Role modeling as an early childhood obesity prevention strategy: effect of parents and teachers on preschool children's healthy lifestyle habits

Physical Activity During Early Childhood: The Importance of Parental Modeling

Increasing physical activity (PA) is a critical issue in improving overall health. Prior attempts by public health campaigns to promote PA through health-focused messaging have faced challenges. As PA and sedentary behaviors are developed during the early childhood period (ages 0 to 5 years), this stage represents a unique opportunity for clinicians to encourage activity at the family level. Clinicians should discuss the holistic benefits of PA, including the development of social skills and relationships, motor skills that could be applicable to sports later in life, and cognitive skills that could translate to academic achievements in school. For PA to occur in children, parents should also be engaged in and model the PA behaviors, increasing the likelihood of young children learning to be physically active.

Communication With Family Child Care Providers and Feeding Preschool-Aged Children: Parental Perspectives

OBJECTIVE

To describe parent communication about child nutrition-related topics with family child care providers (FCCPs).

DESIGN

Five focus groups conducted from December, 2016 to July, 2017.

PARTICIPANTS

Parents (n = 25) of 2- to 5-year-old children attending family child care homes in Rhode Island.

PHENOMENON OF INTEREST

How and what parents communicate about with FCCPs related to feeding young children.

ANALYSIS

Recordings were transcribed verbatim. Two independent coders employed content analysis to analyze transcripts. Reflections, emerging themes, and final themes were discussed.

RESULTS

Participants were recruited through FCCPs and were mostly Hispanic and female. Parents mainly communicated with FCCPs in person. Communication with FCCPs related to how and what children were fed did not occur frequently, and parents usually inquired about how much children ate.

CONCLUSIONS AND IMPLICATIONS

Parents did not engage in frequent child nutrition-related communication with their FCCP. However, parents trusted FCCPs to provide healthy and sufficient food to children. More research is needed to identify effective strategies that facilitate child nutrition communication between parents and FCCPs.

The association between maternal features and nutritional problems in children with autism spectrum disorder

ABSTRACT Objective In the literature, there is almost no data on the relationship between autistic children’s nutritional problems and their mothers’ demographic and nutritional characteristics. Therefore, this study aimed to evaluate whether there was a relationship between maternal features and nutritional problems in autistic children. Methods This study was conducted with the participation of 58 autistic children (6-19 years) and their mothers. Descriptive data were obtained with a general questionnaire. For the evaluation of children’s nutritional status, anthropometric measurements and 24-hour dietary recall were used. Also, the Brief Autism Mealtime Behavior Inventory and ORTO-15 questionnaires were used to evaluate the meal behavior of children and orthorexia tendency of mothers, respectively. Results No significant correlation was found between the Brief Autism Mealtime Behavior Inventory scores in children of mothers with high and low orthorexia tendency. There were also no statistically significant differences between the children of mothers with high and low educational level in terms of Brief Autism Mealtime Behavior Inventory scores. Only the dietary vitamin B6 intake was significantly higher in the children of mothers with high educational level. Maternal age was associated with the dietary energy and protein intake, unlike, maternal orthorexia tendency was not associated with the nutritional status and meal behavior of children. The abdominal pain experience in the last one month was found to be significantly higher in the children of employed mothers than children of unemployed mothers. Conclusion It is thought that the maternal characteristics are not effective on meal behavior in children and also maternal age and educational status have a very limited effect on the nutritional status of children.

Different types of parental stress and childhood obesity: A systematic review of observational studies

Different types of parental stress may influence children's health behaviors and weight. The aim of this review was to systematically examine the relationships between parental stress and child obesity. We reviewed 27 studies published through December 2018 and classified parental stress as parents' general stress, parenting role stress, and life event stress. There were positive relationships of parents' general stress and parenting role stress with child obesity among families with younger children and in longitudinal studies. The relationship between life event stress and child obesity differed by measures. We found that parenting role stress may be associated with unhealthy parenting practices. Contextual factors such as children's and parents' sex, race or ethnicity, socioeconomic status, and family structure appeared to play a moderating role in the relationship between parents' stress and child obesity, which warrant cautious interpretation. Our recommendations for future research include clarifying further the types of parental stress that influence child obesity, evaluating long-term relationship between parental stress and child obesity, and identifying possible mediating factors to support the relationship between parents' stress and child obesity. Researchers may also consider developing stress management programs for parents to address child obesity.

Systematic review of interventions in the childcare setting with direct parental involvement: effectiveness on child weight status and energy balance-related behaviours

BACKGROUND

The early years are a crucial period to promote healthy energy balance-related behaviours in children and prevent overweight and obesity. The childcare setting is important for health-promoting interventions. Increasingly, attention has been paid to parental involvement in childcare-based interventions. The aim of this systematic review is to evaluate the effectiveness of these interventions with direct parental involvement on the children's weight status and behavioural outcomes.

METHODS

A systematic search was conducted in four electronic databases to include studies up until January 2019. Studies written in English, describing results on relevant outcomes (weight status, physical activity, sedentary behaviour and/or nutrition-related behaviour) of childcare-based interventions with direct parental involvement were included. Studies not adopting a pre-post-test design or reporting on pilot studies were excluded. To improve comparability, effect sizes (Cohen's d) were calculated. Information on different types of environment targeted (e.g., social, physical, political and economic) was extracted in order to narratively examine potential working principles of effective interventions.

RESULTS

A total of 22 studies, describing 17 different interventions, were included. With regard to the intervention group, 61.1% found some favourable results on weight status, 73.3% on physical activity, 88.9% on sedentary behaviour, and all on nutrition-related behaviour. There were studies that also showed unfavourable results. Only a small number of studies was able to show significant differences between the intervention and control group (22.2% weight status, 60.0% physical activity, 66.6% sedentary behaviour, 76.9% nutrition behaviour). Effect sizes, if available, were predominantly small to moderate, with some exceptions with large effect sizes. The interventions predominantly targeted the socio-cultural and physical environments in both the childcare and home settings. Including changes in the political environment in the intervention and a higher level of intensity of parental involvement appeared to positively impact intervention effectiveness.

CONCLUSION

Childcare-based interventions with direct parental involvement show promising effects on the children's energy balance-related behaviours. However, evidence on effectiveness is limited, particularly for weight-related outcomes. Better understanding of how to reach and involve parents may be essential for strengthening intervention effectiveness.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 August 2019. We searched Proquest Dissertations and Theses in May 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 78 trials with 214 trial arms and 13,746 participants. Forty-eight trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 20 of the 78 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is very low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 4.45 g as-desired consumption of vegetables (SMD 0.42, 95% CI 0.23 to 0.60; 18 trials, 2004 participants; mean post-intervention follow-up = 8.2 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.34, 95% CI 0.10 to 0.57; 9 trials, 3022 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.36 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; 11 trials, 3078 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) and unintended adverse consequences of interventions (2 trials), limiting their assessment. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 78 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low-quality evidence that child-feeding practice may lead to, and moderate-quality evidence that multicomponent interventions probably lead to small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Weight Control Practices in Children of Parents Participating in Weight Management Programs

Background: Family members influence the behaviors and weight loss of adults in weight management programs (WMPs). Less is known about the weight control practices of children who have a parent participating in a WMP. Thus, we aimed to explore weight control practices in children of parents in WMPs. Methods: We recruited participants who were parents of least one child aged 2-18 living at home from two institution's adult WMPs. Parents reported weight control practices for themselves and their child. We used separate logistic regression models to assess the association of each child weight control practice with parent weight control practice; child age, race, sex, and BMI z-score (BMIz); parent education; and household income. Results: Parents (N = 300) had a mean age of 41 ± 7 and 85% were female. Children (N = 295) had a mean age of 9.3 ± 4.9; 20% had overweight or obesity. Parents reported their child used the following weight control practices in the past year: 12% dieted, 12% ate very little food, 7% used food substitutes, 10% skipped meals, 29% increased fruit and vegetables, 25% reduced calories, 22% reduced snacking, 21% reduced fat intake, and 45% exercised. Children were more likely to utilize weight control practices if their parent utilized the same weight control practice and if children had obesity and were older. Conclusions: Children of parents attending WMPs commonly utilize weight control practices, especially older children with higher BMIz. Adult WMPs should offer guidance to parents on ways to incorporate new healthy dietary practices into their family.

Barriers and Facilitators to Compliance with a State Healthy Eating Policy in Early Care and Education Centers

BACKGROUND

Early care and education (ECE) policies can improve childhood obesity risk factors. We evaluated barriers and facilitators to implementing mandatory nutrition standards for foods provided in South Carolina ECE centers serving low-income children, comparing centers participating in the Child and Adult Care Food Program (CACFP) with non-CACFP centers.

METHODS

We mailed 261 surveys (demographics, policies and practices, barriers and facilitators) to center directors after new state nutrition standards were implemented in South Carolina. We conducted univariate and bivariate analyses to explore relationships between barriers, facilitators, and center-level characteristics, by CACFP status.

RESULTS

We received 163 surveys (62% response rate). Centers had a median [interquartile range (IQR)] of 5 (4-7) classrooms and 59 (37.5-89) total children enrolled. More than half (60.1%) of directors reported they were moderately or fully informed about the standards. The most common barriers were food costs (17.8%) and children's food preferences (17.8%). More non-CACFP directors reported food costs as a barrier (28.6% vs. 6.5%, p < 0.001), having to spend additional money on healthier foods (48.8% vs. 28.6%, p = 0.01), and having to provide additional nutrition education to parents (28.6% vs. 11.7%, p = 0.01), compared with CACFP directors.

CONCLUSIONS

Center directors were generally well informed about the nutrition standards. The most common barriers to implementing the standards were food costs and children's food preferences. Centers participating in CACFP may be in a better position to adhere to new state nutrition standards, as they receive some federal reimbursement for serving healthy foods and may be more accustomed to regulation.

CHAMP: A cluster randomized-control trial to prevent obesity in child care centers

Foundational elements of lifelong health are formed during the preschool years. Child care attendance has nearly doubled in the past 5 years making child care centers an ideal setting to establish healthy habits that prevent pediatric obesity. Despite the promising evidence of efficacy of child care-based obesity prevention interventions, limited attention has been directed to criteria needed for implementation at scale. There is potential to improve children's dietary and physical activity behaviors in diverse communities through theory-based, culturally appropriate, manualized interventions, delivered by child care staff. CHAMP (Creating Healthy Habits Among Maryland Preschoolers) is a 3-arm cluster randomized controlled childhood obesity prevention trial, aiming to improve motor skills, physical activity and willingness to try new foods among 864 preschoolers (age 3-5 years) enrolled in 54 child care centers in 10 Maryland counties. CHAMP is informed by social-cognitive and bioecological theories and based on an evidence-based program, The Food Friends®. The two intervention arms include: 1) child care-center based lessons (18-week gross motor and 12-week nutrition) administered by trained child care staff, and 2) a web-based intervention for caregivers in addition to center-based lessons. Evaluations are conducted among children, caregivers, and child care staff at fall enrollment, midline, and spring, following intervention completion. Analyses include linear mixed-models, accounting for clustering and repeated measures, incorporating center-arms as moderators. CHAMP will provide evidence-based information to inform wellness guidelines and policies that can be disseminated broadly, to ensure that child care centers provide opportunities for children to develop healthy eating, and physical activity habits. Trial Registration: NCT03111264; https://clinicaltrials.gov/ct2/show/NCT03111264.

Pediatric metabolic syndrome

Although the prevalence of obesity and its related complications are increasing among pediatric patients, appropriate management can prevent chronic disease. This article will present an overview of metabolic syndrome, pediatric metabolic syndrome guidelines, pathophysiology, associated risk factors, and clinical practice implications.

Participants' Perceptions of "C.H.A.M.P. Families": A Parent-Focused Intervention Targeting Paediatric Overweight and Obesity

Background: Recently, our team implemented a 13-week group-based intervention for parents of children with obesity ("C.H.A.M.P. Families"). The primary objective of this study was to explore, qualitatively, parents' perspectives of their experiences in and influence of C.H.A.M.P. Families, as well as their recommendations for future paediatric obesity treatment interventions. Methods: Twelve parents (seven mothers, five fathers/step-fathers) representing seven children (four girls, three boys) with obesity participated in one of two focus groups following the intervention. Focus groups were audio recorded and transcribed verbatim and data were analyzed using inductive thematic analysis. Results: Findings showed that parents perceived their participation in C.H.A.M.P. Families to be a positive experience. Participants highlighted several positive health-related outcomes for children, families, and parents. Parents also underscored the importance and positive impact of the group environment, specific educational content, and additional program components such as free child-minding. Recommendations for future interventions were also provided, including greater child involvement and more practical strategies. Finally, parents identified several barriers including socioenvironmental issues, time constraints, and parenting challenges. Conclusions: Researchers developing family-based childhood obesity interventions should consider the balance of parent and child involvement, as well as emphasize group dynamics strategies and positive family communication.

Tracking Changes of Chinese Pre-Service Teachers' Aerobic Fitness, Body Mass Index, and Grade Point Average Over 4-years of College

Although increasing attention has been given to student academic achievement, usually measured by grade point average (GPA), and fitness in children and adolescents, much fewer studies have been conducted in higher education settings, especially in China. This study investigated the longitudinal associations of aerobic fitness (AF), body mass index (BMI), and GPA in Chinese pre-service teachers at a university. A longitudinal research design was employed to track changes in AF, BMI, and GPA, for a total of 1980 students for four years. Multi-level growth models were used to examine the interactive changes of the above three variables. It was found that GPA and BMI increased each year, while AF declined dramatically at the fourth year. The three-way interaction among GPA, gender, and BMI was significant, suggesting females who were overweight/obese had lower GPA. The data from the current study suggested that AF did not impact students' GPA. Class standing (i.e., the fourth year) and gender (i.e., females) need to be taken into consideration when designing interventions to improve student overall fitness and academic performance in Chinese pre-service teacher populations.

An Internet-Based Childhood Obesity Prevention Program (Time2bHealthy) for Parents of Preschool-Aged Children: Randomized Controlled Trial

Background

Electronic health (eHealth) obesity programs offer benefits to traditionally delivered programs and have shown promise in improving obesity-related behaviors in children.

Objective

This study aimed to assess the efficacy of a parent-focused, internet-based healthy lifestyle program for preschool-aged children, who are overweight or at or above the fiftieth percentile for body mass index (BMI) for their age and sex, on child BMI, obesity-related behaviors, parent modeling, and parent self-efficacy.

Methods

The Time2bHealthy randomized controlled trial was conducted in Australia, during 2016 to 2017. Participants were recruited both online and through more traditional means within the community. Parent or carer, and child (aged 2-5 years) dyads were randomized into an intervention or comparison group. Intervention participants received an 11-week internet-based healthy lifestyle program, underpinned by social cognitive theory, followed by fortnightly emails for 3 months thereafter. Intervention participants set goals and received individual feedback from a dietitian. They were also encouraged to access and contribute to a closed Facebook group to communicate with other participants and the dietitian. Comparison participants received email communication only. Objectively measured child BMI was the primary outcome. Secondary outcomes included objectively measured physical activity, parent-measured and objectively measured sleep habits, and parent-reported dietary intake, screen time, child feeding, parent modeling, and parent self-efficacy. All data were collected at face-to-face appointments at baseline, 3 months, and 6 months by blinded data collectors. Randomization was conducted using a computerized random number generator post baseline data collection.

Results

A total of 86 dyads were recruited, with 42 randomized to the intervention group and 44 to the comparison group. Moreover, 78 dyads attended the 3- and 6-month follow-ups, with 7 lost to follow-up and 1 withdrawing. Mean child age was 3.46 years and 91% (78/86) were in the healthy weight range. Overall, 69% (29/42) of participants completed at least 5 of the 6 modules. Intention-to-treat analyses found no significant outcomes for change in BMI between groups. Compared with children in the comparison group, those in the intervention group showed a reduced frequency of discretionary food intake (estimate −1.36, 95% CI −2.27 to −0.45; P=.004), and parents showed improvement in child feeding pressure to eat practices (−0.30, 95% CI 0.06 to −0.00; P=.048) and nutrition self-efficacy (0.43, 95% CI 0.10 to 0.76; P=.01). No significant time by group interaction was found for other outcomes.

Conclusions

The trial demonstrated that a parent-focused eHealth childhood obesity prevention program can provide support to improve dietary-related practices and self-efficacy but was not successful in reducing BMI. The target sample size was not achieved, which would have affected statistical power.

Trial Registration

Australian New Zealand Clinical Trials Registry ANZCTR12616000119493; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=370030 (Archived by WebCite at http://www.webcitation.org/74Se4S7ZZ).

"C.H.A.M.P. Families": Description and Theoretical Foundations of a Paediatric Overweight and Obesity Intervention Targeting Parents-A Single-Centre Non-Randomised Feasibility Study

Childhood obesity represents a significant global health challenge, and treatment interventions are needed. The purpose of this paper is to describe the components and theoretical model that was used in the development and implementation of a unique parent-focussed paediatric overweight/obesity intervention. C.H.A.M.P. Families was a single-centre, prospective intervention offered to parents of children aged between 6–14 years with a body mass index (BMI) ≥85th percentile for age and sex. The intervention included: (1) eight group-based (parent-only) education sessions over 13-weeks; (2) eight home-based activities; and (3) two group-based (family) follow-up support sessions. The first section of the manuscript contains a detailed description of each intervention component, as well as an overview of ongoing feasibility analyses. The theoretical portion details the use of evidence-based group dynamics principles and motivational interviewing techniques within the context of a broader social cognitive theory foundation. This paper provides researchers with practical examples of how theoretical constructs and evidence-based strategies can be applied in the development and implementation of parent-focussed paediatric obesity interventions. Given the need for transparent reporting of intervention designs and theoretical foundations, this paper also adds to the areas of implementation science and knowledge translation research.

Mobile Device Use Among Rural, Low-Income Families and the Feasibility of an App to Encourage Preschoolers' Physical Activity: Qualitative Study

BACKGROUND

As mobile devices are becoming ubiquitous, technology-based interventions provide a promising strategy to positively influence health behaviors of families with young children. However, questions remain about the feasibility and acceptability of intervention delivery via mobile apps in low-income, rural settings and among families with preschoolers.

OBJECTIVE

The aims of this study were to understand the content and context of mobile device use for preschoolers; explore parent beliefs on this topic, including the acceptability of intervention delivery via mobile devices; and test a prototype of an app to encourage preschoolers' physical activity with both parents and children.

METHODS

Parents (n=29) were recruited from 5 preschool centers in eastern, rural Colorado to complete a semistructured telephone interview regarding preschoolers' mobile device use. A second sample of parents (n=31) was recruited from the same preschool centers to view the app prototype independently and provide feedback. A third sample of preschool children (n=24) was videotaped using the app in small groups to measure engagement and record their responses to the app.

RESULTS

Five key content areas emerged from the telephone interviews: (1) mobile devices are an important part of families' everyday routines, and parents have parameters governing their use; (2) parents often use mobile devices as a tool for behavior management; (3) parents clearly distinguish between mobile device use for learning versus entertainment; (4) parents have an overarching desire for balance in regard to their child's mobile device use; and (5) parents were generally supportive of the idea of using mobile apps for intervention delivery. From the app prototype testing with parents, participants reacted positively to the app and felt that it would be useful in a variety of situations. Testing with preschoolers showed the children were highly engaged with the app and a majority remained standing and/or actively moving through the entire length of the app.

CONCLUSIONS

Mobile devices are already integrated into most families' daily routines and appear to be an acceptable method of intervention delivery in low-income families in rural Colorado. The physical activity app represents an innovative way to reach these families and, with further improvements based on participant feedback, will provide children with a unique opportunity to practice key movement skills.

Family characteristics and children's knowledge of cardiovascular risk factors

BACKGROUND

Cardiovascular disease has the highest mortality rate than any other disease globally. Some major risk factors seem to be established in the early stages of life, suggesting preventive strategies as a major means to reduce cardiovascular mortality. The aim of the present study was to investigate the role of socioeconomic status and family characteristics on children's knowledge and perceptions concerning cardiovascular disease risk factors.

METHODS

A cross-sectional survey was conducted among 1,728 children (46% male) aged 10-12 years, attending Greek primary schools in Athens; Heraklion (capital city of the island of Crete); Kalamata; Pyrgos; and Sparti (Peloponnese peninsula), Greece. Sampling was conducted on school premises, during the school years 2014-15 and 2015-16 (participation rate, 95-100%). Data were collected via self-administered, anonymous questionnaire. Children's knowledge of various issues related to cardiovascular risk, such as nutrition, physical activity and smoking was also examined. Data on family characteristics were collected through another questionnaire completed by parents.

RESULTS

Paternal education level and living with both parents instead of single-parent upbringing, were positively associated with children's knowledge of cardiovascular risk factors (b = 0.42; 95%CI: 0.01-0.83; P = 0.04; and b = 0.78; 95%CI: 0.013-1.43; P = 0.02 respectively). Moreover, children with more siblings seemed to have less sufficient knowledge compared with peers with fewer siblings (b per 1 sibling = -0.24; 95%CI: -0.47 to -0.014; P = 0.04).

CONCLUSIONS

The present findings enhance the link between the micro-environment and children's knowledge and perceptions concerning cardiovascular health, providing information to health-care professionals while counseling youths.

Improving Nutrition Habits and Reducing Sedentary Time Among Preschool-Aged Children in Cuenca, Ecuador: A Trial of a School-Based Intervention

INTRODUCTION

In Ecuador, the prevalence of overweight and obesity among school-age children is more than triple that of preschool-age children; however, preschoolers have not been the target of interventions.

METHODS

We developed an educational and behavioral intervention that included games, singing, and storytelling. Children were recruited from municipal preschools in Cuenca and were enrolled in the pilot intervention (PI) (N=155) for the 2015-2016 school year, which consisted of a 3-month in-school program. For the 2016-2017 school year, a separate group of children was enrolled in the enhanced intervention (EI) (N=152), which consisted of a 7-month program at both school and home.

RESULTS

Parents in both groups reported a post-intervention reduction in their child's daily at-home consumption of sugar-sweetened beverages (PI: -23.2%, P < .001; EI: -16.8%, P < .001). Additional beneficial effects of the EI not observed with the PI were an increase in drinking water daily at home (+8.3%, P = .04) and eating fruits and vegetables daily for snacks at home (+21.8%, P < .001), a reduction in excessive weekend screen time (-7.6%, P = .03), and a reduction of 0.11 in mean BMI-for-age z score (P = .003). When comparing the PI and EI, the EI was associated with a greater difference in mean BMI-for-age z score (-0.25; P < .001) and fruit and vegetable consumption (+15.9%; P = .01).

CONCLUSION

Our preschool-based intervention appeared to be successful in promoting healthy lifestyle habits, especially when combined with a household component. Further research is needed to determine if the intervention had long-term effects, as well as to adapt it for different settings.

[Parental obesity is associated with the severity of childhood obesity and its comorbidities]

INTRODUCTION

The influence of parental obesity on their obese offsprings is acknowledged but insufficiently characterised.

PATIENTS AND METHODS

Retrospective study of 800 obese patients (45.2% girls; age: 10.35±3.40 years, body mass index [BMI]:+4.22±1.68 standard deviation score [SDS]). Group comparison according to the presence of obesity in none (n=347) or any of the parents (n=453), and then whether the obese parent was the father (n=185), the mother (n=151), or both parents (n=117) were performed. The parameters analysed were: Age at the onset of the obesity and at their first visit, birth weight (BW), BMI-SDS, blood glucose, insulin level, homeostatic model assessment (HOMA) index, total cholesterol (TC), HDL, LDL, triglycerides, 25-OH-vitamin-D, area under the curve (AUC) for insulin in the oral glucose tolerance test (OGTT), whole body insulin sensitivity index (WBISI), LDL/HDL and TC/HDL ratios, and weight loss after 12 month follow-up.

RESULTS

No differences were observed between groups as regarding gender, ethnic background, or pubertal stage. Patients with one obese parent showed higher BW-SDS and BMI-SDS (P<.01), more severe impairment of carbohydrate metabolism (blood insulin, insulin-AUC, HOMA, HbA1c [P<.01] and lower WBISI [P<.05]) than those with no obese parent. Among those patients with a single obese parent, higher BW-SDS, insulin, HOMA, and lower 25-OH-vitamin D (P<.05) was observed when obesity was present in the mother. There was a higher prevalence of metabolic syndrome when both parents were obese (χ²=5.96, P<.05). A total of 132 patients reduced their BMI by ≥1.5SDS, or their weight by ≥10%, with no influence of the background of parental obesity.

CONCLUSIONS

Obesity in any parent determines a higher severity of their offspring obesity and metabolic comorbidities, more importantly when obesity is present in the mother or in both parents, but without interference in the options of therapeutic success.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2018. We searched Proquest Dissertations and Theses in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 63 trials with 178 trial arms and 11,698 participants. Thirty-nine trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fourteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Nine studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 63 included trials as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining studies.There is very low quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 3.50 g as-desired consumption of vegetables (SMD 0.33, 95% CI 0.13 to 0.54; participants = 1741; studies = 13). Multicomponent interventions versus no intervention may have a very small effect on child consumption of fruit and vegetables (SMD 0.35, 95% CI 0.04 to 0.66; participants = 2009; studies = 5; low-quality evidence), equivalent to an increase of 0.37 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; participants = 3078; studies = 11; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for four studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 63 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low- and low-quality evidence respectively that child-feeding practice and multicomponent interventions may lead to very small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up is required and future research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Exploring How the Home Environment Influences Eating and Physical Activity Habits of Low-Income, Latino Children of Predominantly Immigrant Families: A Qualitative Study

Latinos are the largest and fastest growing minority population group in the United States, and children in low-income Latino families are at elevated risk of becoming overweight or having obesity. A child’s home is an important social environment in which he/she develops and maintains dietary and physical activity (PA) habits that ultimately impact weight status. Previous research suggests the parents are central to creating a home environment that facilitates or hinders the development of children’s early healthy eating and PA habits. Therefore, the purpose of this study was to explore low-income Latino parents’ beliefs, parenting styles, and parenting practices related to their children’s eating and PA behaviors while at home. Methods: Qualitative study using focus group discussions (FGDs) with 33 low-income Latino parents of preschool children 2 to 5 years of age. FGDs were transcribed verbatim and analyzed using thematic analysis. Results: Data analyses revealed that most parents recognize the importance of healthy eating and PA for their children and themselves. However, daily life demands including conflicting schedules, long working hours, financial constraints, and neighborhood safety concerns, etc., impact parents’ ability to create a home environment supportive of these behaviors. Conclusions: This study provides information about how the home environment may influence low-income Latino preschool children’s eating and PA habits, which may be useful for health promotion and disease prevention efforts targeting low-income Latino families with young children, and for developing home-based and parenting interventions to prevent and control childhood obesity among this population group. Pediatric healthcare providers can play an important role in facilitating communication, providing education, and offering guidance to low-income Latino parents that support their children’s development of early healthy eating and PA habits, while taking into account daily life barriers faced by families. Moreover, pediatric healthcare providers also can play an important role in the integration and coordination of home-visitations to complement office-based visits and provide a continuum of care to low-income Latino families.

Close relationships and the management of chronic illness: Associations and interventions

Self-management of a chronic illness involves not only monitoring symptoms, adhering to medication regimens, and keeping medical appointments but also making and maintaining difficult lifestyle changes. This article highlights correlational and intervention research suggesting family members are influential in children's and adults' illness management. The argument is made that a dyadic approach to chronic illness management that targets the influence of close relationships may yield more sustainable effects on patient behavior than has been achieved in the past. In particular, dyadic approaches aimed at helping patients and family members to find ways to collaborate in goal setting for these behaviors is recommended. Such dyadic interventions may also benefit family members who are ill or are at risk because of poor health behaviors. (PsycINFO Database Record

Changes in Nutrition Policies and Dietary Intake in Child Care Homes Participating in Healthy Eating and Active Living Initiative

INTRODUCTION

From 2012 to 2014, a total of 17 family child care homes participated in a multisector, community-wide initiative to prevent obesity. Strategies included staff workshops, materials, site visits, and technical assistance regarding development and implementation of nutrition policies. The purpose of the evaluation was to examine the impact of the initiative on family child care home nutrition-related policies and practices and child dietary intake.

STUDY DESIGN

Pre- and post-intervention without control group. Measures taken at baseline and follow-up included structured observations and questionnaires regarding nutrition policies, practices, and environments; documentation of lunch foods served on 5 days; and lunch plate waste observations on 2 days. Paired t-tests were used to determine the significance of change over time.

SETTING/PARTICIPANTS

Seventeen family child care homes in a low-income diverse community in Northern California; children aged 2-5 years who attended the family child care homes.

MAIN OUTCOME MEASURES

Change in nutrition-related policies and practices, lunch foods served and consumed.

RESULTS

Data was collected at 17 sites for an average of 5.2 children aged 2-5 years per site per day at baseline and 4.6 at follow-up for a total of 333 plate waste observations. There were significant increases in staff training, parental involvement, and several of the targeted nutrition-related practices; prevalence of most other practices either improved or was maintained over time. There were significant increases in the number of sites meeting Child and Adult Care Food Program meal guidelines, variety of fruit and frequency of vegetables offered, and reductions in frequency of juice and high-fat processed meats offered. Adequate portions of all food groups were consumed at both time points with no significant change over time.

CONCLUSIONS

A simple, policy-focused intervention by a child care resource and referral agency was successful at reinforcing and improving upon nutrition-related practices at family child care homes. Children consumed adequate, but not excessive, portions of the balanced meals served to them, suggesting there is no reason to offer unhealthy options.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Predictors of Nutrition Quality in Early Child Education Settings in Connecticut

OBJECTIVE

This study assessed the dietary quality of lunches and feeding practices (family-style service, teacher role modeling) in Connecticut child care centers and made comparisons by center participation in the federal Child and Adult Care Food Program (CACFP).

DESIGN

Plate waste methods and visual observation of lunches served and consumed.

SETTING

A total of 97 randomly selected licensed Connecticut child care centers (53 CACFP and 44 non-CACFP).

PARTICIPANTS

A total of 838 preschool-aged children.

MAIN OUTCOME MEASURES

Total energy intake, macronutrient intake, and intake by CACFP meal component as well as use of family-style dining, management of additional helpings, and whether and what teachers consumed in view of children.

ANALYSIS

Child dietary intake at lunch was compared with dietary and CACFP recommendations using a mixed linear regression model.

RESULTS

The CACFP centers were more likely to offer family-style service and have staff eat the same foods as the children. Children in non-CACFP centers consumed more saturated fat (4.1 vs 2.7 g; P < .001) and trans fats (0.1 vs 0.1 g; P = .02) and less milk (3.5 vs 2.7 oz; P < .001) than did children in CACFP centers. Caloric intake and dietary fiber were below recommendations in both groups. Participation in CACFP was a significant predictor of low-fat milk consumption.

CONCLUSIONS AND IMPLICATIONS

The CACFP-participating centers confer some nutritional advantages in terms of provider behavior during meals, characteristics of food offerings, and child intake. Current feeding practices in child care settings require further exploration in the context of serving children at risk for food insecurity and in light of recent work on responsive feeding.

Community-based childhood obesity prevention intervention for parents improves health behaviors and food parenting practices among Hispanic, low-income parents

Background

Given the current prevalence of childhood obesity among Hispanic populations, and the importance of parental feeding behaviors, we aimed to assess the impact of the evidence-based Healthy Children, Healthy Families (HCHF) intervention on responsive food parenting practices (FPPs) in a low-income Hispanic population.

Methods

This community-based pilot study used a non-experimental pre/post within-subjects design. Parents (n = 94) of children aged 3-11 years old were recruited to participate in an 8-week, weekly group-based intervention. The intervention was delivered to nine groups of parents by trained paraprofessional educators over a two-year period. Children participated in a separate curriculum that covered topics similar to those covered in the parent intervention. Parents completed self-administered pre/post surveys, which included demographic questions, seven subscales from the Comprehensive Feeding Practices Questionnaire, and the 16-item HCHF Behavior Checklist. Descriptive statistics and paired samples t-tests were used to analyze data from parents that completed the intervention.

Results

Fifty-two, primarily Hispanic (93%) parents completed the intervention (39% attrition rate). For parents who completed the intervention, there was a significant increase in one of the feeding practice subscales: encouragement of balance and variety (p = 0.01). There were significant improvements in several parent and child diet and activity outcomes (p ≤ 0.01).

Conclusions

Although attrition rates were high, parents completing the study reported enjoying and being satisfied with the intervention. For parents who completed the intervention, reported 'encouragement of balance and variety', in addition to several health behaviors significantly improved. Larger studies utilizing an experimental design, should further explore the impact of the HCHF curriculum on improving certain FPPs and health behaviors that contribute to obesity.

Characteristics of Effective Interventions Promoting Healthy Eating for Pre-Schoolers in Childcare Settings: An Umbrella Review

Early Childhood Education and Care (ECEC) settings have a pivotal role in shaping children’s dietary food habits by providing the contextual environment within which they develop these behaviours. This study examines systematic reviews for (1) the effectiveness of interventions to promote healthy eating in children aged 2–5 years attending centre-based childcare; (2) intervention characteristics which are associated with promoting healthy eating and; (3) recommendations for child-health policies and practices. An Umbrella review of systematic reviews was undertaken using a standardized search strategy in ten databases. Twelve systematic reviews were examined using validated critical appraisal and data extraction tools. Children’s dietary food intake and food choices were significantly influenced. Interventions to prevent obesity did not significantly change children’s anthropometric measures or had mixed results. Evidence was more convincing if interventions were multi-component, addressed physical activity and diet, targeted individual-level and environmental-level determinants and engaged parents. Positive outcomes were mostly facilitated by researchers/external experts and these results were not replicated when implemented in centres by ECEC providers without this support. The translation of expert-led interventions into practice warrants further exploration of implementation drivers and barriers. Based on the evidence reviewed, recommendations are made to inform child-health directed practices and policies.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases, including cardiovascular disease.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE and Embase to identify eligible trials on 25 September 2017. We searched Proquest Dissertations and Theses and two clinical trial registers in November 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 55 trials with 154 trial arms and 11,108 participants. Thirty-three trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Thirteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Eight studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition intervention delivered to children in increasing child fruit and vegetable intake.We judged 14 of the 55 included trials as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining studies.Meta-analysis of trials examining child-feeding practices versus no intervention revealed a positive effect on child vegetable consumption (SMD 0.38, 95% confidence interval (CI) 0.15 to 0.61; n = 1509; 11 studies; very low-quality evidence), equivalent to a mean difference of 4.03 g of vegetables. There were no short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.11, 95% CI -0.05 to 0.28; n = 3023; 10 studies; very low-quality evidence) or multicomponent interventions versus no intervention (SMD 0.28, 95% CI -0.06 to 0.63; n = 1861; 4 studies; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions. Studies reported receiving governmental or charitable funds, except for three studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 55 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains sparse. There was very low-quality evidence that child-feeding practice interventions are effective in increasing vegetable consumption in children aged five years and younger, however the effect size was very small and long-term follow-up is required. There was very low-quality evidence that parent nutrition education and multicomponent interventions are not effective in increasing fruit and vegetable consumption in children aged five years and younger. All findings should be considered with caution, given most included trials could not be combined in meta-analyses. Given the very low-quality evidence, future research will very likely change estimates and conclusions. Such research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Parent Perceptions of Mobile Device Use Among Preschool-Aged Children in Rural Head Start Centers

OBJECTIVE

To describe child use and parents' beliefs and comfort with young children's use of mobile devices in low-income, rural communities.

METHODS

This was a descriptive, cross-sectional study. The survey, which consisted of 18 multiple-part questions, was distributed to families at 5 Head Start/preschool centers in Colorado.

RESULTS

In total, 192 surveys were returned (28.5% response rate). Most children (92%) used a smartphone or tablet at some frequency and most parents (90%) had downloaded apps specifically for their child. Education and ethnicity were related to parents' technology beliefs. Parent comfort with technology was positively associated with greater child use of technology (P < .001).

CONCLUSIONS AND IMPLICATIONS

Mobile device use was relatively high in this sample. Mobile devices appear to be a feasible platform to offer nutrition and physical activity education for this audience. Ensuring parent comfort with technology and apps will be important.

Training early childcare providers in evidence-based nutrition strategies can help improve nutrition policies and practices of early childcare centres serving racially and ethnically diverse children from low-income families

OBJECTIVE

We evaluated the extent to which providing training and technical assistance to early childcare centre (ECC) directors, faculty and staff in the implementation of evidence-based nutrition strategies improved the nutrition contexts, policies and practices of ECC serving racially and ethnically diverse, low-income children in Broward County, Florida, USA. The nutrition strategies targeted snack and beverage policies and practices, consistent with Caring for Our Children National Standards.

DESIGN

We used the nutrition observation and document review portions of the Environment and Policy Assessment and Observation (EPAO) instrument to observe ECC as part of a one-group pre-test/post-test evaluation design.

SETTING

ECC located within areas of high rates of poverty, diabetes, minority representation and unhealthy food index in Broward County, Florida, USA.

SUBJECTS

Eighteen ECC enrolled, mean 112·9 (sd 53·4) children aged 2-5 years; 12·3 (sd 7·2) staff members; and 10·2 (sd 4·6) children per staff member at each centre.

RESULTS

We found significant improvements in centres' overall nutrition contexts, as measured by total EPAO nutrition scores (P=0·01). ECC made specific significant gains within written nutrition policies (P=0·03) and nutrition training and education (P=0·01).

CONCLUSIONS

Our findings support training ECC directors, faculty and staff in evidence-based nutrition strategies to improve the nutrition policies and practices of ECC serving racially and ethnically diverse children from low-income families. The intervention resulted in improvements in some nutrition policies and practices, but not others. There remains a need to further develop the evaluation base involving the effectiveness of policy and practice interventions within ECC serving children in high-need areas.

Digital Screen Time Limits and Young Children's Psychological Well-Being: Evidence From a Population-Based Study

There is little empirical understanding of how young children's screen engagement links to their well-being. Data from 19,957 telephone interviews with parents of 2- to 5-year-olds assessed their children's digital screen use and psychological well-being in terms of caregiver attachment, resilience, curiosity, and positive affect in the past month. Evidence did not support implementing limits (< 1 or < 2 hr/day) as recommended by the American Academy of Pediatrics, once variability in child ethnicity, age, gender, household income, and caregiver educational attainment were considered. Yet, small parabolic functions linked screen time to attachment and positive affect. Results suggest a critical cost-benefit analysis is needed to determine whether setting firm limits constitutes a judicious use of caregiver and professional resources.

How effective are family-based and institutional nutrition interventions in improving children's diet and health? A systematic review

BACKGROUND

Effective strategies to improve dietary intake in young children are a priority to reduce the high prevalence of chronic non-communicable diseases in adulthood. This study aimed to assess the impact of family-based and school/preschool nutrition programs on the health of children aged 12 or younger, including the sustainability of these impacts and the relevance to socio-economic inequalities.

METHODS

A systematic review of literature published from 1980 to December 2014 was undertaken. Randomised controlled trials involving families with children aged up to 12 years in high income countries were included. The primary outcomes were dietary intake and health status. Results were presented in a narrative synthesis due to the heterogeneity of the interventions and outcomes.

RESULTS

The systematic search and assessment identified 39 eligible studies. 82% of these studies were set in school/preschools. Only one school study assessed the impact of involving parents systematically. The family-based programs which provided simple positive dietary advice to parents and regular follow-up reduced fat intake significantly. School and family-based studies, if designed and implemented well, increased F&V intake, particularly fruit. Effective school-based programs have incorporated role-models including peers, teachers and heroic figures, rewards and increased access to healthy foods. School nutrition programs in disadvantaged communities were as effective as programs in other communities.

CONCLUSIONS

Family and school nutrition programs can improve dietary intake, however evidence of the long-term sustainability of these impacts is limited. The modest overall impact of even these successful programs suggest complementary nutrition interventions are needed to build a supportive environment for healthy eating generally.

The Longitudinal Association Between Early Childhood Obesity and Fathers' Involvement in Caregiving and Decision-Making

OBJECTIVE

Fathers have increased their involvement in child caregiving; however, their changing role in childhood obesity is understudied. This study assessed the longitudinal association between changes in obesity among children aged 2 to 4 years and changes in fathers' involvement with raising children.

METHODS

Longitudinal data from the Early Childhood Longitudinal Study-Birth Cohort were used to conduct child fixed-effects linear and logistic regression analyses to assess the association between changes in childhood obesity-related outcomes (sugar-sweetened beverage consumption, screen time, BMI z score, overweight/obesity, obesity) and fathers' involvement with raising children (caregiving and influencing child-related decisions). Fixed-effects models control for all time-invariant characteristics. Analyses were controlled for time-varying confounders, including child age, maternal and paternal employment, and family poverty status.

RESULTS

Children whose fathers increased their frequency of taking children outside and involvement with physical childcare experienced a decrease in their odds of obesity from age 2 to age 4. Obesity-related outcomes were not associated with fathers' decision-making influence.

CONCLUSIONS

Increases in fathers' involvement with some aspects of caregiving may be associated with lower odds of childhood obesity. Encouraging fathers to increase their involvement with raising children and including fathers in childhood obesity prevention efforts may help reduce obesity risk among young children.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future chronic diseases, including cardiovascular disease.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase Classic and Embase to identify eligible trials on 30 September 2016. We searched CINAHL and PsycINFO in July 2016, Proquest Dissertations and Theses in November 2016 and three clinical trial registers in November 2016 and June 2017. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included studies to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included studies; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures.We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 50 trials with 137 trial arms and 10,267 participants. Thirty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Eleven trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Eight studies examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. One study examined the effect of a nutrition intervention delivered to children in increasing child fruit and vegetable intake.Thirteen of the 50 included trials were judged as free from high risks of bias across all domains; performance, detection and attrition bias were the most common domains judged at high risk of bias of remaining studies.Meta-analysis of trials examining child-feeding practices versus no intervention revealed a positive effect on child vegetable consumption (SMD 0.38, 95% CI 0.15 to 0.61; n = 1509; 11 studies; very low-quality evidence), equivalent to a mean difference of 4.03 grams of vegetables. There were no short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.11, 95% CI -0.05 to 0.28; n = 3023; 10 studies; very low-quality evidence) or multicomponent interventions versus no intervention (SMD 0.28, 95% CI -0.06 to 0.63; n = 1861; 4 studies; very low-quality evidence).Insufficient data were available to assess long-term effectiveness, cost effectiveness and unintended adverse consequences of interventions.Studies reported receiving governmental or charitable funds, except for two studies reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 50 eligible trials of various intervention approaches, the evidence for how to increase fruit and vegetable consumption of children remains sparse. There was very low-quality evidence child-feeding practice interventions are effective in increasing vegetable consumption of children aged five years and younger, however the effect size was very small and long-term follow-up is required. There was very low-quality evidence that parent nutrition education and multicomponent interventions are not effective in increasing fruit and vegetable consumption of children aged five years and younger. All findings should be considered with caution, given most included trials could not be combined in meta-analyses. Given the very low-quality evidence, future research will very likely change estimates and conclusions. Such research should adopt more rigorous methods to advance the field.This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Time2bHealthy - An online childhood obesity prevention program for preschool-aged children: A randomised controlled trial protocol

BACKGROUND

The use of parent-focused internet-based programs for the prevention and treatment of childhood obesity has shown promise but there is an acknowledged gap in parent-focused interventions which target the early childhood stage.

METHODS

The aim of this study is to determine the efficacy of Time2bHealthy - an online healthy lifestyle program for parents of preschool-aged children. The program will be evaluated using a two-arm, parallel, randomised controlled design. The 11-week program is underpinned by Social Cognitive Theory and consists of interactive modules on healthy eating, physical activity, screen-time and sleep. The intervention also involves elements of social media, where participants share discuss ideas and experiences and they can interact and obtain information with experts. Time2bHealthy is being compared to a comparison condition. Outcomes include change in BMI (primary outcome), dietary intake, physical activity, sleep, child feeding, parental role-modelling and parent self-efficacy. Process evaluation data, such as adherence and engagement with the online forums, will also be collected.

DISCUSSION

Time2bHealthy is the first randomised controlled trial to our knowledge to assess the efficacy of an online parent-focussed healthy lifestyle program for preschool-aged children in changing body mass index. Early childhood is a crucial time for establishing healthy lifestyle behaviours and parents play an important role. This study therefore fills an important gap in the literature. If found to be efficacious, Time2bHealthy has potential for broad-reach access and translation into primary health care services.

TRIAL REGISTRATION

The study is registered with the Australian and New Zealand Clinical Trials Registry (12616000119493).

Effectiveness of a Parent Health Report in Increasing Fruit and Vegetable Consumption Among Preschoolers and Kindergarteners

OBJECTIVE

To determine the effectiveness of a parent health report on fruit and vegetable consumption among preschoolers and kindergarteners.

DESIGN

Pre-post open design trial and a randomized controlled trial.

SETTING

A university-sponsored preschool and kindergarten.

PARTICIPANTS

A total of 63 parents of preschool and kindergarten students participated in the pre-post open design trial and 65 parents participated in the randomized controlled trial.

INTERVENTION

Parents in intervention groups were given a parent health report providing information about their child's fruit and vegetable intake as well as recommendations for how to increase their child's fruit and vegetable consumption.

MAIN OUTCOME MEASURE

Change in fruit and vegetable consumption.

ANALYSIS

Latent growth curve modeling with Bayesian estimation.

RESULTS

Vegetable consumption increased by 0.3 servings/d in the open trial and 0.65 servings/d in the randomized trial. Fruit consumption did not increase significantly in either study.

CONCLUSIONS AND IMPLICATIONS

Results from both an open trial and a randomized controlled trial suggested that the parent health report may be a beneficial tool to increase vegetable consumption in preschoolers and kindergarteners. Increases in vegetable consumption can lead to the establishment of lifelong habits of healthy vegetable intake and decrease risk for chronic diseases.

[Reduce sedentary behaviour among children - a systematic review]

BACKGROUND AND OBJECTIVES

Sedentary behaviour is itself a health-related behaviour. This systematic review examines whether family-based interventions can reduce sitting time among children and adolescents and which variables moderate potential intervention effects.

METHODS

Using a systematic literature search we identified family-based randomised controlled intervention studies that focus on sedentary behaviour in 3‑ to 18-year-old children and youth. The methodological quality of studies as well as the intervention effects according to different outcomes (screen-based vs. overall sitting) were analysed and evaluated for moderating effects.

RESULTS

Of 29 studies, 17 reported significant effects and 11 studies showed positive trends for reduced sitting time. The content of interventions, the level of theoretical underpinning as well as the methodological quality of studies were heterogeneous. Most often, screen-based sitting and seldom overall sitting was examined. Concise characteristics of intervention success were not clearly apparent. The proportion of positive intervention effects was higher in reducing sitting in front of TVs compared to other outcomes. An analysis of moderators highlighted that intervention programs among pre-schoolers showed more often positive intervention effects.

DISCUSSION

There are many promising opportunities to reduce sitting time using family-based approaches. Statements in terms of replication of interventions and explanations of the effective mechanisms within interventions are limited. Therefore, future interventions should use subjective as well as objective evaluation measures and consider overall sitting time. To strengthen the basis of interventional effort in this research field, a theoretical planning approach is recommended.

Co-creating healthful eating behaviors with very young children: The impact of information overload on primary caregivers

Primary caregivers of very young children are subject to excessive and often disparate information regarding the instilling of healthful eating behaviors. Our study focuses on the integration of the operant resources of primary caregivers (i.e., their knowledge and modeling skills) and that of their very young children (i.e., their self-regulation of energy intake and food preferences) to co-create healthful eating behaviors as a measure to curb overweight and obesity in adulthood. Our two-stage qualitative study makes original contributions demonstrating that primary caregivers' efforts to co-create healthful eating behaviors with their very young children are adversely affected by information overload.

Strategies to improve the implementation of healthy eating, physical activity and obesity prevention policies, practices or programmes within childcare services

BACKGROUND

Despite the existence of effective interventions and best-practice guideline recommendations for childcare services to implement policies, practices and programmes to promote child healthy eating, physical activity and prevent unhealthy weight gain, many services fail to do so.

OBJECTIVES

The primary aim of the review was to examine the effectiveness of strategies aimed at improving the implementation of policies, practices or programmes by childcare services that promote child healthy eating, physical activity and/or obesity prevention. The secondary aims of the review were to:1. describe the impact of such strategies on childcare service staff knowledge, skills or attitudes;2. describe the cost or cost-effectiveness of such strategies;3. describe any adverse effects of such strategies on childcare services, service staff or children;4. examine the effect of such strategies on child diet, physical activity or weight status.

SEARCH METHODS

We searched the following electronic databases on 3 August 2015: the Cochrane Central Register of Controlled trials (CENTRAL), MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, ERIC, CINAHL and SCOPUS. We also searched reference lists of included trials, handsearched two international implementation science journals and searched the World Health Organization International Clinical Trials Registry Platform (www.who.int/ictrp/) and ClinicalTrials.gov (www.clinicaltrials.gov).

SELECTION CRITERIA

We included any study (randomised or non-randomised) with a parallel control group that compared any strategy to improve the implementation of a healthy eating, physical activity or obesity prevention policy, practice or programme by staff of centre-based childcare services to no intervention, 'usual' practice or an alternative strategy.

DATA COLLECTION AND ANALYSIS

The review authors independently screened abstracts and titles, extracted trial data and assessed risk of bias in pairs; we resolved discrepancies via consensus. Heterogeneity across studies precluded pooling of data and undertaking quantitative assessment via meta-analysis. However, we narratively synthesised the trial findings by describing the effect size of the primary outcome measure for policy or practice implementation (or the median of such measures where a single primary outcome was not stated).

MAIN RESULTS

We identified 10 trials as eligible and included them in the review. The trials sought to improve the implementation of policies and practices targeting healthy eating (two trials), physical activity (two trials) or both healthy eating and physical activity (six trials). Collectively the implementation strategies tested in the 10 trials included educational materials, educational meetings, audit and feedback, opinion leaders, small incentives or grants, educational outreach visits or academic detailing. A total of 1053 childcare services participated across all trials. Of the 10 trials, eight examined implementation strategies versus a usual practice control and two compared alternative implementation strategies. There was considerable study heterogeneity. We judged all studies as having high risk of bias for at least one domain.It is uncertain whether the strategies tested improved the implementation of policies, practices or programmes that promote child healthy eating, physical activity and/or obesity prevention. No intervention improved the implementation of all policies and practices targeted by the implementation strategies relative to a comparison group. Of the eight trials that compared an implementation strategy to usual practice or a no intervention control, however, seven reported improvements in the implementation of at least one of the targeted policies or practices relative to control. For these trials the effect on the primary implementation outcome was as follows: among the three trials that reported score-based measures of implementation the scores ranged from 1 to 5.1; across four trials reporting the proportion of staff or services implementing a specific policy or practice this ranged from 0% to 9.5%; and in three trials reporting the time (per day or week) staff or services spent implementing a policy or practice this ranged from 4.3 minutes to 7.7 minutes. The review findings also indicate that is it uncertain whether such interventions improve childcare service staff knowledge or attitudes (two trials), child physical activity (two trials), child weight status (two trials) or child diet (one trial). None of the included trials reported on the cost or cost-effectiveness of the intervention. One trial assessed the adverse effects of a physical activity intervention and found no difference in rates of child injury between groups. For all review outcomes, we rated the quality of the evidence as very low. The primary limitation of the review was the lack of conventional terminology in implementation science, which may have resulted in potentially relevant studies failing to be identified based on the search terms used in this review.

AUTHORS' CONCLUSIONS

Current research provides weak and inconsistent evidence of the effectiveness of such strategies in improving the implementation of policies and practices, childcare service staff knowledge or attitudes, or child diet, physical activity or weight status. Further research in the field is required.

Impact of 20 Week Lifestyle Intervention Package on Anthropometric Biochemical and Behavioral Characteristics of Schoolchildren in North India

BACKGROUND

Childhood obesity is a public health problem worldwide. There is convincing evidence that school-based interventions are effective in managing childhood obesity. However, the nature of interventions, its impact on prevention of obesity and how they work remain poorly understood. The primary objective of this study was to examine the impact of a multicomponent lifestyle intervention on weight and body mass index (BMI) of children in a school-based setting.

METHODS

It is a cluster randomized trial where four schools were randomly selected and allocated to intervention and control arm equally. Of the 462 schoolchildren selected, 201 were assigned to the intervention group and 261 belonged to the control group. Children in the intervention arm received a multicomponent lifestyle package. Primary outcome measures included anthropometric measurements (weight, BMI, skinfold thickness and waist and hip circumference), whereas secondary outcomes were biochemical parameters, physical activity and dietary intake.

RESULTS

Compared with controls and adjusting for age, sex and clustering within classes, children in the intervention group showed decrease in the weight by - 0.08 (-0.15 to - 0.00, p  =  0.048) z-score units, waist circumference by - 0.14 (-0.25 to - 0.03, p  =  0.01) and triceps thickness by - 0.35 (-0.47 to - 0.22, p < 0.001) z-score units; however, BMI showed no significant decrease. There was significant reduction in intake of energy, protein and fat but no to minimal reduction in biochemical parameters.

CONCLUSION

A school-based lifestyle intervention package favorably affected anthropometric (weight, waist circumference and triceps and biceps thickness) and behavioral parameters. At least 20 weeks of healthy lifestyle promoting intervention package should be included in school curriculum in each academic year for sustainable impact and behavioral change to reduce the burden of lifestyle disorders.

Development and Application of the Remote Food Photography Method to Measure Food Intake in Exclusively Milk Fed Infants: A Laboratory-Based Study

Background

Accurate methods of assessing food intake in infants are needed to assess the relationship between infant feeding practices and risk of childhood obesity. Current methods are either subjective or have limited ability for use beyond clinical research settings.

Objective

To assess the accuracy of the RFPM to evaluate simulated milk intake including energy, macronutrient, and micronutrient intake compared to direct weighing within a controlled study.

Methods

Individuals were recruited to prepare three 2 fl oz, 4 fl oz, 6 fl oz, and 8 fl oz servings of infant formula and to capture photographs at different stages of preparation (dry powdered formula, prepared formula, and liquid waste) using the SmartIntake^® application. Gram weights of the bottles were obtained by the RFPM and direct weighing. Using the United States Department of Agriculture National Nutrient Database for Standard Reference, energy, macronutrient, and micronutrient values were generated from gram weights.

Results

Intake of formula prepared from powder measured by the RFPM was equivalent to weighed intake within 7.5% equivalence bounds among all servings and each serving size. The mean difference between methods varied among servings sizes with the RFPM underestimating intake by 1.6 ± 0.4 kcals in 2 fl oz servings, 4.8 ± 0.6 kcals in 4 fl oz servings, and 6.2 ± 1.0 kcals in 6 fl oz servings, and overestimating intake by 0.1 ± 1.2 kcals in 8 fl oz servings. Bland-Altman analysis showed that the RFPM overestimated intake at lower levels food intake and underestimated intake at higher levels. Considering photographs of only the prepared formula bottle and the bottle with formula waste to simulate ready-to-feed formula and human breast milk, intake estimated by the RFPM was equivalent to the directly weighed intake within 7.5% for all servings.

Conclusions

The RFPM has higher accuracy than subjective methods and similar accuracy as compared to the objective methods in estimating simulated intake of milk and formula with lower burden to caregivers. The RFPM is a viable method for measuring intake in exclusively milk fed infants by caregivers in a controlled environment with potential for widespread use in research and clinical practice.

"Whole-of-Community" Obesity Prevention: A Review of Challenges and Opportunities in Multilevel, Multicomponent Interventions

The causes of obesity worldwide are complex and multilevel, including changing food environments, physical activity levels, policies, and food production systems. This intricate context requires multilevel and multicomponent (MLMC) interventions to improve health outcomes. We conducted a literature review of MLMC interventions for obesity prevention and mitigation; 14 studies meeting search criteria were identified. We found examples of successes in preventing obesity, reducing overweight, improving healthful behaviors, and enhancing some psychosocial indicators. Of eight studies that reported health and behavioral results, five showed no significant impact and three showed reductions in obesity. Four studies showed significant improvement in dietary behavior, and five reported significant desirable effects in physical activity or screen time. Five studies reported psychosocial impacts, and three of these showed significant improvements. MLMC approaches show promising results, particularly when they are able to integrate components at the policy, community, and interpersonal levels.

Perceptions of nursery staff and parent views of healthy eating promotion in preschool settings: an exploratory qualitative study

BACKGROUND

In the UK just over a fifth of all children start school overweight or obese and overweight 2-5 year olds are at least 4 times more likely to become overweight adults. This can lead to serious future health problems. The WHO have recently highlighted the preschool years as a critical time for obesity prevention, and have recommended preschools as an ideal setting for intervention. However, existing evidence suggests that the preschool environment, including the knowledge, beliefs and practices of preschool staff and parents of young children attending nurseries can be a barrier to the successful implementation of healthy eating interventions in this setting.

METHODS

This study examined the perceptions of preschool centre staff and parents' of preschool children of healthy eating promotion within preschool settings. The participants were preschool staff working in private and local authority preschool centres in the North East of England, and parents of preschool children aged 3-4 years. Preschool staff participated in semi-structured interviews (n = 16 female, 1 male). Parents completed a mapping activity interview (n = 14 mothers, 1 father). Thematic analysis was applied to interpret the findings.

RESULTS

Complex communication issues surrounding preschool centre dietary 'rules' were apparent. The staff were keen to promote healthy eating to families and felt that parents needed 'education' and 'help'. The staff emphasised that school policies prohibited providing children with sugary or fatty snacks such as crisps, cakes, sweets and 'fizzy' drinks, however, some preschool centres appeared to have difficulty enforcing such guidelines. Parents were open to the idea of healthy eating promotion in preschool settings but were wary of being 'told what to do' and being thought of as 'bad parents'.

CONCLUSIONS

There is a need to further explore nursery staff members' personal perceptions of health and how food policies which promote healthier food in preschool settings can be embedded and implemented. Family friendly healthy eating strategies and activities which utilise nudge theory should be developed and delivered in a manner that is sensitive to parents' concerns. Preschool settings may offer an opportunity for delivery of such activities.

Parent-Focused Childhood and Adolescent Overweight and Obesity eHealth Interventions: A Systematic Review and Meta-Analysis

Background

Effective broad-reach interventions to reduce childhood obesity are needed, but there is currently little consensus on the most effective approach. Parental involvement in interventions appears to be important. The use of eHealth modalities in interventions also seems to be promising. To our knowledge, there have been no previous reviews that have specifically investigated the effectiveness of parent-focused eHealth obesity interventions, a gap that this systematic review and meta-analysis intends to address.

Objective

The objective of this study was to review the evidence for body mass index (BMI)/BMI z-score improvements in eHealth overweight and obesity randomized controlled trials for children and adolescents, where parents or carers were an agent of change.

Methods

A systematic review and meta-analysis was conducted, which conforms to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Seven databases were searched for the period January 1995 to April 2015. Primary outcome measures were BMI and/or BMI z-score at baseline and post-intervention. Secondary outcomes included diet, physical activity, and screen time. Interventions were included if they targeted parents of children and adolescents aged 0-18 years of age and used an eHealth medium such as the Internet, interactive voice response (IVR), email, social media, telemedicine, or e-learning.

Results

Eight studies were included, involving 1487 parent and child or adolescent dyads. A total of 3 studies were obesity prevention trials, and 5 were obesity treatment trials. None of the studies found a statistically significant difference in BMI or BMI z-score between the intervention and control groups at post-intervention, and a meta-analysis demonstrated no significant difference in the effects of parent-focused eHealth obesity interventions compared with a control on BMI/BMI z-score (Standardized Mean Difference −0.15, 95% CI −0.45 to 0.16, Z=0.94, P=.35). Four of seven studies that reported on dietary outcomes demonstrated significant improvements in at least 1 dietary measurement, and 1 of 6 studies that reported on physical activity outcomes demonstrated significant improvements compared with the control. The quality of the interventions was generally not high; therefore, these results should be interpreted with caution.

Conclusion

It is recommended that larger, longer duration, high-quality parent-focused eHealth studies are conducted, which transform successful components from face-to-face interventions into an eHealth format and target younger age groups in particular.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews: CRD42015019837; http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015019837 (Archived by WebCite at http://www.webcitation.org/6ivBHvBhq)