feeding and weight. Focus group participants completing the Marin Acculturation Scale more closely identified with Latino culture, although the mean score (2.04, SD = 0.59) was close to "bicultural". Analysis revealed seven themes when mothers compared lifestyles between their native countries and the U.S., related to changes in (1) diet, perceived food quality and availability, (2) food and eating practices, (3) breastfeeding practices, (4) beliefs about food, child feeding and weight status, (5) weight status of mothers and children, (6) physical activity and sedentary lifestyles, and (7) social isolation and support.

The influence of acculturation on breast-feeding initiation and duration in low-income women in the US.

While the 'immigrant health paradox' posits better health behaviours and outcomes for immigrants upon arrival to the US, research suggests that this advantage may deteriorate over time. This study analysed the relationship of acculturation and breast-feeding initiation and duration among a sample of predominantly Latina, low-income women in the US. The four measures of acculturation included: mother's nativity (foreign born vs US born), mother's parents' nativity (foreign born vs US born), years of US residence (<8 years vs > or =8 years) and a dichotomous measure of language acculturation adapted from three items on Marin's acculturation scale (preferred language spoken at home, reading language and writing language) as exclusive use of native language versus non-exclusive use (mixed or English only) (Marin et al., 1987; Marin & Gamba, 1996). Final multivariable models showed that mothers who exclusively used their native language were more likely to initiate breast-feeding as well as breast-feed for longer duration compared with mothers with non-exclusive use, whereas years of US residence and mother's nativity were not significantly associated with breast-feeding initiation or duration. Mother's parents' nativity also emerged as a significant predictor of breast-feeding duration, both within final models for immigrants and across study participants. Programmes providing nutrition education to low-income women may wish to consider the role of language as an important determinant of breast-feeding. The role of mother's parents' nativity on breast-feeding practices deserves exploration in future studies, as the cultural practices taught by family members born outside the US may exert strong pressure within immigrant families now living in the US.

Translating research into action: a case study on trans fatty acid research and nutrition policy in Costa Rica.

Mounting epidemiologic evidence worldwide has fostered policy regulation of industrially made trans fatty acids (TFA) in several developed countries. Despite country-specific evidence about the effects of TFA on cardiovascular disease in Costa Rica, policy regulation has yet to occur. This qualitative study uses a conceptual framework to identify factors that may impede or promote the process of translation of scientific evidence about TFA into policy in the specific context of Costa Rica. We used single case-study methodology to integrate two sources of data: review of relevant internal documents and in-depth, semi-structured interviews with 21 respondents purposively sampled from three sectors: the cooking oil and food industries, research and academia, and government entities. Content analysis, guided by a conceptual framework of research utilization, revealed 68 emergent themes divided across four categories of analysis. In brief, study participants perceived the political context suitable for discussing policies related to healthy fats. Nevertheless, TFA regulation was not part of the Costa Rican political agenda. Barriers perceived by respondents that impede knowledge translation included: (1) lack of awareness of in-country scientific studies on health effects of TFA; (2) lack of consensus or information about policy options (nutrition labelling, dietary guidelines, legislative mandates); (3) perceived distrust and disparate attitudes between sectors, believed by study participants to result in (4) limited collaboration across sectors. Commissioned task forces and other mechanisms to foster research engagement and facilitate sustained interaction and systematic collaboration among government, food industry and researcher sectors appear crucial in the consideration and adoption of nutrition policy in Costa Rica and other emerging economies.

A qualitative study of a nutrition working group.

The Behavioral Change Consortium (BCC) Nutrition Workgroup (NWG) is a multidisciplinary collaboration of representatives from BCC sites and federal agencies. Its mission is to improve measurement of dietary variables. This article presents findings from a qualitative study of perceived effectiveness of the workgroup collaboration. Twelve in-depth interviews were conducted and examined for common themes using the constant comparison method. Themes contributing to perceived effectiveness included: funding and additional resources; invested, committed, and collegial members; strong leadership, clearly articulated goals, and regular communication. Influences seen as reducing effectiveness were: distance, disparate nature of the studies, limited time, and problems associated with starting collaboration after the primary studies had begun data collection. NWG members felt that the workgroup would continue to be successful; however, there were concerns about responsibility for writing and authorship of manuscripts and the need for continued funding to ensure full participation and productivity.

The role of parents in preventing childhood obesity.

As researchers continue to analyze the role of parenting both in the development of childhood overweight and in obesity prevention, studies of child nutrition and growth are detailing the ways in which parents affect their children's development of food- and activity-related behaviors. Ana Lindsay, Katarina Sussner, Juhee Kim, and Steven Gortmaker argue that interventions aimed at preventing childhood overweight and obesity should involve parents as important forces for change in their children's behaviors. The authors begin by reviewing evidence on how parents can help their children develop and maintain healthful eating and physical activity habits, thereby ultimately helping prevent childhood overweight and obesity. They show how important it is for parents to understand how their roles in preventing obesity change as their children move through critical developmental periods, from before birth and through adolescence. They point out that researchers, policymakers, and practitioners should also make use of such information to develop more effective interventions and educational programs that address childhood obesity right where it starts-at home. The authors review research evaluating school-based obesity-prevention interventions that include components targeted at parents. Although much research has been done on how parents shape their children's eating and physical activity habits, surprisingly few high-quality data exist on the effectiveness of such programs. The authors call for more programs and cost-effectiveness studies aimed at improving parents' ability to shape healthful eating and physical activity behaviors in their children. The authors conclude that preventing and controlling childhood obesity will require multifaceted and community-wide programs and policies, with parents having a critical role to play. Successful intervention efforts, they argue, must involve and work directly with parents from the earliest stages of child development to support healthful practices both in and outside of the home.