¡Míranos! a Comprehensive Preschool Obesity Prevention Program in Low-Income Latino Children: One-year Results of a Clustered Randomized Controlled Trial.

OBJECTIVE: Test a culturally tailored obesity prevention intervention in low-income, minority preschool-age children. DESIGN: A three-group clustered randomized controlled trial. SETTING: Twelve Head Start Centers were randomly assigned to a center-based intervention, a combined center- and home-based intervention, or control using a 1:1:1 ratio. The center-based intervention modified center physical activity and nutrition policies, staff practices, and child behaviors, while the home-based intervention supported parents for obesity prevention at home. STUDY OUTCOMES: The primary endpoint was change in children's body mass index (BMI; kg/m2) at posttest immediately following completion of the 8-month intervention. Secondary endpoints included standardized scores for BMI (BMIz) and body weight (WAZ), and BMI percentiles (BMI pctl). PARTICIPANTS: Three-year-old children enrolled in Head Start in San Antonio, Texas, with written parent consent (N=325), 87% Latino; 57% female with mean age (SD) of 3.58 years (0.29). RESULTS: Change in BMI at posttest was 1.28 (0.97), 1.28 (0.87), and 1.41 (0.71) in the center+home-based intervention, center-based intervention, and control, respectively. There was no significant difference in BMI change between center+home-based intervention and control or center-based intervention and control at posttest. BMIz (adjusted difference -0.12 [95% CI, -0.24 to 0.01], p = .06) and WAZ (adjusted difference, -0.09 [-0.17 to -0.002], p = .04) were reduced for children in center+home-based intervention compared to control group. CONCLUSIONS: There was no reduction in BMI at posttest in children who received the intervention. Findings shed light on methodological challenges in childhood obesity research and offer future directions to explore health equity-oriented obesity prevention.

A multi-component tailored intervention in family childcare homes improves diet quality and sedentary behavior of preschool children compared to an attention control: results from the Healthy Start-Comienzos Sanos cluster randomized trial.

BACKGROUND: Childcare settings are important environments for influencing child eating and physical activity (PA). Family childcare homes (FCCH) care for many children of low-income and diverse racial/ethnic backgrounds who are at greater risk for poor diet quality, low PA, and obesity, but few interventions have targeted this setting. The aim of this study was to assess the efficacy of a multicomponent intervention conducted in FCCH on the diet quality and PA of 2-5 year old children in their care. TRIAL DESIGN: Cluster randomized trial. METHODS: The cluster-randomized trial, Healthy Start/Comienzos Sanos (2015-2019) evaluated an 8-month nutrition and PA intervention that included four components: (1) monthly telephone calls from a support coach using brief motivational interviewing, (2) tailored reports, newsletters and videos, (3) group support meetings, and (4) active play toys. After completing baseline measurement, FCCH were randomized into intervention or comparison groups in matched pairs. Both groups received the same intervention components but on different topics (intervention: nutrition/PA vs. comparison: reading readiness/literacy). Evaluation staff were blinded to group assignment. Child primary outcome measures collected at baseline and 8-months included: 1) Healthy Eating Index (HEI-2015) scores calculated from diet observation, and 2) accelerometer measurement of PA. Process measures were collected from field data and provider surveys. Generalized Estimating Equation Models assessed changes in HEI-2015 scores and PA over time by experimental condition. RESULTS: Ethnically diverse FCCH providers (n = 119) and 2-to-5-year-old children in their care (n = 377) were included in the final analysis. Process evaluation showed high participation in all intervention components except for group meetings. Compared to children in comparison group FCCH, children in intervention FCCH increased total HEI-2015 scores by 7.2 points (p < .001) including improvement in component scores for vegetables (0.84 points, p = .025) and added sugar (0.94 points, p = .025). For PA, compared to children in the comparison group, children in intervention FCCH decreased sedentary time by 5.7% (p = .021). CONCLUSIONS: The multicomponent Healthy Start intervention was effective in improving diet quality and sedentary behavior of children in FCCH, which demonstrates the promise of obesity prevention interventions in this setting. Future research could include enhancing the Healthy Start intervention to strengthen the PA component, considering virtual peer support, and determining how to best translate and disseminate the intervention into FCCH nationally. TRIAL REGISTRATION: National Institutes of Health, NCT02452645 . Registered 5 May 2015.

Associations between a Universal Free Breakfast Policy and School Breakfast Program Participation, School Attendance, and Weight Status: A District-Wide Analysis.

Breakfast consumption among youth is associated with improved diet quality, weight, cognition, and behavior. However, not all youth in the United States consume breakfast. Participation in the School Breakfast Program (SBP) is also low relative to the lunch program. Universal free breakfast (UFB) policies have been implemented to increase breakfast participation by reducing cost and stigma associated with the SBP. This study examined whether a UFB policy implemented in a school district in the Southeast US was associated with changes in breakfast participation, school attendance, and student weight. A longitudinal study of secondary data was conducted, and a mixed modeling approach was used to assess patterns of change in SBP participation. General linear models were used to assess attendance and student weight change. On average, across schools in the district, there was an increase in breakfast participation of 4.1 percentage points following the implementation of the policy. The change in breakfast participation in schools differed by the percent of students in the school who received school meals for free or at a reduced price, the percent of students of color, and the grade level of the school. Increases in SBP participation were not associated with significant changes in attendance or weight. UFB policies may be effective in increasing participation in the SBP.

Cooking Matters for Kids Improves Attitudes and Self-Efficacy Related to Healthy Eating and Cooking.

OBJECTIVE: To assess changes in self-efficacy and attitudes related to healthy eating and cooking in Cooking Matters for Kids participants. DESIGN: Prepost study design. SETTING: Cooking Matters for Kids programs offered by 35 organizations. PARTICIPANTS: Predominantly third- to fifth-grade children participating in Cooking Matters for Kids lessons during fiscal years 2012-17 with matched presurvey and postsurveys (n = 18,113). INTERVENTION(S): Cooking Matters for Kids consists of six 2-hour experiential nutrition and cooking education lessons. MAIN OUTCOME MEASURE(S): Self-efficacy related to healthy eating and cooking and attitudes toward healthy foods assessed through the Cooking Matters for Kids Participant Survey. ANALYSIS: Changes from the presurvey to postsurvey were assessed using mixed models and repeated measures ordered logistic regression accounting for clustering by course. Effect sizes were calculated using Cohen d for repeated measures. A Bonferroni adjustment was used to correct for multiple comparisons (α = 0.025). RESULTS: Both overall and individual self-efficacy and attitude scores improved from presurvey to postsurvey (P < 0.0001). The effect sizes were 0.35 for overall self-efficacy score and 0.17 for overall attitude score. CONCLUSIONS AND IMPLICATIONS: Participation in Cooking Matters for Kids was associated with improvements in self-efficacy and attitudes related to healthy eating and cooking.

Leveraging family dynamics to increase the effectiveness of incentives for physical activity: the FIT-FAM randomized controlled trial.

BACKGROUND: Insufficient physical activity is a global public health concern. Research indicates incentives can increase physical activity levels of children but has not tested whether incentives targeted at children can be leveraged to increase physical activity levels of their parents. This study evaluates whether a novel incentive design linking children's incentives to both their and their parent's physical activity levels can increase parent's physical activity. METHODS: We conducted a two-arm, parallel, open-labelled randomized controlled trial in Singapore where parent-child dyads were randomly assigned to either (1) rewards to child contingent on child's physical activity (child-based) or (2) rewards to child contingent on both child's and parent's physical activity (family-based). Parents had to be English-speaking, computer-literate, non-pregnant, full-time employees, aged 25-65 years, and with a participating child aged 7-11 years. Parent-child dyads were randomized within strata (self-reported low vs high weekly physical activity) into study arms in a 1:1 ratio. Participants were given activity trackers to assess daily steps. The outcome of interest was the between-arm difference in the change from baseline in parent's mean steps/day measured by accelerometry at months 6 and 12 (primary endpoint). RESULTS: Overall, 159 and 157 parent-child dyads were randomized to the child-based or family-based arms, respectively. Outcomes were evaluated on an intent-to-treat basis. At month 6, there was a 613 steps/day (95% CI: 54-1171) differential in favour of family-based parents. At month 12, our primary endpoint, the differential was reduced to 369 steps/day (95% CI: - 88-1114) and was no longer statistically significant. CONCLUSIONS: Our findings suggest that novel incentive designs that take advantage of group dynamics may be effective. However, in this design, the effectiveness of the family-based incentive to increase parent's physical activity was not sustained through one year. TRIAL REGISTRATION: NCT02516345 (ClinicalTrials.gov) registered on August 5, 2015.

Association of diet in nurseries and physical activity with zBMI in 2-4-year olds in England: a cross-sectional study.

BACKGROUND: Childhood obesity tracks into adulthood with detrimental effects on health. We aimed to examine the relationships of diet in childcare settings and daily physical activity (PA) of preschoolers with body mass index z-score (z-BMI). METHODS: We conducted a cross-sectional study of 150 children aged 2-4-years participating in the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) UK study to examine the associations of their diet in childcare settings and daily PA with z-BMI. Dietary intake was observed and recorded by fieldworkers using a validated tick-list food questionnaire and diet quality was assessed based on adherence to Children's Food Trust (CFT) guidelines. PA was measured using accelerometers. We derived z-BMI scores using the UK 1990 and International Obesity Taskforce growth reference charts. Multilevel regression models were used to estimate associations between diet and PA with z-BMI separately, adjusted for age, gender, ethnicity, parental education level and clustering. RESULTS: Among children who consumed one main meal or snack at childcare, 34.4% and 74.3% met the standards on fruits and vegetables and high sugar or fat snacks, respectively. Adherence to CFT guidelines was not associated with zBMI. Only 11.4% of children met recommended UK guidelines of three hours per day of physical activity. Minutes spent in light PA (ß = 0.08, 95% CI = 0.01, 0.15) and active time (ß = 0.07, 95% CI = 0.01, 0.12) were positively associated with UK 1990 zBMI scores. CONCLUSIONS: The low proportion of children meeting the standards on fruits and vegetables and high sugar or fat snacks and recommended physical activity levels highlight the need for more work to support nurseries and parents to improve preschool children's diet and activity. In our exploratory analyses, we found children with higher zBMI were more physically active which could be attributed to fat-free mass or chance finding and so requires replication in a larger study. TRIAL REGISTRATION: ISRCTN16287377 . Registered 12 June 2014.

Racial Differences in Weight Loss Mediated by Engagement and Behavior Change.

Objective: We set out to determine if a primarily Internet-delivered behavioral weight loss intervention produced differential weight loss in African American and non-Hispanic White women, and to identify possible mediators. Design: Data for this analysis were from a randomized controlled trial, collected at baseline and 4-months. Setting: The intervention included monthly face-to-face group sessions and an Internet component that participants were recommended to use at least once weekly. Participants: We included overweight or obese African American and non-Hispanic White women (n=170), with at least weekly Internet access, who were able to attend group sessions. Intervention: Monthly face-to-face group sessions were delivered in large or small groups. The Internet component included automated tailored feedback, self-monitoring tools, written lessons, video resources, problem solving, exercise action planning tools, and social support through message boards. Main Outcome Measure: Multiple linear regression was used to evaluate race group differences in weight change. Results: Non-Hispanic White women lost more weight than African American women (-5.03% vs.-2.39%, P=.0002). Greater website log-ins and higher change in Eating Behavior Inventory score in non-Hispanic White women partially mediated the race-weight loss relationship. Conclusions: The weight loss disparity may be addressed through improved website engagement and adoption of weight control behaviors.

Assessing foods offered to children at child-care centers using the Healthy Eating Index-2005.

The Healthy Eating Index-2005 (HEI-2005) has been applied primarily to assess the quality of individual-level diets but has recently been applied to environmental-level data as well. Currently, no studies have applied the HEI-2005 to foods offered in child-care settings. This cross-sectional study used the HEI-2005 to assess the quality of foods and beverages offered to preschool children (3 to 5 years old) in child-care centers. Two days of dietary observations were conducted and 120 children (six children per center) were observed at 20 child-care centers in North Carolina between July 2005 and January 2006. Data were analyzed between July 2011 and January 2012 using t tests. Mean total HEI-2005 score (59.12) was significantly (P<0.01) lower than the optimal score of 100, indicating the need to improve the quality of foods offered to children. All centers met the maximum score for milk. A majority also met the maximum scores for total fruit (17 of 20 centers), whole fruit (15 of 20 centers), and sodium (19 of 20 centers). Mean scores for total vegetable (mean=2.26±1.09), dark green/orange vegetables and legumes (mean=0.20±0.43), total grain (mean=1.09±1.25), whole grain (mean=1.29±1.65), oils (mean=0.44±0.25), and meat/beans (mean=0.44±0.25) were significantly lower than the maximum scores recommended (P<0.01). Mean scores for saturated fat (mean=3.32±3.41; P<0.01) and calories from solid fats and added sugars (mean=14.76±4.08; P<0.01) suggest the need to decrease the provision of foods high in these components. These findings indicate the need to improve the quality of foods offered to children at the centers to ensure that the foods provided contribute to children's daily nutrition requirements.

Nutrition policies at child-care centers and impact on role modeling of healthy eating behaviors of caregivers.

Studies suggest that caregivers influence children's dietary behaviors through role modeling in child-care environments. However, few studies have examined role modeling by caregivers and child-care center policies. This cross-sectional study evaluated the associations between child-care center policies about staff eating practices and caregivers' eating behaviors during mealtime interactions with children. Data were collected in 2008-2009 at 50 North Carolina child-care centers. Caregivers (n=124) reported about modeling healthy eating behaviors to children, trained research staff observed caregivers' (n=112) eating behaviors in classrooms, and directors reported about the presence/absence of center policies on staff eating practices. About 90% of caregivers reported modeling healthy eating behaviors to children. At 80% of centers, caregivers were observed modeling healthy dietary behaviors (eg, sitting with or eating same foods as children), but at fewer centers they were observed consuming unhealthy foods (eg, fast foods, salty snacks: 25%; and sugar-sweetened beverages: 50%). Although no substantial associations were observed between caregiver behaviors and center policies, effect size estimates suggest differences that may be of clinical significance. For example, caregivers were observed modeling healthy dietary behaviors more frequently at centers that had written policies about staff discouraging unhealthy foods for meals/snacks and having informal nutrition talks with children at meals. However, caregivers were observed consuming unhealthy foods and sugar-sweetened beverages more often at centers with policies that promoted healthier foods for meals/snacks. Future research should build on this study by using larger samples to understand why healthy food policies in child-care centers may not translate to eating practices among caregivers.