Associations of Neighborhood and School Socioeconomic and Social Contexts With Body Mass Index Among Urban Preadolescent Students.

OBJECTIVES: We examined independent and synergistic effects of school and neighborhood environments on preadolescent body mass index (BMI) to determine why obesity rates nearly double during preadolescence. METHODS: Physical measures and health surveys from fifth and sixth graders in 12 randomly selected schools in New Haven, Connecticut, in 2009 were matched to student sociodemographics and school- and residential census tract-level data, for a total of 811 urban preadolescents. Key independent variables included school connectedness, neighborhood social ties, and school and neighborhood socioeconomic status. We estimated cross-classified random-effects hierarchical linear models to examine associations between key school and neighborhood characteristics with student BMI. RESULTS: Greater average connectedness felt by students to their school was significantly associated with lower BMI. This association was stronger among students living in neighborhoods with higher concentrations of affluent neighbors. CONCLUSIONS: How schools engage and support students may affect obesity rates preferentially in higher-income neighborhoods. Further research should explore the associations between multiple environments to which children are exposed and obesity-related behaviors and outcomes. This understanding of the multiple social-spatial contexts that children occupy has potential to inform comprehensive and sustainable child obesity prevention efforts.

Adolescents Who Visit the Emergency Department Are More Likely to Make Unhealthy Dietary Choices: An Opportunity for Behavioral Intervention.

To identify health behaviors that may be amenable to brief screening and intervention among children in the emergency department (ED), we described the prevalence of health behaviors known to contribute to childhood obesity among middle school students who used the ED recently. Participants included 1590 5th, 7th, and 8th grade students who completed health surveys in 2011. Multivariate logistic regression was used to examine the association between health behaviors and ED use. Children who used the ED reported more unhealthy dietary behaviors, including greater consumption of energy-dense foods such as fried chicken, french fries, and ice cream (OR 1.20, 95% CI 1.06-1.37), fast food (OR 1.07, 95% CI 1.00-1.14) and sugar-sweetened beverages (OR 1.24, 95% CI 1.14-1.35). There was no association with fruit and vegetable consumption, physical activity, or screen time. Unhealthy dietary behaviors are associated with ED use in a low-resource urban population of middle school students.

The Relationship between Parental Behaviors and Children's Sugary Drink Consumption Is Moderated by a Television in the Child's Bedroom.

BACKGROUND: The aim of this longitudinal study was to examine the link between perceived authoritative parenting behaviors and sugary drink consumption among children from low-income families who do or do not have televisions (TVs) in their bedrooms. METHODS: Middle school students (N = 480) completed a baseline survey in sixth grade and a follow-up survey in seventh grade. The students were recruited from 12 schools in a low-income, predominantly black (33%) and Latino (48%), urban school district. The survey assessed the children's perception of their parents' controlling and nurturing behaviors, the presence of a TV in their bedrooms, and their level of sugary drink consumption on the previous school day. Children's report of specific controlling and nurturing parental behaviors were used to create an "authoritative parenting" score. Regression analyses were used to test the main and interactive effects of authoritative parenting behaviors and having a TV in the bedroom with sugary drink consumption in seventh grade, controlling for age, race/ethnicity, gender, BMI, and sugary drink consumption in sixth grade. RESULTS: A significant interaction emerged: The authoritative parenting score predicted lower levels of sugary drink consumption in seventh grade, but this relationship was moderated by whether or not there was a TV in the child's bedroom. CONCLUSION: A TV in the child's bedroom may weaken the positive influence of authoritative parenting behaviors on limiting sugary drink consumption among middle school children from low-income families. Stronger initiatives are recommended to educate parents and help them refrain from placing TVs in their children's bedrooms.

Energy drinks and youth self-reported hyperactivity/inattention symptoms.

OBJECTIVE: To describe patterns in sweetened beverage consumption by race/ethnicity and sex, documenting both the amount and types of sweetened beverages consumed; and to examine the association of sweetened beverage consumption with hyperactivity/inattention symptoms among middle school students in a single urban school district. METHODS: Middle school students (n = 1649; 47% Hispanic and 38% black, non-Hispanic) from 12 schools, randomly selected out of 27 district schools, completed health behavior surveys in fall 2011. Students reported quantity and types of sweetened beverages consumed in the past 24 hours and completed the 5-item Hyperactivity/Inattention subscale of the Strengths and Difficulties Questionnaire to measure symptoms. RESULTS: Amount and variety of reported sweetened beverage consumption (including energy drinks) were greater among boys versus girls and among black and Hispanic versus white students. Risk of hyperactivity/inattention increased by 14% for each additional sweetened beverage consumed, adjusting for age, race/ethnicity, sex, school lunch eligibility, family structure, and sugary food consumption. Students reporting consumption of energy drinks were 66% more likely to be at risk for hyperactivity/inattention after adjusting for number of drinks, other types of drinks consumed, and other potential confounders. CONCLUSIONS: Results support recommendations to limit consumption of sweetened beverages and to avoid consumption of energy drinks among children. Interventions to reduce sweetened beverage consumption should explicitly focus on energy drinks and other emerging sweetened beverages such as sports and sweetened coffee drinks. More research is needed to understand the direction of effects and the mechanisms behind the association between sweetened beverages and hyperactivity/inattention symptoms.

Weight- and race-based bullying: health associations among urban adolescents.

Stigma-based bullying is associated with negative mental and physical health outcomes. In a longitudinal study, surveys and physical assessments were conducted with mostly Black and Latino, socioeconomically disadvantaged, urban students. As hypothesized, greater weight- and race-based bullying each was significantly indirectly associated with increased blood pressure and body mass index, as well as decreased overall self-rated health across 2 years, through the mechanism of more negative emotional symptoms. Results support important avenues for future research on mechanisms and longitudinal associations of stigma-based bullying with health. Interventions are needed to reduce stigma-based bullying and buffer adolescents from adverse health effects.

Positive school climate is associated with lower body mass index percentile among urban preadolescents.

BACKGROUND: Schools are an important environmental context in children's lives and are part of the complex web of factors that contribute to childhood obesity. Increasingly, attention has been placed on the importance of school climate (connectedness, academic standards, engagement, and student autonomy) as 1 domain of school environment beyond health policies and education that may have implications for student health outcomes. The purpose of this study is to examine the association of school climate with body mass index (BMI) among urban preadolescents. METHODS: Health surveys and physical measures were collected among fifth- and sixth-grade students from 12 randomly selected public schools in a small New England city. School climate surveys were completed district-wide by students and teachers. Hierarchical linear modeling was used to test the association between students' BMI and schools' climate scores. RESULTS: After controlling for potentially confounding individual-level characteristics, a 1-unit increase in school climate score (indicating more positive climate) was associated with a 7-point decrease in students' BMI percentile. CONCLUSIONS: Positive school climate is associated with lower student BMI percentile. More research is needed to understand the mechanisms behind this relationship and to explore whether interventions promoting positive school climate can effectively prevent and/or reduce obesity.

Teacher Involvement as a Protective Factor from the Association between Race-Based Bullying and Smoking Initiation.

Experiencing bullying as a victim is associated with negative health and health behavior outcomes, including substance use, among adolescents. However, understandings of protective factors - factors that enhance adolescents' resilience to the negative consequences of bullying - remain limited. The current study investigates whether teacher involvement protects adolescent students from the association between being bullied due to race and smoking initiation. Students were recruited from 12 Kindergarten through 8th grade schools in an urban school district in the Northeast United States. The analytic sample included 769 students who responded to surveys in 5th or 6th grade (2009), and two years later in 7th or 8th grade (2011). Students primarily identified as Latino and/or Black, and 90% were eligible for free or reduced lunch. Fifty-four (7%) students initiated smoking between survey time points. Among students reporting lower teacher involvement, race-based bullying was associated with higher likelihood of smoking initiation (OR = 1.69, p = .03). In contrast, among students reporting higher teacher involvement, racebased bullying was not associated with higher likelihood of smoking initiation (OR = 0.95, p = .81). Results suggest that teacher involvement may protect students from the association between race-based bullying and smoking initiation. Enhancing teacher involvement among students experiencing race-based bullying in schools may limit smoking initiation.

Health and academic achievement: cumulative effects of health assets on standardized test scores among urban youth in the United States.

BACKGROUND: The Institute of Medicine (2012) concluded that we must "strengthen schools as the heart of health." To intervene for better outcomes in both health and academic achievement, identifying factors that impact children is essential. Study objectives are to (1) document associations between health assets and academic achievement, and (2) examine cumulative effects of these assets on academic achievement. METHODS: Participants include 940 students (grades 5 and 6) from 12 schools randomly selected from an urban district. Data include physical assessments, fitness testing, surveys, and district records. Fourteen health indicators were gathered including physical health (eg, body mass index [BMI]), health behaviors (eg, meeting recommendations for fruit/vegetable consumption), family environment (eg, family meals), and psychological well-being (eg, sleep quality). Data were collected 3-6 months prior to standardized testing. RESULTS: On average, students reported 7.1 health assets out of 14. Those with more health assets were more likely to be at goal for standardized tests (reading/writing/mathematics), and students with the most health assets were 2.2 times more likely to achieve goal compared with students with the fewest health assets (both p < .001). CONCLUSIONS: Schools that utilize nontraditional instructional strategies to improve student health may also improve academic achievement, closing equity gaps in both health and academic achievement.

Shift-and-persist: a protective factor for elevated BMI among low-socioeconomic-status children.

OBJECTIVE: Low socioeconomic status (SES) is associated with many adverse health outcomes, including childhood overweight and obesity. However, little is understood about why some children defy this trend by maintaining a healthy weight despite living in obesogenic environments. The objective of this study is to test the hypothesis that the psychological strategy of "shift-and-persist" protects low-SES children from overweight and obesity. Shift-and-persist involves dealing with stressors by reframing them more positively while at the same time persisting in optimistic thoughts about the future. DESIGN AND METHODS: Middle school children (N = 1,523, ages 9-15) enrolled in a school-based obesity prevention trial completed health surveys and physical assessments. Multiple linear regression analysis was used to examine the role of SES, shift-and-persist strategies, and their interaction on BMI z-scores, while controlling for student race/ethnicity, gender, and reported diet and physical activity. RESULTS: Among children reporting engaging in less frequent shift-and-persist strategies, lower SES was associated with significantly higher BMI z-scores (P < 0.05). However, among children reporting engaging in more frequent shift-and-persist strategies, there was no association of SES with BMI z-score (P = 0.16), suggesting that shift-and-persist strategies may be protective against the association between SES and BMI. CONCLUSIONS: Interventions aimed at improving psychological resilience among children of low SES may provide a complementary approach to prevent childhood overweight and obesity among at-risk populations.

Children's report of lifestyle counseling differs by BMI status.

BACKGROUND: This study examined whether children's report of receiving weight, nutrition, and physical activity counseling from their clinicians differs by their BMI status and identified factors associated with higher rates of counseling. METHODS: Physical assessments and health surveys were collected from a school-based sample of 959 5(th) and 6(th) grade students. Multivariate logistic regression analysis was used to examine how lifestyle counseling differs by BMI status, adjusting for race, gender, socioeconomic status, co-morbidities, site of care provider, and age. RESULTS: Healthy weight children reported receiving the least amount of lifestyle counseling, with nearly one-quarter reporting none at all. Overweight children were no more likely than their healthy weight peers to report receiving weight and nutrition counseling. As expected, obese children were approximately two times more likely to report being counseled on their weight, nutrition, or physical activity as compared to healthy weight children (all p values at least <0.01). However, 23.9% of obese children reported receiving no counseling about their weight. After adjusting for BMI and all other confounding factors, for each lifestyle topic, Hispanics were at least 1.84 times more likely than whites to report being counseled (all p values at least <0.05). Blacks were at least 1.38 times more likely than whites to report being counseled (all p values at least <0.05). Girls were at least 1.38 times more likely than boys to report being counseled (all p values at least <0.05). CONCLUSION: Although lifestyle counseling is universally recommended, many children report not receiving counseling. Despite clinical indications for more intensive counseling, overweight children report similar counseling rates as their healthy weight peers. Furthermore, a substantial proportion of obese children report not receiving lifestyle counseling. Future research should examine how lifestyle counseling can more effectively reach all children.

Disentangling neighborhood contextual associations with child body mass index, diet, and physical activity: the role of built, socioeconomic, and social environments.

Obesity prevalence among US children and adolescents has tripled in the past three decades. Consequently, dramatic increases in chronic disease incidence are expected, particularly among populations already experiencing health disparities. Recent evidence identifies characteristics of "obesogenic" neighborhood environments that affect weight and weight-related behaviors. This study aimed to examine associations between built, socioeconomic, and social characteristics of a child's residential environment on body mass index (BMI), diet, and physical activity. We focused on pre-adolescent children living in New Haven, Connecticut to better understand neighborhood environments' contribution to persistent health disparities. Participants were 1048 fifth and sixth grade students who completed school-based health surveys and physical measures in fall 2009. Student data were linked to US Census, parks, retailer, and crime data. Analyses were conducted using multilevel modeling. Property crimes and living further from a grocery store were associated with higher BMI. Students living within a 5-min walk of a fast food outlet had higher BMI, and those living in a tract with higher density of fast food outlets reported less frequent healthy eating and more frequent unhealthy eating. Students' reported perceptions of access to parks, playgrounds, and gyms were associated with more frequent healthy eating and exercise. Students living in more affluent neighborhoods reported more frequent healthy eating, less unhealthy eating, and less screen time. Neighborhood social ties were positively associated with frequency of exercise. In conclusion, distinct domains of neighborhood environment characteristics were independently related to children's BMI and health behaviors. Findings link healthy behaviors with built, social, and socioeconomic environment assets (access to parks, social ties, affluence), and unhealthy behaviors with built environment inhibitors (access to fast food outlets), suggesting neighborhood environments are an important level at which to intervene to prevent childhood obesity and its adverse consequences.

Community-university partnerships in community-based research.

PROBLEM: Community-engaged research (CEnR) is a complex, collaborative process that presents many challenges and requires investment of time and commitment by both community and university research partners. PURPOSE: This paper describes the experience of a group of university and community members developing a set of guidelines for the ethical conduct of CEnR projects. KEY POINTS: The paper outlines the process of guideline development and lessons learned from this collaborative effort, which was based upon approaches and methods of community-based participatory research (CBPR). CONCLUSIONS: The guidelines are included and may serve as a framework to be individualized by other partnerships. Our experience shows that the very process of review, revision, and engagement is extremely helpful in creating a framework that works for the specific communities and for establishing working relationships among the partners so that all stakeholders feel ownership and investment in the framework and the collaborative research efforts.