Results of a multi-level intervention to prevent and control childhood obesity among Latino children: the Aventuras Para Niños Study.

BACKGROUND: Community-based interventions are needed to reduce the burden of childhood obesity. PURPOSE: To evaluate the impact of a multi-level promotora-based (Community Health Advisor) intervention to promote healthy eating and physical activity and prevent excess weight gain among Latino children. METHODS: Thirteen elementary schools were randomized to one of four intervention conditions: individual/family level (Family-only), school/community level (Community-only), combined (Family + Community), or a measurement-only condition. Participants were 808 Latino parents and their children enrolled in kindergarten through 2(nd) grade. Measures included parent and child body mass index (BMI) and a self-administered parent survey that assessed several parent and child behaviors. RESULTS: There were no significant intervention effects on children's BMI z-score. The family intervention changed several obesity-related child behaviors (e.g., fruit/vegetable consumption) and these were mediated by changes in parenting variables (e.g., parent monitoring). CONCLUSION: A promotora-based behavioral intervention was efficacious at changing parental factors and child obesity-related health behaviors.

Evaluating psychosocial and behavioral mechanisms of change in a tailored communication intervention.

This study examined the impact of a tailored nutrition intervention at 3 and 6 months postintervention. In all, 357 Latinas were randomly assigned to one of three conditions: (1) a control condition comprised of previously developed Spanish language targeted materials, (2) tailored print materials, or (3) tailored print materials accompanied by personalized dietary counseling via lay heath advisors (promotoras). At 6 months postintervention, significant group by time interactions were observed on the dietary behavioral strategies scales. The promotora condition resulted in significant behavior change initially; however, receipt of tailored and control materials was instrumental in continued behavior change after intervention activities had ceased. Group main effects suggested that the promotora condition was superior at reducing barriers and improving family interactions supporting healthy behaviors. The promotora model is an effective method for changing important dietary behaviors and psychosocial determinants, but longer term behavior change is achievable with less expensive intervention methods.

Family restaurant choices are associated with child and adult overweight status in Mexican-American families.

Increasing evidence links restaurant food with overweight, but little is known about the relative roles of different types of restaurants, or the effects among Latinos. Using baseline data from an intervention trial, this study tested whether the type of restaurant a family reports visiting most often is associated with the body mass index (BMI; calculated as kg/m(2)) of children and adults. Children, ages 4 to 7, and one primary caregiver for each child (94% mothers), were recruited through public elementary schools in southern San Diego County, CA, with at least 70% Latino enrollment. Weight and height measurements and survey information assessing family restaurant patronage were collected from 223 pairs of children and adults. Logistic regression results showed that children were most likely to be at risk of overweight (BMI >or=85th percentile) in families who ate most often at fast-food chains (odds ratio: 2.2; 95% confidence interval: 1.2 to 4.3). Parent overweight (BMI >or=25) was associated with eating at American restaurants, primarily buffets (odds ratio: 2.8; 95% confidence interval: 1.3 to 6.2). Both child and parent BMI were lowest in families selecting Mexican restaurants. Eating at fast-food chains and other Anglo-oriented restaurants may contribute to higher obesity rates linked to acculturation among Mexican Americans.

Long-term effects of a communication intervention for Spanish-dominant Latinas.

BACKGROUND: Few studies compare the influence of different types of dietary interventions on the dietary practices of Latinas in the short and long term. The present study examined the 1-year impact of two innovative behavior-change approaches to reduce dietary fat and increase fiber. DESIGN: Three-group randomized controlled trial: (1) personalized dietary counseling via lay heath advisors (promotoras) plus tailored print materials delivered via the mail, (2) tailored mailed print materials only, and (3) targeted mailed "off-the-shelf" materials. SETTING/PARTICIPANTS: A total of 357 Latinas were randomly assigned to the three aforementioned conditions. INTERVENTION: Promotora and tailored print materials. MAIN OUTCOME MEASURES: Fat intake (total grams of fat and percent calories from dietary fat) and number of grams of dietary fiber. RESULTS: Earlier work reported that at immediate post-intervention the promotora group achieved significantly lower levels of total fat grams, and lower levels of energy intake, total saturated fat, total carbohydrates, glucose, and fructose than the targeted group. However, the present longitudinal analyses suggest that the effects achieved by the promotoras dissipated over the 12-month follow-up period while the effects of the tailored group concurrently improved. CONCLUSIONS: The high interactivity (i.e., calls, visits) of the promotora condition may have been the most salient reinforcer and may have led to further tailoring, making this type of intervention more effective than the comparison groups in the short term. Further research should explore whether booster sessions involving promotoras help to maintain the impact over time.

Association of a traditional vs shared meal decision-making and preparation style with eating behavior of Hispanic women in San Diego County.

OBJECTIVE: To examine the influence of meal decision-making and preparation on Hispanic women's dietary practices. DESIGN: One-on-one structured interviews were conducted, assessing meal decision-making and preparation practices, barriers, and behavioral strategies to eating low-fat and high-fiber diets, fat and fiber intake, demographic, and other psychosocial factors. SUBJECTS/SETTING: The study population included 357 Hispanic women living in the southern or central regions of San Diego County. Participants were recruited via random-digit dialing to a tailored nutrition communication intervention. MAIN OUTCOME MEASURE: Household decision-making style (alone vs with family) by household activity (decides meals, prepares meals, and decides snacks). STATISTICAL ANALYSES PERFORMED: Multiple logistic regressions were used to evaluate associations between the predictors and dependent variable. All models included adjustments for potential confounders, such as marital status, education, employment, age, and acculturation. RESULTS: A positive statistical association between Hispanic women's acculturation level and shared decision-making style was found. Also, Hispanic women in shared decision-making households faced greater psychosocial barriers to healthful eating and reported less healthful eating compared with Hispanic women in traditional households. Women in shared decision-making households were more likely to eat at fast-food restaurants, less likely to engage in behavioral strategies promoting fiber consumption, eat more saturated fat, and encounter more barriers to reduce dietary fat as compared with Hispanic women in traditional households. Acculturation did not attenuate differences in psychosocial and dietary practices between shared decision-making and traditional households. CONCLUSIONS: Study findings suggest intervention efforts should focus on different aspects of healthful eating among Hispanic women in shared-decision, compared with traditional, households.

Interpersonal and print nutrition communication for a Spanish-dominant Latino population: Secretos de la Buena Vida.

Participants (N=357) were randomly assigned to 1 of 3 conditions: lay health advisor (promotora) plus tailored print materials, tailored print materials only (tailored), or off-the-shelf print materials (control). The primary outcomes were calories from fat and daily grams of fiber. Secondary outcomes included total energy intake, total and saturated fat intake, and total carbohydrates. Adjusted for baseline values, calories from fat were 29%, 30%, and 30% for the promotora, tailored, and control conditions, respectively, and grams of fiber consumed were 16 g, 17 g, and 16 g. Significant Condition X Time interactions were not observed between baseline and 12-weeks postintervention. The LHA condition achieved significantly lower levels of energy intake, total fat and saturated fat, and total carbohydrates. The relative superiority of the promotora condition may derive from the personal touch achieved in the face-to-face interactions or from the women's use of print materials under the promotora's guidance.

Restaurant and food shopping selections among Latino women in Southern California.

OBJECTIVE: This study describes and examines determinants of restaurant and food store selections in a sample of Latino women. DESIGN: Data were collected at the baseline home-based interview from women involved in a randomized community trial to improve dietary behaviors. The interview consisted of both a structured interview and the measurements of height, weight, and waist-to-hip ratio. SUBJECTS/SETTING: Participants included 357 Latino women recruited via random-digit dial in the Southern and Central areas of San Diego County, California. Women were included if they were between 18 and 67 years of age, not currently pregnant, and Spanish-language dominant; women were excluded if a family member was on a special diet or was planning to leave the area during the study. STATISTICAL ANALYSES PERFORMED: Means and frequencies were used to describe preference for various types of restaurants and food stores based on the North American Industry Classification System (NAICS). Independent samples t tests examined differences in levels of importance for preferring fast-food vs other restaurants and supermarkets/produce markets vs other grocery stores. Logistic regression models examined correlates of preferring fast-food restaurants vs all other restaurants and preferring supermarkets/produce markets vs all other grocery stores. RESULTS: More women reported eating at fast-food restaurants, followed by full-service restaurants and cafeterias. Younger women, employed women, women living in higher income households, and women living in the United States for a greater number of years preferred fast food. Supermarkets; grocery stores; and discount, bulk-purchase stores were equally represented as the primary food store. Women who lived in smaller households, had a smaller measured body mass, were married, and were more acculturated to the Anglo culture were more likely to shop at supermarkets compared with women who shopped at other grocery stores. CONCLUSIONS: Our findings suggest specific recommendations for targeting dietary interventions for the growing Latino population that take into account differences in levels of acculturation. For example, young Latino women who more closely identify with the Anglo culture and/or who report living in the United States for a longer period of time may benefit from targeted information on healthy restaurant behavior. On the other hand, traditional Latino women may benefit from instrumental support interventions such as tours to large supermarkets.

Is church attendance associated with Latinas' health practices and self-reported health?

OBJECTIVES: To evaluate (a) the relation between frequency of church attendance, self-rated health, and health behaviors controlling for potential confounders and (b) the influence of acculturation on church attendance and health behaviors. METHODS: Physical activity and dietary patterns, demographics, and acculturation levels were compared among Latinas who attended church frequently, infrequently, and not at all. RESULTS: Church attendance was independently and positively associated with healthier dietary and physical activity behaviors, but not with self-rated health. Acculturation attenuated the relation between physical activity and church attendance. CONCLUSION: Latinas' health behaviors and self-rated health may be related to other variables that explain the salutary effects of church attendance.

Some methodologic issues in analyzing data from a randomized adolescent tobacco and alcohol use prevention trial.

Three issues concerning the design and analysis of randomized behavioral intervention studies are illustrated and discussed within the framework of a tobacco and alcohol prevention trial among migrant Latino adolescents. The first issue arises when subjects are randomized in clusters rather than individually. Because subject observations cannot be assumed to be independent, information pertaining to the degree of clustering must be reported, and analyses must take the clustering into account. The second issue concerns the impact of compliance to the intervention and the importance of measuring compliance in the experimental and attention-control groups. A compliance analysis should control for participant contact with study personnel. Investigators must consider ways of constructing a compliance measure that is common to both conditions. Third, because outcomes are measured repeatedly over time, we illustrate the importance of assessing the impact of missing-data patterns on outcomes and the extent to which the patterns may modify the treatment effect.

Tobacco and alcohol use-prevention program for Hispanic migrant adolescents.

OBJECTIVE: Evaluate a community-based tobacco/alcohol use-prevention program group compared with an attention-control condition (first aid/home safety) group. METHODS: A total of 660 adolescents and 1 adult caregiver for each were recruited through the Migrant Education Program to participate in an 8-week intervention. Random assignment to the two groups occurred in 22 schools. Seventy 8-week intervention groups (37 tobacco/alcohol and 33 attention-control) were conducted. Assessments occurred at baseline, immediate post-intervention, and 1- and 2-year follow-ups. Susceptibility to smoking and alcohol as well as smoking and drinking over the past 30 days were the primary outcomes of interest. RESULTS: Following intervention, no between-group differences in smoking or drinking were significant. Thirty-day smoking started and remained at very low levels, with the highest group prevalence at any measurement period being 4.7% and the lowest 2.5%. Those considered susceptible to smoking dropped by nearly 40% in the attention-control group and by 50% in the intervention group from baseline to the final follow-up. (The overall reduction from post-test to final follow-up was statistically significant.) Less-acculturated children were less likely to report drinking in the past 30 days. CONCLUSIONS: The current intervention was not demonstrated to be effective in preventing cigarette or alcohol consumption. This perhaps is due to very low baseline levels of smoking and drinking in the migrant youth participants.

Correlates of body mass index and waist-to-hip ratio among Mexican women in the United States: implications for intervention development.

INTRODUCTION: This study contributes to our understanding of acculturation and obesity by examining the association between several measures of acculturation, including a bidimensional scale of acculturation, body mass index (BMI), and waist-to-hip ratio (WHR). METHODS: Exploratory analyses were performed using baseline data from 357 Mexican women recruited into a Spanish-language randomized community trial. The women were randomly sampled by telephone and interviewed in their homes. Women's height, weight, waist, and hip were measured to obtain estimates of their BMI and WHR. A face-to-face interview collected data on dietary intake, physical activity, acculturation, and other demographic and psychosocial variables. RESULTS: Less than a quarter of the women were normal weight (39% overweight and 41% obese). Univariate analyses revealed that more years living in the United States and less integration into the Anglo culture were associated with a larger BMI and WHR. However, in the multivariate analyses, significant correlates of a larger BMI were less moderate physical activity and unemployment. There were trends linking a larger BMI with older age, no vigorous physical activity, more energy intake, and less integration into the Anglo culture. These same variables plus less household income were associated with a higher WHR. Exploratory analyses on acculturation revealed that bicultural Mexican-American women were more educated, more likely to be employed, reported a higher household income, and perceived fewer barriers to a healthy diet compared with traditional Mexican women. CONCLUSIONS: Intervention designed to prevent overweight/obesity should consider promoting maintenance of Mexican cultural practices, as well as teach women how to effectively integrate into the Anglo culture.

Longitudinal intervention effects on parenting of the Aventuras para Niños study.

BACKGROUND: Parenting interventions have achieved changes in factors associated with childhood obesity but few have tested the effects on multiple parental influences. PURPOSE: This study examined the efficacy of an intervention aimed at improving several dimensions of parenting related to childhood obesity. DESIGN: The study used a 2 x 2 factorial design. SETTING/PARTICIPANTS: In 2003, a sample of 13 Southern California schools was randomized to one of four conditions: micro-environment only, macro-environment only, micro-plus-macro-environment, and no treatment control condition. Participants included 811 predominantly Mexican immigrant/Mexican-American mothers with children in kindergarten through second grade. INTERVENTION: In both micro conditions, participants received monthly home visits by a promotora over a 7-month period plus monthly mailed newsletters. MAIN OUTCOME MEASURES: In 2008, intervention effects were examined on (1) parenting strategies, including limit setting, monitoring, discipline, control, and reinforcement related to children's diet and physical activity; (2) parental support for physical activity; (3) parent-mediated family behaviors such as family meals eaten together and TV watching during family dinners; and (4) perceived barriers and other parent cognitions related to children's eating and activity. RESULTS: At the 2-year follow-up, significant improvements were observed in three of five parenting strategies, parental support, and two of four parent-mediated family behaviors among parents receiving the micro intervention (i.e., those who received promotora visits and monthly newsletters), as compared with those in the macro-only and control conditions. CONCLUSIONS: Aspects of parenting related to children's risk for obesity and related health outcomes are modifiable with the support of a promotora and print media.

Secretos de la Buena Vida: processes of dietary change via a tailored nutrition communication intervention for Latinas.

Secretos de la Buena Vida was a successful tailored nutrition communication intervention delivered to Latinas living along the US-Mexico border in California. The intervention was delivered over a 14-week period and consisted of three intervention conditions: weekly home visits with promotoras + weekly tailored mailed newsletters in the first condition, weekly tailored mailed newsletters in the second condition and targeted materials in the attention control condition. The current study examined what elements of the promotora + tailored newsletter and tailored newsletter-only conditions were most effective for behavioral adoption and maintenance in a sample of 238 Latina women. Process evaluation measures assessed the implementation, fidelity and dose of these two intervention conditions. Results indicate that there was high fidelity to program implementation and delivery. Perceived effort, perceived support and intervention length predicted adoption of a lower fat diet at the 15-month follow-up. In the promotora + tailored newsletter condition, married women were four times more likely to be adopters of dietary fat changes than single women. These findings highlight the importance of process evaluation measures and help us understand the mechanism by which tailored print materials and interpersonal health communication via promotoras can facilitate health behavior change.

Environmental correlates of physical activity in Mexican American children at home.

BACKGROUND: Understanding home environments might shed light on factors contributing to reduced physical activity (PA) in children, particularly minorities. Few studies have used microlevel observations to simultaneously assess children's PA and associated conditions in homes. METHODS: Trained observers assessed PA and associated physical and social environmental variables in the homes of 139 Mexican American children (69 boys, 70 girls; mean age = 6 years) after school. RESULTS: Children spent most time indoors (77%) and being sedentary (74%). Reduced PA was associated with viewing media, being indoors, and parents being present. Increased PA was associated with prompts for PA and other children being present. PA prompts differed by child gender and location and prompter age status. CONCLUSIONS: Children are frequently sedentary at home. Microlevel observations showed PA is associated with potentially modifiable social and physical factors, including spending time outdoors. Studies to determine whether interventions on these correlates can improve children's PA are needed.

Away-from-home food intake and risk for obesity: examining the influence of context.

OBJECTIVE: This study examined sociodemographic and cultural determinants of away-from-home food consumption in two contexts and the influence of frequency of away-from-home food consumption on children's dietary intake and parent and child weight status. METHODS AND PROCEDURES: Parents of children (N=708) in grades K-2 were recruited from 13 elementary schools in Southern California. Parents were asked through a questionnaire the frequency with which they eat meals away from home and the restaurant they frequented most often. The height and weight of the parents and their children were measured to calculate BMI. RESULTS: Consuming foods at least once a week from relatives/neighbors/friends (RNF) homes was associated with children's dietary intake and children's risk for obesity. For example, children of parents with weekly or greater RNF food consumption drank more sugar-sweetened beverages. Parents of families who ate at restaurants at least weekly reported that their children consumed more sugar-sweetened beverages, more sweet/savory snacks, and less water compared with families who did not frequent restaurants this often. The type of restaurant visited did not affect diet intake or obesity. More acculturated families exhibited less healthy dietary behaviors than less acculturated families. DISCUSSION: Restaurants remain an important setting for preventing child and adult obesity, but other settings outside the home need to be considered in future intervention research. This may especially involve eating in the homes of RNF.