Insights from Multiple Stakeholders Regarding Adolescent Obesity in China: An Exploratory Qualitative Study.

With a significant increase in the obesity epidemic in China, addressing adolescent obesity should be highlighted as a priority. The current qualitative study aims to explore the perspectives of key stakeholders regarding adolescent obesity, providing guidance for developing effective obesity interventions for Chinese adolescents. A total of 12 focus group discussions were convened with a range of representative stakeholders including adolescents (n = 37), parents (n = 28), and school staff (n = 21) from sample schools. Semi-structured topic guides were used for data collection. All data were transcribed verbatim and analyzed thematically. From multiple stakeholder perspectives, we finally identified 3 overarching themes (Understanding adolescent obesity, Key healthy lifestyles, and Barriers to obesity prevention practices) and 8 sub-themes. While participants had mixed perceptions of status and prevalence of adolescent obesity, all acknowledged the serious health consequences associated with it. As significant modifiable risk factors, unhealthy diet and physical activity were identified to be prevalent among Chinese teenagers and lead to excessive weight gain. However, a variety of individual, environmental and sociocultural factors hindered the implementation of healthy lifestyles, affecting adolescent obesity prevention and control. Given adolescent obesity is a complex, multifactorial and multilevel public issue, comprehensive lifestyle interventions are recommended that synergistically engage multiple stakeholders across key communities to fight the ongoing obesity epidemic.

[Childhood overweight and obesity: A biomedical challenge in Mexico]. / Sobrepeso y obesidad infantil: un reto biomédico en México.

In Mexico, 1 out of 3 schoolchildren aged 5 to 11 years is overweight or obese, which represents one of the main public health concerns, due to the fact that this condition in the child population is highly associated with the development of metabolic complications in adults. To date, dietary and physical activity interventions to prevent this problem have shown modest results worldwide. Biomedical studies in Mexico have shown that the pathophysiology of childhood overweight and obesity presents different molecular patterns, inflammation and oxidative stress, possibly associated with specific variants in the genome. However, the challenge is to achieve a secure characterization of this evidence so that it can be used in intervention studies aimed to improve the ability to predict and treat childhood overweight and obesity in Mexico. The biomedical challenge is to make knowledge a prevention strategy in families, in society and in the country, in order to fight the serious problem of obesity and its consequences.

En México 1 de cada 3 escolares de 5 a 11 años presenta sobrepeso u obesidad, lo cual representa una de las principales preocupaciones de salud pública, debido a que en la población infantil este padecimiento se asocia altamente con el desarrollo de complicaciones metabólicas en el adulto. Hasta el momento las intervenciones dietéticas y de actividad física para prevenir este problema han mostrado resultados modestos a nivel mundial. Los estudios biomédicos en México han demostrado que la fisiopatología del sobrepeso y la obesidad infantil presenta diferentes patrones moleculares, de inflamación y de estrés oxidativo, posiblemente asociados a variantes específicas en el genoma. Sin embargo, el reto es lograr la caracterización segura de estas evidencias para que sea posible emplearlas en los estudios de intervención encaminados a mejorar la capacidad de predicción y tratamiento del sobrepeso y la obesidad infantil en México. El reto biomédico es hacer del conocimiento una estrategia de prevención en las familias, en la sociedad y en el país, a fin de combatir el grave problema de la obesidad y sus consecuencias.

Centre-based childcare in early childhood and child obesity: systematic review and meta-analysis protocol.

OBJECTIVES: Centre-based childcare has been identified as a promising environment for obesity prevention in early childhood, but the longitudinal relationships between attending centre-based childcare and child obesity are not well understood. The objective of this systematic review is to evaluate the longitudinal associations between centre-based childcare attendance in early childhood and child body mass index compared with other childcare settings or parental care. Subgroup analyses will also be conducted to determine if socioeconomic factors and characteristics of the childcare setting modify the relationships. METHODS: Databases that will be searched include MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, the Cochrane Database and Web of Science. Longitudinal prospective cohort studies, retrospective cohort studies, case-control studies and intervention trials conducted in middle-income and high-income countries will be included in the search strategy. Sensitivity and subgroup analyses will be conducted to explore factors that may modify the findings. Study selection, data extraction, risk of bias and quality of evidence assessments will be conducted independently and in duplicate by two reviewers. Risk of bias will be assessed using the Risk Of Bias In Non-randomized Studies - of Exposure tool. Meta-analysis will be conducted using random effects models to account for between-study variation. Heterogeneity across included studies will be estimated using the I2 statistic. If meta-analysis is not possible, a narrative summary will be provided. The quality of the evidence will be assessed using the Grading of Recommendations Assessment, Development and Evaluation tool. ETHICS AND DISSEMINATION: Ethical approval is not required for this study since no data will be collected. Findings aim to inform interventions and guide efforts in childcare settings to support optimal child growth. Results will be published in a peer-reviewed journal. Results may be of relevance for childcare and public health policy, researchers, parents and healthcare practitioners. PROSPERO REGISTRATION NUMBER: CRD42023436911.

Impact of the Physical Activity Environment on Change in Body Mass Index Percentile in Child Care Centers Serving Children with Disabilities.

Childcare centers (CCCs) can provide opportunities to implement physical activity (PA) via health promotion interventions to prevent obesity and associated chronic disease risk factors in young children. This study evaluated the impact of the Healthy Caregivers-Healthy Children (HC2) intervention on body mass index percentile (PBMI) and the PA environment in CCCs serving children with disabilities (CWD) over one school year. Ten CCCs were cluster-randomized to either (1) an intervention arm that received the HC2 curriculum adapted for CWD or (2) an attention control arm. Mixed-effect linear regression models analyzed the relationship between change in child PBMI and CCC childcare center PA environment by experimental condition and child disability status over one school year. Findings showed a significant decrease in PBMI among children in the HC2 centers (-6.74, p = 0.007) versus those in control centers (-1.35, p = 0.74) over one school year. Increased PA staff behaviors (mean change 3.66, p < 0.001) and PA policies (mean change 6.12, p < 0.001) were shown in intervention centers during the same period. Conversely, there was a significant increase in sedentary opportunities (mean change 4.45, p < 0.001) and a decrease in the portable play environment (mean change -3.16, p = 0.03) and fixed play environment (mean change -2.59, p = 0.04) in control centers. No significant differences were found in PBMI changes between CWD and children without disabilities (beta = 1.62, 95% CI [-7.52, 10.76], p = 0.73), suggesting the intervention's efficacy does not differ by disability status. These results underscore the importance of (1) including young CWD and (2) PA and the supporting environment in CCC health promotion and obesity prevention interventions.

Non-Pharmacological Treatment for Cardiovascular Risk Prevention in Children and Adolescents with Obesity.

In younger generations, excess weight has reached very alarming levels. Excess weight in adults is associated with increased mortality and morbidity from cardiovascular disease. However, it is not easy to distinguish to what extent these effects are the result of obesity itself or how much is due to the various cardiovascular risk factors that often accompany excess weight. Several risk factors, such as hypertension, dyslipidemia, hyperuricemia, glucose intolerance, and type 2 diabetes mellitus, are already present in pediatric age. Therefore, early intervention with the goal of correcting and/or eliminating them is particularly important. In the child and adolescent with obesity, the first approach to achieve weight reduction and correct the risk factors associated with severe excess weight should always be non-pharmacologic and based on changing poor eating habits and unhealthy lifestyles. The purpose of this review is to give an update on non-pharmacological interventions to be implemented for cardiovascular prevention in children and adolescents with obesity, and their effectiveness. In particular, interventions targeting each individual cardiovascular risk factor will be discussed.

The Prevention of Childhood Obesity Is a Priority: The Preliminary Results of the "EpPOI: Education to Prevent Childhood Obesity" Project.

BACKGROUND: The increase in childhood obesity rates represents a serious public health problem. The project "EpPOI: Education to prevent childhood obesity" is aimed at a multidisciplinary approach to raise awareness of the importance of preventing childhood obesity through lifestyle education. METHODS: Two actions by experts were performed: an intervention with children in schools and a meeting for both parents and school staff. Participants completed a questionnaire structured as a Likert scale. RESULTS: The sample size was 96 people, and awareness of the childhood obesity problem as well as the need for obesity prevention was high among respondents. We also found great interest among participants in having more information on pediatric nutrition and physical activity, with a positive correlation with age. Furthermore, the multivariate regression model configured interest in having more information on nutrition and physical activity as an independent and statistically significant predictor of awareness of childhood obesity as a current issue. CONCLUSIONS: The results highlight the need to act on childhood obesity through lifestyle prevention strategies early in life.

Dietary fiber for the prevention of childhood obesity: a focus on the involvement of the gut microbiota.

Given the worldwide epidemic of overweight and obesity among children, evidence-based dietary recommendations are fundamentally important for obesity prevention. Although the significance of the human gut microbiome in shaping the physiological effects of diet and obesity has been widely recognized, nutritional therapeutics for the mitigation of pediatric obesity globally are only just starting to leverage advancements in the nutritional microbiology field. In this review, we extracted data from PubMed, EMBASE, Scopus, Web of Science, Google Scholar, CNKI, Cochrane Library and Wiley online library that focuses on the characterization of gut microbiota (including bacteria, fungi, viruses, and archaea) in children with obesity. We further review host-microbe interactions as mechanisms mediating the physiological effects of dietary fibers and how fibers alter the gut microbiota in children with obesity. Contemporary nutritional recommendations for the prevention of pediatric obesity are also discussed from a gut microbiological perspective. Finally, we propose an experimental framework for integrating gut microbiota into nutritional interventions for children with obesity and provide recommendations for the design of future studies on precision nutrition for pediatric obesity.

A systems thinking framework for understanding rising childhood obesity in the Caribbean.

OBJECTIVE: The aim of this study is to develop a systems thinking framework to describe the common complexities of childhood obesity in the Caribbean region and identify potential areas of intervention. METHODS: Group model building (GMB) is a form of systems science. Trained GMB facilitators in Puerto Rico, the US Virgin Islands, Barbados, and Trinidad and Tobago convened a group of multi-disciplinary stakeholders in a series of virtual meetings in 2021 to elaborate a hypothesis of the system driving childhood obesity represented by causal loop diagrams (CLD). Commonalities and differences between the CLDs from each island were identified and reconciled to create a synthesized CLD. RESULTS: A single explanatory CLD across the islands was developed and includes nine reinforcing loops. These loops addressed the interconnected role of schools, policy, commercial determinants, community and the personal experience of the child in rising childhood obesity rates. CONCLUSIONS: Despite differences across settings, there is a core system driving childhood obesity in the Caribbean, as described by stakeholders in GMB workshops. Policy solutions to the problem must be multi-faceted and multi-level to address the interlinked reinforcing loops of the complex system and reduce rates of childhood obesity.

Trends in Children's Exposure to Food and Beverage Advertising on Television.

Importance: Reducing children's exposure to advertisements promoting unhealthy foods and beverages has been recognized by the World Health Organization as a key strategy to improve children's diets and reduce childhood obesity. Objective: To examine changes in children's exposure to food-related (food, beverage, and restaurant) television advertising, including for products high in nutrients to limit (NTL; ie, saturated fat, trans fat, total sugars, and sodium) based on federal Interagency Working Group guidelines, following changes in the voluntary industry self-regulatory Children's Food and Beverage Advertising Initiative (CFBAI). Design, Setting, and Participants: This repeated cross-sectional study used US television ratings data on advertising exposure from The Nielsen Company for 2013, 2014, 2015, 2018, and 2022. Food and beverage product advertisements were assessed for nutritional content. Participants included 2- to 5-year-old and 6-to 11-year-old children. Data analysis was performed from July 2023 to January 2024. Exposure: Changes in CFBAI standards in 2014 and 2020. Main Outcomes and Measures: The primary outcome was the number of food-related advertisements seen per year and percentage of food and beverage product advertisements high in NTL, on all programming and children's programming (defined as ≥35% child audience share). Results: From 2013 to 2022, total advertisements seen per year declined by 77.6% (from 4611 to 1035) for 2- to 5-year-olds and by 78.5% (from 4860 to 1046) for 6- to 11-year-olds. Advertisements seen on children's programming decreased by 95.1% (from 1703 to 84 per year) for 2- to 5-year-olds and by 97.0% (from 1745 to 52 per year) for 6- to 11-year-olds. The percentages of advertisements for products high in NTL decreased from 2013 to 2022 but were still high: 68.9% for all programming and 63.9% for children's programming for 2- to 5-year-olds, and 68.4% for all programming and 60.6% for children's programming for 6- to 11-year-olds. The majority (51%-52%) of CFBAI-member food and beverage advertisements on children's programming remained high in NTL. Black children saw more food-related television advertisements than White children (58% more for 2- to 5-year-olds and 72% more for 6- to 11-year-olds); however, the percentage of advertisements for food and beverage products high in NTL seen was similar by race. Conclusions and Relevance: In this repeated cross-sectional study of children's exposure to food-related television advertisements, exposure via children's programming decreased substantially. However, most advertisements seen were still for unhealthy products, and exposure from all programming remained substantial. Findings of more than 90% of advertising exposure not from children's programming and more than 1000 food-related advertisements seen per year suggest the need for government regulations based on time of day rather than programming.

A scoping review of policies related to reducing energy drink consumption in children.

BACKGROUND: Frequent consumption of Energy Drinks (EDs) is associated with numerous health problems, including overweight and obesity, particularly among children and adolescents. The extensive promotion, wide accessibility, and relatively low cost of EDs have significantly increased their popularity among this age group. This paper examines policies/programs that, directly and indirectly, contribute to reducing ED consumption in children and adolescents and shares global experiences to help policymakers adopt evidence-based policies. METHODS: A systematic search was performed using PubMed, Scopus, and Web of Science databases from January 2000 to June 2024, along with reputable international organization websites, to find literature on policies aimed at reducing ED consumption among children and adolescents. All sources meeting the inclusion criteria were included without restrictions. Titles and abstracts were initially screened, followed by a full-text review. After evaluating the quality of the selected studies, data were extracted and, along with information from the selected documents, compiled into a table, detailing the country, policy type, and the effectiveness and weaknesses of each policy. RESULTS: Out of 12166 reviewed studies and documents, 84 studies and 70 documents met the inclusion criteria. 73 countries and territories have implemented policies like taxation, sales bans, school bans, labeling, and marketing restrictions on EDs. Most employ fiscal measures, reducing consumption despite enforcement challenges. Labeling, access restrictions, and marketing bans are common but face issues like black markets. CONCLUSION: This scoping review outlines diverse strategies adopted by countries to reduce ED consumption among children and teenagers, such as taxation, school bans, sales restrictions, and labeling requirements. While heightened awareness of ED harms has reinforced policy efforts, many Asian and African nations lack such measures, some policies remain outdated for over a decade, and existing policies face several challenges. These challenges encompass industry resistance, governmental disagreements, public opposition, economic considerations, and the intricacies of policy design. Considering this, countries should tailor policies to their cultural and social contexts, taking into account each policy's strengths and weaknesses to avoid loopholes. Inter-sectoral cooperation, ongoing policy monitoring, updates, and public education campaigns are essential to raise awareness and ensure effective implementation.

Comprehensive care for childhood obesity in Brazilian municipalities.

OBJECTIVE: To understand the potential and limits of care for childhood obesity from the perspective of comprehensiveness, in the context of Primary Health Care, in Brazilian municipalities. METHODS: A qualitative approach was adopted, with an electronic form of a dissertative nature being applied in 11 municipalities in the five Brazilian regions, derived from the four axes of comprehensiveness defined by Ayres (needs, purposes, articulations, and interactions). RESULTS: Among the strengths for comprehensive care, the following were observed: the provision of services at different levels of care; the relevance of intersectoral programs in the development of actions aimed at the multidimensionality of childhood obesity; the implementation of strategies for systematizing care and tools that encourage the expansion of dialogue and humanization; and intersectoral coordination to create appropriate responses to the expanded needs of children and their families. Limitations include: the centralization of actions in nutrition professionals and in the care sphere; the failure to prioritize childhood obesity in health agendas; and the lack of trained professionals to deal with the complexity of obesity. CONCLUSIONS: The findings suggest that child obesity care practices, in order to be transformative, need to be understood in the context of comprehensiveness. And this includes (re)thinking public policies, professional practices, and the organization of work processes so that they are, in fact, more inclusive, participatory, dialogical, humanized, supportive, fair, and, therefore, effective.

Beneficial effects of short-term breastfeeding versus non-breastfeeding in early life against childhood obesity: findings from the US-based population study NHANES.

BACKGROUND: Breastfeeding is widely recognized for its potential to reduce childhood obesity. However, research investigating these benefits in children breastfed for a short duration (up to 6 months) remains limited despite this being a common practice globally. METHODS: This study focused on a population breastfed for 6 months or less to determine the potential benefits of short-term breastfeeding for preventing childhood obesity. Data were collected from five survey cycles of an US-based population study (the National Health and Nutrition Examination Survey (NHANES)), spanning 2009-2020. A sample of 3,211 children aged 2-6 years was selected, including 1,373 never breastfed and 1,838 ever breastfed. Logistic regression analysis examined the direct association between short-term breastfeeding and childhood obesity. Subsequent subgroup analyses were conducted. Additionally, stratified logistic regression explored the relationship between childhood obesity and the introduction of other early nutrition in both ever-breastfed and never-breastfed children. RESULTS: Overall, breastfeeding for 6 months or less did not directly prevent childhood obesity. However, among participants with older mothers (aged 35 or above), short-term breastfeeding was associated with a lower risk of childhood obesity compared to never being breastfed (OR 0.31, 95% CI: 0.17, 0.59). Similarly, children aged 3-4 years who were breastfed for > 3 ~ 6 months exhibited a lower obesity risk (OR 0.56, 95% CI: 0.35, 0.89). In ever-breastfed children, delayed infant formula introduction was linked to a lower risk of obesity (P-trend < 0.05: introduction at age ≤ 1 vs. >1 ~ 3 vs. >3 months). Conversely, for non-breastfed children, introducing milk (other than breast milk or formula) later (≥ 12 versus < 12 months) and introducing alternatives to whole cow's milk were associated with lower obesity risks (OR 0.54, 95% CI: 0.37, 0.78; OR 0.21, 95% CI: 0.08, 0.60, respectively). Notably, these trends were not observed in ever-breastfed children. CONCLUSIONS: Short-term breastfeeding may offer some benefits in preventing childhood obesity for specific populations. Additionally, it could potentially mitigate risks associated with the introduction of formula and cow's milk at inappropriate times.

Mediation by parent health literacy and behaviour of socioeconomic inequality in child overweight.

BACKGROUND: Socioeconomic inequalities contribute to childhood overweight. Identifying mediators could help reduce these inequalities. OBJECTIVE: We assessed to what extent and how parental health literacy and health behaviours mediate the relationship between parental socioeconomic status and childhood overweight. METHODS: Data were taken from the multigenerational prospective Dutch Lifelines Cohort Study. We included 6683 children, baseline age 9.8 years (SD = 2.6), with an average follow-up of 36.2 months (SD = 9.3). Overweight was defined using age- and sex-specific cut-offs. Three indicators of socioeconomic status were included: education, income and occupation. We assessed the mediating role of parental health literacy and health behaviours (smoking, diet, physical activity and alcohol) using causal mediation. RESULTS: Four additional years of education and an SD-increase in both income and occupation decreased the odds of childhood overweight by 42%, 12% and 20%, respectively. Only parental smoking independently mediated the relationship of both education (6.6%) and occupation (5.7%) with overweight. Parental health behaviours jointly explained 8.4% (education), 19.4% (income) and 9.8% (occupation) per relationship. Lastly, adding parental health literacy explained 10.8% (education), 27.4% (income) and 13.3% (occupation) of these relationships. CONCLUSIONS: We found large socioeconomic inequalities in childhood overweight. Remarkably, parental smoking was a key mediator. Therefore, prevention targeting smoking may reduce socioeconomic inequalities in childhood overweight.

Online retail nudges to help parents with lower-income choose healthy beverages for their children: A randomized clinical trial.

BACKGROUND: Nudges offer a promising tool to reduce sugary drink intake among children who are most at risk for diet-related disease. OBJECTIVE: To examine the impact of online store nudges on purchases of sugary drinks for children in lower-income households. METHODS: Caregivers with lower-income were recruited to an online shopping experiment and instructed to spend $10-$30 on three beverages for their child aged 1-5 years. Participants were randomized to navigate an online supermarket in its standard version (n = 1106) or a version with nudges (n = 1135), including a product placement nudge (i.e. placing healthy beverages in prominent positions) and a swap nudge (i.e. offering a swap of water, plain milk and/or 100% fruit juice upon selection of sugary drinks). RESULTS: On average, participants purchased 1887 (SD = 2113) and 620 (SD = 1528) calories from sugary drinks per basket in the control and experimental conditions, respectively. Model-based results indicate that those in the experimental condition purchased 1267 (95% CI: 1419, 1114) fewer calories from sugary drinks, and fewer grams of total sugar (ß = -253.5 g (95% CI: -286.3, -220.6)) and added sugar (ß = -287.8 g (95% CI: -323.1, -252.5)) purchased from sugary drinks. CONCLUSION: Nudges may be an effective, acceptable, scalable strategy for leading caregivers in lower-income households to purchase fewer sugary drinks for their children.

Community-Based Participatory Obesity Prevention Interventions in Rural Communities: A Scoping Review.

Child obesity is a worldwide public health concern. In America, children from rural areas have greater odds of obesity in comparison to those from urban areas. Community-engaged research is important for all communities, particularly under-represented communities. This paper reports the results of a scoping review investigating community-engaged research in obesity prevention programs tested with school-aged children in rural America. A literature search of Medline Ovid was conducted to identify interventions reporting the results of obesity prevention interventions that promoted a healthy diet or physical activity (PA) behaviors to school-age children in rural communities of the United States (US). After title and abstract review, potentially relevant citations were further examined by assessing the full text. Each stage of review was conducted by two independent reviewers. Twelve studies met the inclusionary criteria and are included in this review. Most of the studies focused on elementary school participants (n = 7) and improving both diet and PA (n = 9). Out of the twelve studies, only five included the target audience in intervention development or implementation. The most popular type of community engagement was community participation (n = 4). This review revealed that community-engaged research is under-utilized in obesity prevention interventions tested with school-aged children in rural US communities.

Improvement of Adherence to the Mediterranean Diet through a Nutrition Education Teaching Pack for Teachers within the "School Fruit Scheme" Program: An Italian Long-Term Trial in School Children.

A previous short time span study related to the effectiveness of a teaching pack (TP) in improving the adherence to the Mediterranean Diet (MD) showed positive results. The present study was aimed at investigating and confirming those results, with a follow up data collection, in the same sample, a year after the baseline intervention. Pre- and post-intervention assessments were conducted. Weight and height were measured. Eating patterns/lifestyle were assessed by the KIDMED test and questionnaires. Thirteen schools in three areas with low, medium and high prevalence of overweight/obesity (North, Center and South respectively) were involved, with a representative baseline cluster sample of 494 fourth class children (8-10 years old) in 2015. An intervention group and a control group were recruited in each school; the intervention group (n = 395) got the intervention, the control group (n = 99) did not. The children's KIDMED score changes were the main outcome measures. Differences in percentages of adherence and in yes/no answers on the KIDMED test, at baseline and after one year, for both the intervention and the control groups, were assessed through contingency tables and statistical tests. Improvements in the high and low adherence rates to MD were observed (high adherence: 24.4% to 43.3%; low adherence: 15.0% to 3.9%, p < 0.0001). The percentages of subjects with optimal adherence improved in both sexes (females: 25.5% to 49.5%, p < 0.0001; males: 23.1% to 36.6%, p < 0.0001) in all the geographical areas and ponderal status classes. Accompanying free distribution of fruit and vegetables with a nutritional intervention led by trained teachers with a cross-curricular approach can be successful in promoting healthy eating in children.

Assessing the acceptability of a culturally adapted group-based pediatric intervention, Kokajjiriri, for Marshallese mothers and infants to improve nutrition and prevent childhood obesity.

BACKGROUND: Marshallese Pacific Islanders experience higher rates of obesity than other racial and/or ethnic communities. Despite the obesity rates experienced in this community, there are currently no childhood obesity prevention interventions designed for Marshallese Pacific Islanders in the United States. The purpose of this study is to assess the acceptability and feasibility of a culturally adapted group-based pediatric intervention, Kokajjiriri, with Marshallese mothers to improve nutrition and reduce childhood obesity. METHODS: A multi-methods design was used to culturally adapt the Kokajjiriri intervention for Marshallese mothers in Arkansas (n = 17). In phase one, we conducted 24-h dietary recalls with 20 Marshallese mothers to inform the cultural adaptation of the group-based pediatric intervention, and then in phase two, we culturally adapted and piloted three sessions of the intervention to determine the acceptability and feasibility of the intervention. RESULTS: Participants found the adapted intervention to be acceptable and feasible, found the location to be convenient and found the facilitator to be knowledgeable. Four themes emerged from the qualitative data: (1) Lactation Support; (2) Introducing Healthy Solids; (3) Rice Portion Control; and (4) Finding Resources. CONCLUSIONS: This is the first study to assess the acceptability and feasibility of a culturally adapted group-based pediatric intervention, Kokajjiriri, with Marshallese mothers to improve nutrition and reduce childhood obesity. The results from this culturally adapted group-based pediatric intervention, Kokajjiriri, will be used to inform future adaptations and implementation of the full intervention for Marshallese women and children.

Effect of Time-Varying Exposure to School-Based Health Promotion on Adiposity in Childhood.

BACKGROUND: The results of most school-based health promotion initiatives are inconclusive. OBJECTIVES: This trial assessed the effect of time-varying exposures to a multicomponent school-based health promotion intervention (SI! Program) on adiposity markers. METHODS: A total of 48 schools in Madrid (Spain) were cluster randomized to receive the SI! Program through elementary education grades 1 to 6 (E1-6, 12 schools, 459 children), 1 to 3 (E1-3, 12 schools, 513 children), or 4 to 6 (E4-6, 12 schools, 419 children) or to receive the standard curriculum (control, 12 schools, 379 children). The primary endpoint was the between-group difference at 3- and 6-year follow-up in the change from baseline in adiposity markers and the overall knowledge-attitudes-habits (KAH) score. RESULTS: At 3-year follow-up, children who had the intervention showed significantly lower increases than the control group in z-scores for body mass index (BMI), waist-to-height ratio (WHtR), and waist circumference (WC) (zBMI: -0.09; 95% CI: -0.16 to -0.03; P = 0.003; zWC and zWHtR: -0.19; 95% CI: -0.28 to -0.10; P < 0.001). At 6-year follow-up, the beneficial trend in zWC and zWHtR was maintained in the E1-6 and E1-3 groups: difference zWC control vs E1-6 (-0.19; 95% CI: -0.36 to -0.03; P = 0.020), control vs E1-3 (-0.22; 95% CI: -0.38 to -0.06; P = 0.009); difference zWHtR control vs E1-6 (-0.24; 95% CI: -0.41 to -0.06; P = 0.009), and control vs E1-3 (-0.29; 95% CI: -0.47 to -0.11; P = 0.001). No significant between-group differences were found in the change of overall KAH score. CONCLUSIONS: Early elementary school interventions may be more effective than later interventions on abdominal adiposity. Further research should assess the sustainability effects of school-based health promotion programs.