The Impact of Structural Racism on Continuity of Care at Pediatric Academic Primary Care Clinics.

OBJECTIVE: Using a structural racism framework, we assessed racial inequities in continuity of care, using the Usual Provider Continuity Index (UPC - the proportion of visits with the provider the patient saw most frequently out of all visits), in a set of large pediatric academic clinics. METHODS: We conducted a retrospective cohort study. Patients 12-24 months seen at three pediatric academic primary care clinics for any visit during October 1-31, 2021 were included. We then reviewed continuity for these patients in the preceding 12 months. Outcomes included each patient's UPC for all visits, and a modified UPC for well child checks only (UPC Well). Covariates included race, ethnicity, insurance, clinic site, age, sex, care management, or seeing a social worker. We evaluated for differences in outcomes using bivariate analyses and multivariable regression models. RESULTS: Our cohort included 356 patients (74% Black, 5% Hispanic, 85% Medicaid, 52% female, median age 15.8 months). The median UPC was 0.33 and median UPC Well was 0.40. Black patients had significantly lower median values for UPC (0.33 Black vs 0.40 non-Black, P < .01) and UPC Well (0.33 Black vs 0.50 non-Black, P < .01). There were similar inequities in continuity rates by insurance and clinic site. In multivariable models, clinic site was the only variable significantly associated with continuity. CONCLUSIONS: Clinic sites serving higher percentages of Black patients had lower rates of continuity. The main driver of racial inequities in continuity rates was at the institutional level.

Early Correlates of School Readiness Before and During the COVID-19 Pandemic Linking Health and School Data.

Importance: Many known correlates of kindergarten readiness are captured in developmental and social screenings in primary care; little is known about how primary care data predicts school readiness. Objective: To identify early Kindergarten Readiness Assessment (KRA) correlates by linking electronic health record (EHR) data with school district KRA data and to examine potential outcomes of the COVID-19 pandemic using KRA scores between 2018 and 2021. Design, Setting, and Participants: This was a retrospective cohort study linking a large primary care practice (PCP) with school assessment data. Linkage used patient name, date of birth, and address. The setting was an urban school district and PCP affiliated with an academic medical center. Students had a KRA score from fall of 2018, 2019, or 2021 (no 2020 KRA due to the COVID-19 pandemic) and at least 1 prior well-child visit at the PCP. Exposures: Exposures included year KRA administered, reported child race and ethnicity, child sex, interpreter for medical visits, child ever failed Ages & Stages Questionnaire (ASQ) 18 to 54 months, ever rarely read to, Medicaid status, food insecurity, housing insecurity, problems with benefits, and caregiver depressive symptoms. Main Outcomes and Measures: KRA score (continuous), with a possible range of 0 to 300 (passing score = 270). Results: A total of 3204 PCP patients (mean [SD] age, 67 [4] months; 1612 male [50.3%]; 2642 Black [82.5%]; 94 Hispanic [2.9%]; 244 White [7.6%]) were matched to their KRA score. Mean (SD) KRA scores were significantly lower in 2021 (mean [SD], 260.0 [13.0]; 214 of 998 [21.4%]) compared with 2019 (mean [SD], 262.7 [13.5]; 317 of 1114 [28.5%]) and 2018 (mean [SD], 263.5 [13.6]; 351 of 1092 [32.1%]), a pattern mirrored in the larger school district. In the linear regression final model (n = 2883), the following binary variables significantly lowered the child's KRA score (points lowered [95% CI]) below a mean passing score of 270.8: child ever failed ASQ after 18 months (-6.7; 95% CI, -7.7 to -5.6), Medicaid insured (-5.7; 95% CI, -9.0 to -2.3), Hispanic ethnicity (-3.8; 95% CI, -6.9 to -0.6), requires interpreter (-3.6; 95% CI, -7.1 to -0.1), 2021 year (-3.5; 95% CI, -4.7 to -2.3), male sex (-2.7; 95% CI, -3.7 to -1.8), ever rarely read to (-1.5; 95% CI, -2.6 to -0.4), and food insecurity (-1.2; 95% CI, -2.4 to -0.1). Race, caregiver depression, housing insecurity, and problems receiving benefits were not associated with KRA scores in final model. Conclusions and Relevance: Findings of this cohort study suggest a deleterious association of the COVID-19 pandemic with early learning and development. There may be potential for PCPs and school districts to collaborate to identify and mitigate risks much earlier.

Beliefs and Motivations Regarding Early Shared Reading of Parents From Low-Income Households: A Qualitative Study.

OBJECTIVE: Parent-child "shared" reading is a catalyst for development of language and other emergent literacy skills. The American Academy of Pediatrics recommends that parents initiate shared reading as soon as possible after birth. Persistent disparities exist in reading resources, routines, and subsequent literacy outcomes, disproportionately impacting low-income households. We sought to understand beliefs, motivations, and experiences regarding shared reading during early infancy among parents from low-income households. METHODS: In this qualitative exploratory study, parents of infants aged 0 to 9 months from low-income households who had initiated shared reading ("readers") and those who had not ("nonreaders") were purposefully recruited to participate in individual semistructured virtual interviews. These interviews were coded using inductive thematic analysis by a 3-member team with diverse backgrounds. RESULTS: A total of 21 parents participated (57% readers, 86% mothers). Infants were 86% African American/Black, with a mean age of 3 months. Barriers noted by readers and nonreaders were i) competing demands on time, ii) lack of resources, and iii) parental mental health. An additional barrier noted solely by nonreaders was iv) it's too early/baby is not ready. Two benefits of reading were noted by both groups: 1) parents as child's first teachers and 2) reading catalyzes the child's development. Benefits noted exclusively by readers included 3) reading begets more reading, 4) bonding, 5) "it works," and 6) "two-for-one" shared reading (other children involved). CONCLUSIONS: This study provided insights into barriers and benefits regarding shared reading by socioeconomically disadvantaged parents of infants and has the potential to inform reading-related guidance and interventions.

A narrative review of clinic-community food provision interventions aimed at improving diabetes outcomes among food-insecure adults: examining the role of nutrition education.

BACKGROUND: Food provision interventions (eg, produce/food prescriptions, food pharmacies, food voucher programs) that bridge clinic and community settings for improved nutritional health outcomes of at-risk patients have gained momentum. Little is known about the role of nutrition education and potential augmented impact on patient outcomes. OBJECTIVE: To describe intervention designs and outcomes of direct food provision clinic-community programs aimed at improving diabetes-related outcomes (glycated hemoglobin [HbA1c] levels) among patients with type 2 diabetes (T2DM) or prediabetes and food insecurity, and to compare nutrition education components across interventions. METHODS: The PubMed and Academic Search Complete databases were systematically searched for original peer-reviewed articles (published during 2011-2022) that described the impact of clinic-community food provision programs (ie, produce/food prescriptions, food pharmacies, and food voucher programs) onHbA1c values among adults diagnosed with T2DM or prediabetes and who screened positive for food insecurity or low income. Study designs, intervention approaches, program implementation, and intervention outcomes were described. RESULTS: Ten studies representing 8 distinct programs were identified. There was a high degree of variation in the studies' design, implementation, and evaluation. Across the 8 programs, 6 included nutrition education; of these, 1 used a theoretical framework, and 3 incorporated goal setting. Nutrition education covered multiple topical contents, including general nutrition knowledge, fruit and vegetable consumption, and accessing resources (eg, enrolling in the Supplemental Nutrition Assistance Program). Furthermore, the education was delivered through various formats (from 1-on-1 to group-based sessions), educators (community health workers, registered dietitians, physicians), and durations (from a single session to biweekly). All programs with a nutrition education component reported reduced participant HbA1c, and 4 demonstrated an increase in fruit and vegetable purchases or improved dietary quality. The remaining 2 programs that did not include nutrition education yielded mixed results. CONCLUSION: The majority of programs included a nutrition education component; however, there was a high degree of heterogeneity in terms of content, educator, and duration. Patients who participated in programs that included nutrition education had consistent reductions in HbA1c. These observational trends warrant further exploration to conclusively determine the impact of nutrition education on patient outcomes participating in clinic-community food provision programs.

Using Quality Improvement to Design Early Childhood Services Navigation in Primary Care.

Enrollment in high-quality early childhood education (ECE) improves educational and health outcomes and can mitigate racial and economic disparities. Pediatricians are encouraged to promote ECE yet lack the time and knowledge to assist families effectively. In 2016, our academic primary care center hired an ECE Navigator to promote ECE and help families enroll. Our SMART aims were to increase the number of children with facilitated referrals to high-quality ECE programs from 0 to 15 per month and to confirm enrollment on a subset to achieve an enrollment rate of 50% by December 31, 2020. Methods: We used the Institute for Healthcare Improvement's Model for Improvement. Interventions included system changes in partnership with ECE agencies (eg, interactive map of subsidized preschool options, streamlined enrollment forms), case management with families, and population-based approaches to understand families' needs and the program's overall impact. We plotted the number of monthly facilitated referrals and the percentage of referrals enrolled on run and control charts. We used standard probability-based rules to identify special causes. Results: Facilitated referrals increased from 0 to 29 per month and remained above 15. The percentage of enrolled referrals increased from 30% to 74% in 2018, then decreased to 27% in 2020 when childcare availability declined during the pandemic. Conclusions: Our innovative ECE partnership improved access to high-quality ECE. Interventions could be adopted in part or whole by other clinical practices or WIC offices to equitably improve early childhood experiences for low-income families and racial minorities.

STEP IN: Supporting Together Exercise and Play and Improving Nutrition; a Feasibility Study of Parent-Led Group Sessions and Fitness Trackers to Improve Family Healthy Lifestyle Behaviors in a Low-Income, Predominantly Black Population.

BACKGROUND: Pediatric obesity is prevalent and challenging to treat. Although family-centered behavioral management is the gold standard, many families face structural inequities to its access and efficacy. Identifying ways to manage pediatric obesity within primary care is needed. METHODS: This feasibility study included three sequential trials of peer-led group sessions occurring biweekly or monthly between 3/2016 and 2/2017. Parent-child dyads were recruited from a large academic primary care clinic via mailed invitations, prioritizing patients living in local zip codes of historical disinvestment. Eligible patients were 6 to 12 years with a body mass index ≥85th percentile, with parent and child interest in making healthy lifestyle changes, and English speaking. RESULTS: 27 dyads participated, 77% were non-Hispanic Black. Retention and attendance rates were highest in the initial four-session biweekly pilot (100%, 0 dropouts), high in the full six-session biweekly cohort (83%, 1 dropout), and moderate in the monthly cohort (62.7%, 4 dropouts). Families reported high satisfaction with the sessions (4.75/5). Qualitative comments suggested social connections had motivated behavior change in some families. CONCLUSION: Parent-led group sessions for pediatric weight management show promise in engaging families. A future large trial is needed to assess behavior change and anthropometric outcomes.

Physical Activity Opportunities in US Early Child Care Programs.

BACKGROUND AND OBJECTIVES: Physical activity provides health and developmental benefits to young children. The Study of Nutrition and Activity in Child Care Settings describes physical activity opportunities and sedentary occasions for children aged 1 to 5 years at programs participating in the US Department of Agriculture Child and Adult Care Food Program. METHODS: The Study of Nutrition and Activity in Child Care Settings obtained a nationally representative sample of classrooms within Child and Adult Care Food Program-participating Head Start and child care centers via multistage cluster sampling. For 1 observation day, an observer in each classroom tallied designated outdoor and indoor playspaces; minutes children spent in playspaces; barriers and facilitators to physical activity; and classroom time when most children were physically active (eg, walking, dancing), sedentary (seated, lying down), or neither. Weighted descriptive tabulations by program type compared outdoor physical activity opportunity counts and total physical activity opportunity durations to national guidelines. Multivariate regression analysis investigated association of barriers with physical activity opportunity duration. RESULTS: The sample included 227 classrooms, 96 in child care centers and 131 in Head Start programs. All had sedentary occasions outside meals, snacks, and naps; virtually all offered opportunities for physical activity. Seventy-four percent of programs met national guidance on sufficient number of outdoor opportunities, weather permitting. Just 50% met guidance of ≥60 to 90 minutes of physical activity, whereas only 43% met both sets of guidance. Weather and staff not joining in outdoor play were associated with 74 and 31 fewer minutes devoted to physical activity, respectively. CONCLUSIONS: Findings suggest ample room for improvement in provision of physical activity opportunities during child care.

The Longitudinal Relation between Infant Feeding Styles and Growth Trajectories among Families from Low-Income Households.

BACKGROUND: Parental feeding styles, including the emotional environment parents create to modify a child's eating behaviors, have been associated with measures of adiposity in cross-sectional studies. The longitudinal relation between parental feeding styles in early infancy and adiposity in later infancy/toddlerhood are scant and have shown mixed results, particularly in families from low-income households. OBJECTIVES: This study examined the relation between parental feeding styles and infant BMI z-score trajectories between 6 and 18 mo in families from low-income households. METHODS: Parent-infant dyads were recruited during the infant's 6-, 9-, or 12-mo well-child visit. Feeding styles were assessed using the Infant Feeding Style Questionnaire (IFSQ). Infant anthropometrics from birth through 18 mo were extracted from the electronic medical record. BMI z-score slopes were estimated for each infant between 0-6 mo and 6-18 mo. Associations between feeding styles and BMI z-score slopes were examined using mixed models controlling for demographic, clinical, and feeding covariates. RESULTS: The final analytic sample included 198 dyads (69% Black; median infant age: 9.0 mo; IQR: 6.8-10.3 mo). The predominant parent feeding styles included the following: laissez-faire (30%), restrictive (28%), responsive (23%), and pressuring (19%). In adjusted models, the predominant feeding style at enrollment was associated with the BMI z-score slope between 6 and 18 mo, with the responsive feeding style exhibiting a steeper increase in BMI z-score than other feeding styles. Infant feeding style was not associated with BMI z-score slope between birth and 6 mo of age. Infants of parents who exhibited restrictive feeding styles were more likely to have a BMI ≥85th percentile at their last measurement. CONCLUSIONS: The predominant parent feeding style during infancy in a low-income population was associated with infant BMI z-score between 6 and 18 mo of age, but not earlier. Further studies are needed to better understand how predictive factors collectively contribute to BMI increase in the first 2 y.

Foods Served in Child Care Programs Participating in the Child and Adult Care Food Program and Alignment with Program Meal Patterns.

OBJECTIVE: Assess Child and Adult Care Food Program (CACFP) program compliance with meal component requirements for children aged 3-5 years by program type, and describe foods and beverages most commonly served. DESIGN: Cross-sectional analysis of 1-week menu surveys during winter/spring 2017. SETTING: US CACFP-participating child care programs. PARTICIPANTS: Nationally representative multistage cluster sample of 664 programs: 222 child care centers, 247 Head Start programs, 195 family child care homes. MAIN OUTCOME MEASURE(S): Percentage of meals including required components; frequently served foods and beverages. ANALYSIS: Mean percentages; 2-tailed t tests; alpha = 0.05 significance level. RESULTS: Most breakfasts (97%), lunches (88%), and afternoon snacks (97%) included all required CACFP meal components. Most breakfasts included fruits (96%), but not vegetables; 16% included a meat/meat alternate. Most lunches (81%) included both fruits and vegetables. Afternoon snacks were mostly grains/breads (80%) and fruits (57%). Most frequently served foods included 1% unflavored milk and fresh fruits such as apples and bananas. Most menus limited juice, offered low-sugar cereal, and did not include flavored milk; very few menus included noncreditable foods with added sugar. CONCLUSIONS AND IMPLICATIONS: Most CACFP meals provided required components, but there is room for improvement, particularly for increasing vegetables served and limiting foods high in added sugar and fat.

Association Between Unscheduled Pediatric Primary Care Visits and Risk of Developmental Delay.

OBJECTIVE: Primary care centers are trialing open access scheduling models to expand access. Given evidence linking irregular caregiver work schedules with adverse child developmental outcomes, we hypothesized that children presenting for unscheduled "walk-in" visits would have higher odds of developmental concerns than those presenting for scheduled visits. METHODS: We conducted a retrospective review of electronic health record data for children aged 6 to 66 months visiting an academic pediatric primary care center between July 1, 2013 and February 1, 2019. Our primary outcome was presence of developmental concerns, defined by results below cutoff on a child's Ages & Stages Questionnaire, Third Edition (ASQ-3). We examined associations between visit stream (unscheduled vs scheduled; time of day) and ASQ-3 using multivariable logistic regression, adjusting for child demographics, visit type (well-child vs ill), and responses to a standardized social history questionnaire. RESULTS: Of 11,169 eligible total encounters each for a unique child, 8% were unscheduled (n = 848); 19% had developmental concerns in at least one domain (n = 2100). Twenty-eight percent of children presenting for unscheduled visits had developmental concerns compared to 18% of those presenting for scheduled visits (P < .0001). Compared to those presenting for scheduled well-child visits, children presenting for unscheduled ill visits had a higher odds of an ASQ-3 score below cutoff (adjusted odds ratio 2.02; 95% confidence interval, 1.54-2.65). CONCLUSIONS: As pediatric primary care centers implement open access scheduling models, they should be prepared to identify and respond to developmental concerns at a rate that may be higher than what is typically seen during scheduled visits.

Dietary Intakes of Children Enrolled in US Early Child-Care Programs During Child-Care and Non-Child-Care Days.

BACKGROUND: Early-child-care (ECE) programs may substantially influence child diet quality. OBJECTIVE: The Study of Nutrition and Activity in Child Care Settings describes the usual food group intake of preschool-aged children attending ECE programs relative to Dietary Guidelines for Americans (DGA) recommendations, comparing intakes during child-care and non-child-care days. DESIGN: Meal observations and parent-completed food diaries in a cross-sectional nationally representative multistage cluster sample of Child and Adult Care Food Program-participating ECE programs. PARTICIPANTS/SETTING: One thousand four hundred sixty-eight children aged 3 to 5 years attending 217 Child and Adult Care Food Program-participating ECE programs (eg, child-care centers and Head Start) during 2017. MAIN OUTCOME MEASURES: Daily energy intake, daily US Department of Agriculture Food Pattern Food Group intakes, and percentage of daily intakes meeting 2015-2020 DGA Food Pattern recommendations. STATISTICAL ANALYSES PERFORMED: Regression-adjusted usual intakes and percentage of children meeting recommendations were estimated using the National Cancer Institute method. Single-day mean intakes were used to test for statistical differences between child-care and non-child-care days. RESULTS: Mean usual energy intake was 1,524 ± 19.3 kcal during child-care days and exceeded the recommended range at 1,702 ± 30.2 kcal during non-child-care days; single-day means indicated significantly lower energy intake on child-care days (P < 0.001). The percent of children meeting DGA recommendations on a child-care day varied by DGA food group: fruits (51.4%), grains (50.1%), dairy (42.5%), vegetables (6.5%), whole grains (4.6%), and protein foods (0.1%). Recommended limits on calories from added sugar and solid fats were met by 28.2% and 14.6% of children, respectively. Compared with mean food group intakes during a single child-care day, non-child-care day intakes were similar for fruits and vegetables, lower for dairy and whole grains, and higher for total grains, protein foods, and calories from added sugars and solid fats. CONCLUSIONS: Although there is room to increase nutrient density inside and outside of child care, intakes on child-care days more closely align to DGAs.

Shared Reading and Risk of Social-Emotional Problems.

BACKGROUND AND OBJECTIVES: The American Academy of Pediatrics recommends literacy promotion as well as routine developmental surveillance during well-child visits to improve academic, relational, and health outcomes. In this study, we examined the possible association between shared reading and social-emotional problems among young children. METHODS: We conducted a retrospective review of longitudinal records for children aged 30 to 66 months presenting for visits to an academic pediatric primary care center between July 1, 2013, and February 1, 2019. The outcome was evidence of social-emotional problems, defined by an Ages and Stages: Social Emotional Questionnaire (ASQ:SE) score above the established cutoff. The predictor was caregiver-reported frequency of shared reading (most = 5-7 days per week, some = 2-4 days per week, rarely = 0-1 days per week) at a previous visit. Generalized linear models with generalized estimating equations were used to assess the association between the longitudinal outcome and predictor, adjusting for child demographics and needs reported on routine social history questionnaires. RESULTS: Analyses included 5693 children who completed at least 1 ASQ:SE (total of 7302 assessments) and had shared reading frequency documented before each ASQ:SE assessment. Children were predominantly Black (75%) and publicly insured (80%). Sixteen percent of ASQ:SE scores were suggestive of social-emotional concerns; 6% of caregivers reported sharing reading rarely. Children with rare shared reading had a higher risk of an ASQ:SE above cutoff compared with those with shared reading on most days (adjusted risk ratio, 1.62; 95% confidence interval, 1.35-1.92). CONCLUSIONS: Less-frequent caregiver-reported shared reading was associated with higher risk of social-emotional problems in young children presenting for primary care. This highlights potential relational and social-emotional benefits of shared reading.

Is Parent Readiness to Change Predictive of Follow-through with Diet and Activity Modifications in Children?

Assessing parental readiness to change their child's lifestyle behaviors can be used as a guide for counseling during well-child appointments. The aim of our study was to determine if parental readiness to change pre-visit was associated with plan adherence post-visit in a predominantly low-income population. Parents (n=178) self-identified readiness to change on a Likert scale and subsequently received counseling. Multivariate logistic regression was used to evaluate associations between readiness to change and plan adherence. There was no association between readiness to change and self-reported follow-through with nutrition plans (AOR at 3 months: 1.5 [0.52; 4.18]; p=.5). The ready-to-change group reported higher, albeit non-significant, follow-through with activity plans at three months (AOR 3.6 [0.82; 15.96]; p=.09). Providers should engage all parent/child dyads in behavior modification for nutrition and activity regardless of parents' pre-visit readiness to change.

Factors Associated With Residential Relocation and Effects on Early Childhood Development in a Low-Income Home Visitation Population.

Residential relocation (RR) is associated with behavior problems and cognitive delays in school-age children. Little is known regarding effects of RR on early childhood development. The data from this study were collected from 2011 to 2016 through the Cincinnati Home Injury Prevention and Literacy Promotion Trial. The purpose of the current study was to identify factors associated with RR and determine effects of RR on early childhood development in a cohort of mother/child dyads (n = 424). High RR was relocating ≥ 3 times over the 24-month study period. Differences in baseline characteristics and early childhood development, measured by the Ages and Stages Questionnaire (ASQ) and MacArthur Bates Communicative Development Inventory, according to relocations, were estimated by negative binomial regression and logistic regression, respectively. Participants moved on average 1.46 times over 24 months. Relocations decreased by 0.05 for each year of increasing maternal age. Mothers with college degrees moved 0.72 fewer times than those with a high school diploma or less. Mothers living alone moved 0.47 fewer times than their counterparts. Mothers who could not count on someone to loan them $1000 and those with food insecurity more (0.41) than their counterparts (0.50). Odds of scoring in the bottom-tertile for the communication domain of the ASQ was significantly higher in those relocating ≥ 3 times. High RR was associated with concern for delayed language development at 24-month follow-up in some, but not all models. Early intervention may be more successful if primary care physicians and community health professionals collaborate to link families at risk of high RR to relevant community based resources.

Giving "prescriptions" for paediatric weight management follow-up in primary care.

The American Academy of Paediatrics recommends that primary care paediatricians "prescribe" follow-up for weight management between well child checks. We sought to describe rates and predictors of prescribed and actual clinic attendance for weight management in primary care in a predominantly low-income population. A chart review was performed at a large, hospital-based, primary care clinic, where a treatment algorithm for obesity exists. Eligible children were 6 to 12 years of age with a body mass index (BMI) ≥85th percentile and seen for a well child check in 2014. Primary outcomes were the physician prescribing follow-up in primary care and the patient returning for weight management. Multivariable logistic regression was used to identify predictors of prescribing follow-up and predictors of return. Participants included 1339 patients: mean age 9 years (SD: 1.8 years); 53% female; 79% Black; 89% Medicaid-insured; 56% with an obese BMI (vs overweight). Twenty-seven percent of patients were prescribed follow-up in primary care, of which 13% returned (only 4% of the original sample). The odds of the physician prescribing follow-up were greater if the child had obesity (vs overweight), was older, female or non-Medicaid insured. Older and non-Black patients had greater odds of returning. Patients prescribed follow-up within 2 months or less (vs 3-6 months) were also more likely to return (aOR 2.66; CI: 1.34, 5.26). Rates of prescription for weight management in primary care are low and few patients return, even when follow-up is prescribed. Prescribing follow-up at shorter intervals from the index visit (≤ 2 months) may improve patient return.

Maternal Body Dissatisfaction and Accuracy of Infant Weight Perception in Families From Low-Income Backgrounds.

OBJECTIVE: To examine the association between maternal body dissatisfaction and mother's (mis)perception of their infant's weight classification among families from low-income households. METHODS: Mother-infant dyads were recruited during well-child visits from 2 urban primary care clinics. Maternal body dissatisfaction was measured using the Stunkard Figure Rating Scale. Perception of infant weight was assessed using a 5-point Likert scale. Infant weight-for-length percentiles were calculated using World Health Organization growth charts. Associations between maternal body dissatisfaction score and mother's (mis)perception of their infant's weight classification were examined using logistic regression allowing for nonlinear associations via restricted cubic splines. RESULTS: Mothers (n = 180) were 26.6 ± 5.1 years old and 72% Black; infants were 8.8 ± 2.1 months old. Mean infant weight-for-length percentile was 64 ± 26. On average, mothers wanted to be one body figure smaller than their perceived current body size. Most mothers (82%) accurately perceived their infant's weight classification while few overestimated (7%) or underestimated (11%) their child's weight category. The probability of mothers misperceiving their infant's weight classification increased as maternal body dissatisfaction increased in either extreme in unadjusted (P < .05) and adjusted analysis (P = .06). CONCLUSIONS: Increased maternal body dissatisfaction may be associated with mother's misperception of infant weight classification. Future studies should examine this relationship in a heterogeneous population.

Child diet and health outcomes of the simple suppers program: a 10-week, 2-group quasi-experimental family meals trial.

BACKGROUND: Racial minority children, particularly from low-income households, are at risk for obesity. Family meals have a protective effect on child nutritional health. However, the current evidence is limited in racial and socioeconomic diversity. The objective of this study was to evaluate the impact of a family meals intervention, Simple Suppers, on improvements in diet and health outcomes from baseline (T0) to post-intervention (T1) in intervention compared to waitlist control participants, and determine retention of change in outcomes among intervention participants at 10-week follow-up (T2). METHODS: Simple Suppers was a 10-week family meals intervention implemented as a 2-group quasi-experimental trial. Ten 90-min lessons were delivered weekly. Data were collected at T0 and T1, and from intervention participants at T2. Participants were racially diverse 4-10 year-old children from low-income households. Setting was a faith-based community center. Main outcomes were daily servings of fruit, vegetables, and sugar-sweetened beverages and diet quality; z-scores for body mass index (BMI), waist circumference, systolic and diastolic blood pressure (BP); weight status categories; food preparation skills; and family meals (frequency of dinner, breakfast, TV viewing during meals, meals in dining area). Generalized linear mixed models (GLMMs) and mixed-effects ordinal regression models were used to assess intervention impact (T0:T1). Paired t-tests examined retention of change among intervention participants (T1:T2). RESULTS: One hundred forty children enrolled and 126 completed T1 (90% retention); 71 of 87 intervention participants completed T2(79% retention). Mean (SD) age was 6.9(1.9) yr, 62% female, 60% Black, and 42% low-income. Intervention vs waitlist controls had higher food preparation skills (p < 0.001) and lower TV viewing during meals (p = 0.04) at T1.There were no group differences in dietary intake or quality or z-scores for BMI, waist circumference, or BP, however intervention versus waitlist controls experienced a greater change toward healthy weight (p = 0.04) At T2, intervention participants demonstrated a retention of improved food preparation skills. CONCLUSIONS: Simple Suppers led to improvements in children's weight status, food preparation skills, and TV viewing during meals, but not diet or z-scores for BMI, waist circumference, or BP. Future research should examine the preventive effects of healthy family mealtime routines in children at greatest risk for obesity. TRIAL REGISTRATION: NCT02923050; Simple Suppers Scale-up (S3); Retrospectively registered on Oct 2016; First participant enrolled on Jan 2015.

Factor structure of the Intuitive Eating Scale-2 among a low-income and racial minority population.

Intuitive eating, where an individual relies on one's own physiologic hunger and satiety cues instead of situational and emotional cues, is associated with healthier lifestyle choices, lower body-mass index (BMI), and positive psychological well-being. Despite the importance of this construct, no assessment measure of intuitive eating has been validated for use in a low-income Black population, who have an elevated risk for poor health outcomes. The aim of this study was to evaluate the factor structure of the Intuitive Eating Scale-2 (IES-2) in a predominately low-income Black population. A confirmatory factor analysis (CFA) followed by an exploratory factor analysis (EFA) were conducted using data from 204 adult participants. A large majority (71%) identified as Black and 89% had public insurance. The relationship between scores on the IES-2, BMI, and body-image dissatisfaction scores were also evaluated. A CFA of the previously used IES-2 structure demonstrated less than optimal fit. An EFA supported a six-factor, twenty-three item measure with the following names set for subscales: Avoiding Forbidden Foods (3 items), Permission to Eat (3 items), Avoiding Emotional Eating (4 items), Avoiding Food-Related Coping Strategies (4 items), Reliance on Hunger and Satiety Cues (6 items), and Body-Food Choice Congruence (3 items). The modified IES-2 scores were negatively associated with BMI and body-image dissatisfaction scores. A modified factor structure of the IES-2 may be a better measure of intuitive eating in low-income Black populations.

Parental intuitive eating behaviors and their association with infant feeding styles among low-income families.

INTRODUCTION: Feeding styles, the attitudes and behaviors parents use to direct their child's eating, shape a child's ability to self-regulate food intake and affects their future risk of obesity. This study examined how parental intuitive eating, where parents follow their own hunger and satiety cues, relates to infant feeding styles in a low-income, predominately Black population. METHODS: Parents of healthy infants aged 5.5-12.5 months were recruited during well-child visits at two urban primary care clinics. Parent's intuitive eating behaviors and infant feeding styles were measured using the Intuitive Eating Scale-2 (IES-2) and the Infant Feeding Style Questionnaire (IFSQ), respectively. Multivariable regression analysis, controlling for maternal and child demographic variables, was conducted to determine the relationship between parent intuitive eating behaviors and five infant feeding styles: restrictive, pressuring, indulgent, laissez-faire, and responsive. RESULTS: 201 parents completed the study, 90% were mothers and 69% were Black. Average infant age was 8.8 ±â€¯2.0 months. Parents who reported relying on their own hunger and satiety cues when eating were more likely to feed their infant in a responsive style (ß 0.10 ±â€¯0.04, p < 0.05). Parents who reported eating unconditionally, not labeling foods as forbidden, were more likely to feed their infant in a laissez-faire (ß 0.16 ±â€¯0.06, p < 0.05) and indulgent (ß 0.09 ±â€¯0.03, p < 0.05) feeding style. CONCLUSIONS: Parental intuitive eating behaviors are associated with both responsive and non-responsive infant feeding styles. Future studies should examine how parental intuitive eating and infant feeding styles affect infant growth trajectories.

Early Care and Education Teacher's Role in Obesity Prevention and Healthy Development of Young American Indian Children.

INTRODUCTION: The purpose of this study was to develop an understanding of how stakeholders, specifically early care and education (ECE) teachers, perceive their role in the development of young American Indian children, and envision working with health care providers and parents in order to enhance children's health. METHODOLOGY: Twenty tribally affiliated ECE teachers from Oklahoma participated in interviews. Thematic analysis was conducted, and three main themes, each with two to three subthemes, emerged. RESULTS: Teachers felt that nutrition and physical activity were important to children's health. Teachers had little professional interaction with health care providers but desired more. Parental empowerment was conveyed as essential to actualize positive changes in their child's behavior. DISCUSSION: Teachers of tribally affiliated ECE centers are important stakeholders in promoting the health and well-being of young American Indian children. Additional efforts are needed to more effectively integrate teachers and nurses in order to create effective interventions. We propose a stakeholder partnership to guide the development of future interventions.