Cross-Cultural Adaptation and Initial Validation of Mi Niño: A Tool to Measure Food-Related Parenting Practices of Spanish-Speaking Parents with Young Children.

Background: Accurate measurement of food-related parenting practices is necessary to inform related interventions and program evaluation. Valid tools reflect cultural attributes that affect household food environments and feeding practices. Simple, unidirectional language adaptation approaches are insufficient to capture these attributes in assessment tools. My Child at Mealtime (MCMT) is a 27-item, validated, visually enhanced self-assessment tool to measure food-related parenting practices of low-income English-speaking parents of preschoolers. Objectives: The aim of this study was to describe the cross-cultural adaptation of MCMT into its Spanish version Mi Niño a la Hora the Comer (Mi Niño) and to establish its face validity, factor structure, and internal consistency. Methods: MCMT was adapted into its Spanish version after an iterative process that triangulated cognitive interviews with verification of conceptual equivalence by content experts to establish face validity and semantic equivalence. The resulting tool underwent confirmatory factor analysis to determine whether internal consistency was equivalent across the 2 versions. Results: Four rounds of cognitive interviews (n = 5, n = 6, n = 2, and n = 4, respectively) with Spanish-speaking women caregivers of children aged 3-5 y recruited from Head Start were conducted. Ten items were modified throughout the adaptation process. Modifications included improved clarity (6 items), comprehension (7 items), appropriateness (4 items), suitability (4 items), and usefulness (2 items) of text and/or accompanying visuals. Confirmatory factor analysis with a sample of Spanish-speaking caregivers (n = 243) resulted in 2 reliable factors representing "child-centered" (α = 0.82) and "parent-centered" (α = 0.87) food-related parenting practices. Conclusions: Face validity, semantic equivalence, and internal consistency of Mi Niño were established. This tool can be used in community settings to inform program content and measure changes in food-related parenting practices of Spanish-speaking parents and assist in setting food-related parenting goals. The next steps include exploring the correspondence of Mi Nino with mealtime behaviors observed through video recording.

Obesity Risk Assessment for Spanish-Speaking Immigrant Families with Young Children in the United States: Reliability and Validity with Nutrient Values.

The purpose is to examine validity and reliability for an obesity risk assessment tool developed in Spanish for immigrant families with children, 3-5 years old using an 8-week cross-sectional design with data collected over 1 year at Head Start and Special Supplemental Nutrition Program for Women, Infants and Children [WIC]. Parent/child dyads (206) provided a child obesity risk assessment, three child modified 24 h dietary recalls, three child 36+ h activity logs and one parent food behavior checklist. Main outcome measures were convergent validity with nutrients, cup equivalents, and diet quality and three assessments of reliability that included item difficulty index, item discrimination index, and coefficient of variation. Validity was demonstrated for assessment tool, named Niños Sanos. Scales were significantly related to variables in direction hypothesized [p ≤ 0.05]: Healthy Eating Index, fruit/vegetable cup equivalents, folate, dairy cup equivalents, vitamins D, ß-carotene, fiber, saturated fat, sugar, time at screen/ sleep/physical activity and parent behaviors. Three measures of reliability were acceptable. The addition of nutrient values as an analytical validation approach adds strength and consistency to previously reported Niños Sanos validation results using children's blood biomarkers and body mass index. This tool can be used by health professionals as an assessment of obesity risk in several capacities: (1) screener for counseling in a clinic, (2) large survey, (3) guide for participant goal setting and tailoring interventions, and (4) evaluation.

Feasibility of Colocating a Nutrition Education Program into a Medical Clinic Setting to Facilitate Pediatric Obesity Prevention.

PURPOSE: Within a medical clinic environment, pediatric obesity prevention education for families faces challenges. Existing long-term government-funded nutrition education programs have the expertise and staff to deliver. The purpose is to determine feasibility of colocating the Expanded Food and Nutrition Education Program (EFNEP) into a medical clinic setting to support pediatric obesity prevention. METHODS: Physicians from a large university teaching and research hospital (n = 73) and 4 small Medicaid-serving community clinics (n = 18) in the same geographic area in northern California were recruited and trained in the patient-referral protocol for a primary prevention intervention provided by EFNEP. The 8-week intervention deployed in the medical clinics, included general nutrition, physical activity and parenting topics anchored with guided goal setting and motivational modeling. Referral, enrollment, and attendance data were collected for 2 years. Parent and physician feasibility surveys, parent interviews and parent risk assessment tools were administered. Paired-sample t-test analysis was conducted. RESULTS: Twenty intervention series with parents of patients (n = 106) were conducted at 5 clinics. Physicians (n = 92) generated 686 referrals. Every 6 referrals generated 1 enrolled parent. Physicians (91%, n = 34) reported the intervention as useful to families. Parents (n = 82) reported improved child behaviors for sleep, screen time, physical activity, and food and beverage offerings (P < .0001) and at family mealtime (P < .001). Focus group interviews (n = 26) with 65 participants indicated that parents (97%) reacted positively to participating in the intervention with about a third indicating the classes were relevant to their needs. CONCLUSION: The intervention is a feasible strategy for the 5 medical clinics. Physicians referred and parents enrolled in the intervention with both physicians and parents indicating positive benefits. Feasibility is contingent upon physician awareness of the intervention and motivation to refer patients and additional EFNEP and clinic staff time to enroll and keep parents engaged.

Obesity Risk Assessment Tool for Low-Income Spanish Speaking Immigrant Parents with Young Children: Validity with BMI and Biomarkers of Obesity.

Children of Hispanic origin bear a high risk of obesity. Child weight gain trajectories are influenced by the family environment, including parent feeding practices. Excessive body fat can result in unhealthful metabolic and lipid profiles and increased risk of metabolic diseases. The objective was to estimate criterion validity of an obesity risk assessment tool targeting Spanish-speaking families of Mexican origin using anthropometric measures and blood values of their young children. A cross-sectional study design with five data collection sessions was conducted over an eight-week period and involved 206 parent/child dyads recruited at Head Start and the Special Supplemental Nutrition Program for Women, Infants and Children in Northern California. Main outcome measures were criterion validity of Niños Sanos, a pediatric obesity risk assessment tool, using anthropometric measures and blood biomarkers. Niños Sanos scores were inversely related to child BMI-for-age percentiles (p = 0.02), waist-for-height ratios (p = 0.05) and inversely related to blood biomarkers for the metabolic index (p = 0.03) and lipid index (p = 0.05) and positively related to anti-inflammatory index (p = 0.047). Overall, children with higher Niños Sanos scores had more healthful lipid, metabolic and inflammatory profiles, as well as lower BMI-for-age percentiles and waist-to height ratios, providing evidence for the criterion validity of the tool. Niños Sanos can be used by child obesity researchers, by counselors and medical professionals during clinic visits as a screening tool and by educators as a tool to set goals for behavior change.

Obesity Risk Assessment Tool among 3-5 Year Olds: Validation with Biomarkers of Low-Grade Chronic Inflammation.

Background: Many families with young children practice nutrition, parenting, and lifestyle behaviors that set their children on trajectories for unhealthful weight gain. Potential adverse health effects of excessive body fat can result in the secretion of proinflammatory molecules and increased risk of inflammation and metabolic diseases. A pediatric obesity risk assessment tool named Healthy Kids (HK), demonstrated validity in a longitudinal study with child's measured BMI and 36-hour diet, screen, sleep, and activity logs. Our objective was to provide additional evidence of validity with low-income families with literacy issues using an inflammation index composed of four proinflammatory biomarkers. Methods: Parent/child pairs (n = 104) from Head Start and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provided HK, blood samples, and measured heights/weights. Select child inflammatory markers were discretized into two groups of HK scores. Data were analyzed with a mixed model adjusted for children's age and BMI. Results: A significant HK-time interaction effect was shown for the child inflammation index with two data collection points 1 year apart (pdid = 0.039). This index increased over 12 months in children with less healthful behaviors (p = 0.007), but not in children with more healthful profiles (p = 0.58). Conclusions: Children with less healthful HK scores had an elevated inflammation index indicating a low-grade chronic systemic inflammatory state. Taken together with our previously published findings, the HK tool has potential as a rapid and easy-to-administer assessment of the family environment and the child's obesity risk. HK can be useful for federal nutrition programs for evaluation, risk assessment, goal setting, and/or program planning in clinical and community environments.

Parent Food-Related Behaviors and Family-Based Dietary and Activity Environments: Associations with BMI z-Scores in Low-Income Preschoolers.

Background: In early childhood, the family dietary and activity environment and parent food-related practices have been found to be important predictors of children's weight. However, few studies account for both of these factors, or the interaction between the 2, when assessing BMI in early childhood. This study aims to examine the association between the family-based dietary and activity environment (including intake, physical activity, and structure) and children's BMI z-scores in the context of parent food-related behaviors in low-income families during the preschool years. Methods: Parents (n = 111) completed questionnaires assessing the family-based dietary and activity environment, including diet, physical activity, screentime and sleep, and their use of parent food-related behaviors including parent-centered (i.e., controlling) and child-centered (i.e., autonomy supportive) practices. Children's BMI z-scores were calculated from researcher-measured height and weight. Results: Parent-centered food-related behaviors were directly related to children's BMI z-scores and moderated the association between the family-based dietary and activity environment and children's BMI z-scores. Family-based behaviors were associated with lower BMI only when parents used fewer parent-centered behaviors. Conclusions: Findings indicate that programs working with low-income families to prevent child obesity should stress both the creation of a healthy home environment and the use of positive parent food-related behaviors with preschool aged children.

Comparisons of school and home-packed lunches for fruit and vegetable dietary behaviours among school-aged youths.

OBJECTIVE: School-based interventions and policies encourage youths to include and consume fruits and vegetables at lunchtime via school lunches, but limited research has examined how these behaviours compare when youths have home-packed lunches. The objective of the present study was to compare fruit and vegetable contents and consumption among students having school or home-packed lunches over the school week. DESIGN: Participants were observed over five consecutive days at school lunchtime. Trained analysts estimated students' lunchtime fruit and vegetable contents and consumption using digital imaging. Mixed models examined associations between fruit and vegetable dietary behaviours and lunch source (school v. home-packed), controlling for student gender, grade and school. SETTING: Three elementary schools in northern California, USA.ParticipantsFourth-, fifth- and sixth-grade students (nchildren 315; nobservations 1421). RESULTS: Students were significantly less likely to have and to consume fruits and vegetables (all P<0·05) when having home-packed lunches, compared with when having school lunches. Among those who did have or did consume these foods, having a home-packed lunch was associated with consuming significantly less fruit (P<0·05) but no differences for other dietary outcomes. CONCLUSIONS: The study adds to a growing body of literature indicating shortfalls in fruit and vegetable contents and consumption associated with having a home-packed lunch, relative to having a school lunch. Findings suggest that school-based interventions, particularly when targeting home-packed lunches, should focus on whether or not these foods are included and consumed, with less emphasis on quantities.

My Child at mealtime parent self-assessment of food related behaviors: Validation with mealtime behaviors.

My Child at Mealtime (MCMT) is a visually enhanced, self-assessment tool designed to measure parent food related behaviors of low-income caregivers of preschool-aged children. The current study examined the factor structure of MCMT and the correspondence between MCMT parent- and child-centered food related behaviors with observed behaviors during a mealtime with their preschool aged child. Caregivers (N = 175) completed MCMT, and a subsample (n = 60) had a mealtime videotaped in their home. Exploratory and confirmatory factor analysis supported a two-factor structure resulting in parent-centered and child-centered MCMT subscales. There was a significant association between parent-centered MCMT scores and observed parent-centered behaviors at mealtime. Behavioral correspondence of MCMT child-centered behaviors was generally weaker. Overall, the findings suggest that caregivers' MCMT responses provide a valid measure of parent food related behaviors.

Parental and family predictors of fruits and vegetables in elementary school children's home-packed lunches across a school week.

Home-packed lunches have been found to be of lower nutritional quality than school-bought lunches, yet little is known about family-based factors associated with lunch packing. The current exploratory study examines parental and family predictors of fruits and vegetables packed in lunches, hypothesizing parents' nutrition knowledge and authoritative parenting as well as children's involvement in lunch decisions would relate to packing more fruits and vegetables, while financial difficulties would relate to packing fewer. Ninety parent-child dyads from 4th-6th grade participated for 5 consecutive school days. Lunch contents were recorded using a digital imaging procedure to capture the number of days a fruit or vegetable was packed, and servings of fruits and vegetables in lunches each day. Parents completed family and parenting questionnaires and daily reports of child involvement in lunch decisions. Count-based regression models and longitudinal analyses within a multilevel modeling framework were used to examine predictors of lunch contents. Higher nutrition knowledge was associated with packing more fruit across the week and more vegetables on Monday. Authoritative parenting was associated with packing fewer vegetables on Monday, but more servings across the week. Financial stress was related to higher rates of never packing vegetables and when vegetables were packed including fewer servings, while child involvement in lunch decisions was associated with packing more fruits across the week, packing vegetables on more days and more servings of vegetables on Monday. Findings suggest parental and family factors impact the foods in packed lunches, with implications for children's dietary intake at school. Outreach programs can help parents pack more fruits and vegetables by providing nutrition education and suggestions for affordable, healthy lunch options as well as encouraging child involvement in the lunch packing process.

An Obesity Risk Assessment Tool for Young Children: Validity With BMI and Nutrient Values.

OBJECTIVE: Demonstrate validity and reliability for an obesity risk assessment tool for young children targeting families' modifiable home environments. DESIGN: Longitudinal design with data collected over 100 weeks. SETTING: Head Start and the Special Supplemental Nutrition Program for Women, Infants, and Children. PARTICIPANTS: Parent-child pairs (n = 133) provided food behavior assessments; 3 child-modified, 24-hour dietary recalls; 3 ≥ 36-hour activity logs; and measured heights and weights. MAIN OUTCOME MEASURE: Five measures of validity and 5 of reliability. RESULTS: Validity was excellent for the assessment tool, named Healthy Kids, demonstrating an inverse relationship with child body mass index percentile-for-age (P = .02). Scales were significantly related to hypothesized variables (P ≤ .05): fruit or vegetable cup equivalents; folate; vitamins A, C, and D; ß-carotene; calcium; fiber; sugar; screen, sleep, and physical activity minutes; and parent behaviors. Measures of reliability were acceptable. CONCLUSIONS AND IMPLICATIONS: Overall, children with higher Healthy Kids scores had a more healthful profile as well as lower body mass index percentiles-for-age 1.5 years later. Healthy Kids has potential for use by nutrition professionals as a screening tool to identify young children most at risk for excess weight gain, as an evaluation to assess intervention impact, and as a counseling tool to tailor intervention efforts. Future research should include validation in other settings and with other populations.

Feasibility and reliability of digital imaging for estimating food selection and consumption from students' packed lunches.

Although increasing attention is placed on the quality of foods in children's packed lunches, few studies have examined the capacity of observational methods to reliably determine both what is selected and consumed from these lunches. The objective of this project was to assess the feasibility and inter-rater reliability of digital imaging for determining selection and consumption from students' packed lunches, by adapting approaches previously applied to school lunches. Study 1 assessed feasibility and reliability of data collection among a sample of packed lunches (n = 155), while Study 2 further examined reliability in a larger sample of packed (n = 386) as well as school (n = 583) lunches. Based on the results from Study 1, it was feasible to collect and code most items in packed lunch images; missing data were most commonly attributed to packaging that limited visibility of contents. Across both studies, there was satisfactory reliability for determining food types selected, quantities selected, and quantities consumed in the eight food categories examined (weighted kappa coefficients 0.68-0.97 for packed lunches, 0.74-0.97 for school lunches), with lowest reliability for estimating condiments and meats/meat alternatives in packed lunches. In extending methods predominately applied to school lunches, these findings demonstrate the capacity of digital imaging for the objective estimation of selection and consumption from both school and packed lunches.

A Multicomponent, School-Based Intervention, the Shaping Healthy Choices Program, Improves Nutrition-Related Outcomes.

OBJECTIVE: To evaluate the effectiveness of the Shaping Healthy Choices Program (SHCP). DESIGN: A clustered, randomized, controlled intervention lasting 1 school year. SETTING: Schools in northern and central California. PARTICIPANTS: Fourth-graders (aged 9-10 years) at 2 control schools (n = 179) and 2 intervention schools (n = 230). INTERVENTION: Garden-enhanced education, family, and community partnerships; increased regionally procured produce in the lunchroom; and school-site wellness committees. MAIN OUTCOME MEASURES: Changes in body mass index (BMI) percentiles/Z-scores; nutrition knowledge, science process skills, and vegetable identification and preferences; and reported fruit and vegetable intake. ANALYSIS: Student t test, chi-square, ANOVA of change, and multilevel regression mixed model to evaluate change in outcomes with school as a random effect to account for cluster design effects. Statistical significance was set at P < .05. RESULTS: There was a greater improvement in BMI percentile (-6.08; P < 0.01), BMI Z-score (-0.28; P < .001), and waist-to-height ratio (-0.02; P < .001) in the intervention compared with the control schools. CONCLUSIONS AND IMPLICATIONS: The SHCP resulted in improvements in nutrition knowledge, vegetable identification, and a significant decrease in BMI percentiles. This supports the concept that the SHCP can be used to improve the health of upper elementary school students.

My child at mealtime: A visually enhanced self-assessment of feeding styles for low-income parents of preschoolers.

The importance of caregiver feeding styles on children's dietary outcomes is well documented. However, the instruments used to assess feeding style are limited by high literacy demands, making selfassessment with low-income audiences challenging. The purpose of the current study is to report on the development of My Child at Mealtime (MCMT), a self-assessment tool with reduced literacy demands, designed to measure feeding styles with parents of preschool-aged children. Cognitive interviews were conducted with 44 Head Start parents of 2-5 year old children to develop question wording and identify appropriate visuals. The resulting tool was administered to 119 ethnically diverse, low-income parents of 2-5 year old children. Factor analysis resulted in a two-factor structure that reflects responsiveness and demandingness in a manner consistent with existing assessment tools. Results indicate the final visually enhanced MCMT self-assessment tool provides a measure of parenting style consistent with existing measures, while reducing the literacy demand.

Correlates of food patterns in young Latino children at high risk of obesity.

OBJECTIVE: The present paper examines the influence of age and gender on food patterns of Latino children. DESIGN: Data are from baseline of a 5-year, quasi-experimental obesity prevention study: Niños Sanos, Familia Sana (NSFS; Healthy Children, Healthy Families). In 2012, the researchers interviewed Latino parents, using a thirty-item questionnaire to ask about their children's food consumption and feeding practices. Statistical tests included t tests and ANCOVA. SETTING: Rural communities in California's Central Valley, USA. SUBJECTS: Two hundred and seventeen parents (87-89% born in Mexico) and their children (aged 2-8 years). RESULTS: Fifty-one per cent of the children were overweight or obese (≥85th percentile of BMI for age and gender). Mean BMI Z-scores were not significantly different in boys (1·10 (SD 1·07)) and girls (0·92 (SD 1·04); P=0·12). In bivariate analysis, children aged 2-4 years consumed fast and convenience foods less often (P=0·04) and WIC (Supplemental Nutrition Program for Women, Infants, and Children)-allowable foods more often than children aged 5-8 years (P=0·01). In ANCOVA, neither age nor gender was significantly related to food patterns. Mother's acculturation level was positively related to children's consumption of fast and convenience foods (P=0·0002) and negatively related to consumption of WIC foods (P=0·01). Providing role modelling and structure in scheduling meals and snacks had a positive effect on the vegetable pattern (P=0·0007), whereas meal skipping was associated with more frequent fast and convenience food consumption (P=0·04). CONCLUSIONS: Acculturation and child feeding practices jointly influence food patterns in Latino immigrant children and indicate a need for interventions that maintain diet quality as children transition to school.

The Shaping Healthy Choices Program: design and implementation methodologies for a multicomponent, school-based nutrition education intervention.

OBJECTIVE: To provide a framework for implementation of multicomponent, school-based nutrition interventions. This article describes the research methods for the Shaping Healthy Choices Program, a model to improve nutrition and health-related knowledge and behaviors among school-aged children. DESIGN: Longitudinal, pretest/posttest, randomized, controlled intervention. SETTING: Four elementary schools in California. PARTICIPANTS: Fourth-grade students at intervention (n = 252) and control (n = 238) schools and their parents and teachers. Power analyses demonstrate that a minimum of 159 students per group will be needed to achieve sufficient power. The sample size was determined using the variables of nutrition knowledge, vegetable preference score, and body mass index percentile. INTERVENTION: A multicomponent school-based nutrition education intervention over 1 academic year, followed by activities to support sustainability of the program. MAIN OUTCOME MEASURES: Dietary and nutrition knowledge and behavior, critical thinking skills, healthy food preferences and consumption, and physical activity will be measured using a nutrition knowledge questionnaire, a food frequency questionnaire, a vegetable preferences assessment tool, the Test of Basic Science Process Skills, digital photography of plate waste, PolarActive accelerometers, anthropometrics, a parent questionnaire, and the School and Community Actions for Nutrition survey. ANALYSIS: Evaluation will include quantitative and qualitative measures. Quantitative data will use paired t, chi-square, and Mann-Whitney U tests and regression modeling using P = .05 to determine statistical significance.

Parental socioeconomic status, communication, and children's vocabulary development: a third-generation test of the family investment model.

This third-generation, longitudinal study evaluated a family investment perspective on family socioeconomic status (SES), parental investments in children, and child development. The theoretical framework was tested for first-generation parents (G1), their children (G2), and the children of the second generation (G3). G1 SES was expected to predict clear and responsive parental communication. Parental investments were expected to predict educational attainment and parenting for G2 and vocabulary development for G3. For the 139 families in the study, data were collected when G2 were adolescents and early adults and their oldest biological child (G3) was 3-4 years of age. The results demonstrate the importance of SES and parental investments for the development of children and adolescents across multiple generations.

Grandmother involvement as a protective factor for early childhood social adjustment.

Despite high rates of grandmother involvement with young grandchildren, very little research has examined the associations between nonresidential grandmother involvement and grandchild social adjustment. The present study involved 127 families enrolled in the Family Transitions Project to consider the degree to which mother-reported maternal grandmother involvement buffered 3- and 4-year-old grandchildren from economic, parenting, and child temperamental risks for reduced social competence and elevated externalizing behaviors. Findings indicate that higher levels of mother-reported grandmother involvement reduced the negative association between observed grandchild negative emotional reactivity and social competence. Furthermore, higher levels of mother-reported grandmother involvement protected grandchildren from the positive association between observed mother harsh parenting and grandchild externalizing behaviors. These findings underscore the relevance of moving beyond the nuclear family to understand factors linked to social adjustment during early childhood.

Differential stability of temperament and personality from toddlerhood to middle childhood.

This prospective, longitudinal investigation examined differential consistency of three core dimensions of individuality from toddlerhood through middle childhood. Data came from 273 families who participated with their child at least once during three developmental periods: toddlerhood (2 years), early childhood (3 to 5 years), and middle childhood (6 to 10 years). Both mothers and fathers reported on attributes of their child using subscales from the Toddler Behavior Assessment Questionnaire, the Child Behavior Questionnaire, and the Iowa Personality Questionnaire. Reports were used as indicators of the latent "Big Three" dimensions of positive emotionality, negative emotionality, and constraint at each of the three developmental periods. Results pointed to consistency in these broad dimensions of temperament and personality from toddlerhood to middle childhood.

Intergenerational Relationship Quality, Gender and Grandparent Involvement.

This prospective, intergenerational study (N = 181) considered how parent (G1, generation 1)-child (G2, generation 2) relationship quality during adolescence and adulthood is associated with G1's level of involvement with their 3-4 year-old grandchildren (G3, generation 3). Path model analyses indicated different patterns of results for the involvement of grandmothers and grandfathers with the children of their G2 sons and daughters. Current parent-reported G1-G2 relationship quality was positively associated with G2 report of G1 involvement with G3, especially for G2 daughters. The relations among confounding variables, including geographic distance, socioeconomic status, and grandparent marital status and grandparent involvement with grandchildren were considered. Results highlight the roles of intergenerational relationship quality and gender configuration of the G1-G2 dyad in shaping grandparent involvement with grandchildren.