Implementation and Evaluation of a mHealth-Based Community Health Worker Feedback Loop for Hispanics with and at Risk for Diabetes.

BACKGROUND: Gaps in accessibility and communication hinder diabetes care in poor communities. Combining mobile health (mHealth) and community health workers (CHWs) into models to bridge these gaps has great potential but needs evaluation. OBJECTIVE: To evaluate a mHealth-based, Participant-CHW-Clinician feedback loop in a real-world setting. DESIGN: Quasi-experimental feasibility study with intervention and usual care (UC) groups. PARTICIPANTS: A total of 134 participants (n = 67/group) who were all low-income, uninsured Hispanics with or at-risk for type 2 diabetes. INTERVENTION: A 15-month study with a weekly to semimonthly mHealth Participant-CHW-Clinician feedback loop to identify participant issues and provide participants monthly diabetes education via YouTube. MAIN MEASURES: We used pre-defined feasibility measures to evaluate our intervention: (a) implementation, the execution of feedback loops to identify and resolve participant issues, and (b) efficacy, intended effects of the program on clinical outcomes (baseline to 15-month HbA1c, systolic blood pressure (SBP), diastolic blood pressure (DBP), and weight changes) for each group and their subgroups (at-risk; with diabetes, including uncontrolled (HbA1c ≥ 7%)). KEY RESULTS: CHWs identified 433 participant issues (mean = 6.5 ± 5.3) and resolved 91.9% of these. Most issues were related to supplies, 26.3% (n = 114); physical health, 23.1% (n = 100); and medication access, 20.8% (n = 90). Intervention participants significantly improved HbA1c (- 0.51%, p = 0.03); UC did not (- 0.10%, p = 0.76). UC DBP worsened (1.91 mmHg, p < 0.01). Subgroup analyses revealed HbA1c improvements for uncontrolled diabetes (intervention: - 1.59%, p < 0.01; controlled: - 0.72, p = 0.03). Several variables for UC at-risk participants worsened: HbA1c (0.25%, p < 0.01), SBP (4.05 mmHg, p < 0.01), DBP (3.21 mmHg, p = 0.01). There were no other significant changes for either group. CONCLUSIONS: A novel mHealth-based, Participant-CHW-Clinician feedback loop was associated with improved HbA1c levels and identification and resolution of participant issues. UC individuals had several areas of clinical deterioration, particularly those at-risk for diabetes, which is concerning for progression to diabetes and disease-related complications. CLINICAL TRIAL: NCT03394456, accessed at https://clinicaltrials.gov/ct2/show/NCT03394456.

Associations of regular consumption of breakfast, lunch and dinner with Body Mass Index during adolescence: longitudinal findings by weight status among the Eating and Activity over Time 2010-2018 cohort.

OBJECTIVE: To examine how the associations between meal consumption and BMI over 8 years differ by weight status in a sample of adolescents. DESIGN: Longitudinal, population-based study. Breakfast, lunch and dinner consumption and BMI were self-reported. Linear regressions were used to examine how the associations between meal consumption and BMI differed by weight status. SETTING: Adolescents in the Minneapolis/St. Paul metropolitan area. PARTICIPANTS: Adolescents (n 1,471) were surveyed as part of the EAT 2010-2018 in 2009-2010 (Mage = 14·3 years) and 2017-2018 (Mage = 22·0 years). RESULTS: The prevalence of regular breakfast, lunch and dinner consumption (≥ 5 times/week) ranged from 45 to 65 %, 75 to 89 % and 76 to 94 %, respectively, depending on weight status category. Among adolescents with a sex- and age-specific BMI < 15th percentile, regular consumptions of breakfast, lunch and dinner during adolescence were positively associated with BMI in emerging adulthood compared with irregular consumption of breakfast, lunch and dinner (<5 times/week) after adjustment for socio-demographic characteristics (ß = 5·43, ß = 5·39 and ß = 6·46, respectively; all P-values <0·01). Among adolescents in the BMI 15-85th and 85-95th percentiles, regular consumptions of breakfast, lunch and dinner were positively associated with BMI but to a lesser extent (P-values <0·01). For participants with a BMI ≥ 95th percentile, regular consumptions of breakfast, lunch and dinner were positively associated with BMI, but the associations were not statistically significant (P-values > 0·05). CONCLUSIONS: The relationship between meal consumption during adolescence and BMI in emerging adulthood differs by adolescent weight status. Future studies should investigate underlying factors related to meal consumption routines and BMI.

Exploring Factors Associated With Accelerometer Validity Among Ethnically Diverse Toddlers.

PURPOSE: Studying physical activity in toddlers using accelerometers is challenging due to noncompliance with wear time (WT) and activity log (AL) instructions. The aims of this study are to examine relationships between WT and AL completion and (1) demographic and socioeconomic variables, (2) parenting style, and (3) whether sedentary time differs by AL completion. METHODS: Secondary analysis was performed using baseline data from a community wellness program randomized controlled trial for parents with toddlers (12-35 mo). Parents had toddlers wear ActiGraph wGT3x accelerometers and completed ALs. Valid days included ≥600-minute WT. Analysis of variance and chi-square analyses were used. RESULTS: The sample (n = 50) comprised racial and ethnically diverse toddlers (mean age = 27 mo, 58% male) and parents (mean age = 31.7 y, 84% female). Twenty-eight families (56%) returned valid accelerometer data with ALs. Participants in relationships were more likely to complete ALs (P < .05). Toddler sedentary time did not differ between those with ALs and those without. CONCLUSIONS: We found varied compliance with WT instructions and AL completion. Returned AL quality was poor, presenting challenges in correctly characterizing low-activity counts to improve internal validity of WT and physical activity measures. Support from marital partners may be important for adherence to study protocols.

The Bead Maze Hand Function Test for Children.

IMPORTANCE: There is a need for a pediatric hand function test that can be used to objectively assess movement quality. We have developed a toy-based test, the Bead Maze Hand Function (BMHF) test, to quantify how well a child performs an activity. This is achieved by assessing the control of forces applied while drawing a bead over wires of different complexity. OBJECTIVE: To study the psychometric properties of the BMHF test and understand the influence of age and task complexity on test measures. DESIGN: A cross-sectional, observational study performed in a single visit. SETTING: Clinical research laboratory. PARTICIPANTS: Twenty-three participants (ages 4-15 yr) were recruited locally. They were typically developing children with no illness or conditions that affected their movement. Interventions/Assessments: Participants performed the BMHF test and the Box and Block test with both hands. OUTCOMES AND MEASURES: Total force and completion time were examined according to age and task complexity using a linear mixed-effects model. We calculated intraclass correlation coefficients to measure interrater reliability of the method and estimated concurrent validity using the Box and Block test. RESULTS: Total force and completion time decreased with age and depended on task complexity. The total force was more sensitive to task complexity. The Box and Block score was associated with BMHF completion time but not with total force. We found excellent interrater reliability. CONCLUSIONS AND RELEVANCE: A familiar toy equipped with hidden sensors provides a sensitive tool to assess a child's typical hand function. Plain-Language Summary: We developed the Bead Maze Hand Function (BMHF) test to determine how well a child performs an activity with their hands. The BMHF test is a toy equipped with hidden sensors. Twenty-three typically developing children with no illnesses or conditions that affected their hand movement participated in the study. We asked the children to perform the BMHF test with both hands. Our study found that occupational therapists can reliably use the BMHF test to assess a child's hand function.

Long-Term Effectiveness of the TIME Intervention to Improve Diabetes Outcomes in Low-Income Settings: a 2-Year Follow-Up.

BACKGROUND: We previously found that a 6-month multidimensional diabetes program, TIME (Telehealth-Supported, Integrated Community Health Workers, Medication-Access) resulted in improved clinical outcomes. OBJECTIVE: To follow TIME participant clinical outcomes for 24 months PARTICIPANTS: Low-income Latino(a)s with type 2 diabetes DESIGN AND INTERVENTION: We collected post-intervention clinical data for five cohorts (n = 101, mean n = 20/cohort) who participated in TIME programs from 2018 to 2020 in Houston, Texas. MAIN MEASURES: We gathered HbA1c (primary outcome), weight, body mass index (BMI), and blood pressure data at baseline, 6 months (intervention end), and semiannually thereafter until 24 months after baseline to assess sustainability. We also evaluated participant loss to follow-up until 24 months. KEY RESULTS: Participants decreased HbA1c levels during the intervention (p < 0.0001) and maintained these improvements at each timepoint from baseline to 24 months (p range: < 0.0001 to 0.015). Participants reduced blood pressure levels during TIME and maintained these changes at each timepoint from baseline until 18 months (systolic p range < 0.0001 to 0.0005, diastolic p range: < 0.0001 to 0.008) but not at 24 months (systolic: p = 0.065; diastolic: p = 0.85). There were no significant weight changes during TIME or post-intervention: weight (p range = 0.07 to 0.77), BMI (p range = 0.11 to 0.71). Attrition rates (loss to follow-up during the post-intervention period) were 5.9% (6 months), 24.8% (12 months), 35.6% (18 months), and 41.8% (24 months). CONCLUSIONS: It is possible for vulnerable populations to maintain long-term glycemic and blood pressure improvements using a multiple dimensional intervention. Attrition rates rose over time but show promise given the majority of post-intervention timepoints occurred during the COVID-19 pandemic when low-income populations were most susceptible to suboptimal healthcare access. Future studies are needed to evaluate longitudinal outcomes of diabetes interventions conducted by local clinics rather than research teams.

A staged approach to address youth unresponsive to initial obesity intervention: a randomized clinical trial.

BACKGROUND/OBJECTIVE: Maintenance interventions inherently require BMI improvement to maintain. This overlooks individuals initially unresponsive to obesity interventions. Staged pediatric clinical treatment guidelines were adapted to the school setting to develop an escalated treatment option for individuals initially unresponsive. This staged randomized controlled trial examined differences between escalated treatment (Take CHARGE!) and a maintenance program (PE Planners). Take CHARGE was hypothesized to have greater improvements in BMI as a percentage of the 95th BMI Percentile (%BMIp95) than PE Planners. SUBJECTS/METHODS: From 2018 to 2020, 171 middle and high schoolers (BMI Percentile ≥ 85) were recruited from a Houston school district to participate in a staged obesity intervention in their physical education (PE) class. After receiving a semester-long intensive lifestyle intervention (ILI) with established efficacy, all participants were randomized to Take CHARGE (n = 85) or PE Planners (n = 86). Take CHARGE escalated the behavioral treatment of obesity received in ILI with more frequent individual sessions, additional opportunities for parental and school staff involvement, and increased mentorship from trained college students. PE Planners allowed participants to decide how they wanted to be active in PE class. Mixed linear modeling examined %BMIp95 overtime between groups. This trial was registered at ClinicalTrials.gov (#NCT04362280). RESULTS: Participants were 13.63 ± 1.32 years old; 59% were female, and 85% were Hispanic. Among those initially unresponsive to ILI, Take CHARGE had significantly greater decreases in %BMIp95 than PE Planners (ß = -0.01, p < 0.01). Conversely, among those initially responsive, Take CHARGE had significantly smaller decreases in %BMIp95 than PE Planners (ß = 0.02, p < 0.05). Intention-to-treat analysis had similar results. CONCLUSIONS: Participant outcomes in semester two differed based on initial response. Individuals responsive to initial intervention were most likely to benefit from a maintenance intervention and those initially unresponsive benefited more from escalated treatment. This indicates the need for staged intervention protocols to better address obesity in the school setting.

Exploring qualities of ethnically diverse parents related to the healthy home environment of toddlers.

Parents serve as role models and household policy makers for their children's home social environment. Also, parents may influence the home physical environment through the provision of resources to support their children's dietary, activity, and sleep behaviors. Understanding the parental characteristics related to children's home environment may allow for tailoring obesity interventions to families' needs. This study aimed to explore parental qualities (general parenting styles, parent feeding practices, and parental BMI) related to healthy home food, physical activity, media and sleep environment of toddlers. A total of 50 multi-ethnic parents with toddler age children who were enrolled in a randomized pilot study of a wellness program completed the Structure and Control in Parent Feeding (SCPF) questionnaire and Comprehensive General Parenting Questionnaire (CGPQ). Parental BMI was calculated using self-reported weight and height data. The Healthy Home Survey, the Home Food Inventory, the Sleep Environment Questionnaire, and items developed for this study were standardized and summed to create home food, physical activity, screen media, and sleep environment scores; high scores reflected healthier environments. To examine the relationships between parental qualities and the home environment, Pearson's correlation test was performed. Parental BMI and overall healthy home environment were inversely associated (r = -0.306; p = 0.032). Structure in general parenting and parental feeding practice were positively correlated with the overall healthy home environment (r = 0.336; p = 0.026) and healthy home food environment (r = 0.415; p = 0.003), respectively. The coercive control general parenting was inversely related to overall healthy home environment score (r = -0.333; p = 0.022). Based on the findings from this study, parents who provide clear communication, set consistent rules, avoid pressure to control their child's behavior, and have lower BMI tend to live in a home environment that support children's health behaviors.

Synthesis of Indoloquinolines: An Intramolecular Cyclization Leading to Advanced Perophoramidine-Relevant Intermediates.

The bioactive natural product perophoramidine has proved a challenging synthetic target. An alternative route to its indolo[2,3-b]quinolone core structure involving a N-chlorosuccinimde-mediated intramolecular cyclization reaction is reported. Attempts to progress towards the natural product are also discussed with an unexpected deep-seated rearrangement of the core structure occurring during an attempted iodoetherification reaction. X-ray crystallographic analysis provides important analytical confirmation of assigned structures.

Levels of adherence needed to achieve significant weight loss.

BACKGROUND/OBJECTIVES: Positive associations have been found between adherence and weight loss in behavioral weight-management interventions. However, less attention has been given to the level of adherence needed to reach clinically significant weight loss. This study examined the levels of adherence associated with a ≥ 5% - < 10% or ≥ 10% weight loss in a community-based, intensive behavioral weight management program, Weight Watchers® (WW), which included three modes of access: (1) 24-weekly WW meetings over 6 months, (2) the WW member website, and (3) the WW mobile application. METHODS: A total of 292 participants were randomized to a WW (n = 147) or a self-help (SH) (n = 145) condition. To assess the impact of adherence, only participants in the WW condition were included in analyses (n = 147). Adherence was defined as use of the three modes of access. Measured heights and weights were obtained at baseline and 6 months. Receiver-operating characteristic curve analyses were conducted to determine the minimal level of adherence associated with clinically significant weight loss. RESULTS: In a 6-month period, increased likelihood of achieving a weight loss ≥ 5% - < 10% was associated with attending approximately one-third (35.4%) of weekly meetings, use of the member website about 25% of days, and use of the mobile application 16.1% of days. Attendance at approximately two-thirds (64.5%) of meetings, use of the member website 41.6% of days, and use of the mobile application 14.7% of days were associated with a clinically significant weight loss of ≥ 10%. Meeting attendance was the strongest predictor of weight loss at 6 months. CONCLUSIONS: Although adherence to a behavioral weight management program was an important predictor of weight loss, extremely high levels were not needed to achieve clinically significant weight loss. These results are important to help patients and treatment providers understand realistic goals for weight management.

Compañeros: High School Students Mentor Middle School Students to Address Obesity Among Hispanic Adolescents.

INTRODUCTION: Promotoras, Hispanic community health workers, are frequently employed to promote health behavioral change with culturally bound Hispanic lifestyle behaviors. Peer health mentors have been used in schools to promote healthy nutrition and physical activity behaviors among students. This study investigates the efficacy of combining these 2 approaches by training high school health mentors, called compañeros, to engage Hispanic middle school students in a school-based obesity intervention as a strategy to promote and sustain reductions in standardized body mass index (zBMI). METHODS: High school compañeros were trained to participate in a 6-month obesity program alongside middle school students in Houston, Texas. Middle school students were randomized to participate in the program either with compañeros (n = 94) or without compañeros (n = 95). The intervention was conducted from 2013 through 2016 in 3 cohorts of students, 1 each school year. Students were followed for 12 months. The primary outcome was zBMI, which was analyzed at baseline, 6 months, and 12 months. RESULTS: Significant differences were found between conditions across time (F = 4.58, P = .01). After the 6-month intervention, students in the condition with compañeros had a larger decrease in zBMI (F = 6.94, P = .01) than students in the condition without compañeros. Furthermore, students who received the intervention with compañeros showed greater sustained results at 12 months (F = 7.65, P = .01). CONCLUSION: Using high school compañeros in an obesity intervention for Hispanic middle school students could be effective in promoting and maintaining reductions in zBMI.

Obesity status trajectory groups among elementary school children.

BACKGROUND: Little is known about patterns in the transition from healthy weight to overweight or obesity during the elementary school years. This study examined whether there were distinct body mass index (BMI) trajectory groups among elementary school children, and predictors of trajectory group membership. METHODS: This is a secondary analysis of 1651 elementary school children with complete biannual longitudinal data from kindergarten to the beginning of 5(th) grade. Heights and weights were measured by trained school nurses using standard procedures at the beginning and end of each school year for 11 consecutive assessments. Group-based trajectory clustering and multinomial logit modeling were conducted. RESULTS: When using BMIz score, six trajectory groups were identified revealing substantial consistency in BMIz score across time. When using a categorical variable separating overweight/obese children (BMI ≥ 85%ile) from the rest, five developmental trajectories (persistently non-overweight/obese weight: 51.1 %; early-onset overweight/obese: 9.2 %; late-onset overweight/obese: 9.7 %; becoming healthy weight: 8.2 %; and chronically overweight/obese: 21.8 %) were identified. When using a categorical variable separating obese children (BMI ≥ 95%ile) from the rest, three trajectories (persistently non-obese: 74.1 %, becoming obese: 12.8 %; and chronically obese: 13.2 %) were identified. For both cutoffs (≥ BMI percentile 85 % or 95 %), girls were more likely than boys to be classified in the persistently non-overweight and/or obese group (odds ratios (OR) ranged from 0.53 to 0.67); and Hispanic children and non-Hispanic Black children were more likely to be chronically overweight and/or obese than non-Hispanic White children (OR ranged from 1.57 to 2.44). Hispanic children were also more likely to become obese (OR: 1.84) than non-Hispanic White children when ≥ BMI percentile 95 % was used. CONCLUSIONS: Boys, Hispanic and non-Hispanic Black children were at higher risk of being overweight or obese throughout their elementary school years, supporting the need for obesity treatment. Post kindergarten and post second grade summer months were times when some children transitioned into overweight/obesity. It will be important to identify which behavioral factors (e.g., diet, physical activity, sedentary behaviors, and/or sleep) predisposed children to becoming overweight/obese, and whether these factors differ by time (Kindergarten versus second grade). If behavioral predisposing factors could be identified early, targeted obesity prevention should be offered.

Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes.

Look AHEAD (Action for Health in Diabetes) was a randomized controlled trial that examined the impact of long-term participation in an intensive weight loss intervention on cardiovascular disease (CVD) morbidity and mortality in people with type 2 diabetes (T2D). The results from this trial suggest that intensive lifestyle interventions are effective in helping patients to achieve management of cardiovascular risk factors and reducing the need to initiate medication usage to manage these conditions, though the benefits in terms of the prevention of CVD morbidity and mortality beyond those achieved through aggressive medical management of hypertension and dyslipidemia is not clear. Additional benefits of participation in an intensive lifestyle intervention such as lowered chronic kidney disease risk, blood pressure, medication usage, improved sleep apnea, and partial remission of diabetes are discussed.

The most optimal school recruitment strategies for school-based obesity prevention and health promotion research in the United States: A systematic review with Delphi study.

This systematic review with the Delphi study aimed to identify effective and resource-efficient (optimal) strategies for recruiting schools into health promotion interventions in the United States. A literature search was conducted in PubMed, Cochrane Library, and CINAHL (EBSCO). A total of 116 interventions reported in 160 articles were included. Most school-based interventions did not report data regarding school recruitment duration (81%), target school size (63%), and school recruitment strategies (78%). Further, no details were provided regarding the reasons for declining to participate despite being eligible. For the Delphi, responses from 23 researchers in school-based clinical trials were collected. A qualitative descriptive approach was used for coding responses and collapsed into higher-order categories based on school recruitment strategies. Delphi participants reported that (1) creating new or leveraging pre-existing partnerships, (2) intervention champion, (3) minimal school disruptions, (4) working with open mind/flexibility, and (5) transparent communication are the most optimal school recruitment strategies. Staff time and travel were the most frequently reported costs for implementing those strategies. The overall trend in school-based obesity prevention intervention studies illustrates the importance of a better understanding school recruitment. Improved reporting can allow researchers to budget their time and resources better and provide greater confidence in reaching their target school size.

Virtual Programming for Physical Activity Interventions: Integration of Behavioral Components.

The SARS-Cov-2 pandemic changed many contemporary experiences, including how healthcare and exercise programming are delivered. As a result of the pandemic, there was an increase in virtual services and programming and there continues to be a demand for virtual options. The results from Desir et al support the use of virtual visits to successfully change lifestyle factors, specifically nutrition and physical activity. The use of individualized dietary and exercise goals were important to the success of the intervention, and should not be disregarded. As virtual healthcare and exercise continues to evolve, to maximize behavior change, we should also consider how to include the social and community aspects of exercise. Regardless, it is encouraging to see that significant advances are being made in virtual programming and that the needed engagement can occur in a virtual setting.

The Importance of Social Networks for Support and Health Beliefs throughout Pregnancy.

Pregnancy is a unique time when health care providers have more regular contact with women. Using this time to more fully understand the social influences at play can provide physicians an opportunity to leverage networks to improve health and wellbeing while stemming the exposure to health misinformation. Advocating for supportive social networks or exercise groups/programs can provide additional support and behavioral reinforcement which is needed for sustained behavior change. In this manner, fostering these networks is likely more beneficial to supporting healthy exercise behavior during pregnancy than education alone.

The Use of Reframing: Increasing the Importance of Lifestyle Medicine.

Lifestyle behavior modification is an essential component to prevention and treatment of non-communicable diseases worldwide. For the last 40 years, studies have recognized that there is suboptimal training of physicians in lifestyle medicine and its implementation in clinical settings. The lack of nutrition and exercise counseling occurring in the medical office does not reflect the high level of evidence supporting its use. Lifestyle behavior counseling is complex; as are the individualized needs of patients. Therefore, we suspect that the lack of knowledge in nutrition and exercise prescriptions are not the only barriers to providing optimal care. Reframing lifestyle medicine interventions like nutrition and exercise from adjunctive to central to treatment and reframing the role of the physician therein may be necessary to address important barriers to overall lifestyle behavioral counseling.

Exploratory Decision Trees to Predict Obesity Intervention Response among Hispanic American Youth.

Introduction: Individual variability in weight-related outcomes from obesity intervention is widely acknowledged, yet infrequently addressed. This study takes a first step to address individual variation by determining characteristics that distinguish responsive (improvements in BMI) from unresponsive individuals. Methods: Classification regression tree (CRT) analysis grouped 185 low-income, Hispanic American middle school students who received a school-based obesity intervention. Predictors included baseline age, gender, standardized BMI, health-related quality of life (PedsQL), minutes of moderate-vigorous physical activity (MVPA; accelerometry), energy consumption, and dietary quality (Block Kids 2004 Food Frequency Questionnaire). Response regarding weight-related outcomes to the intervention was defined according to the American Academy of Pediatrics (AAP) guidelines. Six trees were produced, one for 3- and one for 6-month outcomes among all participants, participants with healthy weight status, and participants with overweight/obesity at baseline. Results: The AAP criteria for response were met by 57.3% and 35.1% of participants at 3 and 6 months, respectively. CRT produced six unique trees. Notably, minutes of MVPA appeared twice (the first time at the top of the tree) in most 3-month models. In addition, response at 3 months consistently appeared as the first variable in all the 6-month models. Conclusions: Overall, the number of distinct pathways and the repeated appearance of the same variable within a pathway illustrate the complex, interactive nature of factors predicting an intervention response. Initially unresponsive individuals were unlikely to respond later in the intervention. More complex modeling is needed to better understand how to best predict who will be responsive to interventions.

The Rationale and Logistics for Incorporating Community Health Workers Into the Multidisciplinary Team.

Community Health Workers (CHWs) have shown value in diabetes care. CHWs are often the individuals who provide behavioral lifestyle intervention to underserved communities and are often the first to assist patients in gaining appropriate access to care. As trusted members of their communities, they have the ability to significantly impact psychosocial and biomedical outcomes, making them important members of the behavioral medicine team. However, lack of recognition of CHWs within multidisciplinary teams (MDTs) gives rise to the issue of the underutilization of their services. Therefore, barriers to including CHWs in MDTs including standardized training and strategies to overcome these are discussed.

Short-Term Efficacy of a Childhood Obesity Prevention Program Designed to Pair Feeding Content With Nutrition Education.

Background: Family-based programs show considerable promise in preventing overweight and obesity in young children. However, dissemination is difficult because significant participant and staff involvement is required. This study examined the short-term efficacy of adding parental feeding content to a widely-used nutrition education curriculum for families in low-resourced communities comparing the influence of two delivery methods (in-class and online) on parents' feeding knowledge, practices, and styles. Methods: In this cluster randomized controlled trial, parents of 2- to 8-year-old children enrolled in the EFNEP (Expanded Food and Nutrition Education Program) in Colorado and Washington were randomly assigned to: in-class nutrition education only, in-class nutrition education with in-class feeding content, or in-class nutrition education with online feeding content. Data from the 382 participants who completed both pretest and posttest assessments are reported in this study. Results: Multilevel analyses showed empirical support for the influence of the program on parents' feeding knowledge, practices, and styles. Online and in-class methods were equally effective in delivering feeding content in low-resourced communities. Consistent effects were seen across the two delivery methods for encouraging children to try new foods (p < 0.05), use of child-centered feeding practices (i.e., greater responsiveness, p < 0.05), child involvement in food preparation (p < 0.05), and understanding the number of presentations often necessary for child acceptance of a new food (p < 0.001). Location and language differences were seen across some constructs. Conclusions: This study demonstrates the efficacy of in-class and online approaches to feeding highlighting the program's positive effects on promoting healthy feeding behaviors for parents of children in low-resourced families. ClinicalTrials.gov Identifier: NCT03170700.

Determining call-to-entry rate and recruitment barriers in clinical studies for community clinics serving low-income populations: a cohort study.

BACKGROUND: Recruitment for clinical studies is challenging. To overcome barriers, investigators have previously established call-to-entry rates to assist in planning. However, rates specific to low-income minority populations are needed to account for additional barriers to enrolment these individuals face. OBJECTIVE: To obtain a call-to-entry rate in a low-income uninsured Hispanic population with chronic disease. METHODS: We used data from four of our randomised clinical studies to determine the call-to-entry rate for individuals (n=1075) with or at risk for type 2 diabetes: participants needed/potential participants contacted=recruitment rate (yield). Research staff contacted potential participants to enrol in a study that evaluated 6 month diabetes programmes at community clinics from 2015 to 2020. We recorded call-to-entry rates, reasons for declining the study, show rates, and attrition. RESULTS: The call-to-entry rate was 14.5%. Forty per cent of potential participants could not be contacted, and 30.6%, 19.1%, and 5.4% responded yes, no, and maybe, respectively. No show percentages were 54% for yes and 91.4% for maybe responders. The majority (61.6%) declined due to inability to attend; reasons to decline included work (43%), eligibility (18%), transportation (10%), out of town (9%), did not think they needed the programme (7%) and other/unknown (14%). Being a physician predicted inability to reach participants (adjusted OR 2.91, 95% CI 1.73 to 4.90). Attrition was 6.8%. CONCLUSIONS: We described a call-to-entry rate and detailed recruitment data, including reasons to decline the study. This valuable information can assist investigators in study planning and overcoming enrolment barriers in low-income populations. Telehealth-based or strategies that limit transportation needs may increase participant involvement. TRIAL REGISTRATION NUMBER: NCT03394456.