Provider-Selected Training Needs and Associations With Related Practices in Childcare Settings in Minnesota and Wisconsin.

BACKGROUND: Early care and education settings (ECE) are potential venues for young children to develop healthy lifestyle habits. The study assesses training needs and associations with relevant practices of licensed ECE providers across Minnesota and Wisconsin. METHODS: A random sample of 823 providers completed a 97-item survey assessing nutrition and physical activity (PA) practices and training needs. Logistic regression, adjusted for program type (center- and family home-based), and location (urban/rural) examined associations between the top 3 selected training needs and provider practices. RESULTS: Top training needs: (1) ways to effectively engage parents about healthy eating and PA, (2) low-cost ways to serve healthy foods, and (3) fun and easy nutrition education curricula. Providers who reported being not happy/somewhat happy vs happy/very happy with parent communication were more likely to need training to engage parents. Among providers who prepared food on-site, shopping at Farmer's Market had lower odds of needing training for serving healthy meals on a budget. Not having completed nutrition training in the past year providers were more likely to need training for fun and easy nutrition education curricula. CONCLUSIONS: Providers need additional training to improve communication with parents, healthy food shopping practices, and nutrition-related games.

Evaluation of a multi-year policy-focused intervention to increase physical activity and related behaviors in lower-resourced early care and education settings: Active Early 2.0.

Physical activity is a critical component of obesity prevention, but few interventions targeting early childhood have been described. The Active Early guide was designed to increase physical activity in early care and education (ECE) settings. The purpose of Active Early 2.0 was to evaluate the effectiveness of Active Early along with provider training, microgrant support, and technical assistance over 2 years (2012-2014) to increase physical activity and related behaviors (e.g., nutrition) in settings serving a high proportion of children from underserved groups in recognition of significant disparities in obesity and challenges meeting physical activity recommendations in low-resource settings. The physical activity and nutrition environment were assessed before and after the intervention in 15 ECE settings in Wisconsin using the Environment and Policy Observation Assessment tool, and interviews were conducted with providers and technical consultants. There was no significant change in Total Physical Activity Score or any EPAO subscale over the intervention period; however, significant improvements in the Total Nutrition Score and the several Nutrition subscales were observed. Additionally, the percentage of sites with written activity policies significantly increased. Overall minutes of teacher-led physical activity increased to 61.5 ± 29.0 min (p < 0.05). Interviews identified key benefits to children (i.e., more energy, better rest, improved behavior) and significant barriers, most notably care provider and child turnover and low parent engagement. Moderate policy and environmental improvements in physical activity and nutrition were achieved with this intervention, but more work is needed to understand and address barriers and to support sustained changes in lower-resource ECE settings.

Obesity Prevention in Early Child Care Settings.

BACKGROUND: Long-term evaluation studies reveal that high-quality early care and education (ECE) programs that include a lifestyle component predict later adult health outcomes. The purpose of this article is to characterize the nutrition and physical activity (PA) practices, including implementation difficulty and barriers, of licensed center- and family home-based ECE programs serving 2- to 5-year-old children in Minnesota (MN) and Wisconsin (WI). METHOD: A stratified random sampling procedure was used to select representative cross sections of licensed ECE providers in MN and WI. A total of 2,000 providers (1,000 center-based, 1,000 family home-based) were randomly selected and invited to respond to a 97-item survey with questions representing (1) nutrition and PA practices, (2) barriers to meeting nutrition and PA best practices, and (3) written and implemented nutrition and PA policies. Summated scales were constructed for nutrition-related (range 0-15; Cronbach's α = .86) and for PA-related best practices (range 0-10; Cronbach's α = .82). RESULTS: A total of 823 providers returned surveys between August 2010 and March 2011, resulting in a 44% bistate participation rate. Across all programs an average ( SD) of 7.0 (4.1) nutrition best practices were already implemented. Center-based providers reported on average 0.8 additional nutrition best practice (7.4 vs. 6.6, p = .01). Across all programs an average ( SD) of 5.2 (3.1) PA best practices were already implemented. Center-based providers reported on average one more PA best practice (5.3 vs. 4.3, p < .01). The cost of healthy food and the weather were identified as barriers by 80% of providers, regardless of program type.

Active Early: one-year policy intervention to increase physical activity among early care and education programs in Wisconsin.

BACKGROUND: Early childcare and education (ECE) is a prime setting for obesity prevention and the establishment of healthy behaviors. The objective of this quasi-experimental study was to examine the efficacy of the Active Early guide, which includes evidenced-based approaches, provider resources, and training, to improve physical activity opportunities through structured (i.e. teacher-led) activity and environmental changes thereby increasing physical activity among children, ages 2-5 years, in the ECE setting. METHODS: Twenty ECE programs in Wisconsin, 7 family and 13 group, were included. An 80-page guide, Active Early, was developed by experts and statewide partners in the fields of ECE, public health, and physical activity and was revised by ECE providers prior to implementation. Over 12 months, ECE programs received on-site training and technical assistance to implement the strategies and resources provided in the Active Early guide. Main outcome measures included observed minutes of teacher-led physical activity, physical activity environment measured by the Environment and Policy Assessment and Observation (EPAO) instrument, and child physical activity levels via accelerometry. All measures were collected at baseline, 6 months, and 12 months and were analyzed for changes over time. RESULTS: Observed teacher-led physical activity significantly increased from 30.9 ± 22.7 min at baseline to 82.3 ± 41.3 min at 12 months. The change in percent time children spent in sedentary activity decreased significantly after 12 months (-4.4 ± 14.2 % time, -29.2 ± 2.6 min, p < 0.02). Additionally, as teacher led-activity increased, percent time children were sedentary decreased (r = -0.37, p < 0.05) and percent time spent in light physical activity increased (r = 0.35, p < 0.05). Among all ECE programs, the physical activity environment improved significantly as indicated by multiple sub-scales of the EPAO; scores showing the greatest increases were the Training and Education (14.5 ± 6.5 at 12-months vs. 2.4 ± 3.8 at baseline, p < 0.01) and Physical Activity Policy (18.6 ± 4.6 at 12-months vs. 2.0 ± 4.1 at baseline, p < 0.01). CONCLUSIONS: Active Early promoted improvements in providing structured (i.e. teacher-led) physical activity beyond the recommended 60 daily minutes using low- to no-cost strategies along with training and environmental changes. Furthermore, it was observed that Active Early positively impacted child physical activity levels by the end of the intervention. However, resources, training, and technical assistance may be necessary for ECE programs to be successful beyond the use of the Active Early guide. Implementing local-level physical activity policies combined with support from local and statewide partners has the potential to influence higher standards for regulated ECE programs.

Structural equation modeling of the associations between the home environment and obesity-related cardiovascular fitness and insulin resistance among Hispanic children.

Hispanic children are disproportionally affected by obesity-related risk of metabolic disease. We used the structural equation modeling to examine the associations between specific diet and physical activity (PA) behaviors at home and Hispanic children's metabolic health. A total of 187 Hispanic children and their parents from an urban community in Wisconsin participated in the study. Exposure variables included, children's daily intake of sugar-sweetened beverages (SSB) and PA; home availability of SSB and PA areas/equipment; and parents' intake of SSB and PA, assessed through self-administered questionnaires. Outcome variables for children's metabolic health included, measured anthropometrics; cardiovascular fitness assessed using the Progressive Aerobic Cardiovascular Endurance Run (PACER); and insulin resistance determined with the homeostasis model assessment of insulin resistance (HOMAIR). We found that children's daily intake of SSB was positively associated with BMI z-score, which in turn, was positively associated with HOMAIR (P < 0.05). Specific diet behaviors at home associated with children's intake of SSB, included home availability of SSB, which mediated the association between parents' and children's intake of SSB (P < 0.05). Children's PA was positively associated with PACER z-score, which in turn, was inversely associated with HOMAIR (P < 0.05). Specific PA behaviors at home associated with children's PA, included home availability of PA areas/equipment, which mediated the association between parents' and children's PA (P < 0.05). The structural equation model indices suggested a satisfactory model fit (Chi-square, X(2) = 53.1, comparative fix index = 0.92, root-mean-squared error associated = 0.04). The findings confirm the need for interventions at the family level that promotes healthier home environments by targeting poor diet and low levels of PA in all family members.

Home food availability, parental dietary intake, and familial eating habits influence the diet quality of urban Hispanic children.

BACKGROUND: The home food environment influences children's eating behaviors and potentially affects overall diet quality. The aim of the present study was to evaluate the relationship between the home food environment and Hispanic children's diet quality. METHODS: Hispanic children, 10-14 years of age (n=187), and their parents participated in this cross-sectional study. The Healthy Eating Index (HEI) was used to determine diet quality based on reported dietary intake obtained through a food frequency questionnaire administered to the children. Parents self-reported home food availability, familial eating habits, and their own habitual diet through a home environment survey. RESULTS: The children's HEI total score was 59.4±8.8. Reported diets did not adhere to the dietary recommendations for total vegetables, greens and beans, whole grains, seafood and plant proteins, fatty acids, refined grains, sodium, solid fats, and added sugars. None of the participants had "good" scores (HEI, >80), 86% had scores that "need improvement" (HEI, 51-80), and 14% had "poor" scores (HEI, <50). Children with lower HEI scores had sugar-sweetened beverages available at home and participated in family meals while watching television more frequently, when compared with children with higher HEI scores. CONCLUSIONS: Home food availability, parental diet, and familial eating habits seem to play an important role in the diet quality of children. Interventions targeting family education on healthful dietary habits at home could have a positive impact on children's diet quality and overall health.

Smokers' physical activity and weight gain one year after a successful versus unsuccessful quit attempt.

OBJECTIVE: To examine whether smokers' physical activity is related to weight change following a quit attempt. METHOD: Data were analyzed for participants (n=683) of a randomized controlled trial comparing the efficacy of different smoking cessation pharmacotherapies (Wisconsin, 2005-2008). Activity (assessed via pedometry) and body weight were measured in the days surrounding the quit day and again one year later, at which time 7-day point-prevalence abstinence from smoking was assessed. We examined the effects of quitting, physical activity, and their interaction, on a one-year weight change with relevant covariate adjustment. RESULTS: Participants were predominantly female (57%), 46 ± 11 years of age (mean ± SD), and took 7544 ± 3606 steps/day at baseline. Of those who quit, 87% gained weight. A main effect was found for quitting (p<0.001), but not physical activity (p=0.06). When pattern of activity was examined across the 1-year study period, quitters who decreased their physical activity had significantly greater weight gain than quitters who increased their physical activity (p<0.01) or maintained a high level of activity (p=0.02). CONCLUSION: Physical activity is associated with an attenuation of the weight gain that often occurs after quitting smoking.

The Healthy Children, Strong Families intervention: design and community participation.

Healthy Children, Strong Families (HCSF) is a 2-year, community-driven, family-based randomized controlled trial of a healthy lifestyles intervention conducted in partnership with four Wisconsin American Indian tribes. HCSF is composed of 1 year of targeted home visits to deliver nutritional and physical activity curricula. During Year 1, trained community mentors work with 2-5-year-old American Indian children and their primary caregivers to promote goal-based behavior change. During Year 2, intervention families receive monthly newsletters and attend monthly group meetings to participate in activities designed to reinforce and sustain changes made in Year 1. Control families receive only curricula materials during Year 1 and monthly newsletters during Year 2. Each of the two arms of the study comprises 60 families. Primary outcomes are decreased child body mass index (BMI) z-score and decreased primary caregiver BMI. Secondary outcomes include: increased fruit/vegetable consumption, decreased TV viewing, increased physical activity, decreased soda/sweetened drink consumption, improved primary caregiver biochemical indices, and increased primary caregiver self-efficacy to adopt healthy behaviors. Using community-based participatory research and our history of university-tribal partnerships, the community and academic researchers jointly designed this randomized trial. This article describes the study design and data collection strategies, including outcome measures, with emphasis on the communities' input in all aspects of the research.

Dietary intakes and physical activity among preschool-aged children living in rural American Indian communities before a family-based healthy lifestyle intervention.

OBJECTIVE: To report dietary intake and physical activity among preschool-aged children living in rural American Indian communities before participation in a family-based healthy lifestyle intervention and to compare data to current age-specific recommendations. SUBJECTS/DESIGN: One hundred thirty-five preschool-aged children, living in rural American Indian communities, provided diet and physical activity data before participating in a 2-year randomized healthy lifestyle intervention. Three 24-hour dietary recalls assessed nutrient and food and added sugar intake, which were compared to the National Academy of Science's Dietary Reference Intakes, the US Department of Agriculture's MyPyramid, and American Heart Association recommendations. Time watching television and moderate plus vigorous activity was compared to MyPyramid and American Academy of Pediatrics recommendations. STATISTICAL ANALYSIS: Nutrient, food group, added sugar intake, and time watching television and in moderate or vigorous activity were compared to recommendations by computing the percent of recommendations met. Nonparametric tests identified differences in diet and physical activity among age groups and normal and overweight children (body mass index <85th and > or = 85th percentile). RESULTS: Average nutrient intakes met recommendations whereas food group intakes did not. Mean fruit and vegetable intakes for 2- to 3-year-olds were 0.36 c/day fruit and 0.45 c/day vegetables and, for 4- to 5-year-olds, 0.33 c/day fruit and 0.48 c/day vegetables. Both age groups reported consuming more than 50 g added sugar, exceeding the recommendation of 16 g. Overweight vs normal weight children reported significantly more sweetened beverage intake (8.0+/-0.10 vs 5.28+/-0.08 oz/day, P<0.01). On average, all children reported watching television 2.0 hours/day and significant differences were observed for total television viewing and nonviewing time between overweight and normal weight children (8.52+/-0.6 vs 6.54+/-0.6 hours/day, P<0.01). All children engaged in <20 minutes/day of moderate or vigorous activity. CONCLUSIONS: Overall, children in this sample did not meet MyPyramid recommendations for fruits or vegetables and exceed added sugar intake recommendations. Television viewing time and time when the television was on in the home was highly prevalent along with low levels of moderate or vigorous activity. The Healthy Children Strong Families intervention we studied has potential for improving nutrition and physical activity among preschool-aged children living in rural American Indian communities.

Obesity and smoking: comparing cessation treatment seekers with the general smoking population.

Obesity and smoking represent the leading preventable causes of morbidity and mortality in the United States. This study compared the prevalence of obesity among smokers seeking cessation treatment (n=1,428) vs. a general population (n=4,081) of never smokers, former smoker, and current smokers. Data from treatment-seeking smokers in the Wisconsin Smokers' Health Study (WSHS) and individuals who completed the National Health and Nutrition Examination Survey (NHANES) 2005-2006 were pooled and obesity rates and other health characteristics were compared. The prevalence of obesity was significantly higher among WSHS treatment-seeking smokers (36.8%) vs. NHANES current smokers (29.6%), but the obesity rates of WSHS treatment-seeking smokers did not differ from NHANES former smokers (36.5%) or never smokers (36.5%). Treatment-seeking smokers were more likely to be female and to have higher educational attainment compared to NHANES participants. Analysis of health characteristics revealed that treatment-seeking smokers had higher levels of dietary fiber and vitamin C and lower blood levels of total cholesterol, triglycerides, and fasting glucose compared to NHANES current smokers. Results suggest that treatment-seeking smokers may have a different health profile than current smokers in the general population. Health care providers should be aware of underlying heath issues, particularly obesity, in patients seeking smoking cessation treatment.

Macular pigment density and age-related maculopathy in the Carotenoids in Age-Related Eye Disease Study. An ancillary study of the women's health initiative.

PURPOSE: To examine the association between intermediate age-related macular degeneration (AMD) and the optical density of macular pigment (MPOD), which is composed of lutein and zeaxanthin from the diet. DESIGN: Cross-sectional cohort study. PARTICIPANTS: We included 1698 of 2005 women ages 54 to 86 years and participating in the Carotenoids in Age-Related Eye Disease Study, an ancillary study of the Women's Health Initiative. METHODS: The MPOD was measured noninvasively by heterochromatic flicker photometry. Fundus photographs were taken to document prevalent AMD. MAIN OUTCOME MEASURES: Intermediate AMD (n = 305) and two subtypes-large drusen (n = 233) and pigmentary abnormalities (n = 157). RESULTS: After adjusting for covariates, the odds ratio (OR) and 95% confidence interval (CI) for AMD among women in quintile (Q) 5 (n = 339) versus 1 (n = 340) for MPOD was 1.4 (0.9, 2.1). However, after excluding women with possible unstable diets and recent supplement use due to chronic disease history, associations reversed (OR Q2-5 vs. 1, 0.8; 95% CI, 0.5-1.2), but remained nonsignificant. Associations also differed between middle-aged (54-69 years) and older (> or =70 years) women (P-interaction = 0.09), but less so, after excluding women who were likely to have unstable diets: adjusted ORs (95% CI) were 0.5 (0.3-1.0; P = 0.08) for intermediate AMD among middle-aged women (n = 516) with MPOD in Q2 to Q5 versus 1 and 1.0 (0.5-2.0; P = 0.90) for older women (n = 422). CONCLUSIONS: The MPOD is not cross-sectionally associated with AMD. The inconsistency of relationships across age groups and in subgroups of women who are likely to have more stable diets suggests that cross-sectional associations may be biased and highlights the need to study these relationships prospectively.

Development of a culturally appropriate, home-based nutrition and physical activity curriculum for Wisconsin American Indian families.

We designed an obesity prevention intervention for American Indian families called Healthy Children, Strong Families using a participatory approach involving three Wisconsin tribes. Healthy Children, Strong Families promotes healthy eating and physical activity for preschool children and their caregivers while respecting each community's cultural and structural framework. Academic researchers, tribal wellness staff, and American Indian community mentors participated in development of the Healthy Children, Strong Families educational curriculum. The curriculum is based on social cognitive and family systems theories as well as on community eating and activity patterns with adaptation to American Indian cultural values. The curricular materials, which were delivered through a home-based mentoring model, have been successfully received and are being modified so that they can be tailored to individual family needs. The curriculum can serve as a nutrition and physical activity model for health educators that can be adapted for other American Indian preschool children and their families or as a model for development of a culturally specific curriculum.

Beverage patterns, diet quality, and body mass index of US preschool and school-aged children.

OBJECTIVE: To evaluate diet quality and body mass index (BMI) by beverage patterns in children aged 2 to 11 years. DESIGN: Beverage patterns were formed using 24-hour dietary recall diet variables from the 2001-2002 National Health and Nutrition Examination Survey. Diet quality was assessed using energy, micronutrient intakes, and Healthy Eating Index (HEI) scores (a 100-point scale that measures adherence to the Dietary Guidelines for Americans). SUBJECTS/SETTING: Children, aged 2 to 5 years (n=541) and 6 to 11 years (n=793), were selected from 2001-2002 National Health and Nutrition Examination Survey data. STATISTICAL ANALYSIS: Cluster analysis was used to identify beverage patterns in preschool and school-aged children. General linear models were used to compare HEI scores, energy, micronutrient intakes, and BMI across beverage clusters. RESULTS: Four and five beverage clusters were identified for preschool and school-aged children, respectively. In preschool children, mean HEI differed between the fruit juice cluster (79.0) vs the high-fat milk cluster (70.9, P<0.01); however, both fruit juice and high-fat milk clusters had the highest micronutrient intakes. Mean HEI differed significantly across beverage patterns for school-aged children (from 63.2 to 69.9, P<0.01), with the high-fat milk cluster having the best diet quality, reflected by HEI and micronutrient intakes. Adjusted mean BMI differed significantly across beverage clusters only in school-aged children (from 17.8 to 19.9, P<0.05). CONCLUSIONS: Beverage patterns were related to diet quality among preschool and school-aged children, but were only related to BMI in school-aged children. Children from all clusters could benefit by consuming fewer calorically sweetened beverages and increasing micronutrient-dense foods.

Predictors of optical density of lutein and zeaxanthin in retinas of older women in the Carotenoids in Age-Related Eye Disease Study, an ancillary study of the Women's Health Initiative.

BACKGROUND: Lifestyle, diet, and physical and health predictors of xanthophyll carotenoids in the retina are poorly understood. OBJECTIVE: We aimed to investigate the predictors of the density of lutein and zeaxanthin in the macula of the retina. DESIGN: Macular pigment optical density (MPOD) was measured by heterochromatic flicker photometry. Relations to dietary lutein and zeaxanthin and to other predictors were measured in 1698 women aged 53-86 y. The women were members of observational study cohorts of the Women's Health Initiative at Iowa City, IA, Madison, WI, or Portland, OR, and participated in the Carotenoids in Age-Related Eye Disease Study (2001-2004). RESULTS: MPOD at 0.5 degrees from the foveal center was 30% higher in women in the highest quintile for lutein and zeaxanthin intake [x (+/-SD): 0.40 +/- 0.21] than in women in the lowest quintile (0.31 +/- 0.21) and 20% higher after adjustment for other predictors. Dietary intake of lutein, zeaxanthin, fiber, and polyunsaturated fatty acids (% of energy) together explained 3% of the variability in MPOD. Higher waist circumference and diabetes, which are related to lower MPOD, together with study site explained an additional 5% of variation. The total explained variability increased to 12% when lutein and zexanthin concentrations obtained from the serum, which were collected 4-7 y earlier, were added to the model. CONCLUSIONS: MPOD is directly related to dietary intake of lutein and zeaxanthin but even more strongly to serum concentrations, which may reflect unmeasured physical and medical factors that influence the uptake, distribution, and utilization of lutein and zeaxanthin. Higher abdominal body fat and diabetes are related to lower MPOD. Unknown predictors of retinal carotenoids remain.