Systematic Review of Prevalence of Young Child Overweight and Obesity in the United States-Affiliated Pacific Region Compared With the 48 Contiguous States: The Children's Healthy Living Program.

We estimated overweight and obesity (OWOB) prevalence of children in US-Affiliated Pacific jurisdictions (USAP) of the Children's Healthy Living Program compared with the contiguous United States. We searched peer-reviewed literature and government reports (January 2001-April 2014) for OWOB prevalence of children aged 2 to 8 years in the USAP and found 24 sources. We used 3 articles from National Health and Nutrition Examination Surveys for comparison. Mixed models regressed OWOB prevalence on an age polynomial to compare trends (n = 246 data points). In the USAP, OWOB prevalence estimates increased with age, from 21% at age 2 years to 39% at age 8 years, increasing markedly at age 5 years; the proportion obese increased from 10% at age 2 years to 23% at age 8 years. The highest prevalence was in American Samoa and Guam.

A community engagement process identifies environmental priorities to prevent early childhood obesity: the Children's Healthy Living (CHL) program for remote underserved populations in the US Affiliated Pacific Islands, Hawaii and Alaska.

Underserved minority populations in the US Affiliated Pacific Islands (USAPI), Hawaii, and Alaska display disproportionate rates of childhood obesity. The region's unique circumstance should be taken into account when designing obesity prevention interventions. The purpose of this paper is to (a), describe the community engagement process (CEP) used by the Children's Healthy Living (CHL) Program for remote underserved minority populations in the USAPI, Hawaii, and Alaska (b) report community-identified priorities for an environmental intervention addressing early childhood (ages 2-8 years) obesity, and (c) share lessons learned in the CEP. Four communities in each of five CHL jurisdictions (Alaska, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Hawai'i) were selected to participate in the community-randomized matched-pair trial. Over 900 community members including parents, teachers, and community leaders participated in the CEP over a 14 month period. The CEP was used to identify environmental intervention priorities to address six behavioral outcomes: increasing fruit/vegetable consumption, water intake, physical activity and sleep; and decreasing screen time and intake of sugar sweetened beverages. Community members were engaged through Local Advisory Committees, key informant interviews and participatory community meetings. Community-identified priorities centered on policy development; role modeling; enhancing access to healthy food, clean water, and physical activity venues; and healthy living education. Through the CEP, CHL identified culturally appropriate priorities for intervention that were also consistent with the literature on effective obesity prevention practices. Results of the CEP will guide the CHL intervention design and implementation. The CHL CEP may serve as a model for other underserved minority island populations.

Children's Dietary Intake by Early Care and Education Setting in the US Affiliated Pacific.

OBJECTIVE: Examine differences in dietary intake of children aged 2-5 years in early care and education (ECE) setting in the US Affiliated Pacific (USAP). DESIGN: Secondary analysis of cross-sectional data collected by the Children's Healthy Living program. PARTICIPANTS: Children (n = 1,423) with complete dietary records and information on the ECE setting. MAIN OUTCOME MEASURES: Dietary intake by ECE setting; Head Start (HS), other ECE (OE), and no ECE. ANALYSIS: Comparison of mean dietary intake across ECE settings and multivariate logistic regression to evaluate ECE setting and likelihood for meeting dietary reference intake (DRI). RESULTS: Children in HS and OE settings had a significantly higher intake of several food groups and nutrients, compared with no ECE; vegetables (0.4 cup-equivalents per thousand kcals [CETK] vs 0.3 CETK; P < 0.001), fruits (0.8 CETK vs 0.6 CETK; P = 0.001), milk (0.9 CETK for HS and 1.0 CETK for OE vs 0.8 CETK; P < 0.001). Sixty-five percent of the HS group met DRI and had greater odds of meeting calcium DRI (odds ratio, 1.8; 95% confidence interval, 1.2-2.7) compared with other groups. The OE group had the lowest proportion of children meeting recommended intakes for 19 out of 25 nutrients. CONCLUSIONS AND IMPLICATIONS: Mean intakes of foods and nutrients for children across the USAP meet some, but not all, recommendations and intakes vary across children attending various ECE setting types. Additional research on the clinical importance of these differences and the impact of the complex food systems in the USAP may identify systematic strategies for improving diet among children.

Dietary patterns change over two years in early adolescent girls in Hawai'i.

BACKGROUND AND OBJECTIVES: In investigating diet-disease relationships, examination of dietary patterns allows for conclusions to be drawn based on overall intake. This study characterized dietary patterns of early adolescent girls over a two-year period and examined the relationship between dietary patterns and body mass index (BMI). METHODS AND STUDY DESIGN: Cross-sectional analyses were performed using longitudinal data from food records of early adolescent girls (n=148) 9 to 14 years in Hawai'i from the Female Adolescent Maturation (FAM) study. Dietary patterns were identified using principal component analysis (PCA). Pearson's correlations between BMI percentile and z-score and dietary pattern factor scores at Times 1 (2001-2002) and 2 (2002-2003) were calculated. For each dietary pattern, participants were divided into low, intermediate, and high scorers. Mean BMI percentiles and z-scores were compared between groups using analysis of covariance. RESULTS: At Time 1, three patterns were identified, characterized by: (1) whole grains, nuts and seeds, added sugar; (2) non-whole grain, tomatoes, discretionary fat; and (3) deep yellow vegetables, other starchy vegetables, cooked dry beans/peas. At Time 2, three different dietary patterns emerged: (1) non-whole grains, meat, discretionary fat; (2) other vegetables, fish, eggs; and (3) whole grain, tomatoes, other vegetables. BMI percentile and z-score differed between high and low scorers on Time 1-Pattern 1 and Time 2-Pattern 3. CONCLUSION: Results revealed changes in dietary patterns over time and an association between intake and BMI. Findings demonstrate the importance of frequent nutrition assessment to monitor changes in intake that may be improved to prevent obesity.

Dietetics Practice in the Unique, Culturally Diverse Pacific Island Region.

The Pacific Island region is geographically the most isolated region in the world representing a diverse population of indigenous peoples, migrated groups and new-comers. Rates of chronic disease are predominately high in populations identified as Pacific Islander. The practice of dietetics, defined as nutrition education for the prevention of disease and medical nutrition therapy for the treatment of chronic diseases, proves challenging with the unique cultural diversity in the region. There is a need to describe dietetics practice, populations served, and needs for resources identified by nutrition-related topic and cultural relevance for Registered Dietitian Nutritionists in the Pacific Island region. An online survey was distributed to all members of the Hawai'i Affiliate of the Academy of Nutrition and Dietetics in 2013-2014. The online survey yielded 104 usable responses. Most participants were female and lived and worked in the Hawaiian Island region. One-third of practicing Registered Dietitian Nutritionists saw >100 patients or clients per month. Most prevalent populations served were identified as Asian and Pacific Islanders. Culturally relevant resources of the highest need were relevant to Asian and Pacific Islander cultures, specifically addressing weight control and diabetes. Dietetics practice in the Pacific Island region is unique given the prevalence of Asians and Pacific Islanders served by Registered Dietitian Nutritionists. Findings will inform the development of new, culturally appropriate online nutrition resources, to enhance dietetics practice in the region. Making these resources available online will be useful for Registered Dietitian Nutritionists and other health care practitioners working in the Pacific Island region.

Effect of the Children's Healthy Living Program on Young Child Overweight, Obesity, and Acanthosis Nigricans in the US-Affiliated Pacific Region: A Randomized Clinical Trial.

Importance: Pacific Islanders have among the highest rates of obesity and type 2 diabetes in the world. Targeting children is critical for primary prevention. Objectives: To prevent young child overweight and obesity and to improve health in the US-Affiliated Pacific region via the Children's Healthy Living Program. Design, Setting, and Participants: In this multijurisdictional, multilevel, multicomponent community randomized clinical trial, where all evaluable children were analyzed according to the random assignment of their community, hierarchical difference-in-difference models accounted for the community randomization, community clustering with jurisdictions, and these models were adjusted for the age and sex distribution of the community. The setting was 27 communities in 5 jurisdictions (Alaska, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, and Hawaii). Participants were 4329 children (time 1) and 4042 children (time 2) aged 2 to 8 years in 27 selected communities from October 7, 2012, to October 25, 2015. Data analysis was completed in June 2018. Interventions: Nineteen activities addressed policy, environment, messaging, training, and 6 target behaviors (sleep time, screen time, physical activity, fruits and vegetables, water, and sugar-sweetened beverages). Main Outcomes and Measures: Primary outcomes were body size measurements. Secondary outcomes were acanthosis nigricans, sleep quality and duration, dietary intake, physical activity, and other questionnaire reponses. Results: The study included 27 communities and 8371 evaluable children (mean [SD] age, 5.4 [1.8] years; 50.9% male [n = 4264]). Data analysis included 952 children in the intervention group and 930 children in the control group aged 2 to 5 years at time 1; 825 children in the intervention group and 735 children in the control group aged 2 to 5 years at time 2; 565 children in the intervention group and 561 children in the control group aged 6 to 8 years at time 1; and 517 children in the intervention group and 560 children in the control group aged 6 to 8 years at time 2. The intervention communities showed significant improvement compared with control communities in overweight and obesity prevalence (effect size [d] = -3.95%; 95% CI, -7.47% to -0.43%), waist circumference (d = -0.71 cm; 95% CI, -1.37 to -0.05 cm), and acanthosis nigricans prevalence (d = -2.28%; 95% CI, -2.77% to -1.57%). Age and sex subgroup analysis revealed greater difference among the intervention communities in acanthosis nigricans prevalence in the group aged 2 to 5 years (-3.99%) vs the group aged 6 to 8 years (-3.40%), and the interaction was significant (d = 0.59%, P < .001), as well as the smaller difference in the group aged 2 to 5 years (-0.10%) vs the group aged 6 to 8 years (-1.07%) in screen time (d = -0.97 hour per day, P = .01). Conclusions and Relevance: The intervention reduced the prevalence of young child overweight and obesity and acanthosis nigricans. Comprehensive, effective, and sustainable interventions are needed to improve child health in the US-Affiliated Pacific region. Trial Registration: ClinicalTrials.gov Identifier: NCT01881373.

Examining Plausibility of Self-Reported Energy Intake Data: Considerations for Method Selection.

Self-reported dietary intake data contain valuable information and have long been used in the development of nutrition programs and policy. Some degree of measurement error is always present in such data. Biological plausibility, assessed by determining whether self-reported energy intake (rEI) reflects physiological status and physical activity level, must be examined and accounted for before drawing conclusions about intake. Methods that may be used to account for plausibility of rEI include crude methods such as excluding participants reporting EIs at the extremes of a range of intake and individualized methods such as statistical adjustment and applying cutoffs that account for the errors associated with within-participant variation in EI and total energy expenditure (TEE). These approaches allow researchers to determine how accounting for under- and overreporting affects study results and to appropriately address misreporting in drawing conclusions with data collected and in interpreting reported research. In selecting a procedure to assess and account for plausibility of intake, there are a number of key considerations, such as resources available, the dietary-report instrument, as well as the advantages and disadvantages of each method. While additional studies are warranted to recommend one procedure as superior to another, researchers should apply one of the available methods to address the issue of implausible rEI. If no method is applied, then at minimum, mean TEE or rEI/TEE should be reported to allow readers to ascertain the degree of misreporting at a gross level and better interpret the data and results provided.

Para I Famagu'on-Ta: Fruit and Vegetable Intake, Food Store Environment, and Childhood Overweight/Obesity in the Children's Healthy Living Program on Guam.

This cross-sectional study examined the: (1) association between food store environment (FSE), fruit and vegetable (FV) availability and access, and prevalence of early childhood overweight/obesity (COWOB); and (2) influence of young child actual FV intake on the relationship between the FSE and early COWOB prevalence. Anthropometric and socio-demographic data of children (2 to 8 years; N=466) in baseline communities on Guam participating in the Children's Healthy Living (CHL) Program community trial were included. CDC year 2000 growth charts were used to calculate BMI z-scores and categories. FSE factors (fresh FV scores, store type) were assessed using the CX3 Food Availability and Marketing Survey amended for CHL. ArcGIS maps were constructed with geographic coordinates of participant residences and food stores to calculate food store scores within 1 mile of participant's residences. A sub-sample of participants (n = 355) had Food and Activity Log data to calculate FV and energy intakes. Bivariate correlations and logistic regression evaluated associations. Of 111 stores surveyed, 73% were small markets, 16% were convenience stores, and 11% were large grocery/supermarkets. Supermarkets/large grocery stores averaged the highest FV scores. Most participants did not meet FV intake recommendations while nearly half exceeded energy intake recommendations. Living near a small market was negatively correlated with BMI z-score (r = - 0.129, P < .05) while living near a convenience store was positively correlated with BMI z-score (r = 0.092, P < .05). Logistic regression analysis yielded non-significant associations. The high density of small markets may be an opportunity for FSE intervention but further investigation of Guam's FSE influence on health is needed.

Prevalence of obesity and acanthosis nigricans among young children in the children's healthy living program in the United States Affiliated Pacific.

Estimate prevalence of obesity and acanthosis nigricans (AN) among children in United States Affiliated Pacific (USAP) jurisdictions.Cross-sectional measurement of weight, height, and AN in 5775, 2 to 8 years old in 51 communities-Hawai'i, Alaska, Commonwealth of the Northern Mariana Islands, Guam, American Samoa, Palau, Republic of the Marshall Islands (RMI), 4 Federated States of Micronesia (Pohnpei, Yap, Kosrae, Chuuk). Analyses weighted to jurisdiction-specific sex and age distributions accounting for clustering of communities within jurisdictions.Prevalence of obesity was 14.0%, overweight 14.4%, healthy weight 68.9%, and underweight 2.6%, higher in males (16.3%) than females (11.6%), higher among 6 to 8 years old (16.3%) than 2 to 5 years old (12.9%), highest in American Samoa (21.7%), and absent in RMI. In total, 4.7% of children had AN, with no sex difference, higher in 6 to 8 years old (6.8%) than 2 to 5 years old (3.5%) and highest in Pohnpei (11.9%), and absent in Alaska. Obesity was highly associated with AN (odds ratio = 9.25, 95% confidence interval = 6.69-12.80), with the strongest relationships among Asians, followed by Native Hawaiians and Pacific Islanders (NHPI).Obesity, age, and Asian and NHPI race were positively associated with AN.

Quality assurance of data collection in the multi-site community randomized trial and prevalence survey of the children's healthy living program.

BACKGROUND: Quality assurance plays an important role in research by assuring data integrity, and thus, valid study results. We aim to describe and share the results of the quality assurance process used to guide the data collection process in a multi-site childhood obesity prevalence study and intervention trial across the US Affiliated Pacific Region. METHODS: Quality assurance assessments following a standardized protocol were conducted by one assessor in every participating site. Results were summarized to examine and align the implementation of protocol procedures across diverse settings. RESULTS: Data collection protocols focused on food and physical activity were adhered to closely; however, protocols for handling completed forms and ensuring data security showed more variability. CONCLUSIONS: Quality assurance protocols are common in the clinical literature but are limited in multi-site community-based studies, especially in underserved populations. The reduction in the number of QA problems found in the second as compared to the first data collection periods for the intervention study attest to the value of this assessment. This paper can serve as a reference for similar studies wishing to implement quality assurance protocols of the data collection process to preserve data integrity and enhance the validity of study findings. TRIAL REGISTRATION: NIH clinical trial #NCT01881373.

Children's Healthy Living Program (CHL) Indigenous Workforce Training to Prevent Childhood Obesity in the Underserved U.S. Affiliated Pacific Region.

The U.S. Affiliated Pacific Region (USAPR) is an underserved region with high rates of obesity-related, non-communicable diseases and a low proportion of trained obesity prevention professionals, especially indigenous professionals. The Children's Healthy Living Training Program was developed to enhance the USAPR's capacity to address childhood obesity prevention.