Toddler obesity prevention: A two-generation randomized attention-controlled trial.

Rapid weight gain increases risks of obesity and associated co-morbidities. The objective was to reduce the rate of body mass index (BMI) growth (BMI z score), relative to control. Secondary outcomes were toddler-mother physical activity, mealtime interactions and fruit/vegetable intake. The randomized three-arm, eight-session, 4-month trial, conducted 2009-2013, included two intervention arms (responsive parenting and maternal lifestyle) and an attention control (home safety). Baseline and 6- and 12-month follow-up evaluations included weight and length/height, ankle accelerometry, video-recorded mealtime interactions (Emotional Availability Scales) and 24-h diet recalls (Healthy Eating Index-2015 [HEI-2015]). Analyses used linear mixed-effects models with repeated measures comparing intervention versus control changes in BMI z score. We recruited 277 racially mixed (70% African American) toddler-mother dyads (mean ages 20.1 months and 27.3 years) from US WIC and primary care clinics and randomized them into intervention versus control; 31% toddlers and 73% mothers were overweight/obese. At follow-up, changes in the rate of toddler BMI z score and maternal BMI were non-significant. Maternal lifestyle group toddlers and mothers spent 24.43 and 11.01 more minutes in physical activity (95% confidence interval [CI]: 2.55, 46.32, and 95% CI: 1.48, 20.54, respectively). Fruit intake increased in both intervention groups. Hostile mealtime interactions increased in the maternal lifestyle group, and in supplementary analyses, mealtime interactions were significantly higher in the responsive parenting group than in the maternal lifestyles group, suggesting that toddler dietary interventions include responsive parenting. Intervention effects were stronger among older versus younger toddlers. Despite no impact on weight gain, additional research should examine integrated two-generation responsive parenting and maternal lifestyle interventions among toddler-mother dyads.

Collaboration, Innovation, and Time: A Shared Journey Through Child Psychiatric Consultation in the School Setting.

About 20% of students in U.S. communities have diagnoses of emotional and behavioral disturbances. Even when mental health services are in place, students and teachers often struggle in the classroom. In this column, the authors describe a partnership with a public school system to provide collaborative, innovative support that also offered a novel training opportunity for child and adolescent psychiatry fellows. Over three years of collaborative work, the child psychiatry team (attending child psychiatrist and two child psychiatry fellows) offered direct clinical care and consultation in a school-based clinic. In later years, the team provided ongoing professional development and consultation to teachers, and the model was implemented districtwide. The authors describe challenges of engaging and working in the school setting, which call on key strengths of an effective partnership: communication, respect, and trust. The multiyear partnership offered a mutually beneficial experience for both educators and psychiatry trainees.

Toddler physical activity study: laboratory and community studies to evaluate accelerometer validity and correlates.

BACKGROUND: Toddlerhood is an important age for physical activity (PA) promotion to prevent obesity and support a physically active lifestyle throughout childhood. Accurate assessment of PA is needed to determine trends/correlates of PA, time spent in sedentary, light, or moderate-vigorous PA (MVPA), and the effectiveness of PA promotion programs. Due to the limited availability of objective measures that have been validated and evaluated for feasibility in community studies, it is unclear which subgroups of toddlers are at the highest risk for inactivity. Using Actical ankle accelerometry, the objectives of this study are to develop valid thresholds, examine feasibility, and examine demographic/ anthropometric PA correlates of MVPA among toddlers from low-income families. METHODS: Two studies were conducted with toddlers (12-36 months). Laboratory Study (n = 24)- Two Actical accelerometers were placed on the ankle. PA was observed using the Child Activity Rating Scale (CARS, prescribed activities). Analyses included device equivalence reliability (correlation: activity counts of two Acticals), criterion-related validity (correlation: activity counts and CARS ratings), and sensitivity/specificity for thresholds. Community Study (n = 277, low-income mother-toddler dyads recruited)- An Actical was worn on the ankle for > 7 days (goal >5, 24-h days). Height/weight was measured. Mothers reported demographics. Analyses included frequencies (feasibility) and stepwise multiple linear regression (sMLR). RESULTS: Laboratory Study- Acticals demonstrated reliability (r = 0.980) and validity (r = 0.75). Thresholds demonstrated sensitivity (86 %) and specificity (88 %). Community Study- 86 % wore accelerometer, 69 % had valid data (mean = 5.2 days). Primary reasons for missing/invalid data: refusal (14 %) and wear-time ≤2 days (11 %). The MVPA threshold (>2200 cpm) yielded 54 min/day. In sMLR, MVPA was associated with age (older > younger, ß = 32.8, p < 0.001), gender (boys > girls, ß = -11.21, p = 0.032), maternal MVPA (ß = 0.44, p = 0.002) and recruitment location (suburban > urban, ß = 19.6, p < 0.001), or race (non-Black > Black, ß = 18.5, p = 0.001). No association with toddler weight status. CONCLUSIONS: Ankle accelerometry is a valid, reliable, and feasible method of assessing PA in community studies of toddlers from low-income families. Sub-populations of toddlers may be at increased risk for inactivity, including toddlers that are younger, female, Black, those with less active mothers, and those living in an urban location.

Systematic development and validation of a theory-based questionnaire to assess toddler feeding.

This paper describes the development and validation of a 27-item caregiver-reported questionnaire on toddler feeding. The development of the Toddler Feeding Behavior Questionnaire was based on a theory of interactive feeding that incorporates caregivers' responses to concerns about their children's dietary intake, appetite, size, and behaviors rather than relying exclusively on caregiver actions. Content validity included review by an expert panel (n = 7) and testing in a pilot sample (n = 105) of low-income mothers of toddlers. Construct validity and reliability were assessed among a second sample of low-income mothers of predominately African-American (70%) toddlers aged 12-32 mo (n = 297) participating in the baseline evaluation of a toddler overweight prevention study. Internal consistency (Cronbach's α: 0.64-0.87) and test-retest (0.57-0.88) reliability were acceptable for most constructs. Exploratory and confirmatory factor analyses revealed 5 theoretically derived constructs of feeding: responsive, forceful/pressuring, restrictive, indulgent, and uninvolved (root mean square error of approximation = 0.047, comparative fit index = 0.90, standardized root mean square residual = 0.06). Statistically significant (P < 0.05) convergent validity results further validated the scale, confirming established relations between feeding behaviors, toddler overweight status, perceived toddler fussiness, and maternal mental health. The Toddler Feeding Behavior Questionnaire adds to the field by providing a brief instrument that can be administered in 5 min to examine how caregiver-reported feeding behaviors relate to toddler health and behavior.

Do depression, self-esteem, body-esteem, and eating attitudes vary by BMI among African American adolescents?

OBJECTIVE: To examine how psychosocial factors vary by body weight and gender among African-American adolescents. METHODS: A community sample of 235 low-income, predominantly African-American adolescents completed measures of depression, self-esteem, body-esteem, and eating attitudes. Measured weight and height were converted to body mass index (kg/m(2)) age and gender-adjusted z-scores. Data were analyzed using 2-factor multivariate analysis of variance. RESULTS: Obese youths had significantly worse scores on all psychosocial domains than normal weight youths, with no differences between overweight and normal weight youths. Obese youths had significantly worse scores than overweight youths on body-esteem and self-esteem. Female adolescents had significantly worse scores than males on depressed mood, body-esteem, and eating attitudes. CONCLUSIONS: Among a community sample of predominantly African-American adolescents, obesity, not overweight, was associated with poor psychosocial health. Findings suggest that overweight may be perceived as normative, and that weight-related programs consider adolescents' psychosocial functioning.

The perceived and built environment surrounding urban schools and physical activity among adolescent girls.

BACKGROUND: Neighborhood perceived/built environment and physical activity (PA) associations have been examined for adolescents around homes, but not surrounding schools. PURPOSE: The purpose of this paper is to examine if positive perceptions/built environment in neighborhoods surrounding schools predict PA among low-income, urban adolescent girls. METHODS: Measures include: minutes in moderate-vigorous PA (MVPA, ankle accelerometry), perceptions of the school environment (questionnaire), built environment (neighborhood audit). Analyses include multi-level models. RESULTS: Two hundred twenty-four sixth and seventh grade girls [mean(sd) age = 12.1(0.7) years] from 12 schools serving low-income, primarily African American communities; mean MVPA 35.4 min (mean days assessed = 5.8). Girls in schools with more positive perceptions of the neighborhood environment surrounding the school were less active (ß = 7.2, p = 0.043). Having "places to go within walking distance" (perceptions) and number of food stores near school (built environment) positively relate to MVPA (ß = 5.5, p = 0.042 and ß = 0.59, p = 0.047). CONCLUSIONS: Among neighborhoods surrounding urban schools, positive perceptions do not predict PA; accessibility, via both perceived and built environment, support PA.

Maternal perceptions of toddler body size: accuracy and satisfaction differ by toddler weight status.

OBJECTIVES: To examine (1) accuracy of maternal perceptions of toddler body size; (2) factors associated with accuracy of toddler body size; and (3) how maternal satisfaction relates to accuracy/toddler body size. DESIGN: Cross-sectional. SETTING: Low-income community sample from suburban Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)/urban pediatric clinics. PARTICIPANTS: Two hundred eighty-one mother-toddler dyads (toddlers: 54.1% male; mean age, 20.2 months; 70.8% African American; 8.5% underweight [<15th weight-for-length percentile]; and 29.2% overweight [≥85th weight-for-length percentile]). MAIN EXPOSURE: Measured anthropometry (mother/toddler) and demographics. OUTCOME MEASURE: Validated toddler silhouette scale (accuracy and satisfaction). RESULTS: Nearly 70% of mothers were inaccurate in assessing their toddler's body size. Compared with mothers of healthy-weight toddlers, mothers of underweight toddlers were 9.13 times more likely to be accurate (95% CI, 2.94-28.36) and mothers of overweight toddlers were 87% less likely to be accurate (95% CI, 0.05-0.33); accuracy did not differ by toddler age, sex, or race or mother's education or weight status. More than 70% of all mothers and 81.7% of mothers of overweight toddlers were satisfied with their toddler's body size. Accurate mothers of underweight toddlers were less likely to be satisfied than accurate mothers of healthy-weight toddlers (30.0% vs 76.8%; P < .001). CONCLUSIONS: Mothers of overweight toddlers had inaccurate perceptions of their toddler's body size and were highly satisfied, suggesting a view of heavy toddlers as normative. Mothers of underweight toddlers had accurate perceptions yet were dissatisfied, suggesting recognition of their child as outside the norm. Because inaccurate perceptions begin early in toddlerhood, pediatric providers should help improve families' understanding of healthy body size. Future studies should examine how satisfaction and accuracy relate to parenting behaviors.