Evaluation of a cluster-randomized controlled trial: Communities for Healthy Living, family-centered obesity prevention program for Head Start parents and children.

BACKGROUND: This study reports the outcomes of Communities for Healthy Living (CHL), a cluster randomized obesity prevention trial implemented in partnership with Head Start, a federally-funded preschool program for low-income families. METHODS: Using a stepped wedge design, Head Start programs (n = 16; Boston, MA, USA) were randomly assigned to one of three intervention start times. CHL involved a media campaign and enhanced nutrition support. Parents were invited to join Parents Connect for Healthy Living (PConnect), a 10-week wellness program. At the beginning and end of each school year (2017-2019), data were collected on the primary outcome of child Body Mass Index z-score (BMIz) and modified BMIz, and secondary outcomes of child weight-related behaviors (diet, physical activity, sleep, media use) and parents' weight-related parenting practices and empowerment. Data from 2 years, rather than three, were utilized to evaluate CHL due to the COVID-19 pandemic. We used mixed effects linear regression to compare relative differences during intervention vs. control periods (n = 1274 vs. 2476 children) in (1) mean change in child BMIz and modified BMIz, (2) the odds of meeting child health behavior recommendations, (3) mean change in parenting practices, and (4) mean change in parent empowerment. We also compared outcomes among parents who chose post-randomization to participate in PConnect vs. not (n = 55 vs. 443). RESULTS: During intervention periods (vs. control), children experienced greater increases in BMIz and modified BMIz (b = 0.06, 95% CI = 0.02,0.10; b = 0.07, 95% CI = 0.03, 0.12), yet were more likely to meet recommendations related to three of eight measured behaviors: sugar-sweetened beverage consumption (i.e., rarely consume; Odds Ratio (OR) = 1.5, 95% CI = 1.2,2.3), water consumption (i.e., multiple times per day; OR = 1.6, 95% CI = 1.2,2.3), and screen time (i.e., ≤1 hour/day; OR = 1.4, 95% CI = 1.0,1.8). No statistically significant differences for intervention (vs. control) periods were observed in parent empowerment or parenting practices. However, parents who enrolled in PConnect (vs. not) demonstrated greater increases in empowerment (b = 0.17, 95% CI = 0.04,0.31). CONCLUSIONS: Interventions that emphasize parent engagement may increase parental empowerment. Intervention exposure was associated with statistically, but not clinically, significant increases in BMIz and increased odds of meeting recommendations for three child behaviors; premature trial suspension may explain mixed results. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03334669 , Registered October 2017.

Exploring a theory of change: Are increases in parental empowerment associated with healthier weight-related parenting practices?

INTRODUCTION: Parent health-related empowerment is defined as the process by which parents realize control over their life situation and take action to promote a healthier lifestyle. For decades, researchers have described the theoretical potential of empowerment in health promotion efforts, though few have empirically examined this hypothesized relationship. This study is one of the first to examine the relationship between parental empowerment and healthy weight parenting practices (i.e., food, physical activity, sleep, and media parenting), as a mechanism for early childhood health promotion in community settings. METHODS: Low-income parents of preschool-aged children attending Head Start in Greater Boston between fall 2017 and spring 2019 were invited to complete a survey in the fall and spring of each academic school year (n = 578 with two surveys and n = 45 with four). Parental empowerment and healthy weight parenting practices were assessed using validated surveys. We used a multilevel difference-in-difference approach to estimate changes in healthy weight parenting practices score by changes in parental empowerment score. RESULTS: Out of a possible score of four, the unadjusted mean (SD) score in fall was 3.20 (0.40) for empowerment and 3.01 (0.40) for parenting. An increase in parental empowerment was associated with an increase in healthier parenting practices (b = 0.14; 95% CI = 0.08, 0.20; p < 0.0001). CONCLUSIONS: Parent empowerment may be an important target in interventions to prevent obesity in low-income children.

Summer Weight Gain Among Preschool-Aged Children With Obesity: An Observational Study in Head Start.

School-aged children gain weight most rapidly in summer, but few studies have investigated summer weight gain among preschool-aged children. We fit continuous linear spline mixed models to test for accelerated summer weight gain among 2,044 children attending 16 Boston-area Head Start programs between fall 2016 and spring 2019. Academic year and summer rates of change in modified body mass index z-score differed (P < .001), with accelerated summer weight gain most pronounced among children with obesity. As with school-aged children, increased focus on the summer is warranted for promoting healthy weight among children in Head Start.

Acceptability and appropriateness of a novel parent-staff co-leadership model for childhood obesity prevention in Head Start: a qualitative interview study.

BACKGROUND: Peer leadership can be an effective strategy for implementing health programs, benefiting both program participants and peer leaders. To realize such benefits, the peer leader role must be appropriate for the community context. Also, peer leaders must find their role acceptable (i.e., satisfactory) to ensure their successful recruitment and retention. To date, parent peer leaders have seldom been part of early childhood obesity prevention efforts. Moreover, parents at Head Start preschools have rarely been engaged as peer leaders. The aim of this study is to evaluate the appropriateness and acceptability of an innovative model for engaging parents as peer leaders for this novel content area (early childhood obesity prevention) and setting (Head Start). METHODS: Parents Connect for Healthy Living (PConnect) is a 10-session parent program being implemented in Head Start preschools as part of the Communities for Healthy Living early childhood obesity prevention trial. PConnect is co-led by a parent peer facilitator who is paired with a Head Start staff facilitator. In the spring of 2019, 10 PConnect facilitators participated in a semi-structured interview about their experience. Interview transcripts were analyzed by two coders using an inductive-deductive hybrid analysis. Themes were identified and member-checked with two interviewees. RESULTS: Themes identified applied equally to parent and staff facilitators. Acceptability was high because PConnect facilitators were able to learn and teach, establish meaningful relationships, and positively impact the parents participating in their groups, although facilitators did express frustration when low attendance limited their reach. Appropriateness was also high, as PConnect provided adequate structure and support without being overly rigid, and facilitators were able to overcome most challenges they encountered. CONCLUSIONS: The PConnect co-facilitation model was highly acceptable and appropriate for both the parent facilitators (peer leaders) and the staff facilitators. Including parents as peer leaders aligns to Head Start's emphasis on parent engagement, making it a strong candidate for sustained implementation in Head Start. The insights gained about the drivers of peer leadership appropriateness and acceptability in this particular context may be used to inform the design and implementation of peer-led health programs elsewhere. TRIAL REGISTRATION: clinicaltrials.gov, NCT03334669 (7-11-17).

A typology of dietary and anthropometric measures of nutritional need among children across districts and parliamentary constituencies in India, 2016.

BACKGROUND: Anthropometry is the most commonly used approach for assessing nutritional need among children. Anthropometry alone, however, cannot differentiate between the two immediate causes of undernutrition: inadequate diet vs disease. We present a typology of nutritional need by simultaneously considering dietary and anthropometric measures, dietary and anthropometric failures (DAF), and assess its distribution among children in India. METHODS: We used the 2015-16 National Family Health Survey, a nationally representative sample of children aged 6-23 months (n = 67 247), from India. Dietary failure was operationalized using World Health Organization (WHO) standards for minimum dietary diversity. Anthropometric failure was operationalized using WHO child growth reference standard z-score of <-2 for height-for-age (stunting), weight-for-age (underweight) and weight-for-height (wasting). We also created a combined anthropometric measure for children who had any one of these three anthropometric failures. We cross-tabulated dietary and anthropometric failures to produce four combinations: Dietary Failure Only (DFO), Anthropometric Failure Only (AFO), Both Failures (BF), and Neither Failure (NF). We estimated the prevalence and distribution of the four types, nationally, and across 640 administrative districts and 543 Parliamentary Constituencies (PCs) in India. RESULTS: Nationally, 80.3% of children had dietary failure and 53.7% had at least one anthropometric failure. The prevalence for the four DAF types was: 44.0% (BF), 36.3% (DFO), 9.8% (AFO), and 9.9% (NF). Dietary and anthropometric measures were discordant for 46.1% of children; these children had nutritional needs identified by only one of the two measures. Nationally, this translates to 12 181 627 children with DFO and 3 281 913 children with AFO; the nutritional needs of these children would not be captured if using only dietary or anthropometric assessment. Substantial variation was observed across districts and PCs for all DAF types. The interquartile ranges for districts were largest for BF (29.8%-53.0%) and lowest for AFO (5.5%-13.4%). CONCLUSIONS: The current emphasis on anthropometry for measuring nutritional need should be complemented with diet- and food-based measures. By differentiating inadequate food intake from other causes of undernutrition, the DAF typology brings precision in identifying nutritional needs among children. These insights may improve the development and targeting of nutrition interventions.

Dietary Variation among Children Meeting and Not Meeting Minimum Dietary Diversity: An Empirical Investigation of Food Group Consumption Patterns among 73,036 Children in India.

BACKGROUND: Minimum Dietary Diversity (MDD) is a widely used indicator of adequate dietary micronutrient density for children 6-23 mo old. MDD food-group data remain underutilized, despite their potential for further informing nutrition programs and policies. OBJECTIVES: We aimed to describe the diets of children meeting MDD and not meeting MDD in India using food group data, nationally and subnationally. METHODS: Food group data for children 6-23 mo old (n = 73,036) from the 2015-16 National Family Health Survey in India were analyzed. Per WHO standards, children consuming ≥5 of the following food groups in the past day or night met MDD: breast milk; grains, roots, or tubers; legumes or nuts; dairy; flesh foods; eggs; vitamin A-rich fruits and vegetables; and other fruits and vegetables. Children not meeting MDD consumed <5 food groups. We analyzed the number and types of foods consumed by children meeting MDD and not meeting MDD at the national and subnational geographic levels. RESULTS: Nationally, children not meeting MDD most often consumed breast milk (84.5%), grains, roots, and tubers (62.0%), and/or dairy (42.9%). Children meeting MDD most often consumed grains, roots, and tubers (97.6%), vitamin A-rich fruits and vegetables (93.8%), breast milk (84.1%), dairy (82.1%), other fruits and vegetables (79.5%), and/or eggs (56.5%). For children not meeting MDD, district-level dairy consumption varied the most (6.4%-79.9%), whereas flesh foods consumption varied the least (0.0%-43.8%). For children meeting MDD, district-level egg consumption varied the most (0.0%-100.0%), whereas grains, roots, and tubers consumption varied the least (66.8%-100.0%). CONCLUSIONS: Children not meeting MDD had low fruit, vegetable, and protein-rich food consumption. Many children meeting MDD also had low protein-rich food consumption. Examining the number and types of foods consumed highlights priorities for children experiencing the greatest dietary deprivation, providing valuable complementary information to MDD.

Communities for Healthy Living (CHL) A Community-based Intervention to Prevent Obesity in Low-Income Preschool Children: Process Evaluation Protocol.

BACKGROUND: Process evaluation can illuminate barriers and facilitators to intervention implementation as well as the drivers of intervention outcomes. However, few obesity intervention studies have documented process evaluation methods and results. Community-based participatory research (CBPR) requires that process evaluation methods be developed to (a) prioritize community members' power to adapt the program to local needs over strict adherence to intervention protocols, (b) share process evaluation data with implementers to maximize benefit to participants, and (c) ensure partner organizations are not overburdened. Co-designed with low-income parents using CBPR, Communities for Healthy Living (CHL) is a family-centered intervention implemented within Head Start to prevent childhood obesity and promote family well-being. We are currently undertaking a randomized controlled trial to test the effectiveness of CHL in 23 Head Start centers in the greater Boston area. In this protocol paper, we outline an embedded process evaluation designed to monitor intervention adherence and adaptation, support ongoing quality improvement, and examine contextual factors that may moderate intervention implementation and/or effectiveness. METHODS: This mixed methods process evaluation was developed using the Pérez et al. framework for evaluating adaptive interventions and is reported following guidelines outlined by Grant et al. Trained research assistants will conduct structured observations of intervention sessions. Intervention facilitators and recipients, along with Head Start staff, will complete surveys and semi-structured interviews. De-identified data for all eligible children and families will be extracted from Head Start administrative records. Qualitative data will be analyzed thematically. Quantitative and qualitative data will be integrated using triangulation methods to assess intervention adherence, monitor adaptations, and identify moderators of intervention implementation and effectiveness. DISCUSSION: A diverse set of quantitative and qualitative data sources are employed to fully characterize CHL implementation. Simultaneously, CHL's process evaluation will provide a case study on strategies to address the challenges of process evaluation for CBPR interventions. Results from this process evaluation will help to explain variation in intervention implementation and outcomes across Head Start programs, support CHL sustainability and future scale-up, and provide guidance for future complex interventions developed using CBPR. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03334669 . Registered on October 10, 2017.