Proportion and Correlates of Children in the US-Affiliated Pacific Region Meeting Sleep, Screen Time, and Physical Activity Guidelines.

INTRODUCTION: Limited data on 24-hour movement behaviors of children aged 5-8 years exist globally. We describe the prevalence and sociodemographic associations of meeting physical activity (PA), sedentary recreational screen time (ST), and sleep guidelines among children from 11 jurisdictions in the US-Affiliated Pacific region. METHODS: Cross-sectional representative data from 1192 children aged 5-8 years living in the US-Affiliated Pacific region were drawn from the baseline 2012-2014 Children's Healthy Living Program. Sleep and moderate- to vigorous-intensity PA were calculated from accelerometry. ST and sociodemographic data were collected from caregiver surveys. The percentage of children meeting the Asia-Pacific 24-hour movement guidelines for PA (≥60 min/d of moderate- to vigorous-intensity PA), sleep (≥9 and ≤ 11 h/d) and ST (≤2 h/d) were calculated. Generalized linear mixed models were used to examine associations with adiposity and sociodemographic variables. RESULTS: Twenty-seven percent (95% confidence interval, 24.6-30.0) of children met integrated guidelines; 98% (96.2-98.0) met PA, 78% (75.4-80.0) met sleep, and 35% (32.6-38.0) met ST guidelines. Females (adjusted odds ratio = 1.40 [95% confidence interval, 1.03-1.91]) and those living in lower-middle-income jurisdictions (2.29 [1.49-3.54]) were more likely to meet ST guidelines. Overweight children (0.62 [0.40-0.96]), those aged 8 years (0.39 [0.22-0.69]), and children with caregivers of an education level of high school or beyond (0.44 [0.29-0.68]) were less likely to achieve ST guidelines. Children from midrange annual household incomes were less likely to meet combined guidelines (0.60 [0.39-0.92]). CONCLUSIONS: Three-quarters of children are not meeting integrated Asia-Pacific 24-hour movement guidelines. Future strategies for reducing ST and increasing integrated guidelines compliance are needed.

Social determinants of health literacy among parents and caregivers in the US-Affiliated Pacific.

Health literacy is understudied in the US-Affiliated Pacific (USAP), where local populations have historically experienced social marginalization and disproportionate health inequities caused by the social determinants of health (SDOH). This cross-sectional study analyzed several SDOH indicators-acculturation, use of food assistance programs and demographic characteristics (race and ethnicity, household income, primary language spoken at home and educational attainment)-and their relationship to health literacy among 1305 parents/caregivers of young children ages 2-8 years old who participated in the Children's Healthy Living (CHL) program in Alaska, American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Guam, and Hawai'i. Significantly increased odds of low health literacy were found among parents/caregivers with households where a language other than English was the primary language compared to English-only households (OR = 1.86, 95% CI = 1.22, 2.82), household income of <$35 000 compared to ≥$35 000 (OR = 2.15, 95% CI = 1.13, 4.07), parents/caregivers of Asian children compared to parents/caregivers of White children (OR = 2.68, 95% CI = 1.05, 6.84), parent/caregivers with less than or some high school education compared to high school completion (1st- to 8th-grade OR = 4.46, 95% CI = 2.09, 9.52; 9th- to 11th-grade OR 1.87, 95% CI = 1.06, 3.30) and parent/caregivers with acculturation status defined as marginalized as compared to integrated (OR = 2.31, 95% CI = 1.09, 4.86). This study indicates that some USAP parents/caregivers may lack the capacity to acquire health information, utilize health resources, and navigate health decision making. Future efforts to understand and improve health literacy in the USAP should be population specific, thoroughly assess personal and organizational health literacy, and inventory community health care capacity.

Diet Quality of Young Children in the US-Affiliated Pacific's Children's Healthy Living (CHL) Program.

BACKGROUND: Childhood diet can impact health outcomes over the life course. Few studies have assessed dietary quality among infants and children in the US-Affiliated Pacific (USAP) region. OBJECTIVE: The aim of this study was to examine the differences in diet quality among Pacific children in the Children's Healthy Living (CHL) program by Pacific jurisdiction and by their World Bank Income Group (WBIG) level. DESIGN: This cross-sectional study used dietary records collected from 2012 to 2015. PARTICIPANTS/SETTING: Data were collected on 2- to 8-year-old children (n = 3,529) enrolled in the Children's Healthy Living Program for Remote Underserved Minority Populations in the Pacific region, conducted in the USAP jurisdictions of Alaska, Hawai'i, American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Guam, Federated States of Micronesia (FSM islands include Chuuk, Kosrae, Pohnpei, Yap), Republic of the Marshall Islands (RMI), and Republic of Palau. MAIN OUTCOME MEASURE: Diet quality was assessed using the Healthy Eating Index-2005 (HEI-2005). This HEI version was commensurate with the time of dietary data collection for the CHL project and previous studies, thus allowing cross-study comparisons. STATISTICAL ANALYSIS PERFORMED: Means of total HEI-2005 scores between jurisdictions and their WBIG level were compared using linear models, with and without adjustment for age, sex, and dietary energy. RESULTS: Differences in mean HEI-2005 scores among children were found between jurisdictions and their WBIG level. Alaska had the highest adjusted mean score (63.3). RMI had the lowest adjusted mean score (50.1). By WBIG, lower-middle income jurisdictions had the lowest adjusted mean HEI-2005 score (56.0), whereas high income jurisdictions had the highest adjusted mean HEI-2005 score (60.5). CONCLUSIONS: Variation in children's diet quality was found between USAP jurisdictions, notably between jurisdictions of different WBIG levels. Future research is needed to deepen understanding of these differences in diet quality by WBIG level, such as whether differences may be attributable to the jurisdictions' varying food systems, and possibly explained by the nutrition transition. Understanding childhood diet quality in this region can inform approaches for nutrition programs in the Pacific region.

Diet and Acanthosis Nigricans over a Two-Year Period in Children of the Pacific Region.

BACKGROUND: The impact that dietary carbohydrates have on children developing type 2 diabetes remains controversial. Furthermore, there are limited pediatric longitudinal studies on changes in body mass index (BMI) and diet related to the development of acanthosis nigricans (AN), a risk factor associated with type 2 diabetes. METHODS: Two 24 h dietary records were collected for 558 children, 2-8 years of age, at baseline and at a 2-year follow-up. Data on age, sex, BMI, and the presence of AN were also collected at each time point from the Children's Healthy Living Program. Logistic regression was used to determine factors associated with the presence of AN at follow-up. Multinominal regression was used to determine factors associated with changes in AN status. Linear regression was used to measure the associations between changes in dietary intake and in the Burke Score for AN. RESULTS: AN was present in 28 children at baseline and 34 children at follow-up. Adjusting for the presence of AN at baseline, age, sex, study group, baseline BMI, change in BMI z-score, time between assessments, and baseline intake, an increase from baseline for each teaspoon of sugar and serving of carbohydrate-rich food increased the risk for having AN at follow-up by 9% and 8%, respectively (p ≤ 0.05). An increased intake of added sugar (teaspoons) increased the risk of developing AN by 13% (p ≤ 0.01) and an increase in servings of foods rich in starch increased the risk of developing AN by 12% (p ≤ 0.01) compared to children who never had AN. Increasing the intake of fruit was also associated with decreased Burke Scores using multiple regression. However, the intake of energy and macronutrients were not associated with AN. CONCLUSIONS: Added sugar and foods rich in starch were independently associated with the occurrence of AN, suggesting the type of carbohydrates consumed is a factor in AN occurrence.

Children's Dietary Intake by Early Care and Education Setting in the US Affiliated Pacific.

OBJECTIVE: Examine differences in dietary intake of children aged 2-5 years in early care and education (ECE) setting in the US Affiliated Pacific (USAP). DESIGN: Secondary analysis of cross-sectional data collected by the Children's Healthy Living program. PARTICIPANTS: Children (n = 1,423) with complete dietary records and information on the ECE setting. MAIN OUTCOME MEASURES: Dietary intake by ECE setting; Head Start (HS), other ECE (OE), and no ECE. ANALYSIS: Comparison of mean dietary intake across ECE settings and multivariate logistic regression to evaluate ECE setting and likelihood for meeting dietary reference intake (DRI). RESULTS: Children in HS and OE settings had a significantly higher intake of several food groups and nutrients, compared with no ECE; vegetables (0.4 cup-equivalents per thousand kcals [CETK] vs 0.3 CETK; P < 0.001), fruits (0.8 CETK vs 0.6 CETK; P = 0.001), milk (0.9 CETK for HS and 1.0 CETK for OE vs 0.8 CETK; P < 0.001). Sixty-five percent of the HS group met DRI and had greater odds of meeting calcium DRI (odds ratio, 1.8; 95% confidence interval, 1.2-2.7) compared with other groups. The OE group had the lowest proportion of children meeting recommended intakes for 19 out of 25 nutrients. CONCLUSIONS AND IMPLICATIONS: Mean intakes of foods and nutrients for children across the USAP meet some, but not all, recommendations and intakes vary across children attending various ECE setting types. Additional research on the clinical importance of these differences and the impact of the complex food systems in the USAP may identify systematic strategies for improving diet among children.

Food Security is Associated with Higher Diet Quality Among Children of the US-Affiliated Pacific Region.

BACKGROUND: The prevalence of food insecurity and its relationship to diet quality are factors impacting the health of persons living across the United States-affiliated Pacific region (USAP). OBJECTIVES: The aim of this study was to describe characterize the relationship between household food security status and diet quality of 2- to 8-y-old children across jurisdictions in the USAP. METHODS: Baseline data from 2- to 8-y-olds (n = 3099) enrolled in the Children's Healthy Living Program for Remote Underserved Minority Populations in the Pacific region, an obesity prevention study conducted in communities across Alaska, American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Guam, and Hawaii, and a concomitant prevalence study in communities across the Freely Associated States (FAS) (the Federated States of Micronesia: Kosrae, Pohnpei, Chuuk, Yap; Republic of Marshall Islands; Republic of Palau) were collected in 2012. Caregivers self-reported sociodemographic data and food insecurity. Assisted by their caregiver, children completed two dietary records on nonconsecutive, randomly assigned days. The Healthy Eating Index 2005 (HEI-2005) was used to assess the diet quality. Data were summarized overall and by jurisdiction. Differences in HEI-2005 and HEI component scores among jurisdictions and by household food security status were tested using 1-factor ANOVA. RESULTS: Half or more of participants from American Samoa, Guam, CNMI, and FAS reported household food insecurity (n = 295, 59.7%; n = 292, 49.9%; n = 267, 54.6%; n = 572, 69.0%, respectively). HEI-2005 scores varied by jurisdiction (P < 0.001) and were significantly lower among FAS participants (54.7 ± 1.2) than among all other jurisdictions (P < 0.05). Total diet quality scores did not differ by food security status (59.9 ± 0.8 food secure compared with 58.3 ± 1.1 food insecure, P = 0.07); however, most diet quality adequacy component scores were significantly higher and moderation component scores significantly lower among participants in food secure households than those in food insecure households. CONCLUSIONS: Significant differences in children's diet quality and household food security existed across USAP jurisdictions.

Food and Physical Activity Environment in the US-Affiliated Pacific Region: The Children's Healthy Living Program.

OBJECTIVE: To describe the quality of food and physical activity (PA) environments by World Bank Income level in jurisdictions from the Children's Healthy Living Program. DESIGN: Baseline cross-sectional community data were analyzed from 11 jurisdictions categorized by World Bank Income levels to describe exposure to different food and PA outlets. The Children's Healthy Living Program was a multilevel, multijurisdictional prevalence study and community intervention trial that reduced child obesity in the US-Affiliated Pacific region. SETTING: US-Affiliated Pacific region. PARTICIPANTS: Food (n = 426) and PA (n = 552) Outlets. MAIN OUTCOME MEASURES: Physical activity and food scores that reflect the quality of the outlets that support being physically active and healthy eating options, respectively. ANALYSIS: Descriptive statistics are presented as means ± SD or percentages. RESULTS: High-income-income level jurisdictions had higher food and PA scores than middle-income level jurisdictions. CONCLUSIONS AND IMPLICATIONS: The US-Affiliated Pacific region has limited quality food and PA outlets in underserved communities at risk for obesity. The findings in this paper can be used to develop tools and design interventions to improve the food and PA environment to increase a healthier, active lifestyle.

Food Group, Macronutrient Intake, and Metabolic Status in the US-Affiliated Pacific's Children's Healthy Living (CHL) Program.

BACKGROUND: The Children's Healthy Living study provided dietary intake information for understudied Native Hawaiian and Other Pacific Islander (NHOPI) young children. OBJECTIVES: Our objective was to describe food group and macronutrient intakes of NHOPI children in the US-Affiliated Pacific region (USAP), overall and by jurisdiction, income level, and metabolic status. METHODS: We evaluated 2-8-y-olds (n = 3520) in a cross-sectional cluster sampled study using 2 d of dietary records completed by caregivers using provided tools, quantified by a specially developed food composition table and compared with US dietary recommendations. Overweight and obesity (OWOB) and acanthosis nigricans (AN) assessment (metabolic status) was completed by trained evaluators using standard tools. Demographic data were collected by questionnaire. Regression analysis identified differences in dietary component means by jurisdiction, World Bank income groups (WBIGs), and metabolic status, adjusted for age and sex. RESULTS: Few children met US recommendations for vegetable (2.4%) and milk (4.1%) food groups. US macronutrient recommendations were generally met. Food group and macronutrient intakes were significantly different by jurisdiction and WBIG. Means for food groups, except meats, and macronutrients, except protein, were higher in overweight/obese (OWOB) compared with healthy-weight children. Grain intake of 7.25 (SE: 0.08) oz was higher (P < 0.05) and milk intake of 0.90 (SE: 0.05) cups was lower (P < 0.05) in children with OWOB compared with those without OWOB [grains: 7.17 (SE: 0.07) oz; and milk: 0.96 (SE: 0.04) cups]. Monounsaturated fat intake of 11.68 (SE: 0.10) % energy was higher in those with OWOB, compared with healthy-weight children [11.56 (SE: 0.08) % energy, P < 0.05]. CONCLUSIONS: Young children's diets in the USAP did not meet milk, vegetable, or fruit intake recommendations. There was variability in dietary patterns across the USAP and by WBIG. Grain intake and monounsaturated fat intake were lower and milk intake was higher in children with better metabolic status.

Maintenance Outcomes of the Children's Healthy Living Program on Overweight, Obesity, and Acanthosis Nigricans Among Young Children in the US-Affiliated Pacific Region: A Randomized Clinical Trial.

Importance: Few obesity prevention trials among children have demonstrated sustainable outcomes in the long term. Objectives: To sustain a community-wide decrease in the prevalence of overweight and obesity among young children in the US-affiliated Pacific region. Design, Setting, and Participants: In the Children's Healthy Living community-randomized clinical trial, hierarchical modeling comparing the change in intervention and control communities accounted for community randomization (community clustering with jurisdictions), and adjusted for the age and sex distribution of the assessed children in a cross-sectional design. The outcome measures were repeated in communities rather than among individual children. A total of 27 communities in 5 jurisdictions (Hawai'i, Alaska, Commonwealth of the Northern Mariana Islands, American Samoa, and Guam) of the US-affiliated Pacific region were included. Participants included children aged 2 to 8 years in the 27 selected communities from October 1, 2012 (4329 in time 1 [baseline]) to August 31, 2015 (4043 in time 2 [intervention end]) and from January 1, 2019, to April 30, 2020 (1469 in time 3 [maintenance period]). Study analysis was completed March 25, 2022. Interventions: Nineteen activities addressed training, policies, systems, and environments of communities and 6 target behaviors of children (consumption of fruit and vegetables, water, and sugar-sweetened beverages; sleep; physical activity; and screen time) during a 2-year intervention period. Continued partnership with community coalitions, ongoing academic training of community partners, and use of trial data during a 6-year maintenance period. Main Outcomes and Measures: The primary outcome was measured anthropometry; secondary outcomes were the presence of acanthosis nigricans, dietary intake derived from 2 days of food records, and survey questions on screen time and sleep disturbance. Results: Among the 9840 children included in the analysis (4866 girls [49.5%] and 4974 boys [50.5%]; 6334 [64.4%] aged 2-5 years), the intervention group showed significant improvements compared with the control group from times 1 to 3 in prevalence of overweight plus obesity (d = -12.60% [95% CI, -20.92% to -4.28%]), waist circumference (d = -1.64 [95% CI, -2.87 to -0.41] cm), and acanthosis nigricans prevalence (d = -3.55% [95% CI, -6.17% to -0.92%]). Significant improvements were also observed from times 2 to 3 in prevalence of overweight plus obesity (d = -8.73% [95% CI, -15.86% to -1.60%]) but not in waist circumference (d = -0.81 [95% CI, -1.85 to 0.23] cm). Conclusions and Relevance: This randomized clinical trial found that the outcomes of the Children's Healthy Living intervention were maintained and enhanced 6 years after the intervention among young children in the US-affiliated Pacific region. The prevalence of overweight, obesity, and acanthosis nigricans was further reduced in communities, suggesting that multilevel multicomponent interventions may help reduce child overweight and obesity in this region. Trial Registration: ClinicalTrials.gov Identifier: NCT01881373.