Cross-Cultural Adaptation and Initial Validation of Mi Niño: A Tool to Measure Food-Related Parenting Practices of Spanish-Speaking Parents with Young Children.

Background: Accurate measurement of food-related parenting practices is necessary to inform related interventions and program evaluation. Valid tools reflect cultural attributes that affect household food environments and feeding practices. Simple, unidirectional language adaptation approaches are insufficient to capture these attributes in assessment tools. My Child at Mealtime (MCMT) is a 27-item, validated, visually enhanced self-assessment tool to measure food-related parenting practices of low-income English-speaking parents of preschoolers. Objectives: The aim of this study was to describe the cross-cultural adaptation of MCMT into its Spanish version Mi Niño a la Hora the Comer (Mi Niño) and to establish its face validity, factor structure, and internal consistency. Methods: MCMT was adapted into its Spanish version after an iterative process that triangulated cognitive interviews with verification of conceptual equivalence by content experts to establish face validity and semantic equivalence. The resulting tool underwent confirmatory factor analysis to determine whether internal consistency was equivalent across the 2 versions. Results: Four rounds of cognitive interviews (n = 5, n = 6, n = 2, and n = 4, respectively) with Spanish-speaking women caregivers of children aged 3-5 y recruited from Head Start were conducted. Ten items were modified throughout the adaptation process. Modifications included improved clarity (6 items), comprehension (7 items), appropriateness (4 items), suitability (4 items), and usefulness (2 items) of text and/or accompanying visuals. Confirmatory factor analysis with a sample of Spanish-speaking caregivers (n = 243) resulted in 2 reliable factors representing "child-centered" (α = 0.82) and "parent-centered" (α = 0.87) food-related parenting practices. Conclusions: Face validity, semantic equivalence, and internal consistency of Mi Niño were established. This tool can be used in community settings to inform program content and measure changes in food-related parenting practices of Spanish-speaking parents and assist in setting food-related parenting goals. The next steps include exploring the correspondence of Mi Nino with mealtime behaviors observed through video recording.

Obesity Risk Assessment for Spanish-Speaking Immigrant Families with Young Children in the United States: Reliability and Validity with Nutrient Values.

The purpose is to examine validity and reliability for an obesity risk assessment tool developed in Spanish for immigrant families with children, 3-5 years old using an 8-week cross-sectional design with data collected over 1 year at Head Start and Special Supplemental Nutrition Program for Women, Infants and Children [WIC]. Parent/child dyads (206) provided a child obesity risk assessment, three child modified 24 h dietary recalls, three child 36+ h activity logs and one parent food behavior checklist. Main outcome measures were convergent validity with nutrients, cup equivalents, and diet quality and three assessments of reliability that included item difficulty index, item discrimination index, and coefficient of variation. Validity was demonstrated for assessment tool, named Niños Sanos. Scales were significantly related to variables in direction hypothesized [p ≤ 0.05]: Healthy Eating Index, fruit/vegetable cup equivalents, folate, dairy cup equivalents, vitamins D, ß-carotene, fiber, saturated fat, sugar, time at screen/ sleep/physical activity and parent behaviors. Three measures of reliability were acceptable. The addition of nutrient values as an analytical validation approach adds strength and consistency to previously reported Niños Sanos validation results using children's blood biomarkers and body mass index. This tool can be used by health professionals as an assessment of obesity risk in several capacities: (1) screener for counseling in a clinic, (2) large survey, (3) guide for participant goal setting and tailoring interventions, and (4) evaluation.

Feasibility of Colocating a Nutrition Education Program into a Medical Clinic Setting to Facilitate Pediatric Obesity Prevention.

PURPOSE: Within a medical clinic environment, pediatric obesity prevention education for families faces challenges. Existing long-term government-funded nutrition education programs have the expertise and staff to deliver. The purpose is to determine feasibility of colocating the Expanded Food and Nutrition Education Program (EFNEP) into a medical clinic setting to support pediatric obesity prevention. METHODS: Physicians from a large university teaching and research hospital (n = 73) and 4 small Medicaid-serving community clinics (n = 18) in the same geographic area in northern California were recruited and trained in the patient-referral protocol for a primary prevention intervention provided by EFNEP. The 8-week intervention deployed in the medical clinics, included general nutrition, physical activity and parenting topics anchored with guided goal setting and motivational modeling. Referral, enrollment, and attendance data were collected for 2 years. Parent and physician feasibility surveys, parent interviews and parent risk assessment tools were administered. Paired-sample t-test analysis was conducted. RESULTS: Twenty intervention series with parents of patients (n = 106) were conducted at 5 clinics. Physicians (n = 92) generated 686 referrals. Every 6 referrals generated 1 enrolled parent. Physicians (91%, n = 34) reported the intervention as useful to families. Parents (n = 82) reported improved child behaviors for sleep, screen time, physical activity, and food and beverage offerings (P < .0001) and at family mealtime (P < .001). Focus group interviews (n = 26) with 65 participants indicated that parents (97%) reacted positively to participating in the intervention with about a third indicating the classes were relevant to their needs. CONCLUSION: The intervention is a feasible strategy for the 5 medical clinics. Physicians referred and parents enrolled in the intervention with both physicians and parents indicating positive benefits. Feasibility is contingent upon physician awareness of the intervention and motivation to refer patients and additional EFNEP and clinic staff time to enroll and keep parents engaged.

Obesity Risk Assessment Tool for Low-Income Spanish Speaking Immigrant Parents with Young Children: Validity with BMI and Biomarkers of Obesity.

Children of Hispanic origin bear a high risk of obesity. Child weight gain trajectories are influenced by the family environment, including parent feeding practices. Excessive body fat can result in unhealthful metabolic and lipid profiles and increased risk of metabolic diseases. The objective was to estimate criterion validity of an obesity risk assessment tool targeting Spanish-speaking families of Mexican origin using anthropometric measures and blood values of their young children. A cross-sectional study design with five data collection sessions was conducted over an eight-week period and involved 206 parent/child dyads recruited at Head Start and the Special Supplemental Nutrition Program for Women, Infants and Children in Northern California. Main outcome measures were criterion validity of Niños Sanos, a pediatric obesity risk assessment tool, using anthropometric measures and blood biomarkers. Niños Sanos scores were inversely related to child BMI-for-age percentiles (p = 0.02), waist-for-height ratios (p = 0.05) and inversely related to blood biomarkers for the metabolic index (p = 0.03) and lipid index (p = 0.05) and positively related to anti-inflammatory index (p = 0.047). Overall, children with higher Niños Sanos scores had more healthful lipid, metabolic and inflammatory profiles, as well as lower BMI-for-age percentiles and waist-to height ratios, providing evidence for the criterion validity of the tool. Niños Sanos can be used by child obesity researchers, by counselors and medical professionals during clinic visits as a screening tool and by educators as a tool to set goals for behavior change.

Obesity Risk Assessment Tool among 3-5 Year Olds: Validation with Biomarkers of Low-Grade Chronic Inflammation.

Background: Many families with young children practice nutrition, parenting, and lifestyle behaviors that set their children on trajectories for unhealthful weight gain. Potential adverse health effects of excessive body fat can result in the secretion of proinflammatory molecules and increased risk of inflammation and metabolic diseases. A pediatric obesity risk assessment tool named Healthy Kids (HK), demonstrated validity in a longitudinal study with child's measured BMI and 36-hour diet, screen, sleep, and activity logs. Our objective was to provide additional evidence of validity with low-income families with literacy issues using an inflammation index composed of four proinflammatory biomarkers. Methods: Parent/child pairs (n = 104) from Head Start and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provided HK, blood samples, and measured heights/weights. Select child inflammatory markers were discretized into two groups of HK scores. Data were analyzed with a mixed model adjusted for children's age and BMI. Results: A significant HK-time interaction effect was shown for the child inflammation index with two data collection points 1 year apart (pdid = 0.039). This index increased over 12 months in children with less healthful behaviors (p = 0.007), but not in children with more healthful profiles (p = 0.58). Conclusions: Children with less healthful HK scores had an elevated inflammation index indicating a low-grade chronic systemic inflammatory state. Taken together with our previously published findings, the HK tool has potential as a rapid and easy-to-administer assessment of the family environment and the child's obesity risk. HK can be useful for federal nutrition programs for evaluation, risk assessment, goal setting, and/or program planning in clinical and community environments.

Parent Food-Related Behaviors and Family-Based Dietary and Activity Environments: Associations with BMI z-Scores in Low-Income Preschoolers.

Background: In early childhood, the family dietary and activity environment and parent food-related practices have been found to be important predictors of children's weight. However, few studies account for both of these factors, or the interaction between the 2, when assessing BMI in early childhood. This study aims to examine the association between the family-based dietary and activity environment (including intake, physical activity, and structure) and children's BMI z-scores in the context of parent food-related behaviors in low-income families during the preschool years. Methods: Parents (n = 111) completed questionnaires assessing the family-based dietary and activity environment, including diet, physical activity, screentime and sleep, and their use of parent food-related behaviors including parent-centered (i.e., controlling) and child-centered (i.e., autonomy supportive) practices. Children's BMI z-scores were calculated from researcher-measured height and weight. Results: Parent-centered food-related behaviors were directly related to children's BMI z-scores and moderated the association between the family-based dietary and activity environment and children's BMI z-scores. Family-based behaviors were associated with lower BMI only when parents used fewer parent-centered behaviors. Conclusions: Findings indicate that programs working with low-income families to prevent child obesity should stress both the creation of a healthy home environment and the use of positive parent food-related behaviors with preschool aged children.

My Child at mealtime parent self-assessment of food related behaviors: Validation with mealtime behaviors.

My Child at Mealtime (MCMT) is a visually enhanced, self-assessment tool designed to measure parent food related behaviors of low-income caregivers of preschool-aged children. The current study examined the factor structure of MCMT and the correspondence between MCMT parent- and child-centered food related behaviors with observed behaviors during a mealtime with their preschool aged child. Caregivers (N = 175) completed MCMT, and a subsample (n = 60) had a mealtime videotaped in their home. Exploratory and confirmatory factor analysis supported a two-factor structure resulting in parent-centered and child-centered MCMT subscales. There was a significant association between parent-centered MCMT scores and observed parent-centered behaviors at mealtime. Behavioral correspondence of MCMT child-centered behaviors was generally weaker. Overall, the findings suggest that caregivers' MCMT responses provide a valid measure of parent food related behaviors.

An Obesity Risk Assessment Tool for Young Children: Validity With BMI and Nutrient Values.

OBJECTIVE: Demonstrate validity and reliability for an obesity risk assessment tool for young children targeting families' modifiable home environments. DESIGN: Longitudinal design with data collected over 100 weeks. SETTING: Head Start and the Special Supplemental Nutrition Program for Women, Infants, and Children. PARTICIPANTS: Parent-child pairs (n = 133) provided food behavior assessments; 3 child-modified, 24-hour dietary recalls; 3 ≥ 36-hour activity logs; and measured heights and weights. MAIN OUTCOME MEASURE: Five measures of validity and 5 of reliability. RESULTS: Validity was excellent for the assessment tool, named Healthy Kids, demonstrating an inverse relationship with child body mass index percentile-for-age (P = .02). Scales were significantly related to hypothesized variables (P ≤ .05): fruit or vegetable cup equivalents; folate; vitamins A, C, and D; ß-carotene; calcium; fiber; sugar; screen, sleep, and physical activity minutes; and parent behaviors. Measures of reliability were acceptable. CONCLUSIONS AND IMPLICATIONS: Overall, children with higher Healthy Kids scores had a more healthful profile as well as lower body mass index percentiles-for-age 1.5 years later. Healthy Kids has potential for use by nutrition professionals as a screening tool to identify young children most at risk for excess weight gain, as an evaluation to assess intervention impact, and as a counseling tool to tailor intervention efforts. Future research should include validation in other settings and with other populations.

Vegetable behavioral tool demonstrates validity with MyPlate vegetable cups and carotenoid and inflammatory biomarkers.

Young children are not meeting recommendations for vegetable intake. Our objective is to provide evidence of validity and reliability for a pictorial vegetable behavioral assessment for use by federally funded community nutrition programs. Parent/child pairs (n=133) from Head Start and the Special Supplemental Nutrition Program for Women, Infants and Children [WIC] provided parent-administered vegetable tools, three child 24-hour diet recalls, child blood sample and measured heights/weights. The 10-item Focus on Veggies scale, with an alpha of .83 and a stability reliability coefficient of .74, was positively related to vegetables in cup equivalents [p≤.05]; dietary intakes of folate, vitamin C, ß-carotene, potassium and magnesium [p≤.05-.01]; and soluble fiber [p≤.001]. The child vegetable scores were related to the parent's mediators [p≤.00001] and vegetable behaviors [p≤.00001]. Children's plasma inflammatory markers were negatively related to the 10 item scale [p≤.05] and are indicators of the child's health status. The positive relationship between the serum carotenoid index and a sub-scale of child vegetable behaviors offered additional support for criterion validity [p≤.05]. Finally, the inverse relationship of BMI-for-age percentile one year post baseline and a sub-scale of child vegetable behaviors supported the predictive validity [p≤.05]. Focus on Veggies, a simple assessment tool, can inform practitioners about the child's health status. A child with a high score, shows a healthful profile with a lower inflammation index, higher carotenoid index, lower BMI and higher vegetable intake. In conclusion, validity of Focus on Veggies has been demonstrated using vegetable cup equivalents and micronutrient intakes, anthropometry and blood biomarkers.

My child at mealtime: A visually enhanced self-assessment of feeding styles for low-income parents of preschoolers.

The importance of caregiver feeding styles on children's dietary outcomes is well documented. However, the instruments used to assess feeding style are limited by high literacy demands, making selfassessment with low-income audiences challenging. The purpose of the current study is to report on the development of My Child at Mealtime (MCMT), a self-assessment tool with reduced literacy demands, designed to measure feeding styles with parents of preschool-aged children. Cognitive interviews were conducted with 44 Head Start parents of 2-5 year old children to develop question wording and identify appropriate visuals. The resulting tool was administered to 119 ethnically diverse, low-income parents of 2-5 year old children. Factor analysis resulted in a two-factor structure that reflects responsiveness and demandingness in a manner consistent with existing assessment tools. Results indicate the final visually enhanced MCMT self-assessment tool provides a measure of parenting style consistent with existing measures, while reducing the literacy demand.

Misreporting of dietary intake affects estimated nutrient intakes in low-income Spanish-speaking women.

Misreporting of dietary intake affects the validity of data collected and conclusions drawn in studies exploring diet and health outcomes. One consequence of misreporting is biological implausibility. Little is known regarding how accounting for biological implausibility of reported intake affects nutrient intake estimates in Hispanics, a rapidly growing demographic in the United States. Our study explores the effect of accounting for plausibility on nutrient intake estimates in a sample of Mexican-American women in northern California in 2008. Nutrient intakes are compared with Dietary Reference Intake recommendations, and intakes of Mexican-American women in a national survey are presented as a reference. Eighty-two women provided three 24-hour recalls. Reported energy intakes were classified as biologically plausible or implausible using the reported energy intakes to total energy expenditure cutoff of <0.76 or >1.24, with low-active physical activity levels used to estimate total energy expenditure. Differences in the means of nutrient intakes between implausible (n=36) and plausible (n=46) reporters of energy intake were examined by bivariate linear regression. Estimated energy, protein, cholesterol, dietary fiber, and vitamin E intakes were significantly higher in plausible reporters than implausible. There was a significant difference between the proportions of plausible vs implausible reporters meeting recommendations for several nutrients, with a larger proportion of plausible reporters meeting recommendations. Further research related to misreporting in Hispanic populations is warranted to explore the causes and effects of misreporting in studies measuring dietary intake, as well as actions to be taken to prevent or account for this issue.

Vegetable variety is a key to improved diet quality in low-income women in California.

Primary prevention education interventions, including those sponsored by the US Department of Agriculture for low-income families, encourage and support increases in vegetable intake. Promoting vegetable variety as a focal point for behavior change may be a useful strategy to increase vegetable consumption. A simple vegetable variety evaluation tool might be useful to replace the time-intensive 24-hour dietary recall. The purpose of our study was to determine whether vegetable variety is associated with vegetable consumption and diet quality among US Department of Agriculture program participants. Variety of vegetable intake and measures of total vegetable intake, diet quality, and diet cost were evaluated. Low-income, female participants (N=112) aged 20 to 55 years with body mass index 17.7 to 68.5 who were the primary food purchasers/preparers for their households were recruited from four California counties representing rural, urban, and suburban areas. Energy density and Healthy Eating Index-2005 were used to assess diet quality. Vegetable variety was based on number of different vegetables consumed per week using a food frequency questionnaire, and three groups were identified as: low variety, ≤5 different vegetables per week; moderate variety, 6 to 9 vegetables per week; and high variety, ≥10 vegetables per week. Compared with the low-variety group, participants in the high-variety group ate a greater quantity of vegetables per day (P<0.001); their diets had a higher Healthy Eating Index score (P<0.001) and lower energy density (P<0.001); and costs of their daily diet and vegetable use were higher (P<0.001). Thus, greater vegetable variety was related to better overall diet quality, a larger quantity of vegetables consumed, and increased diet cost.

Improving the quality of data from EFNEP participants with low literacy skills: a participant-driven model.

Low literacy skills and poor evaluation tool readability combined with the stresses of the classroom environment create a high cognitive load for Expanded Food and Nutrition Education Program (EFNEP) participants, resulting in lower quality data. The authors advocate for 9 strategies for improving the participant cognitive load for the evaluation process using the EFNEP Family Record as an example.

Estimating dietary costs of low-income women in California: a comparison of 2 approaches.

BACKGROUND: Currently, no simplified approach to estimating food costs exists for a large, nationally representative sample. OBJECTIVE: The objective was to compare 2 approaches for estimating individual daily diet costs in a population of low-income women in California. DESIGN: Cost estimates based on time-intensive method 1 (three 24-h recalls and associated food prices on receipts) were compared with estimates made by using less intensive method 2 [a food-frequency questionnaire (FFQ) and store prices]. Low-income participants (n = 121) of USDA nutrition programs were recruited. Mean daily diet costs, both unadjusted and adjusted for energy, were compared by using Pearson correlation coefficients and the Bland-Altman 95% limits of agreement between methods. RESULTS: Energy and nutrient intakes derived by the 2 methods were comparable; where differences occurred, the FFQ (method 2) provided higher nutrient values than did the 24-h recall (method 1). The crude daily diet cost was $6.32 by the 24-h recall method and $5.93 by the FFQ method (P = 0.221). The energy-adjusted diet cost was $6.65 by the 24-h recall method and $5.98 by the FFQ method (P < 0.001). CONCLUSIONS: Although the agreement between methods was weaker than expected, both approaches may be useful. Additional research is needed to further refine a large national survey approach (method 2) to estimate daily dietary costs with the use of this minimal time-intensive method for the participant and moderate time-intensive method for the researcher.

Acculturation, physical activity and television viewing in Hispanic women: findings from the 2005 California Women's Health Survey.

OBJECTIVE: To assess the relationship of acculturation with physical activity and sedentary behaviours among Hispanic women in California. DESIGN: Data from the 2005 California Women's Health Survey (CWHS) - a cross-sectional telephonic survey of health indicators and health-related behaviours and attitudes - were used. SETTING: Using a random-digit dialling process, data were collected monthly from January to December 2005. SUBJECTS: A total of 1298 women aged ≥18 years in California who self-identified as Hispanic. RESULTS: Of the participants included in the analysis, 49 % were adherent to physical activity recommendations (with 150 min of weekly activity signifying adherence). There was no significant association between language acculturation and moderate or vigorous physical activity after controlling for potential confounders such as smoking, age and employment status. There was also no association between duration of residence in the USA and moderate or vigorous physical activity. Language acculturation was positively associated with television (TV) viewing, with highly acculturated women reporting more hours of TV viewing compared with women with an intermediate acculturation score (P = 0·0001), and those with an intermediate score reporting more hours of TV viewing compared with those with a low score (P = 0·003). This relationship persisted after inclusion of smoking, employment status, age and education in the model. CONCLUSIONS: Higher levels of language acculturation may be associated with increased sedentary behaviours because of the influence of US culture on those women who have assimilated to the culture. Acculturation is an important factor to be taken into account when designing health education interventions for the Hispanic female population.

Patient-driven education materials: low-literate adults increase understanding of health messages and improve compliance.

Providing educational materials for low-literate patients is an enormous challenge for nursing professionals given that 90 million adults in the health care setting have limited literacy skills. Through the use of a 5-step process, patient educational materials can be created to increase patient understanding of health messages and improve patient compliance.

Assessing factorial and convergent validity and reliability of a food behaviour checklist for Spanish-speaking participants in US Department of Agriculture nutrition education programmes.

OBJECTIVE: To assess convergent validity, factorial validity, test-retest reliability and internal consistency of a diet quality food behaviour checklist (FBC) for low-literate, low-income Spanish speakers. DESIGN: Participants (n 90) completed three dietary recalls, the Spanish-language version of the US Department of Agriculture (USDA) Household Food Security Survey Module (HFSSM) and the Spanish-language FBC. Factor structure was examined using principal component analysis. Spearman correlation coefficients between FBC item responses and nutrient intakes from 24 h recalls were used to estimate convergent validity. Correlation coefficients were also calculated between FBC item responses at two time points in another group of participants (n 71) to examine test-retest reliability. Cronbach's α coefficient was determined for items within each sub-scale. SETTING: Non-profit community agencies serving low-income clients, migrant farm worker camps and low-income housing sites in four California counties. SUBJECTS: Spanish-speaking women (n 161) who met income eligibility for the SNAP-Ed (Supplemental Nutrition Assistance Program-Education). RESULTS: Factor analysis resulted in six sub-scales. Responses to nineteen food behaviour items were significantly correlated with hypothesized 24 h recall data (with a maximum correlation of 0·44 for drinking milk and calcium) or the USDA HFSSM (0·42 with the food security item). Coefficients for test-retest reliability ranged from 0·35 to 0·79. Cronbach's α ranged from 0·49 for the diet quality sub-scale to 0·80 for the fruit and vegetable sub-scale. CONCLUSIONS: The twenty-two-item FBC and instruction guide will be used to evaluate USDA community nutrition education interventions with low-literate Spanish speakers. This research contributes to the body of knowledge about this at-risk population in California.