Healthy for Two/Healthy for You: Design and methods for a pragmatic randomized clinical trial to limit gestational weight gain and prevent obesity in the prenatal care setting.

OBJECTIVE: To compare the effect of Healthy for Two/Healthy for You (H42/H4U), a health coaching program, in prenatal care clinics that serve a racially and economically diverse population, on total gestational weight gain (GWG) (vs. usual care). We hypothesize that compared to usual prenatal care, intervention participants will have lower GWG and lower rates of gestational diabetes mellitus (GDM). METHODS: We report the rationale and design of a pragmatic, parallel arm randomized clinical trial with 380 pregnant patients ≤15 weeks gestation with overweight or obesity from one of 6 academic and community-based obstetrics practices, randomized to either H42/H4U or usual prenatal care in a 1:1 ratio. The study duration is early pregnancy to 6 months postpartum. The primary outcome is total GWG, calculated as the difference between first clinic-assessed pregnancy weight and the weight at 37 weeks gestation. Key maternal and infant secondary outcomes include GDM incidence, weight retention at 6 months postpartum, infant weight, maternal health behaviors and wellness. CONCLUSIONS: This pragmatic clinical trial embeds a pregnancy health coaching program into prenatal care to allow parallel testing compared to usual prenatal care on the outcome of total GWG. The real-world design provides an approach to enhance its sustainability beyond the trial to ultimately improve maternal/child health outcomes and reduce future obesity. TRIAL REGISTRATION: The study was first registered at clinicaltrials.gov on 1/26/21 (NCT04724330).

Racial/Ethnic Disparities in Parent Activation: Implications for Developing Interventions Addressing Early Childhood Obesity.

OBJECTIVE: Examine racial/ethnic differences in parent activation and associations with child obesity risk behaviors in low-income families. METHODS: Cross-sectional survey study of 300 low-income Black, Latinx, and White parents of patients aged 2 to 5 years receiving primary care within 2 health care systems (Systems 1 & 2). In-person and phone surveys were conducted. Parent activation, defined as parents' knowledge, confidence, and willingness to act concerning their child's health, was measured using the standardized 13-item Parent Patient Activation Measure (P-PAM). Differences in parent activation by race/ethnicity were assessed using analysis of variance. Multivariate regression analyses were used to test associations between parent activation and child obesity risk behaviors. RESULTS: In pooled unadjusted analyses, Latinx parents had significantly lower activation compared to Black parents (P = .023), but these differences were no longer statistically significant after adjusting for other sociodemographic characteristics (P = .06). Higher activation was associated with slightly greater odds of consuming ≥ 5 daily servings of fruits and vegetables for System 2 only (odds ratio: 1.04, 95% confidence interval: 1.01, 1.07). Associations between parental activation and child screen time or physical activity were not significant. CONCLUSIONS: Findings highlight potential measurement limitations of the P-PAM including the inability of the measure to capture barriers to health system navigation and cultural and linguistic considerations. Further attention to the nuanced interplay between parental activation and contextual and sociodemographic risk factors (eg, food availability, immigrant status, economic opportunity, language proficiency) should be considered in the development of early childhood obesity interventions in primary care settings.

Do Neighborhoods Matter? A Systematic Review of Modifiable Risk Factors for Obesity among Low Socio-Economic Status Black and Hispanic Children.

BACKGROUND: Childhood obesity increases the risk of obesity and harmful comorbidities later in life. It is influenced by characteristics of a child's neighborhood, particularly among underserved groups. Our objective was to systematically review the evidence relating neighborhood environment and obesity risk among urban, low socioeconomic status (SES) Black and Hispanic children. METHODS: We included studies published from 1993 through early 2017 from PubMed, SCOPUS, Web of Science, and Sociological Abstracts databases investigating relationships between empirically measured neighborhood characteristics and obesity risk factors in the populations of interest. Databases were last searched on May 8, 2018. Initial analysis took place during 2014 and was completed during 2017. We extracted data on study population, design, and associations between neighborhood characteristics and obesity risk factors. RESULTS: We identified 2011 unique studies; 24 were included. Few studies demonstrated consistent patterns of association. Most neighborhood characteristics were not examined across multiple studies. BMI may be related to living in a lower-income neighborhood or convenience store access. CONCLUSIONS: This review found that the body of evidence relating neighborhood exposures and obesity risk factors among urban, low SES Black (also commonly referred to in the literature as "non-Hispanic Black" or African American) and Hispanic children is limited. Given the high risk of obesity and cardiovascular disease among these populations throughout the life course, research on neighborhood determinants of obesity should specifically include these populations, ensuring adequate power and methodological rigor to detect differences.

Parental Activation and Obesity-Related Health Behaviors Among a Racially and Ethnically Diverse Population of Low-Income Pediatric Patients: Protocol for a Cross-Sectional Survey Study.

BACKGROUND: Despite a recent decline in the obesity prevalence among preschool-aged children, obesity remains disproportionately high among children from low-income racial or ethnic minority families. Promoting healthy lifestyles (eg, obesity-preventative behaviors) in primary care settings is particularly important for young children, given the frequency of preventative health visits and parent-provider interactions. Higher adoption of specific health behaviors is correlated with increased patient activation (ie, skill, confidence, and knowledge to manage their health care) among adults. However, no published study, to date, has examined the relationship between parental activation and obesity-related health behaviors among young children. OBJECTIVE: The goal of this study is to measure parental activation in low-income parents of preschoolers in 2 large health systems and to examine the association with diet, screen-time, and physical activity behaviors. METHODS: We will conduct a cross-sectional study of parents of preschool-aged patients (2-5 years) receiving primary care at multiple clinic sites within 2 large health care systems. Study participants, low-income black, Hispanic, and white parents of preschool-aged patients, are being recruited across both health systems to complete orally administered surveys. RESULTS: Recruitment began in December 2017 and is expected to end in May 2018. A total of 267 low-income parents of preschool-aged children have been enrolled across both clinic sites. We are enrolling an additional 33 parents to reach our goal sample size of 300 across both health systems. The data analysis will be completed in June 2018. CONCLUSIONS: This protocol outlines the first study to fully examine parental activation and its relationship with parent-reported diet, physical activity, and screen-time behaviors among low-income preschool-aged patients. It involves recruitment across 2 geographically distinct areas and resulting from a partnership between researchers at 2 different health systems with multiple clinical sites. This study will provide new knowledge about how parental activation can potentially be incorporated as a strategy to address childhood obesity disparities in primary care settings. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/9688.

Where Children Live: Examining Whether Neighborhood Crime and Poverty Is Associated With Overweight and Obesity Among Low-Income Preschool-Aged Primary Care Patients.

Introduction: Low-income and racial/ethnic minority preschoolers (aged 2-5 years) are disproportionately affected by obesity and its associated health consequences. Individual-level factors (e.g., diet) and environmental factors (e.g., neighborhood conditions) contribute to these disparities. However, there is limited research examining the role of neighborhood factors on obesity risk specifically among high-risk preschoolers. The objectives of this study are to describe the geographic distribution of preschool patients receiving care at two primary care pediatrics clinics affiliated with an academic medical center, and explore whether exposure to neighborhood crime and poverty is associated with obesity risk among this population. Methods: Cross-sectional multilevel study linking clinical administrative data on patient visits between 2007 and 2012 with data from the American Community Survey and the Baltimore City Police Department. Home addresses of 2-5 year-old patients were geocoded to their neighborhood (i.e., census block group) of residence. We used logistic regression to examine the cross-sectional relationship between obesity and overweight and neighborhood-level factors. All analyses were adjusted for age and gender, and stratified by race/ethnicity (Black, Hispanic, and White). Results: The majority of preschool patients lived in moderate or high crime (84%) or high poverty (54%) neighborhoods. A significantly higher proportion of Black preschoolers lived in high poverty neighborhoods compared to White preschoolers (61% vs. 38%, p < 0.001). Among this clinic-based sample of preschoolers, living in high crime or high poverty neighborhoods was not associated with a clinically significant increased odds of overweight or obesity. Conclusions: This study examines the association between neighborhood factors and obesity and overweight among a clinic-based population of low-income racial/ethnic minority preschoolers. The neighborhoods where preschoolers in this sample lived, on average had higher crime counts and poverty than the citywide average for Baltimore. Our findings also suggest that Black preschoolers are exposed to higher levels of neighborhood poverty compared to Whites. While no meaningful association between these neighborhood factors and odds of obesity or overweight was found in this cross-sectional analysis, our findings suggest avenues for future studies informative to the development of clinic-based obesity management interventions aimed at effectively addressing neighborhood contributors to early childhood obesity disparities.

The association between parent-reported provider communication quality and child obesity status: Variation by parent obesity and child race/ethnicity.

OBJECTIVE: To examine the association between healthcare provider communication quality and child obesity status, and the role of parent obesity and child race/ethnicity regarding this association. METHODS: We conducted a cross-sectional secondary data analysis with the 2011-2013 Medical Expenditures Panel Survey of parents with children ages 6-12 (n=5390). We used multivariable logistic regression to examine the association of parent-reported healthcare provider communication quality (explaining well, listening carefully, showing respect, and spending enough time) with child obesity status, and effect modification by parent obesity and child race/ethnicity. RESULTS: Parents of obese children were more likely to report that their child's healthcare provider listened carefully (OR=1.41, p=0.002) and spent enough time (OR=1.33, p=0.022) than parents of non-obese children. Non-obese parents of obese children experienced better communication in the domains of listening carefully (p<0.001) and spending enough time (p=0.007). Parents of obese non-Hispanic Asian children and non-Hispanic Black children were more likely to report that providers explained things well (p=0.043) and listened carefully (p=0.012), respectively. CONCLUSION: Parents of obese children experienced better communication if parents were non-obese or children were non-Hispanic Black or Asian. PRACTICE IMPLICATIONS: Healthcare providers should ensure effective communication with obese parents of obese children.

Parent and Clinician Perspectives on Sustained Behavior Change after a Prenatal Obesity Program: A Qualitative Study.

BACKGROUND: Infants of obese women are at a high risk for development of obesity. Prenatal interventions targeting gestational weight gain among obese women have not demonstrated consistent benefits for infant growth trajectories. METHODS: To better understand why such programs may not influence infant growth, qualitative semi-structured interviews were conducted with 19 mothers who participated in a prenatal nutrition intervention for women with BMI 30 kg/m2 or greater, and with 19 clinicians (13 pediatric, 6 obstetrical). Interviews were transcribed and coded with themes emerging inductively from the data, using a grounded theory approach. RESULTS: Mothers were interviewed a mean of 18 months postpartum and reported successful postnatal maintenance of behaviors that were relevant to the family food environment (Theme 1). Ambivalence around the importance of postnatal behavior maintenance (Theme 2) and enhanced postnatal healthcare (Theme 3) emerged as explanations for the failure of prenatal interventions to influence child growth. Mothers acknowledged their importance as role models for their children's behavior, but they often believed that body habitus was beyond their control. Though mothers attributed prenatal behavior change, in part, to additional support during pregnancy, clinicians had hesitations about providing children of obese parents with additional services postnatally. Both mothers and clinicians perceived a lack of interest or concern about infant growth during pediatric visits (Theme 4). CONCLUSIONS: Prenatal interventions may better influence childhood growth if paired with improved communication regarding long-term modifiable risks for children. The healthcare community should clarify a package of enhanced preventive services for children with increased risk of developing obesity.

Neighborhood and Parental Influences on Diet and Physical Activity Behaviors in Young Low-Income Pediatric Patients.

This study explores the relationship between neighborhood characteristics and caregiver preferences for establishing diet and physical activity behaviors among low-income African American and Hispanic young children (2-5 years). Primary caregivers of young children were recruited from 2 urban pediatric clinics to participate in focus groups (n = 33). Thematic analysis of transcripts identified 3 themes: neighborhood constraints on desired behaviors, caregivers' strategies in response to neighborhoods, and caregivers' sense of agency in the face of neighborhood constraints. This study elucidates the dynamic relationship between neighborhoods and caregiver preferences, their interrelated impacts on establishment of diet and physical activity behaviors among young children, and the important role of caregiver agency in establishing behaviors among young children. To effectively address obesity disparities among young children, primary care behavioral interventions must leverage and support such resilient caregiver responses to neighborhood constraints in order to optimally address racial/ethnic and socioeconomic disparities in obesity among young children.

Infant Growth following Maternal Participation in a Gestational Weight Management Intervention.

BACKGROUND: Obesity is widespread and treatment strategies have demonstrated limited success. Changes to obstetrical practice in response to obesity may support obesity prevention by influencing offspring growth trajectories. METHODS: This retrospective cohort study examined growth among infants born to obese mothers who participated in Nutrition in Pregnancy (NIP), a prenatal nutrition intervention at one urban hospital. NIP participants had Medicaid insurance and BMIs of 30 kg/m(2) or greater. We compared NIP infant growth to a historical control cohort, matched on maternal factors: age, race/ethnicity, prepregnancy BMI, parity, and history of prepregnancy hypertension or preterm birth. RESULTS: Growth data were available for 61 NIP and 145 control infants. Most mothers were African American (94%). Mean maternal BMI was 39.9 kg/m(2) (standard deviation [SD], 5.6) for NIP participants and 38.8 kg/m(2) (SD, 6.0) for controls. Pregnancy outcomes, including preterm birth, gestational diabetes, and birth weight, did not differ between groups. NIP participants were more likely to attend a postpartum visit (69% vs. 52%; p value, 0.03). At 1 year, 17% of NIP infants and 15% of controls had weight-for-length (WFL) ≥95th percentile (p value, 0.66). Other markers of accelerated infant growth, including crossing WFL percentiles and peak infant BMI, did not differ between groups. CONCLUSIONS: There was no difference in growth between infants whose mothers participated in a prenatal nutrition intervention and those whose mothers did not. Existing prenatal programs for obese women may be inadequate to prevent pediatric obesity without pediatric collaboration to promote family-centered support beyond pregnancy.

A systematic review of home-based childhood obesity prevention studies.

BACKGROUND AND OBJECTIVES: Childhood obesity is a global epidemic. Despite emerging research about the role of the family and home on obesity risk behaviors, the evidence base for the effectiveness of home-based interventions on obesity prevention remains uncertain. The objective was to systematically review the effectiveness of home-based interventions on weight, intermediate (eg, diet and physical activity [PA]), and clinical outcomes. METHODS: We searched Medline, Embase, PsychInfo, CINAHL, clinicaltrials.gov, and the Cochrane Library from inception through August 11, 2012. We included experimental and natural experimental studies with ≥1-year follow-up reporting weight-related outcomes and targeting children at home. Two independent reviewers screened studies and extracted data. We graded the strength of the evidence supporting interventions targeting diet, PA, or both for obesity prevention. RESULTS: We identified 6 studies; 3 tested combined interventions (diet and PA), 1 used diet intervention, 1 combined intervention with primary care and consumer health informatics components, and 1 combined intervention with school and community components. Select combined interventions had beneficial effects on fruit/vegetable intake and sedentary behaviors. However, none of the 6 studies reported a significant effect on weight outcomes. Overall, the strength of evidence is low that combined home-based interventions effectively prevent obesity. The evidence is insufficient for conclusions about home-based diet interventions or interventions implemented at home in association with other settings. CONCLUSIONS: The strength of evidence is low to support the effectiveness of home-based child obesity prevention programs. Additional research is needed to test interventions in the home setting, particularly those incorporating parenting strategies and addressing environmental influences.