Building Healthy Families: Outcomes of an Adapted Family Healthy Weight Program Among Children in a Rural Mid-Western Community.

Background: This study aimed to evaluate the effectiveness of implementing an adapted, evidence-based 12-week Family Healthy Weight Program (FHWP), Building Healthy Families, on reducing BMI metrics and clinical health indicators in a real-world community setting. Methods: Ninety child participants with a BMI percentile greater or equal to the 95th percentile for gender and age and their parents/guardians (n = 137) enrolled in the program. Families attended 12 weekly group-based sessions of nutrition education, family lifestyle physical activity, and behavior modification. A pre-post study design with a 6-month follow-up was used. Results: Nine cohorts of families between 2009 and 2016 completed the program with 82.1% retention at 12 weeks and 53.6% at 6 months. Participants had statistically significant improvements at 12 weeks in BMI z-score, %BMIp95, body mass, body fat, fat mass, fat-free mass, and systolic blood pressure with greater improvement at 6 months in body mass, BMI metrics, body fat, fat mass, fat-free mass, and systolic blood pressure. Parents/guardians of the participants had similar statistically significant body composition and blood pressure improvements (p < 0.05). In addition, children had significant improvements in high-density lipoprotein (HDL) cholesterol and aspartate aminotransferase (AST) liver enzymes at 6 months. Conclusions: Overall, this study demonstrated that an evidence-based FHWP can result in statistically meaningful declines in BMI z-score and accompanied clinically meaningful changes in health risk. Participants lost ∼4% of their body mass in 12 weeks, while their parents/guardians lost closer to 7% of their body mass, which supports previous literature suggesting body mass changes influence health.

Understanding implementation costs of a pediatric weight management intervention: an economic evaluation protocol.

BACKGROUND: Understanding the cost and/or cost-effectiveness of implementation strategies is crucial for organizations to make informed decisions about the resources needed to implement and sustain evidence-based interventions (EBIs). This economic evaluation protocol describes the methods and processes that will be used to assess costs and cost-effectiveness across implementation strategies used to improve the reach, adoption, implementation, and organizational maintenance of an evidence-based pediatric weight management intervention- Building Health Families (BHF). METHODS: A within-trial cost and cost-effectiveness analysis (CEA) will be completed as part of a hybrid type III effectiveness-implementation trial (HEI) designed to examine the impact of an action Learning Collaborative (LC) strategy consisting of network weaving, consultee-centered training, goal-setting and feedback, and sustainability action planning to improve the adoption, implementation, organizational maintenance, and program reach of BHF in micropolitan and surrounding rural communities in the USA, over a 12-month period. We discuss key features of implementation strategy components and the associated cost collection and outcome measures and present brief examples on what will be included in the CEA for each discrete implementation strategy and how the results will be interpreted. The cost data will be collected by identifying implementation activities associated with each strategy and using a digital-based time tracking tool to capture the time associated with each activity. Costs will be assessed relative to the BHF program implementation and the multicomponent implementation strategy, included within and external to a LC designed to improve reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) of BHF. The CEA results will be reported by RE-AIM outcomes, using the average cost-effectiveness ratio or incremental cost-effectiveness ratio. All the CEAs will be performed from the community perspective. DISCUSSION: The proposed costing approach and economic evaluation framework for dissemination and implementation strategies and EBI implementation will contribute to the evolving but still scant literature on economic evaluation of implementation and strategies used and facilitate the comparative economic analysis. TRIAL REGISTRATION: ClinicalTrials.gov NCT04719442 . Registered on January 22, 2021.

Qualitative Comparative Analysis of Program and Participant Factors That Explain Success in a Micropolitan Pediatric Weight Management Intervention.

Background: Building Healthy Families (BHF) was developed through a community-academic partnership to provide a 12-week family-based obesity treatment program. Nine cohorts of BHF have been delivered in multiple micropolitan settings between 2009 and 2016, but participant outcomes have varied. This study sought to explore the variation in BHF outcomes to identify the necessary and sufficient conditions that are associated with larger 12-week reductions in BMI z-scores. Methods: A qualitative comparative analysis was used to determine potential causal conditions or combination of conditions associated with larger reductions in BMI z-score. Seventy-five participants with 12-week outcome data were rank ordered as the 10 most successful participants (largest reductions in BMI z-score; m ± std = -0.64 ± 0.18) and the 10 least successful participants (smallest reductions or an increase in BMI z-score; m ± std = 0.02 ± 0.04). The conditions selected for analysis were identified based on theory and the delivery team's experience with implementing BHF. Results: Necessary conditions (i.e., present in all highly successful participants, but also some less successful participants) included children with high attendance and self-regulation, at least one adult with high attendance and self-regulation, a mother who lost weight during the program and achieved clinically meaningful weight loss. Sufficient conditions (i.e., present in only the highly successful participants) included mothers with self-regulation scores >45% (range 46.7%-98.2%), and children with a combination of high attendance (72%-100%) and self-regulation scores ≥45% (45%-92.7%). Conclusion: Program implementers should continue to focus on encouraging high attendance and emphasize the necessity of enacting self-regulation strategies at both the child and parent level.

Packaging of a Pediatric Weight Management Intervention and Implementation Blueprint for Rural and Micropolitan Communities: The Nebraska CORD 3.0 Project.

Pediatric weight management interventions (PWMIs) have resulted in positive changes among family members and, if widely disseminated, could have an impact on pediatric weight management in rural communities. The purpose of this article is to describe a backward design approach taken to create an online packaged program and implementation blueprint for building healthy families (BHF), an effective PWMI for implementation in rural communities. The backward design process included the identification of end users: primary (facilitators to be trained through the packaged program and implementation blueprint), secondary (researchers and evaluators), terminal (caregivers and children impacted by PWMI participation), tertiary (community support organizations, funding agency promoting widespread PWMI, and payors), as well as, key outcomes for respective end user groups based on the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) framework. This process resulted in the BHF Online Training Resources and Program package and implementation blueprint that included a modular approach encompassing the interplay of training modules for program facilitators, knowledge checks to ensure mastery of program components, recruitment resources for school and clinical settings, all program materials, embedded fidelity assessments for quality assurance, and a data portal to track participant success. Next steps include preliminary product testing with potential facilitators and a type 3 effectiveness implementation trial to determine the utility of the BHF Online Training Resources and Program package with and without participation in a learning collaborative to support implementation and sustainability.

A Type III Hybrid Effectiveness-Implementation Pilot Trial Testing Dissemination and Implementation Strategies for a Pediatric Weight Management Intervention: The Nebraska Childhood Obesity Research Demonstration Project.

Background: Several family-based efficacious pediatric weight management interventions (PWMIs) have been developed to reduce child weight status. These programs are typically based in larger cities delivered by an interdisciplinary team in a hospital or medical center. The degree to which these efficacious PWMIs have been translated to, and are feasible in, rural or micropolitan areas is unclear. This study protocol describes a pilot Type III hybrid effectiveness-implementation (T3HEI) trial testing a multilevel strategy that focuses on the adoption, implementation, and sustainability of a PWMI online training program and resource package designed for implementation in micropolitan and rural areas. Methods: The trial design employed the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate outcomes and the Promoting Action on Research Implementation in Health Services framework to specify potential mechanisms of adoption, implementation, and sustainability. The study will test the feasibility of a fund and contract dissemination strategy in the adoption of a PWMI in four to eight rural communities, compare a learning collaborative implementation strategy including embedded training and sustainability action planning with communities who receive the PWMI online program and resources alone, and determine whether the PWMI reach, effectiveness, and maintenance are of magnitude similar to previous effectiveness trials. The dissemination and implementation process focused on an integrated research-practice partnership process model that includes a systems-based approach with multiple sectors and vertical decision-making representation. Conclusions: Our pilot T3HEI study has the potential to inform how best to move and sustain evidence-based PWMIs into practice. The findings will inform larger scale dissemination, implementation, and sustainability efforts in medically underserved areas across the country. Trial registration: This protocol is registered with clinicaltrials.gov (NCT04719442).

A Dissemination Strategy to Identify Communities Ready to Implement a Pediatric Weight Management Intervention in Medically Underserved Areas.

PURPOSE AND OBJECTIVES: We developed a competitive application process to test the feasibility of a fund and contract dissemination strategy to identify and engage communities that demonstrated the necessary resources and motivation to adopt, implement, and sustain a pediatric weight management intervention, Building Healthy Families, in rural and micropolitan (<50,000 residents) communities in Nebraska. INTERVENTION APPROACH: From April through December 2019, a community advisory board with representation from rural and micropolitan clinical, public health, education, and recreational organizations collaboratively developed a request for applications, as a fund and contract dissemination strategy, to encourage community adoption of Building Healthy Families. EVALUATION METHODS: Quantitative assessments included determining the distribution of requests for applications, evaluating organizational readiness to change assessment (ORCA) ratings (on a scale of 1 to 5, from strongly disagree to strongly agree that the organization is ready to change), and reviewing community advisory board member ratings of applications. We gathered qualitative data from community narratives provided in response to the request for applications and community advisory board reviews of the applications. RESULTS: The request for applications was distributed to all 93 counties in Nebraska. Of the 8 communities that submitted a letter of intent, 7 submitted a community narrative. Across the 8 communities, 31 ORCAs were completed by the organizational decision makers (n = 15) and staff members (n = 16) who would be responsible for screening, recruiting, or implementing the intervention. Overall mean ORCA scores varied by ratings of evidence (4.1-4.6), context (4.2-4.9), and facilitation (4.3-4.8), indicating a high degree of readiness. Community advisory board ratings of applications ranged from 2.3 to 3.4 of 4 points. Qualitative data indicated that lower community narrative scores were primarily caused by weak implementation and sustainability plans. IMPLICATIONS FOR PUBLIC HEALTH: Findings provide guidance for translating pediatric weight management programs in medically underserved geographic areas by maximizing the probability of successful adoption and implementation through a fund and contract dissemination strategy.

Impact of schoolchildren's involvement in the design process on the effectiveness of healthy food promotion materials.

Marketing techniques may improve children's vegetable consumption. However, student participation in the design of marketing materials may increase the material's salience, while also improving children's commitment and attitudes towards healthy eating. The impact of student-led design of vegetable promotional materials on choice and consumption was investigated using 1614 observations of students' vegetable choice and plate waste in four public elementary schools in Kearney, Nebraska. Data were collected on children's vegetable choice and consumption in four comparison groups: 1) control; 2) students designed materials only; 3) students were exposed to promotional materials only; and 4) students designed materials that were then posted in the lunchroom. Vegetable choice and consumption data were collected through a validated digital photography-based plate-waste method. Multivariate linear regression was used to estimate average treatment effects of the conditions at various time periods. Dependent variables were vegetable choice and consumption, and independent variables included the condition, time period, and interaction terms, as well as controls for gender and grade. Relative to baseline, students in group 4 doubled their vegetable consumption (p < 0.001) when materials were posted. Vegetable consumption remained elevated at a follow-up 2-3 months later (p < 0.05). Students in group 3 initially increased the quantity of vegetables selected (p < 0.05), but did not increase consumption. In the follow-up period, however, students in group 3 increased their vegetable consumption (p < 0.01). Involving elementary-aged students in the design of vegetable promotional materials that were posted in the lunchroom increased the amount of vegetables students consumed.

Validity of HydraTrend reagent strips for the assessment of hydration status.

Hydration is used by athletic governing organizations for weight class eligibility. The measurement of urine specific gravity (USG) as a measure of hydration by reagent strips is a controversial issue. The purpose of this study was to determine the validity of HydraTrend reagent strips that facilitate the correction of USG for alkaline urine samples against refractometry for the assessment of USG. Fifty-one participants (33 males, age = 22.3 ± 1.3 years; 18 females, age = 22.4 ± 1.2 years) provided 84 urine samples. The samples were tested for USG using refractometry and reagent strips and for pH using reagent strips and a digital pH meter. Strong correlation coefficients were found between refractometry and reagent strips for USG (rs(82) = 0.812, p < 0.01) and between reagent strips and pH meter for pH (rs(82) = 0.939, p < 0.01). It was observed that false negative results for National Collegiate Athletic Association (NCAA) requirements (fail refractometry with USG >1.020, pass reagent strips with USG ≤1.020) occurred 39% (33/84) of the time and false negative results for National Federation of State High School Association (NFHS) requirements (fail refractometry with USG >1.025, pass reagent strips with USG ≤1.025) occurred 14% (12/84) of the time. There were no false positives (pass refractometry and fail reagent strips) for NCAA or NFHS requirements. These data show that refractometry and reagent strips have strong positive correlations. However, the risk of a false negative result leading to incorrect certification of euhydration status outweighs the benefits of the HydraTrend reagent strips for the measurement of USG.

Evaluation of school transportation patterns and the associated impact on BMI in 2 Midwestern communities.

BACKGROUND: The decline in active commuting to and from school in the United States is, in part, due to urban design standards and public policies that promote automobile travel and discourage pedestrian activity. PURPOSE: The current investigation examines active commuting at neighborhood schools and how it is altered by distance to school, student age and its potential impact on Body Mass Index. METHODS: Demographic and transportation datasets were obtained for 5367 elementary students (K-5th grade) and middle school students (6th-8th grade) in 2 Midwestern communities. RESULTS: 4379 (81.6%) students were successfully geocoded and 21.9% actively commute to school at least half of the time meeting the Healthy People 2010 objective 22-14. Of those students who could potentially actively commute to school (0.5 mile for grades K-5 and 1 mile for grades 6-8) 36.6% are passive commuters. No significant negative associations were found between BMI z-score or BMI percentile with accumulation of activity through active commuting (frequency × distance) for elementary (r = -0.04, P = .27) or middle school students (r = .027, P = .56). CONCLUSION: Many elementary students living within 0.3-0.4 miles are being driven to school. Promoting pedestrian-friendly communities and making healthy and sustainable transportation choices should be priorities for community leaders and school administrators.

Oxygen consumption, heart rate, and blood lactate responses to an acute bout of plyometric depth jumps in college-aged men and women.

Although plyometrics are widely used in athletic conditioning, the acute physiologic responses to plyometrics have not been described. The purpose of this study was to investigate the oxygen consumption, heart rate, and blood lactate responses to a single session of plyometric depth jumps. Twenty recreationally trained college-aged subjects (10 men, 10 women) participated in a single session of 8 sets of 10 box depth jumps from a height of 0.8 m with 3 minutes of passive recovery between each set. Plyometric depth jumping elicited 82.5 +/- 3.1% and 77.8 +/- 3.1% of the measured maximal oxygen consumption (O2max) for women and men, respectively, with no difference in oxygen consumption in ml/kg/min or percent O2max between sexes or sets. Heart rate significantly increased (p < 0.05) from 68.1 +/- 2.9 beatsxmin-1 at rest to 169.6 +/- 1.2 beatsxmin-1 during depth jumping. Sets 5 to 8 elicited a higher (p < 0.05) heart rate (173.3 +/- 1.3 beatsxmin-1) than sets 1 to 4 (164.6 +/- 1.8 beatsxmin-1). Women exhibited a higher heart rate (p < 0.05) during sets 1 and 2 (169.9 +/- 2.8 beatsxmin-1) than men (150.7 +/- 4.4 beatsxmin-1). The blood lactate concentrations were significantly (p < 0.05) increased above resting throughout all sets (1.0 +/- 0.2 mmolxL-1 compared with 2.9 +/- 0.1 mmolxL-1), with no differences between sexes or sets. Plyometric depth jumping significantly increased oxygen consumption, heart rate, and blood lactate in both men and women, but no significant difference was found between the sexes. Plyometric depth jumping from a height of 0.8 m has similar energy system requirements to what Wilmore and Costill termed "Aerobic Power" training, which should enhance O2max, lactate tolerance, oxidative enzymes, and lactate threshold.

Evaluation of a walking school bus for promoting physical activity in youth.

BACKGROUND: Walking to and from school has potential to increase daily physical activity among children. METHODS: A Walking School Bus (WSB) intervention was implemented for 2 years in 2 schools with a third school as a control. The primary aim evaluated school-wide prevalence of walking to school by self-report 6 times (fall, winter, spring). The secondary aims compared objective physical activity levels among a subsample of research participants (intervention [INT] = 201, control [CON] = 123) and between frequency of walking to school groups. INT and CON participants wore an accelerometer during 4 time periods to assess daily physical activity and were measured for body mass index (BMI) and body fat each fall and spring. RESULTS: School-wide prevalence of walking to school frequently (> 50% of the time each week) was 27% higher in the WSB schools than in the control school. INT obtained significantly more daily physical activity than CON (78.0 [38.9] vs 60.6 [27.7] min/d, P < .05). In addition, across all schools, frequent walkers obtained 25% more physical activity (P < .05), gained 58% less body fat (P < .05), and attenuated BMI by 50% (P < .05) compared with passive commuters. CONCLUSION: This study suggests a WSB intervention may increase frequency of walking to school and establishes a link with increased daily physical activity.