Results from "Live Well", a randomized controlled community-based participatory intervention to prevent obesity in new immigrant mother-child dyads.

BACKGROUND: Upon arrival, the prevalence of overweight and obesity is lower in new immigrants than their native counterparts in the U.S. With longer residency in the U.S., these differences converge over time, followed by higher prevalence among immigrants than native U.S. residents. Results from the Live Well project in the Greater Boston area demonstrate the viability of utilizing a culturally adapted, community-based participatory research (CBPR) approach to reduce weight gain among newly immigrated mother-child dyads. METHODS: Haitian, Latina, and Brazilian mother-child dyads (n = 390), new to the U.S. (fewer than 10 years) were enrolled in a one- to two-year long CBPR lifestyle intervention that targeted dietary and physical activity behaviors. Attendance was recorded to establish dose. Demographics, anthropometrics, and relevant covariates were collected from participants at baseline, 6, 12, 18, and 24 months. Body Mass Index (BMI) was calculated using objectively measured height and weight. Linear mixed regression models were used to assess change in BMI and BMI z-score of mothers and children respectively. RESULTS: At baseline, nearly 75% of mothers and 50% of children were either overweight or obese (BMI ≥ 25.0 and BMI z-score ≥ 85th percentile, respectively). Only 20% of mothers attended all 12 intervention sessions in year 1. Using intent-to-treat analyses, no significant time, intervention, or time × intervention effects were observed for weight change of mothers or children at follow-up. Mothers in the highest quantile (those who attended all 12 intervention sessions) had significant reductions in BMI at 18 months (1.76 units lower, 95%CI: -3.14, -0.37) and 24 months (2.61 units, 95%CI -3.92, -1.29) compared to mothers in the lower quantiles, including those with no exposure. Such dose effects on BMI z-scores were not noted for children. CONCLUSIONS: Findings from Live Well demonstrate the viability of utilizing a CBPR approach to address overweight and obesity among immigrant mothers. Given the higher-than-expected prevalence of overweight and obesity among mother-child dyads by ~ 6 years of U.S. residency, and lower maternal participation rates in the intervention, additional research is necessary to identify the optimal intervention length, retention strategies, and approach to jointly support healthy maternal and child weight.

"They See Us As Machines:" The Experience of Recent Immigrant Women in the Low Wage Informal Labor Sector.

This study explores the organization of work and occupational health risk as elicited from recently immigrated women (n = 8) who have been in the US for less than three years and employed in informal work sectors such as cleaning and factory work in the greater Boston area in Massachusetts. Additional interviews (n = 8) with Community Key Informants with knowledge of this sector and representatives of temporary employment agencies in the area provides further context to the interviews conducted with recent immigrant women. These results were also compared with our immigrant occupational health survey, a large project that spawned this study. Responses from the study participants suggest health outcomes consistent with being a day-laborer scholarship, new immigrant women are especially at higher risk within these low wage informal work sectors. A difference in health experiences based on ethnicity and occupation was also observed. Low skilled temporary jobs are fashioned around meeting the job performance expectations of the employer; the worker's needs are hardly addressed, resulting in low work standards, little worker protection and poor health outcomes. The rising prevalence of non-standard employment or informal labor sector requires that policies or labor market legislation be revised to meet the needs presented by these marginalized workers.

Household and family factors related to weight status in first through third graders: a cross-sectional study in Eastern Massachusetts.

BACKGROUND: Early environmental influences have been linked to child weight status, however further understanding of associations in diverse populations is needed. METHODS: A cross-sectional analysis of household and family factors associated with overweight was conducted on a culturally diverse, urban dwelling sample of 820 first through third graders (mean age 7.6 ± 1.0 years) residing in three eastern Massachusetts cities. Overweight was defined as BMI > 85th percentile, based on measured height and weight, and the CDC growth reference. Multivariate logistic regression was used to identify demographic, behavioral, and social environmental variables significantly related to weight status. Independent variables included race-ethnicity, age, sex, servings of sugar-sweetened beverages/week, hours of screen time/week, parent overweight, (calculated from self-reported weight/height), parent education, household food restriction rules regarding snacking and/or kitchen access, frequency of having dinner as a family (reported as "a lot" vs. "sometimes/rarely/never") and child vitamin/mineral supplement use. Selected interactions were explored based on prior studies. RESULTS: Prevalence of overweight was 35.5% in girls and 40.8% in boys. In the final, adjusted model, compared to white children, the odds of overweight were higher in children of Hispanic race-ethnicity (odds ratio (OR) = 2.4, 95% CI = 1.4 - 4.1). In the same adjusted model, compared to children with no household food restriction rules, the odds of overweight were 2.6 (95% CI = 1.3-5.1) times higher and 3.5 (95% CI = 1.9-6.4) times higher for children having one rule or two rules, respectively. Parent report of frequent family dinner and child vitamin use were protective, with a halving of risk for overweight for each behavior (OR = 0.47, 95% CI = 0.31-0.71 and OR = 0.54, 95% CI = 0.37-0.78, respectively). CONCLUSIONS: In the presence of other factors, frequent family dinner and vitamin use were associated with lower risk of overweight and household food restriction rules with higher risk. Although such relationships have previously been reported, this investigation is among the first to demonstrate these associations in a low-income, racially-diverse early elementary school population, and suggest potential targets of opportunity within the family context that could reduce child overweight risk in a subgroup of children at elevated risk of obesity.

Effect of glycemic load on eating behavior self-efficacy during weight loss.

High eating behavior self-efficacy may contribute to successful weight loss. Diet interventions that maximize eating behavior self-efficacy may therefore improve weight loss outcomes. However, data on the effect of diet composition on eating behavior self-efficacy are sparse. To determine the effects of dietary glycemic load (GL) on eating behavior self-efficacy during weight loss, body weight and eating behavior self-efficacy were measured every six months in overweight adults participating in a 12-mo randomized trial testing energy-restricted diets differing in GL. All food was provided during the first six months and self-selected thereafter. Total mean weight loss did not differ between groups, and GL-level had no significant effect on eating behavior self-efficacy. In the combined cohort, individuals losing the most weight reported improvements in eating behavior self-efficacy, whereas those achieving less weight loss reported decrements in eating behavior self-efficacy. Decrements in eating behavior self-efficacy were associated with subsequent weight regain when diets were self-selected. While GL does not appear to influence eating behavior self-efficacy, lesser amounts of weight loss on provided-food energy restricted diets may deter successful maintenance of weight loss by attenuating improvements in eating behavior self-efficacy.

A food service intervention improves whole grain access at lunch in rural elementary schools.

BACKGROUND: Whole grain (WG) options are often limited in schools, which may impact rural, low-income students who rely on school meals for a substantial portion of their food intake. This study examined the changes in the availability and quantity of WG and refined grain foods offered in schools participating in the Creating Healthy, Active and Nurturing Growing-up Environments (CHANGE) study, a randomized, controlled intervention among rural communities (4 intervention and 4 control). METHODS: Foods were assessed using production records, recipes, and nutrition labels from breakfast and lunch over 1 week during fall 2008 and spring 2009. Key informant interviews were conducted with school food service directors in the spring 2009. RESULTS: The CHANGE intervention schools significantly increased the average percent of school days WGs were offered (p = .047) and the amount of WGs offered/food item (ounces) at lunch compared with control schools (p = .02). There was a significant decrease in the percent of students with access to refined grains at lunch compared with control schools (p = .049), although there were no significant differences in WG availability during breakfast. CONCLUSIONS: The CHANGE schools improved WG availability, enabling student's WG consumption to be closer to national recommendations.

Baseline Socio-demographic characteristics and self-reported diet and physical activity shifts among recent immigrants participating in the randomized controlled lifestyle intervention: "Live Well".

The goal of this paper is to describe the baseline characteristics of Live Well (intervention to prevent weight gain in recent immigrant mother-child dyads from Brazil, Haiti, and Latin America) participants, and to explore self-reported changes in diet and physical activity post-immigration. Baseline data from 383 mothers were used for this study. Dyads attended a measurement day where they completed self-administered surveys collecting information about socio-demographics, diet, physical activity, other psychosocial variables, and height and weight. Haitian mothers' socio-demographic profile differed significantly from that of Brazilians' and Latinas': they have been in the US for a shorter period of time, have higher rates of unemployment, are less likely to be married, more likely to have ≥3 children, more likely to be obese, and have immigrated for family or other reasons. In multivariate models, self-reported changes in diet and physical activity since migrating to the US were significantly associated with BMI with non-linear relationships identified. Future research is needed to understand how diet and physical activity change while acculturating to the US and explore the adoption of both healthy and unhealthy dietary changes.

The CHANGE study: a healthy-lifestyles intervention to improve rural children's diet quality.

BACKGROUND: Despite the high rates of overweight and obesity among rural children, there have been limited interventions reported to improve the diet quality of rural, low-income children in the United States. OBJECTIVE: Our aim was to evaluate students' diet quality at baseline and after implementing the CHANGE (Creating Healthy, Active and Nurturing Growing-Up Environments) study, a 2-year (2007-2009) randomized, controlled, community- and school-based intervention to prevent unhealthy weight gain among rural school-aged children. DESIGN: We used a school and community-based group randomized, controlled design. PARTICIPANTS/SETTING: Data were collected in eight rural communities in California, Kentucky, Mississippi, and South Carolina (one elementary school per community). Children in grades 1 to 6 participated in the study (n=432; mean age=8.65 years ± 1.6 years). Students' diets were assessed at baseline (spring or early fall 2008) and post intervention (spring 2009) using the Block Food Screener for ages 2 to 17 years. STATISTICAL ANALYSES: Mixed-model analysis of variance was used to examine the effect of the CHANGE study intervention on students' diets. Results were adjusted for corresponding baseline dietary values, sex, age, grade, race/ethnicity, and state, with school included as a random effect nested within condition. RESULTS: At the end of 1 year, students enrolled in the CHANGE study intervention schools consumed significantly more vegetables (0.08 cups/1,000 kcal/day; P=0.03) and combined fruits and vegetables (0.22 cups/1,000 kcal/day; P<0.05) compared with students in control schools. Students in the intervention schools also showed a reduction in the average daily dietary glycemic index (GI=-1.22; P<0.05) and a trend toward more fruit consumption (0.15 cups/1,000 kcal/day; P=0.07). There were no significant differences in students' consumption of whole grains, legumes, dairy, potatoes/potato products, saturated fat, added sugars, or dietary fiber consumption. CONCLUSIONS: The CHANGE study enhanced some aspects of rural students' dietary intake. Implementing similar interventions in rural America can be promising to support vegetable consumption.

Multinutrient-fortified juices improve vitamin D and vitamin E status in children: a randomized controlled trial.

BACKGROUND: Provision of fortified juices may provide a convenient method to maintain and increase blood fat-soluble vitamins. OBJECTIVE: To determine whether children consuming orange juice fortified with calcium and combinations of vitamins D, E, and A could increase serum 25-hydroxyvitamin D [25(OH)D], α-tocopherol, and retinol levels. DESIGN: A 12-week randomized, double-blind, controlled trial. PARTICIPANTS/SETTING: One hundred eighty participants (aged 8.04±1.42 years) were recruited at Tufts (n=70) and Boston University (n=110) during 2005-2006. Of those recruited, 176 children were randomized into three groups: CaD (700 mg calcium+200 IU vitamin D), CaDEA (700 mg calcium+200 IU vitamin D+12 IU vitamin E+2,000 IU vitamin A as beta carotene), or Ca (700 mg calcium). Children consumed two 240-mL glasses of CaD, CaDEA, or Ca fortified orange juice daily for 12 weeks. MAIN OUTCOME MEASURES: Serum 25(OH)D, α-tocopherol, and retinol concentrations. STATISTICAL ANALYSES: Changes in 25(OH)D, α-tocopherol, retinol, and parathyroid hormone concentrations were examined. Covariates included sex, age, race/ethnicity, body mass index, and baseline 25(OH)D, α-tocopherol, retinol, or parathyroid hormone levels. Multivariate models and repeated measures analysis of variance tested for group differences with pre-post measures (n=141). RESULTS: Baseline 25(OH)D was 68.4±27.7 nmol/L (27.4±11.10 ng/mL) ), with 21.7% of participants having inadequate 25(OH)D (<50 nmol/L [20.03 ng/mL]). The CaD group's 25(OH)D increase was greater than that of the Ca group (12.7 nmol/L [5.09 ng/mL], 95% CI 1.3 to 24.1; P=0.029). The CaDEA group's increase in α-tocopherol concentration was greater than that in the Ca or CaD groups (3.79 µmol/L [0.16 µg/mL], 95% CI 2.5 to 5.1 and 3.09 µmol/L [0.13 µg/mL], 95% CI -1.8 to 4.3), respectively (P<0.0001). Retinol levels did not change, and body weight remained as expected for growth. CONCLUSIONS: Daily consumption of orange juice providing 200 IU vitamin D and 12 IU vitamin E increased 25(OH)D and α-tocopherol concentrations in young children within 12 weeks.

Changes in diet and physical activity resulting from the Shape Up Somerville community intervention.

BACKGROUND: The purpose of this study is to describe the behavioral changes in children resulting from Shape Up Somerville (SUS), a community-based, participatory obesity prevention intervention that used a multi-level, systems-based approach. It was set in Somerville, an urban, culturally diverse community in Massachusetts, USA. METHODS: This was a non-randomized, controlled 2-year community-based intervention trial with children enrolled in grades 1 to 3 (ages 6-8 years). Overall, the SUS intervention was designed to create environmental and policy change to impact all aspects of a child's day. Pre-post outcomes were compared between Somerville and two control communities that were chosen based on socio-demographic similarities. Behavioral outcomes were fruit and vegetable and sugar-sweetened beverage consumption; number of organized sports and physical activities per year; walking to and from school; screen and television time; television in bedroom; and dinner in room with television on. These measures were assessed by parent/caregiver report using a 68-item Family Survey Form. Data were analyzed using multiple linear regression, accounting for covariates and clustering by community. RESULTS: Intervention group children, compared to the control group, significantly reduced sugar-sweetened beverage consumption (-2.0 ounces per day; 95% CI -3.8 to -0.2), increased participation in organized sports and physical activities (0.20 sports or activities per year; 95% CI 0.06 to 0.33), and reduced their screen time (-0.24 hours per day; 95% CI -0.42 to -0.06). CONCLUSIONS: Results of this study, particularly intake of sugar-sweetened beverages and screen time, are similar to others that used a multi-level approach to realize change in behavior. These results support the efficacy of a multi-level and systems-based approach for promoting the behavioral changes necessary for childhood obesity prevention. This study is registered at ClinicalTrials.gov as NCT00153322.

Shape Up Somerville two-year results: a community-based environmental change intervention sustains weight reduction in children.

OBJECTIVE: The objective of this study was to test the hypothesis that community-based environmental change intervention prevents undesirable weight gain in children. METHOD: The method used in this study was a two-year, non-randomized, controlled trial (2003-2005) using community-based participatory methodology in three diverse cities in Massachusetts: one intervention and two socio-demographically-matched control communities (pooled for analysis). Children (n=1028), with a mean age=7.61+1.04years participated. Interventions were made to improve energy balance by increasing physical activity options and availability of healthful foods (Year 1). To firmly secure sustainability, the study team supported policies and shifted intervention work to community members (Year 2). RESULTS: Change in body mass index z-score (BMIz) was assessed by multiple regression, accounting for clustering within communities and adjusting for baseline covariates. Sex-specific overweight/obesity prevalence, incidence and remission were assessed. Over the two-year period, BMIz of children in the intervention community decreased by -0.06 [p=0.005, 95% confidence interval: -0.08 to -0.04] compared to controls. Prevalence of overweight/obesity decreased in males (OR=0.61, p=0.01) and females (OR=0.78, p=0.01) and remission increased in males (OR 3.18, p=0.03) and females (OR 1.93, p=0.03) in intervention compared to controls. CONCLUSION: Results demonstrate promise for preventing childhood obesity using a sustainable multi-level community-based model and reinforce the need for wide-reaching environmental and policy interventions.

Immigrating to the US: what Brazilian, Latin American and Haitian women have to say about changes to their lifestyle that may be associated with obesity.

Our goal was to explore the perceived determinants of obesity in Brazilian, Latin American and Haitian women. This is part of an ongoing community-based participatory intervention. Focus groups by immigrant group were conducted and themes extracted. Women expressed differences in beliefs, attitudes, and barriers regarding diet and physical activity in the US versus their home country. Participants thought food in the US is "less natural," there is less time for preparation, and there is more variety. The weather is a barrier to physical activity in the US and work is more physically demanding. Job-related efforts were not considered physical activity. They reported higher levels of stress, less control of their time and less social support in the US. Providing immigrants with appropriate support and education early in the acculturation process has the potential to help prevent obesity.

Whole grain consumption is inversely associated with BMI Z-score in rural school-aged children.

OBJECTIVE: To examine the relationship between intake of whole grains and BMI Z-score in rural children. DESIGN: General linear models and logistic regression were used to examine the cross-sectional associations between whole grain intake and BMI Z-score, prevalence and odds ratios of overweight and obesity. Dietary intake was assessed using the Block Food Screener for ages 2-17 years. Children were classified into three categories according to servings of whole grain intake: <1·0 serving/d, 1·0-1·5 servings/d and >1·5 servings/d. SETTING: The CHANGE (Creating Healthy, Active and Nurturing Growing-up Environments) study, an obesity prevention intervention in elementary schools in eight rural US communities in California, Mississippi, Kentucky and South Carolina. SUBJECTS: Seven hundred and ninety-two children attending 3rd-6th grade. RESULTS: After adjusting for age, sex, race/ethnicity, physical activity and state of residence, whole grain intake was inversely associated with BMI Z-score (0·90 v. 0·61 in the lowest v. the highest whole grain intake category; P trend = 0·01). Children who consumed >1·5 servings of whole grains/d had a 40 % lower risk of being obese (OR = 0·60; 95 % CI 0·38, 0·95, P = 0·02) compared with children who consumed <1·0 serving/d. Further adjustment for potential dietary predictors of body weight (fruit, vegetable and dairy intakes) did not change the observed associations. CONCLUSIONS: Increasing the intake of whole grains as part of an overall healthy lifestyle may be beneficial for children to achieve and maintain a healthy weight.

Acculturation and gestational weight gain in a predominantly Puerto Rican population.

BACKGROUND: Identifying risk factors that affect excess weight gain during pregnancy is critical, especially among women who are at a higher risk for obesity. The goal of this study was to determine if acculturation, a possible risk factor, was associated with gestational weight gain in a predominantly Puerto Rican population. METHODS: We utilized data from Proyecto Buena Salud, a prospective cohort study of Hispanic women in Western Massachusetts, United States. Height, weight and gestational age were abstracted from medical records among participants with full-term pregnancies (n=952). Gestational weight gain was calculated as the difference between delivery and prepregnancy weight. Acculturation (measured via a psychological acculturation scale, generation in the US, place of birth and spoken language preference) was assessed in early pregnancy. RESULTS: Adjusting for age, parity, perceived stress, gestational age, and prepregnancy weight, women who had at least one parent born in Puerto Rico/Dominican Republic (PR/DR) and both grandparents born in PR/DR had a significantly higher mean total gestational weight gain (0.9 kg for at least one parent born in PR/DR and 2.2 kg for grandparents born in PR/DR) and rate of weight gain (0.03 kg/wk for at least one parent born in PR/DR and 0.06 kg/wk for grandparents born in PR/DR) vs. women who were of PR/DR born. Similarly, women born in the US had significantly higher mean total gestational weight gain (1.0 kg) and rate of weight gain (0.03 kg/wk) vs. women who were PR/ DR born. Spoken language preference and psychological acculturation were not significantly associated with total or rate of pregnancy weight gain. CONCLUSION: We found that psychological acculturation was not associated with gestational weight gain while place of birth and higher generation in the US were significantly associated with higher gestational weight gain. We interpret these findings to suggest the potential importance of the US "obesogenic" environment in influencing unhealthy pregnancy weight gains over specific aspects of psychological acculturation.

Healthy-lifestyle behaviors associated with overweight and obesity in US rural children.

BACKGROUND: There are disproportionately higher rates of overweight and obesity in poor rural communities but studies exploring children's health-related behaviors that may assist in designing effective interventions are limited. We examined the association between overweight and obesity prevalence of 401 ethnically/racially diverse, rural school-aged children and healthy-lifestyle behaviors: improving diet quality, obtaining adequate sleep, limiting screen-time viewing, and consulting a physician about a child's weight. METHODS: A cross-sectional analysis was conducted on a sample of school-aged children (6-11 years) in rural regions of California, Kentucky, Mississippi, and South Carolina participating in CHANGE (Creating Healthy, Active, and Nurturing Growing-up Environments) Program, created by Save the Children, an independent organization that works with communities to improve overall child health, with the objective to reduce unhealthy weight gain in these school-aged children (grades 1-6) in rural America. After measuring children's height and weight, we17 assessed overweight and obesity (BMI ≥ 85th percentile) associations with these behaviors: improving diet quality18 (≥ 2 servings of fruits and vegetables/day), reducing whole milk, sweetened beverage consumption/day; obtaining19 adequate night-time sleep on weekdays (≥ 10 hours/night); limiting screen-time (i.e., television, video, computer,20 videogame) viewing on weekdays (≤ 2 hours/day); and consulting a physician about weight. Analyses were adjusted 21 for state of residence, children's race/ethnicity, gender, age, and government assistance. RESULTS: Overweight or obesity prevalence was 37 percent in Mississippi and nearly 60 percent in Kentucky. Adjusting for covariates, obese children were twice as likely to eat ≥ 2 servings of vegetables per day (OR=2.0,95% CI 1.1-3.4), less likely to consume whole milk (OR=0.4,95% CI 0.2-0.70), Their parents are more likely to be told by their doctor that their child was obese (OR=108.0,95% CI 21.9-541.6), and less likely to report talking to their child about fruits and vegetables a lot/sometimes vs. not very much/never (OR=0.4, 95%CI 0.2-0.98) compared to the parents of healthy-weight children. CONCLUSIONS: Rural children are not meeting recommendations to improve diet, reduce screen time and obtain adequate sleep. Although we expected obese children to be more likely to engage in unhealthy behaviors, we found the opposite to be true. It is possible that these groups of respondent parents were highly aware of their weight status and have been advised to change their children's health behaviors. Perhaps given the opportunity to participate in an intervention study in combination with a physician recommendation could have resulted in actual behavior change.

Permissive parental feeding behavior is associated with an increase in intake of low-nutrient-dense foods among American children living in rural communities.

Parents play an important role in shaping children's eating habits. Few studies have evaluated the influence of both parenting style and parenting practices on child outcomes such as dietary intake. During spring 2007, 99 parent-child dyads from four rural US areas participated in this cross-sectional study. Child food intake was reported during two interviewer-administered, parent-assisted 24-hour recalls. Diet quality was defined as the average number of low-nutrient-dense (LND) foods consumed. Validated questionnaires were used to assess parental feeding practices and feeding style. Pearson correlations identified relationships among child food intake, parental feeding style typologies, and covariates. Regression analyses were used to predict child diet quality. Sixty percent of children and 76% of parents were overweight or obese. A permissive feeding style, which is highly responsive to a child's requests and sets few demands on him or her, was the most common (n=37) parental feeding style. This feeding style was associated with child intake of LND foods (r=0.3; P<0.001) and moderated the relationship between parental feeding practices and child intake of LND foods. In the presence of a permissive feeding style, higher levels of monitoring were associated with child intake of LND foods (ß=.69; P<0.05). Parental feeding style may alter the effectiveness of parental feeding practices on children's food intake. More research is needed to understand the parent-child feeding relationship in the context of parental feeding styles and practices.

Feeding styles and child weight status among recent immigrant mother-child dyads.

BACKGROUND: Research has shown that parental feeding styles may influence children's food consumption, energy intake, and ultimately, weight status. We examine this relationship, among recent immigrants to the US. Given that immigrant parents and children are at greater risk for becoming overweight/obese with increased time in the US, identification of risk factors for weight gain is critical. METHODS: Baseline data was collected on 383 mother-child dyads enrolled in Live Well, a community-based, participatory, randomized controlled lifestyle intervention to prevent weight gain in recent immigrant mothers. Socio-demographic information together with heights and weights were collected for both mother and child. Acculturation, behavioral data, and responses to the Caregiver's Feeding Styles Questionnaire (CFSQ) were also obtained from the mother. RESULTS: The children's average age was 6.2 ± 2.7 years, 58% male. Mothers had been in the country for an average of 6.0 ± 3.3 years, and are Brazilian (36%), Haitian (34%) and Latino (30%). Seventy-two percent of the mothers were overweight/obese, while 43% of the children were overweight/obese. Fifteen percent of mothers reported their feeding style as being high demanding/high responsive; 32% as being high demanding/low responsive; 34% as being low demanding/high responsive and 18% as being low demanding/low responsive. In bivariate analyses, feeding styles significantly differed by child BMIz-score, ethnic group, and mother's perceived stress. In multiple linear regression, a low demanding/high responsive feeding style was found to be positively associated (ß = 0.56) with a higher child weight as compared to high demanding/high responsive, controlling for known covariates (p = 0.01). CONCLUSIONS: Most mothers report having a low demanding/high responsive feeding style, which is associated with higher child weight status in this diverse immigrant population. This finding adds to the growing literature that suggests this type of feeding style may be a risk factor for childhood obesity. Further research is needed to help understand the larger socio-cultural context and its influence on feeding dynamics among immigrant families and families of lower incomes. How parents establish a certain feeding style in their home country compared to when they move to the US "obesogenic" environment, should also be explored.

Development of the Rural Active Living Perceived Environmental Support Scale (RALPESS).

BACKGROUND: Evidence supports the role of physical and social environments in active living, including perception of environment. However, measurement of perceived environments in rural settings is lacking. This study describes the development of the Rural Active Living Perceived Environmental Support Scale (RALPESS). METHODS: Premised on social ecological and cognitive perspectives, 85 initial items were generated through a literature review and a mixed-methods investigation of "activity-friendly" environments. Items were organized by resource areas--town center, indoor and outdoor physical activity areas, schools, churches, and areas around the home/neighborhood--and submitted for expert panel review. In 2009, a revised questionnaire was disseminated to adolescents, parents, public school staff, and older adults in 2 rural southeastern United States counties. Principal component analysis with varimax rotation was used to explore factor structure (n = 542). RESULTS: The final analysis yielded 33 items with 7 factors: 1) church facilities, 2) town center connectivity, 3) indoor areas, 4) around the home/neighborhood, 5) town center physical activity resources, 6) school grounds, and 7) outdoor areas. CONCLUSIONS: The RALPESS is a valid, internally consistent, and practically useful instrument to measure perceptions of rural environments in the context of physical activity across the lifespan. Confirmatory factor analysis is recommended to validate factor structure.

Using the Community Readiness Model to select communities for a community-wide obesity prevention intervention.

To build on a growing interest in community-based obesity prevention programs, methods are needed for matching intervention strategies to local needs and assets. We used the Community Readiness Model (CRM), a structured interview guide and scoring system, to assess community readiness to act on childhood obesity prevention, furthering a replication study of a successful intervention. Using the CRM protocol, we conducted interviews with 4 stakeholders in each of 10 communities of similar size, socioeconomic status, and perceived readiness to implement a community-wide obesity prevention intervention. Communities were in California, Florida, Illinois, Massachusetts, New York, North Carolina, Pennsylvania, and Tennessee. The 4 stakeholders were the mayor or city manager, the school superintendent, the school food service director, and a community coalition representative. Interviews were recorded and professionally transcribed. Pairs of trained reviewers scored the transcriptions according to CRM protocol. The CRM assesses 9 stages of readiness for 6 dimensions: existing community efforts to prevent childhood obesity, community knowledge about the efforts, leadership, community climate, knowledge about the issue, and resources. We calculated an overall readiness score for each community from the dimension scores. Overall readiness scores ranged from 2.97 to 5.36 on the 9-point scale. The mean readiness score, 4.28 (SD, 0.68), corresponds with a "preplanning" level of readiness. Of the 6 dimensions, community climate varied the least (mean score, 3.11; SD, 0.64); leadership varied the most (mean score, 4.79; SD, 1.13). The CRM quantified a subjective concept, allowing for comparison among 10 communities. Dimension scores and qualitative data from interviews helped in the selection of 6 communities for a replication study.

Active living for rural children: community perspectives using PhotoVOICE.

BACKGROUND: Active living integrates physical activity into one's daily routine. Current understanding of active living among children and their families living in rural communities is limited. A community perspective is critical to understand the contextual factors that influence children's physical activity in rural areas. PURPOSE: The purpose of this study was to identify the perceived environmental factors that support or hinder physical activity among rural children to develop testable hypotheses to inform future interventions for reducing unhealthy weight gain and preventing chronic diseases associated with physical inactivity. METHODS: PhotoVOICE was used to explore active living opportunities and barriers for children living in four low-income, rural U.S. communities. In 2007, parents (n=99) and elementary school staff (n=17) received disposable cameras to document their perspective. Using their photographs and narratives, participants developed emergent themes during a facilitated group discussion. In 2008, study authors used the Analysis Grid for Environments Linked to Obesity (ANGELO) framework to categorize the themes. RESULTS: Microenvironment themes include physical (e.g., natural features, topography); sociocultural (e.g., isolation); policy (e.g., time for school recess); and economic (e.g., funding for physical activity programs). Macroenvironmental themes related to the built and natural environments and transportation infrastructure. CONCLUSIONS: This study identified rural environment elements that community members perceived as influencing children's physical activity patterns. Certain aspects were unique to rural areas, whereas other urban and suburban factors may be generalizable to rural settings. PhotoVOICE was a useful participatory research method to gain insight into perceived factors affecting rural children's physical activity behaviors.

Parent-child interactions and objectively measured child physical activity: a cross-sectional study.

BACKGROUND: Parents influence their children's behaviors directly through specific parenting practices and indirectly through their parenting style. Some practices such as logistical and emotional support have been shown to be positively associated with child physical activity (PA) levels, while for others (e.g. monitoring) the relationship is not clear. The objectives of this study were to determine the relationship between parent's PA-related practices, general parenting style, and children's PA level. METHODS: During the spring of 2007 a diverse group of 99 parent-child dyads (29% White, 49% Black, 22% Hispanic; 89% mothers) living in low-income rural areas of the US participated in a cross-sectional study. Using validated questionnaires, parents self-reported their parenting style (authoritative, authoritarian, permissive, and uninvolved) and activity-related parenting practices. Height and weight were measured for each dyad and parents reported demographic information. Child PA was measured objectively through accelerometers and expressed as absolute counts and minutes engaged in intensity-specific activity. RESULTS: Seventy-six children had valid accelerometer data. Children engaged in 113.4 ± 37.0 min. of moderate-vigorous physical activity (MVPA) per day. Children of permissive parents accumulated more minutes of MVPA than those of uninvolved parents (127.5 vs. 97.1, p < 0.05), while parents who provided above average levels of support had children who participated in more minutes of MVPA (114.2 vs. 98.3, p = 0.03). While controlling for known covariates, an uninvolved parenting style was the only parenting behavior associated with child physical activity. Parenting style moderated the association between two parenting practices - reinforcement and monitoring - and child physical activity. Specifically, post-hoc analyses revealed that for the permissive parenting style group, higher levels of parental reinforcement or monitoring were associated with higher levels of child physical activity. CONCLUSIONS: This work extends the current literature by demonstrating the potential moderating role of parenting style on the relationship between activity-related parenting practices and children's objectively measured physical activity, while controlling for known covariates. Future studies in this area are warranted and, if confirmed, may help to identify the mechanism by which parents influence their child's physical activity behavior.