Identifying meaningful dietary intake and physical activity questions for individual and population health.

We aimed to identify valid screening questions for adults regarding physical activity and dietary behaviours that (a) were correlated with BMI, (b) were deemed by patients and providers to be relevant to clinical care, and (c) have utility for longitudinal understanding of health behaviours in populations. The goal was to identify screening questions that could be implemented at annual health care visits. First, we identified dietary behaviour questions and solicited patient input. Next, we tested both physical activity and dietary behaviour questions in a large sample to test their potential utility. Finally, we used cognitive interviews with patients and physicians to narrow our assessment for clinical settings. We present a parsimonious and reliable six-question scale of physical activity and dietary behaviours for research settings, as well as a three-question scale for clinical settings. We demonstrate a robust relationship between these measures and obesity. Additionally, we present evidence that these measures may serve as a useful red flag for patients before they develop obesity. We provide a concise and useful tool for assessing patients' physical activity and dietary behaviours in a variety of research settings. We also highlight the importance of incorporating this tool into the clinical intake flow for inclusion in patients' Electronic Health Record.

Applying the Behavior Change Technique Taxonomy to Four Multicomponent Childhood Obesity Interventions.

Applying the Behavior Change Technique Taxonomy has the potential to facilitate identification of effective childhood obesity intervention components. This article evaluates the feasibility of coding Childhood Obesity Prevention and Treatment Consortium interventions and compares reliability between external taxonomy-familiar coders and internal intervention-familiar coders. After training, coder pairs independently coded prespecified portions of intervention materials. An adjudication process was used to explore coding discrepancies. Reliability between internal and external coders was moderate (prevalence and bias-adjusted kappa .38 to .55). Reliability for specific target behaviors varied with substantial agreement for physical activity (.63 to .76) and moderate for dietary intake (.44 to .63). Applying the taxonomy to these interventions was feasible, but agreement was modest. Coding discrepancies highlight the importance of refining coding to capture the complexities of childhood obesity interventions, which often engage multiple recipients (e.g., parents and/or children) and address multiple behaviors (e.g., diet, physical activity, screen time).

Development of Brief Child Nutrition and Physical Activity Screening Questions for Electronic Health Record Use.

Background: To develop and test brief nutrition and physical activity screening questions for children ages 2-11 years that could be used as a pragmatic screening tool to tailor counseling, track behavior change, and improve population health. Methods: A literature review identified existing validated questions for nutrition and physical activity behaviors in children ages 2-11 years. Response variation and concurrent validity was then assessed using a mechanical Turk (MTurk) crowdsourcing survey employed in 2018. Additionally, cognitive interviews were conducted with both providers and parents of 2- to 11-year-old children to assess screening question priorities and perceived added value. Results: The literature review identified 260 questions, and 20 items were selected with expert guidance based on prespecified criteria (simplicity and potential utility for both clinical interactions during a well-child exam and population health). MTurk surveys yielded 1147 records that met eligibility criteria and revealed 6 items that had adequate response variation and were significantly correlated with parent-reported child BMI or BMI percentile, exhibiting concurrent validity. Cognitive interviews with 10 providers and 20 parents uncovered themes regarding suggestions and usability of the questions, eliminating 3 items due to parent and provider concerns. Combining quantitative and qualitative results, 3 nutrition and physical activity screening items remained for inclusion into the electronic health record (EHR). Conclusions: The three-pronged validation methodology produced a brief, 3-item child nutrition and physical activity screener to incorporate in the EHR, where it can inform tailored counseling for well-child care and be used to test associations with population health outcomes.

Salivary epigenetic biomarkers as predictors of emerging childhood obesity.

BACKGROUND: Epigenetics could facilitate greater understanding of disparities in the emergence of childhood obesity. While blood is a common tissue used in human epigenetic studies, saliva is a promising tissue. Our prior findings in non-obese preschool-aged Hispanic children identified 17 CpG dinucleotides for which differential methylation in saliva at baseline was associated with maternal obesity status. The current study investigated to what extent baseline DNA methylation in salivary samples in these 3-5-year-old Hispanic children predicted the incidence of childhood obesity in a 3-year prospective cohort. METHODS: We examined a subsample (n = 92) of Growing Right Onto Wellness (GROW) trial participants who were randomly selected at baseline, prior to randomization, based on maternal phenotype (obese or non-obese). Baseline saliva samples were collected using the Oragene DNA saliva kit. Objective data were collected on child height and weight at baseline and 36 months later. Methylation arrays were processed using standard protocol. Associations between child obesity at 36 months and baseline salivary methylation at the previously identified 17 CpG dinucleotides were evaluated using multivariable logistic regression models. RESULTS: Among the n = 75 children eligible for analysis, baseline methylation of Cg1307483 (NRF1) was significantly associated with emerging childhood obesity at 36-month follow-up (OR = 2.98, p = 0.04), after adjusting for child age, gender, child baseline BMI-Z, and adult baseline BMI. This translates to a model-estimated 48% chance of child obesity at 36-month follow-up for a child at the 75th percentile of NRF1 baseline methylation versus only a 30% chance of obesity for a similar child at the 25th percentile. Consistent with other studies, a higher baseline child BMI-Z during the preschool period was associated with the emergence of obesity 3 years later, but baseline methylation of NRF1 was associated with later obesity even after adjusting for child baseline BMI-Z. CONCLUSIONS: Saliva offers a non-invasive means of DNA collection and epigenetic analysis. Our proof of principle study provides sound empirical evidence supporting DNA methylation in salivary tissue as a potential predictor of subsequent childhood obesity for Hispanic children. NFR1 could be a target for further exploration of obesity in this population.

Effect of a Behavioral Intervention for Underserved Preschool-Age Children on Change in Body Mass Index: A Randomized Clinical Trial.

Importance: Prevention of obesity during childhood is critical for children in underserved populations, for whom obesity prevalence and risk of chronic disease are highest. Objective: To test the effect of a multicomponent behavioral intervention on child body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) growth trajectories over 36 months among preschool-age children at risk for obesity. Design, Setting, and Participants: A randomized clinical trial assigned 610 parent-child pairs from underserved communities in Nashville, Tennessee, to a 36-month intervention targeting health behaviors or a school-readiness control. Eligible children were between ages 3 and 5 years and at risk for obesity but not yet obese. Enrollment occurred from August 2012 to May 2014; 36-month follow-up occurred from October 2015 to June 2017. Interventions: The intervention (n = 304 pairs) was a 36-month family-based, community-centered program, consisting of 12 weekly skills-building sessions, followed by monthly coaching telephone calls for 9 months, and a 24-month sustainability phase providing cues to action. The control (n = 306 pairs) consisted of 6 school-readiness sessions delivered over the 36-month study, conducted by the Nashville Public Library. Main Outcomes and Measures: The primary outcome was child BMI trajectory over 36 months. Seven prespecified secondary outcomes included parent-reported child dietary intake and community center use. The Benjamini-Hochberg procedure corrected for multiple comparisons. Results: Participants were predominantly Latino (91.4%). At baseline, the mean (SD) child age was 4.3 (0.9) years; 51.9% were female. Household income was below $25 000 for 56.7% of families. Retention was 90.2%. At 36 months, the mean (SD) child BMI was 17.8 (2.2) in the intervention group and 17.8 (2.1) in the control group. No significant difference existed in the primary outcome of BMI trajectory over 36 months (P = .39). The intervention group children had a lower mean caloric intake (1227 kcal/d) compared with control group children (1323 kcal/d) (adjusted difference, -99.4 kcal [95% CI, -160.7 to -38.0]; corrected P = .003). Intervention group parents used community centers with their children more than control group parents (56.8% in intervention; 44.4% in control) (risk ratio, 1.29 [95% CI, 1.08 to 1.53]; corrected P = .006). Conclusions and Relevance: A 36-month multicomponent behavioral intervention did not change BMI trajectory among underserved preschool-age children in Nashville, Tennessee, compared with a control program. Whether there would be effectiveness for other types of behavioral interventions or implementation in other cities would require further research. Trial Registration: ClinicalTrials.gov Identifier: NCT01316653.

Parental feeding patterns and child weight status for Latino preschoolers.

OBJECTIVE: To examine the relationships between parental patterns regarding child feeding and child body mass index (BMI) percentile in Latino parent€-preschooler dyads participating in a clinical trial. METHODS: This secondary analysis examined data collected during a randomized clinical trial of a culturally tailored healthy lifestyle intervention focused on childhood obesity prevention, Salud Con La Familia. We analyzed 77 Latino parent-child dyads who completed baseline and 3-month follow-up data collection, assessing associations between preschool child BMI percentile and parental response to the Child Feeding Questionnaire (CFQ) over time. RESULTS: Higher child BMI was related to higher parental CFQ concern scores (r = 0.41, p < .001). A general inverse association between child BMI percentile and parental responsibility was also observed (r = -0.23, p = .040). Over the 3-month period, no statistically significant associations between changes in the CFQ subscale scores and changes in child BMI percentile were identified. CONCLUSIONS: Child BMI percentile consistent with overweight/obese is associated with parental concern about child weight and child BMI percentile consistent with normal weight is associated with perceived responsibility for feeding. Emphasizing parental responsibility to help children to develop healthy eating habits could be an important aspect of interventions aimed at both preventing and reducing pediatric obesity for Latino preschoolers.

Growing Right Onto Wellness (GROW): a family-centered, community-based obesity prevention randomized controlled trial for preschool child-parent pairs.

Growing Right Onto Wellness (GROW) is a randomized controlled trial that tests the efficacy of a family-centered, community-based, behavioral intervention to prevent childhood obesity among preschool-aged children. Focusing on parent-child pairs, GROW utilizes a multi-level framework, which accounts for macro (i.e., built-environment) and micro (i.e., genetics) level systems that contribute to the childhood obesity epidemic. Six hundred parent-child pairs will be randomized to a 3-year healthy lifestyle intervention or a 3-year school readiness program. Eligible children are enrolled between ages 3 and 5, are from minority communities, and are not obese. The principal site for the GROW intervention is local community recreation centers and libraries. The primary outcome is childhood body mass index (BMI) trajectory at the end of the three-year study period. In addition to other anthropometric measurements, mediators and moderators of growth are considered, including genetics, accelerometry, and diet recall. GROW is a staged intensity intervention, consisting of intensive, maintenance, and sustainability phases. Throughout the study, parents build skills in nutrition, physical activity, and parenting, concurrently forming new social networks. Participants are taught goal-setting, self-monitoring, and problem solving techniques to facilitate sustainable behavior change. The GROW curriculum uses low health literacy communication and social media to communicate key health messages. The control arm is administered to both control and intervention participants. By conducting this trial in public community centers, and by implementing a family-centered approach to sustainable healthy childhood growth, we aim to develop an exportable community-based intervention to address the expanding public health crisis of pediatric obesity.

The relationship between executive function and obesity in children and adolescents: a systematic literature review.

The objective of this paper is to examine the relationship between the development of executive function (EF) and obesity in children and adolescents. We reviewed 1,065 unique abstracts: 31 from PubMed, 87 from Google Scholar, 16 from Science Direct, and 931 from PsycINFO. Of those abstracts, 28 met inclusion criteria and were reviewed. From the articles reviewed, an additional 3 articles were added from article references (N = 31). Twenty-three studies pertained to EF (2 also studied the prefrontal and orbitofrontal cortices (OFCs); 6 also studied cognitive function), five studied the relationship between obesity and prefrontal and orbitofrontal cortices, and three evaluated cognitive function and obesity. Inhibitory control was most often studied in both childhood (76.9%) and adolescent (72.7%) studies, and obese children performed significantly worse (P < 0.05) than healthy weight controls on various tasks measuring this EF domain. Although 27.3% of adolescent studies measured mental flexibility, no childhood studies examined this EF domain. Adolescents with higher BMI had a strong association with neurostructural deficits evident in the OFC. Future research should be longitudinal and use a uniform method of EF measurement to better establish causality between EF and obesity and consequently direct future intervention strategies.

Culturally tailored, family-centered, behavioral obesity intervention for Latino-American preschool-aged children.

OBJECTIVE: To test the effect of a culturally tailored, family-centered, short-term behavioral intervention on BMI in Latino-American preschool-aged children. METHODS: In a randomized controlled trial, 54 parent-child dyads were allocated to the intervention and 52 dyads were allocated to an alternative school-readiness program as the control condition. Parent-child dyads were eligible if the parent self-defined Latino, was at least 18 years old, had a 2- to 6-year-old child not currently enrolled in another healthy lifestyle program, had a valid telephone number, and planned on remaining in the city for the next 6 months. The Salud Con La Familia (Health with the Family) program consisted of 12 weekly 90-minute skills-building sessions designed to improve family nutritional habits and increase physical activity. Both programs were conducted in a community recreation center serving an urban neighborhood of mostly Spanish-speaking residents. RESULTS: Forty-two percent of participating preschool-aged children were overweight or obese. Controlling for child age, gender, and baseline BMI, the effect of the treatment condition on postintervention absolute BMI was B = -0.59 (P < .001). The intervention effect seemed to be strongest for obese children. CONCLUSIONS: A skills-building, culturally tailored intervention involving parent-child dyads changed short-term early growth patterns in these Latino-American preschool-aged children. Examining long-term effects would be a prudent next step.

Systematic exposure to recreation centers increases use by Latino families with young children.

BACKGROUND: Living near community recreation centers (CRC) is associated with increases in adolescent and adult physical activity, but the efficacy of efforts to increase use among Latino parents and young children is unknown. We hypothesized that Latino parent-child dyads with exposure to a CRC through culturally tailored programming would be more likely to use the facility for physical activity a year after programming ended than dyads living in the same geographic area who were not exposed to the programming. METHODS: Self-identified Latino parent-child dyads who had participated in a randomized controlled trial (RCT) of a culturally tailored healthy lifestyle program and completed a 12-month follow-up assessment constituted the "exposed" group (n = 66). The "unexposed" group included 62 parent-child dyads living in the same zip codes as the exposed group, all within a 5-mile radius of the CRC. Participants completed in-person structured interviews. RESULTS: Approximately two-thirds of exposed parents reported more than monthly use of the CRC for themselves a year after programming ended, compared to one-third of unexposed Latino families with the same geographic access (χ(2) = 11.26, p < 0.01). Parents in the exposed group were four times more likely than the unexposed group to use the CRC with their children on a monthly basis (odds ratio = 4.18, p < 0.01). CONCLUSIONS: CRCs that develop culturally tailored programs that invite Latino families inside can increase sustained CRC use for physical activity in this population at heightened risk for childhood obesity.

Use of drugs known to cause fetal harm among women delivering infants in Haiti.

OBJECTIVE: To estimate the prevalence of use of fetal-harm drugs among women who received postpartum care in hospitals in Haiti and to identify groups of women at higher risk for potentially harmful medication exposures. METHODS: Women who received postpartum care in 2 large hospitals in Port-au-Prince, Haiti, from August 18 to December 1, 2008, were surveyed in Creole about their use of medications in pregnancy, including fetal-harm drugs. RESULTS: We surveyed 482 women who had a median age of 26 years. Approximately 75% reported using at least 1 medicine in pregnancy, with the most common being amoxicillin (n = 127), acetaminophen (n = 109), metronidazole (n = 79), and misoprostol (n = 38). More than 13% used fetal-harm drugs, including misoprostol and tetracycline. Unmarried women (adjusted relative risk [RR] 2.2; 95% confidence interval [CI], 1.0-4.7) and separated women (adjusted RR 4.6; CI, 1.8-11.9) were more likely than married women to report use of fetal-harm drugs. In addition, women with 4 or more children were more likely to report use of medications known to cause fetal harm (adjusted RR 4.3; CI, 1.9-9.9). CONCLUSION: Women who delivered infants in Haiti commonly report use of fetal-harm drugs. The public health implications of these findings are broad and relate to complex issues such as pregnancy planning and regulation of medications to prevent potentially harmful exposures.

Pediatric obesity community programs: barriers & facilitators toward sustainability.

Our current generation of young people could become the first generation to live shorter lives than their parents. Families need resources in their community to address this issue. Identifying barriers and facilitators of community organizations to offer obesity-related services is a first step in understanding sustainable community programs. The objective of this study is to identify common barriers and facilitators in community organizational programs designed to prevent or reduce pediatric obesity. We conducted an exploratory qualitative research study based on grounded theory. Thirty-six community organizations were identified based on self-descriptions of goals involving pediatric obesity. Semi-structured, systematic, face-to-face interviews among program directors (n = 24) were recorded, transcribed, and coded for recurrent themes. Relevant themes were abstracted from interviews by a standardized iterative process by two independent reviewers between December 2007 and November 2008. Theme discordance was reconciled by a third reviewer. Seventy percent of organizations indicated that obesity prevention/treatment was their explicit goal with remaining groups indicating healthy lifestyles as a more general goal. Facilitators to provision of these programs included: programmatic enhancements such as improved curriculums (73%), community involvement such as volunteers (62.5%), and partnerships with other programs (54.2%). Barriers that threatened sustainability included lack of consistent funding (43.8%), lack of consistent participation from the target population (41.7%) and lack of support staff (20.8%). New approaches in fostering partnerships between organizations need to be developed. Building coalitions and engaging community members in developing community based programs may be a helpful strategy to strengthen community-based programs to address the pediatric obesity epidemic.