Comparison of height, weight, and body mass index data from state-mandated school physical fitness testing and a districtwide surveillance project.

BACKGROUND: Approximately one third of California school-age children are overweight or obese. Legislative approaches to assessing obesity have focused on school-based data collection. During 2010-2011, the Chula Vista Elementary School District conducted districtwide surveillance and state-mandated physical fitness testing (PFT) among fifth grade students. We compared height, weight, and body mass index (BMI) to examine measurement differences between the projects. METHODS: We assessed demographic characteristics and BMI category frequencies. We used paired t-tests to test continuous variables. κ statistics were used to assess categorical agreement. RESULTS: Of 3549 children assessed, 69% were Hispanic. Fifty-one percent were boys. Mean heights, weights, and BMIs were significantly different for each project (p < .0001). Surveillance height (106.7-165.1 cm) and weight (21.6-90.8 kg) ranges were lesser than PFT ranges (109.2-180.3 cm and 22.7-98.4 kg). The overall BMI category agreement was good (weighted κ = 0.77). Categorical percentage agreement was highest among normal weight children (94.9%) and lowest among underweight children (56.6%). CONCLUSIONS: Methodological differences might have resulted in the observed height, weight, and BMI differences. As school-based interventions become common, districts should carefully consider measurement reliability, training, and data-handling protocols to have confidence in their findings.

San Diego Healthy Weight Collaborative: a systems approach to address childhood obesity.

A collaborative approach to identify opportunities for interactions between multiple systems is an important model for childhood obesity prevention. This paper describes a process aligning multiple partners in primary care, public health, university research, schools, and community organizations. Jointly implemented strategies in a Latino underserved community included: (1) building an effective and sustainable collaborative team; (2) disseminating a healthy weight message across sectors; (3) assessing weight status and healthy weight plans in primary care, school, and early childhood settings; and (4) implementing policy changes to support healthy eating and physical activity. The process and lessons learned were analyzed so other communities can utilize a systems approach to develop culturally appropriate interventions tailored to a specific community.

A culturally appropriate intervention to improve health behaviors in Hispanic mother-child dyads.

BACKGROUND: Obesity interventions targeting Hispanic preschool children are still nascent, and few are culturally appropriate. We evaluated the feasibility of a culturally relevant 9-month intervention program to improve health behaviors in low-income Mexican mothers with 3- to 5-year-old children. METHODS: A community engagement approach was used to culturally and linguistically tailor an intervention program that was pilot tested with 33 mother-child dyads enrolled from a large California urban health center. A one-group, pretest-posttest design assessed changes in children's consumption of sugar-sweetened beverages (SSB), mothers' pedometer steps, and BMI. Data were collected at baseline, postintervention and at 6 months postintervention. RESULTS: At postintervention, SSB consumption had significantly decreased for soda and other sugary drinks with a modest reduction for 100% juice. Consumption of water had significantly increased, whereas milk had an increased trend. Maternal step counts significantly increased for weekdays by 69% and weekend days by 49%. Overall, maternal BMI decreased while children's BMI% remained stable. At 6 months postintervention, children's soda and juice consumption reverted toward baseline levels, as did maternal step counts, but children's consumption of sugary drinks remained lower, while water and milk remained higher. CONCLUSIONS: Findings suggest that a culturally relevant intervention was feasible for improving target health behaviors in a low-income Mexican community. Future work should assess an enhanced intervention including a maintenance phase for long-term adherence to health behavior changes and influence on maternal and child BMI.

Next steps in obesity prevention: altering early life systems to support healthy parents, infants, and toddlers.

There is an urgent need for effective, sustainable child obesity prevention strategies. Progress toward this goal requires strengthening current approaches to add a component that addresses pregnancy onward. Altering early-life systems that promote intergenerational transmission of obesity holds promise for interrupting the continuing cycle of the obesity epidemic. A 2011 Institute of Medicine (IOM) report emphasizes the need for interventions early in life to prevent obesity. A 2010 IOM report called for addressing gaps in existing obesity research evidence by using a systems perspective, simultaneously addressing interacting obesity promoting factors in multiple sectors and at multiple societal levels. A review of evidence from basic science, prevention, and systems research supports an approach that (1) begins at the earliest stages of development, and (2) uses a systems framework to simultaneously implement health behavior and environmental changes in communities.

Learning from state surveillance of childhood obesity.

Data on childhood obesity collected by the Centers for Disease Control and Prevention helped reveal the nation's epidemic of overweight and obese children. But more information is needed. Collecting body mass index (BMI)-the widely accepted measurement of childhood weight status-at the state and local levels can be instrumental in identifying and tracking obesity trends, designing interventions to help overweight children, and guiding broader policy solutions. Approximately thirty states have enacted or proposed BMI surveillance laws and regulations. Arkansas stands out as the state with the highest-quality surveillance data. Innovative strategies being pursued in a number of other states should be explored for broader dissemination.

The relationship between body mass index and behavior in children.

OBJECTIVE: To examine reciprocal relationships between body mass index (BMI) and internalizing and externalizing problems from infancy through middle childhood, with a focus on sex and history of overweight. STUDY DESIGN: Data from 1254 children in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development were used to conduct longitudinal analyses of the relationship between BMI and scores on the Child Behavior Checklist from age 2 years through the 6th grade. RESULTS: BMI and behavior problems demonstrated stability across the 7 measurement occasions. No consistent relationship between BMI and behavior problems was evident before school entry, but higher BMI was associated with later internalizing problems beginning in the 1st grade for boys and girls. Higher BMI was not associated with increased conduct problems. CONCLUSIONS: As children move into middle childhood, higher BMI is associated with increased likelihood of developing internalizing problems. Health care providers should monitor BMI as children enter school and provide guidance to parents regarding emerging symptoms of anxiety and depression.

Moderate-to-vigorous physical activity from ages 9 to 15 years.

CONTEXT: Decreased physical activity plays a critical role in the increase in childhood obesity. Although at least 60 minutes per day of moderate-to-vigorous physical activity (MVPA) is recommended, few longitudinal studies have determined the recent patterns of physical activity of youth. OBJECTIVE: To determine the patterns and determinants of MVPA of youth followed from ages 9 to 15 years. DESIGN, SETTING, AND PARTICIPANTS: Longitudinal descriptive analyses of the 1032 participants in the 1991-2007 National Institute of Child Health and Human Development Study of Early Child Care and Youth Development birth cohort from 10 study sites who had accelerometer-determined minutes of MVPA at ages 9 (year 2000), 11 (2002), 12 (2003), and 15 (2006) years. Participants included boys (517 [50.1%]) and girls (515 [49.9%]); 76.6% white (n = 791); and 24.5% (n = 231) lived in low-income families. MAIN OUTCOME MEASURE: Mean MVPA minutes per day, determined by 4 to 7 days of monitored activity. RESULTS: At age 9 years, children engaged in MVPA approximately 3 hours per day on both weekends and weekdays. Weekday MVPA decreased by 37 minutes per year [corrected], while weekend MVPA decreased by 39 minutes per year [corrected]. By age 15 years, adolescents were only engaging in MVPA for 50 minutes per weekday [corrected] and 36 minutes per weekend day [corrected]. Boys were more active than girls, spending 18 and 14 more minutes per day [corrected] in MVPA on the weekdays and weekends, respectively. The rate of decrease in MVPA was the same for boys and girls. The estimated age at which girls crossed below the recommended 60 minutes of MVPA per day was approximately 13.2 years for weekday [corrected] activity compared with boys at 14.9 years [corrected], and for weekend activity, girls crossed below the recommended 60 minutes of MVPA at 12.7 years [corrected] compared with boys at 13.6 years [corrected]. CONCLUSION: In this study cohort, measured physical activity decreased significantly between ages 9 and 15 years.

Association of neighborhood design and recreation environment variables with physical activity and body mass index in adolescents.

PURPOSE: To examine associations of neighborhood walkability and recreation environment variables with physical activity in adolescents. METHODS: The cross-sectional study was conducted with 98 white or Mexican-American adolescents (mean age = 16.2 years). Physical activity was measured with 7 days of accelerometer monitoring. Height and weight were measured to compute body mass index (BMI). Environmental measures were created using geographic information systems. A neighborhood walkability index was based on land use mix, retail density, street connectivity, and residential density. Proximity to public and private recreation facilities was assessed. RESULTS: In a linear regression, the walkability index within 0.5 mile of homes was related to minutes of moderate to vigorous physical activity, explaining approximately 4% of variance. Recreation variables were not related to physical activity, and BMI was not explained by environmental variables. CONCLUSION: Neighborhood walkability was related to adolescents'physical activity, similar to findings for adults.

Evaluation of residency training in the delivery of culturally effective care.

OBJECTIVE: To augment resident training in the delivery of culturally effective care in order to improve clinician capacity to effectively care for patients from diverse backgrounds. METHODS: Residents from the Naval Medical Center San Diego and the University of California San Diego participated in experiential learning and service activities. Programme evaluation assessed aspects of the delivery of culturally effective care in community settings. A community-based participatory approach to engaging residents in the delivery of culturally effective care and evaluation of the effectiveness of this approach are described. RESULTS: A significant pre-post rotation increase was noted in residents' self-perceived ability to identify culture-related issues that may impact on the patient's view of illness (P<0.001) and ability to address a culture-related issue (P<0.001). Community evaluations rated residents positively on behaviours that reflected communication skills and professionalism, but less positively on knowledge about communities. CONCLUSIONS: The authors conclude that resident exposure to the block rotation curriculum contributes to improved knowledge of the skills necessary to provide culturally effective care in diverse community settings.

Identifying risk for obesity in early childhood.

OBJECTIVES: Our aim with this study was to assist clinicians by estimating the predictive value of earlier levels of BMI status on later risk of overweight and obesity during the middle childhood and early adolescent years. METHODS: We present growth data from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development, a longitudinal sample of 1042 healthy US children in 10 locations. Born in 1991, their growth reflects the secular trend of increasing overweight/obesity in the population. Height and weight of participating children in the study were measured at 7 time points. We examined odds ratios for overweight and obesity at age 12 years comparing the frequency with which children did versus did not reach specific BMI percentiles in the preschool- and elementary-age periods. To explore the question of whether and when earlier BMI was predictive of weight status at age 12 years, we used logistic regression to obtain the predicted probabilities of being overweight or obese (BMI > or = 85%) at 12 years old on the basis of earlier BMI. RESULTS: Persistence of obesity is apparent for both the preschool and elementary school period. Children who were ever overweight (> 85th percentile), that is, > or = 1 time at ages 24, 36, or 54 months during the preschool period were > 5 times as likely to be overweight at age 12 years than those who were below the 85th percentile for BMI at all 3 of the preschool ages. During the elementary school period, ages 7, 9, and 11 years, the more times a child was overweight, the greater the odds of being overweight at age 12 years relative to a child who was never overweight. Sixty percent of children who were overweight at any time during the preschool period and 80% of children who were overweight at any time during the elementary period were overweight at age 12 years. Follow-up calculations showed that 2 in 5 children whose BMIs were > or = 50th percentile by age 3 years were overweight at age 12 years. No children who were < 50th percentile for BMI at all points during elementary school were overweight at age 12 years. Children who have higher range BMIs earlier, but not at the 85th percentile, are also more likely to be overweight at age 12 years. Even at time points before and including age 9 years, children whose BMIs are between the 75th and 85th percentile have an approximately 40% to 50% chance of being overweight at age 12 years. Children at 54 months old whose BMIs are between the 50th and 75th percentile are 4 times more likely to be overweight at age 12 years than their contemporaries who are < 50th percentile, and those whose BMIs are between the 75th and 85th percentile are > 6 times more likely to be overweight at age 12 years than those < 50th percentile. CONCLUSIONS: The data from this study indicate that children with BMIs > 85th percentile, as well as with BMIs in the high reference range are more likely than children whose BMI is < 50th percentile to continue to gain weight and reach overweight status by adolescence. Pediatricians can be confident in counseling parents to begin to address the at-risk child's eating and activity patterns rather than delaying in hopes that overweight and the patterns that support it will resolve themselves in due course. Identifying children at risk for adolescent obesity provides physicians with an opportunity for earlier intervention with the goal of limiting the progression of abnormal weight gain that results in the development of obesity-related morbidity.

Acculturation, parent-child acculturation differential, and chronic disease risk factors in a Mexican-American population.

Acculturation is typically defined in terms of individual responses to a dominant culture. In the present study, we examined the effects of different levels of acculturation among family members. Specifically, we looked at the health and risk behavior in Mexican-American children as related to a variety of psychosocial predictors, especially the differences in orientation toward Mexican- and Anglo-American cultures between them and their parents. Mother and child pairs (n = 106) noted their orientation toward both Anglo and Mexican cultures. Children's dietary and sedentary behaviors, tobacco and alcohol use (and susceptibility to use), and depressive symptoms were also measured. Males were more likely to be sedentary and consume higher levels of total fat and saturated fat, whereas girls reported higher levels of depression. Anglo-oriented youth consumed lower levels of calories from fat but also more alcohol than did their Mexican-oriented counterparts. The latter was particularly the case among those children who were relatively more Anglo oriented than were their parents. Parent-child acculturation differential in terms of the differences in Mexican orientation, in comparison, predicted susceptibility to tobacco use. However, the sum of the absolute values of these two differences predicted only lifetime alcohol use, and in a counter-intuitive direction. This familial measure of acculturation shows some promise, but additional formative research is needed to operationalize this construct.

School-based health education programs can be maintained over time: results from the CATCH Institutionalization study.

BACKGROUND: Developing and evaluating interventions to influence students' opportunities for healthful choices has been a focus of school-based health promotion research; however, few studies have examined the sustainability of these programs and viability of continued organizational implementation. METHODS: The purpose of this study was to determine the maintenance of Child and Adolescent Trial for Cardiovascular Health (CATCH) school-level changes in former intervention (n = 56) and former comparison (n = 20) schools 5 years post-intervention. Twelve schools unexposed to CATCH were measured as controls. Macronutrient content of 5 days of school lunch menus, amount and type of physical education (PE) classes, and health instruction practices in the classroom were assessed. An institutionalization score for schools was developed, using program maintenance variables: % kcal from fat and saturated fat in school lunches, % PE class spent in vigorous and moderate-to-vigorous physical activity, and class time devoted to CATCH topics. RESULTS: Menus from 50% of former intervention cafeterias met the Eat Smart guidelines for fat, compared to 10% of former control cafeterias and 17% of unexposed school cafeterias (P < 0.005). There were no significant differences in implementation of CATCH PE goals between conditions. Although the total time spent teaching CATCH was low in former CATCH schools, the former intervention schools spent significantly more time teaching CATCH and taught more lessons as compared to former comparison schools. Former intervention schools had a higher mean institutionalization score than former comparison schools (P < 0.001). Training had the greatest impact on maintenance of CATCH. CONCLUSIONS: Results from this study suggest that changes in the school environment to support healthful behaviors can be maintained over time. Staff training is an important factor in achieving institutionalization of these programs.

A prenatal intervention study to improve timeliness of immunization initiation in Latino infants.

This was a prospective randomized cohort study to assess the effectiveness of an educational immunization intervention with pregnant Latinas on timely initiation of infant immunization. Study participants were recruited from two community clinics in north San Diego County. A total of three hundred and fifty-two Latinas in the third trimester of pregnancy were recruited and randomly assigned to intervention or control groups. Participants received either a culturally and linguistically appropriate session on infant immunization (intervention) or a session on prevention of Sudden Infant Death Syndrome (control). The main outcome measures were pre-post immunization knowledge change and infant immunization status at 92 days. Immunization knowledge increased significantly in the intervention group [p < .0001, 95%CI (1.76, 2.47)]. No difference was found between groups in immunization series initiation: 95 percent of the children in the intervention group were up-to-date by 92 days from birth, and 93 percent of the control group was up-to-date at 92 days. The lack of significant association between receiving immunization education and infant immunization series initiation suggests that parent education may be necessary but not sufficient for timely immunization, particularly in clinics with effective well-child programs. Given the significant increase in immunization knowledge, the broader and perhaps more important implication is that language- and culturally specific infant health education messages in the prenatal period may have a positive long-term impact on the child's health and promote well-child care overall. Future studies should assess the role of prenatal well-child education in the context of clinics with low immunization levels.

Two national surveys on pediatric training and activities in school health: 1991 and 2001.

OBJECTIVE: To determine from 2 surveys, in 1991 and 2001, 1) the proportion of pediatricians and which pediatricians report doing school health, 2) which school health activities are most commonly engaged in and whether this has changed, 3) whether training/education during residency influences doing school health later in practice, and 4) whether the amount or nature of residency training in school health (as reported by practicing pediatricians) increased over time, as recommended by various task forces. METHODS: Surveys were mailed to a 10% randomly selected group of the voting membership of the American Academy of Pediatrics. RESULTS: An estimated 50% to 70% of pediatricians report doing school health, and a consistent 20% report having had training in school health. The nature of school health work varies in urban, suburban, and rural areas, and pediatricians who practice in rural areas are more likely to be involved in school health. When resident education in school health is offered during residency, it is associated with a higher likelihood of pediatricians' doing school health later in practice. Recent trainees report having more residency training in school health, yet fewer recent trainees report doing school health compared with their older colleagues. CONCLUSIONS: The gap between those who do school health and have received education in school health during residency has continued over at least a 10-year period. Recommendations include specification of school health and community pediatrics competencies for the effective practice of pediatrics in the future.

Retaining school children and families in community research: lessons from the Study of Children's Activity and Nutrition (SCAN).

Retaining school-aged study participants poses a major challenge in any longitudinal research study. Dropouts produce bias in the remaining sample and this loss may affect study findings and their interpretation. Dominant factors that influence retention in pediatric research studies include family versus individual participation, patient management strategies of study personnel, knowledge about the condition or therapy, age and gender factors, credibility within the community, monetary incentives, and altruism. Eleven years after baseline assessment, Studies of Children's Activity and Nutrition boasts a 53% retention of the original biethnic cohort in San Diego. Retention occurred partly due to a trained measurement team which completed sequential observations primarily in family homes and implemented continuous participant follow-up procedures. Approaches for increasing student retention based on carefully designed studies and adherence indicators can assist researchers seeking maximum retention of school-aged participants.

Frequency and intensity of activity of third-grade children in physical education.

BACKGROUND: Health recommendations are for preadolescent children to have daily school physical education (PE) classes that engage children in moderate to vigorous physical activity at least 50% of class time. OBJECTIVE: To observe activity of children in PE classes in third grades across 10 different sites. DESIGN: Observational study. SETTING: Six hundred eighty-four elementary schools in 10 sites. SUBJECTS: A total of 814 children (414 boys, 400 girls; mean age, 9.0 years) enrolled in the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development. METHODS: Each child was observed during 1 scheduled PE class. MAIN OUTCOME MEASURE: The SOFIT (System for Observing Fitness Instruction Time) observation method, a validated, heart rate observation system, yields levels of activity the child is engaged in as well as the lesson context, type of teacher, and location of the PE class. RESULTS: Children averaged 2.1 PE lessons per week, of 33 minutes each. Only 5.9% of children had daily PE. Children accrued 4.8 very active and 11.9 minutes of moderate to vigorous physical activity per PE lesson, 15.0% and 37.0% of lesson time, respectively. Lesson length and number of minutes per week were similar for boys and girls; however, boys spent proportionately more PE time in very active and moderate to vigorous activity. This resulted in boys having a higher energy expenditure rate than girls. CONCLUSION: Children observed in this study received 25 min/wk of moderate to vigorous activity in school PE, falling far short of national recommendations.

Childhood movement skills: predictors of physical activity in Anglo American and Mexican American adolescents?

We assessed the relationship between young children's movement skills and their physical activity in early adolescence. Balance, agility, eye-hand coordination, and skinfold thicknesses in 207 Mexican American and Anglo American children (104 boys, 103 girls) were measured at ages 4, 5, and 6 years. Habitual physical activity was assessed at the age of 12 years by two interviewer-administered 7-day recalls. Ethnic differences in movement skills were not found. Young girls were better at jumping and balancing, and young boys were better at catching. Tracking of skills was low, and children's early childhood skills were not related to their physical activity 6 years later. Further studies involving additional movement skills and other populations are recommended to determine if enhanced movement skills in children promote subsequent physical activity.

Maintenance of lightweight correlates with decreased cardiovascular risk factors in early adolescence.

PURPOSE: To describe predictors of lightweight in 11-year-olds and how weight changes between ages 9-11 years affected selected cardiovascular risk factors. METHODS: Cohort study among an ethnically and geographically diverse group of 5098 nine-year-olds who participated in the Child and Adolescent Trial for Cardiovascular Health (CATCH) and were followed from 1991 to 1994 until age 11 years. Lightweight (body mass index [BMI] <15th percentile) was defined from gender- and age-adjusted data on the total population in the National Health and Nutrition Examination Survey I of 1971 to 1973. Weight (BMI) category at follow-up (age 11 years) was the dependent variable in the logistic regression. Gender, race/ethnicity, school site, weight category at baseline, and participation in the CATCH (intervention or control group) were examined for possible predictors. RESULTS: The prevalence of lightweight was much lower than the 15% expected at both ages 9 and 11 years; 4.7% for males (M) and 7.4% for females (F) and at age 11 years; 5.9% for M and 8.3% for F. Lightweight at age 9 years was the best predictor of lightweight at age 11 years (OR = 56.8; CI 41.3, 78.2). Normal-weight children who entered the overweight category exhibited striking adverse percent changes in serum cholesterol and in both serum high-density cholesterol and apolipoprotein B cholesterol levels. Among children in each weight group at age 9 years, the heavier children at age 11 years had higher percent changes in systolic blood pressure, and lower times on the 9-min run. Maintenance of lightweight was associated with the most favorable pattern of cardiovascular risk factors. Differences between groups were not found for percent change in total calorie intake or percentage of calories from fat. Normal-weight children who became overweight exhibited striking percentage increases in levels of serum cholesterol and in serum apolipoprotein B cholesterols. CONCLUSIONS: Population-based anticipatory guidance about weight should focus on all children in mid-childhood, not only those at the upper extremes of weight. These who are genetically lean and healthy should be encouraged to remain so. Maintenance or achievement of lightweight was associated with favorable changes in systolic blood pressure in CATCH children during early adolescence. Those below the 5th percentile should be assessed and treated if eating disorders, undernutrition, or chronic illness are present. Optimal weight and optimal health should not be confused.