Protocol for the Rhode Island CORD 3.0 Study: Adapting, Testing, and Packaging the JOIN for ME Family-Based Childhood Obesity Program in Low-Income Communities.

Background: Overweight and obesity in children is a public health crisis in the United States. Although evidence-based interventions have been developed, such programs are difficult to access. Dissemination of evidence-based pediatric weight management interventions (PWMIs) to families from diverse low-income communities is the primary objective of the CDC Childhood Obesity Research Demonstration (CORD) projects. Methods: The goal of the Rhode Island CORD 3.0 project is to adapt the evidence-based PWMI, JOIN for ME, for delivery among diverse families from low-income backgrounds and to test it in a hybrid effectiveness-implementation trial design in which the aims are to examine implementation and patient-centered outcomes. Children between the ages of 6 and 12 years with BMI ≥85th percentile and a caregiver will be recruited through two settings, a federally qualified health center, which serves as a patient-centered medical home, or low-income housing. Dyads will receive a remotely delivered group-based intervention that is 10 months in duration and includes 16 weekly sessions, followed by 4 biweekly and 4 monthly meetings. Assessments of child and caregiver weight status and child health-related quality of life will be conducted at baseline, and at 4 and 10 months after the start of intervention. Implementation outcomes assessing intervention acceptability, adoption, feasibility, fidelity, and penetration/reach will be collected to inform subsequent dissemination. Conclusions: If the adapted version of the JOIN for ME intervention can be successfully implemented and is shown to be effective, this project will provide a model for a scalable PWMI for families from low-income backgrounds. ClinicalTrials.gov no. NCT04647760.

Processed and Packed: How Refined Are the Foods That Children Bring to School for Snack and Lunch?

BACKGROUND: Increasing consumption of highly processed foods has been associated with adverse health outcomes among children. In the US, children consume up to half of their daily energy intake at school. OBJECTIVES: We sought to characterize foods that children bring from home to school according to processing level and to evaluate the effectiveness of a school-based intervention, Great Taste Less Waste (GTLW), in reducing the proportion of energy brought from highly processed foods from home compared with control. DESIGN: Secondary data analysis of a 7-month school-based, cluster-randomized trial. PARTICIPANTS/SETTING: Third- and fourth-grade students (n = 502, mean age: 9.0 ± 0.62 years) at 10 public elementary schools in Eastern Massachusetts (school year 2012-2013). INTERVENTION: GTLW included a 22-lesson classroom curriculum, homework activities, monthly parent newsletters, a food shopping and packing guide for parents, food demonstrations, school-wide announcements, and a poster contest. MAIN OUTCOME MEASURES: The energy content of foods brought to school was estimated from digital photographs, and foods were assigned to 1 of 3 processing levels (less processed or unprocessed, moderately processed, or highly processed) based on an established classification system. STATISTICAL ANALYSES PERFORMED: The percentage of energy brought from foods categorized into each processing level was calculated and compared pre- and postintervention using hierarchical linear models. RESULTS: Most of the food brought from home to school was highly processed (70% of food energy brought). Foods categorized as snack foods and desserts contributed the greatest percentage of total energy to the highly processed category at baseline and follow-up (72% and 69%, respectively). Energy from foods brought for snack tended to be more highly processed than those brought for lunch. No significant differences were observed from pre- to postintervention in the GTLW group compared with control for the percentage of energy brought from highly processed foods in adjusted models (ß: -1.1, standard error: 2.2, P = .6) or any other processing level. CONCLUSIONS: Highly processed foods were prevalent in home-packed lunches and snacks, and these patterns persisted after a targeted intervention. Further research is needed to identify strategies to improve the healthfulness of foods brought from home to school.

A qualitative exploration of potential determinants of accelerated summer weight gain among school-age children: perspectives from parents.

BACKGROUND: There is growing evidence that school children in the United States gain weight more rapidly during the summer than the school year, but few studies have explored the causes of this phenomenon. The goal of this study was to qualitatively explore potential determinants of accelerated summer weight gain by interviewing parents of school-age children. METHODS: Key informant interviews were conducted with parents of third and fourth grade students enrolled in a school-based physical activity intervention in three peri-urban communities in Eastern Massachusetts. A structured interview guide was developed to assess school year and summertime differences in child diet, physical activity, daily routine, and family rules. Interviews were recorded and transcribed verbatim. Transcripts were coded and major themes were identified using thematic analysis. RESULTS: Summer activities varied substantially by family. Many parents characterized summer as a time with less structure and more relaxed rules, particularly around bedtime and screen use. Parents perceived their child to be more physically active in the summer and reported few barriers to summertime physical activity. Parents reported increases in both positive (increased consumption of fruits and vegetables) and negative (increased consumption of "sweets" and "junk foods") dietary behaviors. They highlighted several stressors unique to summer, such as the high cost of camps and the need to coordinate childcare and manage children's time. CONCLUSIONS: Parents perceived their children to be more physically active in the summer and consume more fruits and vegetables than during the school year. However, they also perceived children to consume more energy-dense, nutrient poor foods, engage in more screen time, and have later bedtimes during the summer. These behaviors are important targets for summertime obesity prevention interventions. Large-scale quantitative studies are needed to determine whether these parent perceptions reflect meaningful risk factors for accelerated summer weight gain.

Accelerated Summer Weight Gain in a Low-Income, Ethnically Diverse Sample of Elementary School Children in Massachusetts.

Background: Several studies have found that children in the United States gain weight at a faster rate in the summer than in the school year, but little is known about the prevalence of this problem, its effect on high-risk subgroups, or its determinants. This study compares school year and summer weight change in a low-income, ethnically diverse sample of school-age children in Massachusetts and explores differences by race/ethnicity, weight status, and exposure to school year physical activity (PA) programming. Diet and PA are examined as potential mediators of summer weight gain. Methods: Children participating in a school-based PA program evaluation (in which weight change was not a primary outcome) had their height and weight measured three times between October 2015 and September 2016 to capture a school year and summer interval. Diet and PA patterns were assessed mid-school year and mid-summer in a subsample of children. Mixed linear models were used to estimate the effect of season (school year vs. summer) on change in BMI and to examine the influence of race/ethnicity, weight status, and program (walk/run, classroom activity breaks, or control) on any observed effects. Structural equation models were used to explore diet and PA as mediators of seasonal weight change in a subsample of participants. Results: Of 769 participants, 53% were non-Caucasian, 40% were overweight or obese, and 58% were eligible for free or reduced-price school meals. BMI increased in both the school year and summer but increased more rapidly in the summer (0.046 kg/m2 more per month, p = 0.007). Of the three tested interactions, statistical significance was only observed between season and program (χ2 = 14.90, p < 0.001); on average, children exposed to a school year walk/run program did not gain weight more rapidly during the summer, whereas children in the control group and a classroom activity breaks program did. Poorer diet and PA patterns were observed in the summer, but neither diet nor PA was statistically significant mediators of BMI change. Conclusions: Children in this high-risk sample gained weight at a faster rate during the summer than during the school year, with no discernable demographic differences. However, this phenomenon was not observed in the subgroup exposed to a school year walk/run program. More research is needed to clarify the determinants of summer weight gain and understand how school year programming and its effects can be transferred to the summer months.

The State of the Summer: a Review of Child Summer Weight Gain and Efforts to Prevent It.

PURPOSE OF REVIEW: Accumulating evidence shows that children in the USA gain weight more rapidly during the summer, when school is not in session. This narrative review spanning 2007 to 2017 summarizes efforts to characterize the problem, identify key determinants, and intervene to prevent excess summer weight gain. RECENT FINDINGS: Summer weight gain remains a concern for elementary-age youth. Few studies have examined its determinants, but unfavorable summertime shifts in diet, physical activity, sedentary time, screen media use, and sleep have been reported. Increased structure is thought to protect against summer weight gain. Interventions to support physical activity and nutrition during the summer show promise, though large-scale impact on weight outcomes remains to be seen. Supporting health behaviors during the summer remains a priority for obesity prevention researchers, practitioners, and policymakers. Strategies to expand access to structured programs and reach beyond such programs to improve behaviors at home are of particular importance.

Branding a School-Based Campaign Combining Healthy Eating and Eco-friendliness.

OBJECTIVE: To develop a branding strategy for a campaign to improve the quality of foods children bring from home to school, using a combined healthy eating and eco-friendly approach and for a control campaign focusing solely on nutrition. METHODS: Formative research was conducted with third- and fourth-grade students in lower- and middle-income schools in Greater Boston and their parents. Phase I included concept development focus groups. Phase II included concept testing focus groups. A thematic analysis approach was used to identify key themes. RESULTS: In phase I, the combined nutrition and eco-friendly messages resonated; child preference emerged as a key factor affecting food from home. In phase II, key themes included fun with food and an element of mystery. Themes were translated into a concept featuring food face characters. CONCLUSIONS AND IMPLICATIONS: Iterative formative research provided information necessary to create a brand that appealed to a specified target audience.

Comparative Study of a New Dietary Screener to Assess Food Groups of Concern in Children.

BACKGROUND: Although there are several valid and reliable dietary screeners to measure child intake patterns, there is a paucity of brief assessment tools targeting under- and overconsumed foods. OBJECTIVE: To compare the Fueling Learning through Exercise study (FLEX) dietary questionnaire, a screener designed to assess consumption patterns in third to fifth graders, to a validated dietary assessment tool. METHODS: The FLEX dietary questionnaire was developed to assess fruit, vegetable, snack, and beverage consumption and was compared to the Block Kids Food Screener (BKFS). Correlations were analyzed using Pearson correlation coefficient. Agreement was assessed using Bland-Altman plots. RESULTS: The sample (n = 63) had mean age of 9.9 years (SD 0.7). Most participants were non-Hispanic white (70%) and eligible for free/reduced price lunch (57%). Correlations between food group categories were significant for all groups ( P < .05) except fruits ( r = 0.51) and sugar-sweetened beverages (SSBs) ( r = 0.21). We found moderate-to-strong correlations between reported vegetable, salty snack, sweet snack, total beverage, milk, and fruit juice consumption (0.62, 0.59, 0.69, 0.47, 0.48, and 0.46, respectively). The FLEX screener reported systematically higher mean servings per day (0.24-1.1) compared to the BKFS (0.05-0.51). CONCLUSION: Based on these correlations, the FLEX dietary questionnaire performs similarly to a validated tool in assessing intake of under- and overconsumed food groups in a diverse third to fifth grade population. Overall serving size discrepancies are likely due to more relevant food items on the FLEX questionnaire and a more child-friendly format. This study highlights the need to update older diet screeners to reflect current child consumption patterns.

Great Taste, Less Waste: a cluster-randomized trial using a communications campaign to improve the quality of foods brought from home to school by elementary school children.

OBJECTIVE: Great Taste, Less Waste (GTLW), a communications campaign, capitalized on the synergy between healthy eating and eco-friendly behaviors to motivate children to bring more fruits and vegetables and fewer sugar-sweetened beverages (SSBs) to school. METHODS: A cluster-randomized trial in Eastern Massachusetts elementary schools in 2011-2012 tested the hypothesis that GTLW would improve the quality of foods from home more than a nutrition-only campaign--Foods 2 Choose (F2C)--or control. Lunch and snack items from home were measured at baseline and 7 months later using digital photography. Mixed linear models compared change in mean servings of fruits, vegetables, and SSBs among groups, and change in mean prevalence of packaging type. Change in prevalence of food items of interest was compared among groups using generalized linear models. RESULTS: Five hundred and eighty-two third and fourth graders from 82 classrooms in 12 schools participated. At follow-up, no significant differences were observed between groups in change in mean servings or change in prevalence of items of interest. No packaging differences were observed. CONCLUSION: GTLW was well received, but no significant changes were observed in the quality of food brought to school. Whether classrooms are an effective environment for change remains to be explored. ClinicalTrials.gov identifier: NCT0157384.