Parent health literacy and "obesogenic" feeding and physical activity-related infant care behaviors

Infant Feeding Outcomes from a Culturally-Adapted Early Obesity Prevention Program for Immigrant Chinese American Parents

OBJECTIVE

To examine whether a cultural adaptation of an early childhood obesity prevention program promotes healthy infant feeding practices.

STUDY DESIGN

Prospective quasi-experimental study of a community-engaged multiphasic cultural adaptation of an obesity prevention program set at a federally qualified health center serving immigrant Chinese American parent-child dyads (N=298). In a group of historical controls, we assessed early infant feeding practices (breastfeeding, sugar-sweetened beverage intake) in 6-month-olds and then the same practices alongside early solid food feeding practices (bottle weaning, fruit, vegetable, sugary or salty snack consumption) in 12-month-olds. After implementation, we assessed these practices in an intervention cohort group at 6 and 12 months. We used cross-sectional groupwise comparisons and adjusted regression analyses to evaluate group differences.

RESULTS

At 6 months, the intervention group had increased odds of no sugar-sweetened beverage intake (aOR: 5.69 [95% CI: 1.65, 19.63], p=0.006). At 12 months, the intervention group also had increased odds of no sugar-sweetened beverage intake (aOR: 15.22 [95% CI: 6.33, 36.62], p<0.001), increased odds of bottle weaning (aOR: 2.34 [95% CI: 1.05, 5.23], p=0.03), and decreased odds of sugary snack consumption (aOR: 0.36 [0.18, 0.70], p= 0.003). We did not detect improvements in breastfeeding, fruit, vegetable, or salty snack consumption.

CONCLUSION

A cultural adaptation of a primary care-based educational obesity prevention program for immigrant Chinese American families with low-income is associated with certain healthy infant feeding practices. Future studies should evaluate cultural adaptations of more intensive interventions that better address complex feeding practices like breastfeeding and evaluate long-term weight outcomes.

Development of the Conversational Health Literacy Assessment Tool for maternity care (CHAT-maternity-care): participatory action research

BACKGROUND

Limited health literacy in (expectant) parents is associated with adverse health outcomes. Maternity care providers often experience difficulties assessing (expectant) parents' level of health literacy. The aim was to develop, evaluate, and iteratively adapt a conversational tool that supports maternity care providers in estimating (expectant) parents' health literacy.

METHODS

In this participatory action research study, we developed a conversational tool for estimating the health literacy of (expectant) parents based on the Conversational Health Literacy Assessment Tool for general care, which in turn was based on the Health Literacy Questionnaire. We used a thorough iterative process including different maternity care providers, (expectant) parents, and a panel of experts. This expert panel comprised representatives from knowledge institutions, professional associations, and care providers with whom midwives and maternity care assistants work closely. Testing, evaluation and adjustment took place in consecutive rounds and was conducted in the Netherlands between 2019 and 2022.

RESULTS

The conversational tool 'CHAT-maternity-care' covers four key domains: (1) supportive relationship with care providers; (2) supportive relationship within parents' personal network; (3) health information access and comprehension; (4) current health behaviour and health promotion. Each domain contains multiple example questions and example observations. Participants contributed to make the example questions and example observations accessible and usable for daily practice. The CHAT-maternity-care supports maternity care providers in estimating (expectant) parents' health literacy during routine conversations with them, increased maternity care providers' awareness of health literacy and helped them to identify where attention is necessary regarding (expectant) parents' health literacy.

CONCLUSIONS

The CHAT-maternity-care is a promising conversational tool to estimate (expectant) parents' health literacy. It covers the relevant constructs of health literacy from both the Conversational Health Literacy Assessment Tool and Health Literacy Questionnaire, applied to maternity care. A preliminary evaluation of the use revealed positive feedback. Further testing and evaluation of the CHAT-maternity-care is required with a larger and more diverse population, including more (expectant) parents, to determine the effectiveness, perceived barriers, and perceived facilitators for implementation.

Health literacy and parenting infants at home: protocol for a qualitative systematic review of parents' experiences

OBJECTIVE

This systematic review will identify and synthesize the available qualitative evidence regarding parents' experiences of health literacy in parenting infants at home.

INTRODUCTION

Parental health literacy, which is essential for parents' and children's health, is associated with parents' health knowledge, parenting practices, and children's health outcomes. Parents face difficulties pertaining to their health literacy skills in daily health education and health care for their infants; therefore, understanding their parenting experience with infants from a health literacy perspective is important for health professionals. This review will evaluate and integrate qualitative evidence regarding parental experiences of health literacy in daily parenting of infants at home.

INCLUSION CRITERIA

This review will include qualitative data from empirical studies describing parents' experiences of health literacy in parenting infants at home. Parents of infants (0-1 year of age) living at home in Organisation for Economic Co-operation and Development member countries will be included.

METHODS

This review will follow the JBI approach for qualitative systematic reviews. The following databases will be searched for published and unpublished studies: MEDLINE (EBSCOhost), CINAHL (EBSCOhost), PsycINFO (EBSCOhost), and ProQuest Health and Medical Collection (in English and Japanese); Open Access Theses and Dissertations (in English); and Ichushi-Web, CiNii, and the Institutional Repositories Database (in Japanese). Study selection, data extraction, and critical appraisal of the methodological quality of studies will be undertaken by 2 reviewers independently. Data synthesis will be conducted using the meta-aggregation approach, and the synthesized findings will be assessed using the ConQual approach.

REVIEW REGISTRATION

PROSPERO CRD42022345187.

Value of video-based education to enhance infant motor development

BACKGROUND

Parents play a vital role in promoting infant motor development and physical activity; however, there is little information available to parents on how to support healthy movement. Therefore, the purpose of this study was to assess the feasibility of implementing video-based education to improve infant physical activity and motor development.

METHODS

This multiple case study consisted of semi-structured interviews with mothers (n = 12) and early childhood experts (n = 5, e.g., pediatrician, home visitor). Participants watched pre-recorded videos and answered questions which were developed following Bowens and colleagues guide for designing feasibility studies. Data were analyzed using a directed content analysis approach.

RESULTS

Most mothers (91.7 %) reported they were highly likely to recommend the videos to others and said the best way to share these videos would be through an app or social media (83.3 %) or health care entities (e.g., hospital, pediatrician, 75 %). Half of mothers (50 %) reported they would be interested in seeing videos once a month or once every couple of months. Further, all experts agreed parents would be somewhat or highly likely to use the videos and a majority (80 %) stated they were highly likely to recommend and share videos like these. Experts' top suggestions for sharing the videos was through an app/social media (40 %) and credible websites (40 %).

DISCUSSION

Overall, the videos appear feasible for mothers. Both groups primarily suggested that videos be disseminated through social media, online, or through an app. Future research should engage parents and healthcare providers in developing videos.

Communication strategies and effectiveness of early childhood obesity-related prevention programs for linguistically diverse communities: A rapid review

Children from culturally and linguistically diverse backgrounds experience higher rates of obesity and have poorer outcomes in obesity prevention studies. Interventions tailored to specific cultural groups may be limited within linguistically diverse, multicultural communities, and thus, alternative approaches to childhood obesity prevention in these communities are needed. This study aims to describe communication strategies used in interventions targeting prevention of obesity/obesity-related behaviors, among children 0-5 years, from linguistically diverse communities, and assess their effectiveness. A rapid review was conducted by systematically searching Medline, Embase, and CINAHL. The inclusion criteria are as follows: Studies reported an intervention tailored to linguistically diverse communities targeting at least one obesity-related behavior among children 0-5 years. The exclusion criteria are as follows: Interventions used simple language translations, targeted one language group, or treated obesity. A total of 4677 articles were identified with 14 studies meeting inclusion criteria. Key communication strategies included materials in multiple languages, English text written at a set readability level, and multimodal delivery. Six studies reported effectiveness data, of which five had effective primary or secondary outcomes. This is the first rapid review to identify communication strategies used in childhood obesity prevention interventions for linguistically diverse communities, highlighting a need for future research to incorporate and evaluate the communication strategies identified.

Early Sweet Tooth: Juice Introduction During Early Infancy is Related to Toddler Juice Intake

OBJECTIVE

To assess if 100% fruit juice intake prior to 6 months is associated with juice and sugar-sweetened beverage (SSB) intake at 24 months and whether this differs by sociodemographic factors.

METHODS

We used longitudinal data from infants enrolled in the control (no obesity intervention) arm of Greenlight, a cluster randomized trial to prevent childhood obesity which included parent-reported child 100% fruit juice intake at all well child checks between 2 and 24 months. We studied the relationship between the age of juice introduction (before vs after 6 months) and juice and SSB intake at 24 months using negative binomial regression while controlling for baseline sociodemographic factors.

RESULTS

We report results for 187 participants (43% Hispanic, 39% non-Hispanic Black), more than half (54%) of whom had reported 100% fruit juice intake before 6 months. Average 100% fruit juice intake at 24 months was greater than the recommended amount (of 4 oz) and was 8.2 oz and 5.3 oz for those who had and had not, respectively, been introduced to juice before 6 months. In adjusted models, early introduction of juice was associated with a 43% (95% confidence interval: 5%-96%) increase in juice intake at 24 months.

CONCLUSIONS

100% fruit juice intake exceeding recommended levels at 6 and 24 months in this diverse cohort was prevalent. Introducing 100% fruit juice prior to 6 months may put children at greater risk for more juice intake as they age. Further research is necessary to determine if early guidance can reduce juice intake.

Development of Mothers' Health Literacy: Findings From the KUNO-Kids Study

BACKGROUND AND OBJECTIVE

The aim of this study was to analyze the longitudinal development of health literacy (HL) in a large cohort of new mothers in Germany and to investigate which determinants are associated with the initial HL level and with change over time.

METHODS

Longitudinal data from 1,363 mothers participating with their child in the KUNO-Kids Health Study was used; data were collected at birth of the child (baseline), after 6 and 12 months, using interviews and self-report questionnaires. The HL of mothers was assessed with the health care scale of the European Health Literacy Survey Questionnaire, which has 16 items on accessing, understanding, appraising, and applying health information in the health care setting. Latent growth curve models were used to analyze average trajectories and predictors of HL in the total sample and in the subgroup of first-time mothers.

KEY RESULTS

HL values increased from baseline (M = 35.46, standard deviation [SD] = 7.34) over 6 months (M = 37.31, SD = 7.31) to 12 months (M = 38.01, SD = 7.41). The increase was statistically significant in the total sample (1.188, standard error [SE] = 0.087, p < .001) and in the subgroup of first-time mothers (1.357, SE = 0.113, p <. 001), with a steeper trajectory for mothers with lower HL at baseline. Several personal and situational variables were associated with HL at baseline (e.g., education, child health) and with its development (e.g., number of children).

CONCLUSION

Overall, new mothers became slightly more health literate during their child's first year of life. However, some groups of mothers could benefit from support in developing HL skills even before childbirth. [HLRP: Health Literacy Research and Practice. 2023;7(1):e39-e51.] Plain Language Summary: We investigated how health literacy (that is the ability to find, understand, and apply health information) develops in new mothers in Germany. Mothers told us that this ability slightly improved during the child's first year of life. Some mothers still have difficulties in dealing with health information; these mothers should be supported even before childbirth.

"I Am Afraid of Positioning my Baby in Prone": Beliefs and Knowledge about Tummy Time Practice

Objective

To identify beliefs and knowledge about tummy time (TT) practice and its repercussions on motor development.

Methods

Longitudinal study carried out with parents/caregivers of infants older than 30 days of life. Two assessments were performed. A structured interview was conducted, while the babies were between one and six months old to identify beliefs, knowledge about TT, and the motor milestone achievement expected for the age. At six to 12 months, the risk of motor development delay was tracked using the survey of well-being of young infant questionnaire (SWYC).

Results

41 families responded to the SWYC questionnaire (21 were allocated to the TT group). 31.70% reported that it was not important to put the infants in a prone position while awake, and 70.70% said they are afraid their babies would become breathless when positioned in a prone position. 85.70% of infants from the TT group showed typical development, while 55% of the control group showed atypical development for their age (p = 0.01). Only three infants from the control group were at risk of delayed motor development (p = 0.10).

Conclusions

Most of the families feel insecure about proning their babies and fear breathlessness when positioned. Acquisition of motor milestones prevailed in the TT group, suggesting an association between TT practice and motor milestone achievement.

The home environment and its relation to bottle feeding outcomes in the first year of life

BACKGROUND

The home environment and caregiver interactions have an impact on infant development. However, there is a paucity of research surrounding the home environment and its relation to early feeding outcomes within the first year of life. Therefore, the aim of this study was to examine the relationship between the home environment and infant bottle feeding outcomes at 3 and 12 months of age.

METHODS

Seventy-two full-term infants completed this study at 3 months of age and fifty-five infants completed the study at 12 months. Data in the current study were collected from a larger, ongoing study completed in the infant's home at 3 and 12 months of age. The Infant-Toddler Home Observation for Measurement of Environment Inventory (IT-HOME) was utilized to assess the infant's home environment. The Oral Feeding Skills (OFS) scale was completed while the infant was observed during a bottle feed. Caregivers completed a questionnaire about their infant's feeding abilities via the Neonatal Eating Assessment Tool (Neo-EAT) at 3 months and Pediatric Eating Assessment Tool (Pedi-EAT) at 12 months.

RESULTS

At 3 months of age, the IT-HOME Involvement subscale was associated with an increase in the amount of milk provided in the infant's bottle. There were no significant associations between the IT-HOME and caregiver report of feeding at 3 months of age. At 12 months of age, the IT-HOME Acceptance subscale was associated with an increase in oral transfer rate and the IT-HOME Variety subscale was associated with a decrease in oral transfer rate. Additionally, the IT-HOME Organization subscale was associated with caregiver report of feeding on the following Pedi-EAT scales: Mealtime Behaviors, Selective Restrictive Eating, and Oral Processing at 12 months.

CONCLUSIONS

These findings reveal that the home environment is significantly related to different infant bottle feeding outcomes over the first year of life. At 3 months, IT-HOME Involvement was associated with the amount of milk offered in the bottle, whereas at 12 months of age, subscales of the IT-HOME were associated with oral feeding transfer rate and caregiver report of feeding. Clinically, these findings point to the importance of considering the infant's bottle feeding skills in conjunction with certain aspect within the infant's environment. Additional research is needed to further explore these relationships in greater detail, with a larger sample size and across patient populations.

Association between the dietary literacy of children's daily diet providers and school-age children's nutritional status and eating behaviours: a cross-sectional study

BACKGROUND

Overweight and obesity rates have increased rapidly in Chinese school-age children, and previous studies have indicated that poor dietary literacy can lead to unhealthy eating behaviours. However, few studies have investigated the association between the dietary literacy of daily diet providers and the eating behaviours and nutritional status of school-age children raised by the providers. Thus, we aimed to explore this association.

METHODS

We collected data on the eating behaviours and nutritional status of children in two primary schools in Anhui Province, as well as the dietary literacy of their daily diet providers. T-tests, one-way ANOVA, chi-square tests, and multiple linear regression were used to analyse the association.

RESULTS

We found significant differences in the scores on the Questionnaire of Children's Daily Diet Providers' Dietary Literacy (QCDDPDL) by region, relationship with the child, age, and educational level of the daily diet provider (all p < .05). Moreover, the children in the low QCDDPDL score group were inclined to engage in unhealthy eating behaviours such as emotional undereating and overeating (p < .05). In addition, the incidence of overweight and obesity was higher in the low QCDDPDL attitude score group than in the high score group (p = .006).

CONCLUSIONS

Our study showed that the dietary literacy of diet providers may influence children's health and eating behaviours. Improving the dietary literacy of diet providers may promote the health status and eating behaviours of school-age children.

Feeding and Activity Environments for Infants and Toddlers in Childcare Centers and Family Childcare Homes in Southeastern New England

Few studies have documented the food and physical activity (PA) environments of childcare settings caring for children <24 months of age, although they may be key contributors to developing child PA and diet patterns. We used an adapted Environment and Policy Assessment and Observation tool to assess the food and activity environments for infants and toddlers in childcare centers (n = 21) and family childcare homes (FCCH) (n = 20) and explored differences by childcare type. Many similarities were found between childcare site types; however, centers used more recommended feeding practices than FCCH (e.g., 100% of center providers talked with toddlers about feelings of hunger or fullness compared to 18% of family childcare providers (FCCP), p < 0.01). Differences in non-recommended feeding practices (e.g., spoon feeding, bottle propping and encouraging unhealthy foods) were mixed between childcare types. Toddlers in centers spent more time playing at higher PA levels than those in FCCH (61 vs. 13 min, p < 0.001). Screen time was observed in FCCH, but not in centers. Differences between childcare types may indicate differential influences on infant and toddler feeding and PA behaviors, which could predict disparate obesity risk. Future research should further observe these behaviors in a larger sample of centers and FCCH to inform childcare interventions and policies.

Overconfidence in Managing Health Concerns: The Dunning-Kruger Effect and Health Literacy

Health literacy is often low within the general population. The Dunning–Kruger effect (DKE) suggests that individuals may experience a cognitive bias in which they overestimate their own knowledge base. This study examines the DKE regarding health literacy and health behaviors. A community sample (n = 504) completed questionnaires measuring objective health literacy, confidence in health knowledge, and health behaviors and medical conditions. Results support the presence of a DKE for health literacy; individuals with low health literacy reported equal or greater confidence in health knowledge than individuals with higher health literacy. Individuals with lower health literacy reported more problematic engagement in health behaviors. Low health literacy can impact engagement in health behavior and effect health outcomes, but individuals may not realize this deficit. Implications for clinical intervention include the need to address cognitive bias and enhance motivation to participate in health literacy interventions.

Managing health in inequitable contexts: Health capacities as integral to life course health development

Health behavior models are widely used in prevention research with children and adolescents; yet, many of these models were developed based on adult experiences and fail to consider the development of health constructs. The concept of health capacity development is a theoretical model of how health capacities, the health-related developmental sociocultural resources individuals use to regulate their coactions with their environments to sustain health, develop. Health capacities are formed through person-environment transactions and thus, are informed by, and help individuals manage, the opportunities and constraints situated in their environments. The extent to which health capacities support long-term adaptive health development varies; yet, health capacities may be leveraged for adaptative functioning. Grounded in the Life Course Health Development (LCHD) framework and the principles of Relational Developmental Systems (RDS) metatheory, the development of three health capacities, their role in managing person-environment coactions, and their potential for facilitating displays of resilient functioning in inequitable contexts are described. Implications of the model, its limitations, and avenues for future research are discussed.

Information seeking of French parents regarding infant and young child feeding: practices, needs and determinants

OBJECTIVE

As part of an update of feeding benchmarks targeting children aged 0-3 years, this study aimed to explore parental perceptions, information-seeking practices and needs concerning infant and young child feeding (IYCF) to design an efficient communication strategy.

DESIGN

Participants were recruited using the quota sampling to complete an online survey. Effects of parity, child age, prematurity, parental education and financial situation on parents' responses were evaluated separately.

SETTING

France.

PARTICIPANTS

A nationally representative sample of 1001 parents of children <4 years.

RESULTS

Parents whose child had any medical condition affecting feeding (children with medical condition (CMC), 17 %) were considered separately from healthy children's parents. All the healthy children's parents recognised the importance of IYCF for children's health and growth; however, one-third considered the available advice contradictory and not guilt-free. The most used information sources were healthcare professionals (HCP, 81 %), internet (72 %) and parental networks (63 %). The most influential sources (mean influence ± sd) included HCP (7·7 ± 1·7/10), childcare professionals (7·3 ± 1·8/10) and parental networks (6·9 ± 1·8/10). Parents searched for practical tips for implementing IYCF starting when their child was 5 months old. Differences regarding the type of source used by parents with higher v. lower educations were small. Search strategies differed according to parity or child age but not to prematurity. The CMC parents reported slightly different practices and needs.

CONCLUSIONS

Parents receive information from multiple sources, which can lead to confusion when deciding which advice to follow. A public health communication strategy adapted to the current parental needs should target these various sources.

Breastfeeding behavior is not associated with health literacy: evidence from the German KUNO-Kids birth cohort study

PURPOSE

Despite the health benefits of full breastfeeding for both infants and mothers, less than 50% of mothers in Germany practice this method for at least 4 months after childbirth. Because of the growing importance of health literacy to improve public health, we investigated the role of maternal health literacy in breastfeeding behavior.

METHODS

We analyzed the data of 1172 mother-child dyads of the KUNO-Kids health study of the University Children's and Maternity Hospital Regensburg. Maternal health literacy was assessed with the HLS-EU-Q47 questionnaire (sub-index health care) up to 48 h after childbirth. Outcome was analyzed 6 months after childbirth and categorized into full breastfeeding for less than 4 months or for at least 4 months. The association between breastfeeding and maternal health literacy was calculated with univariable and multivariable logistic regression analyses.

RESULTS

38.8% of mothers showed inadequate or limited health literacy. 75.9% of mothers had fully breastfed their child for at least 4 months. Univariable logistic regression analysis showed that health literacy and full breastfeeding for at least 4 months were not associated (OR = 0.995 [CI 0.977-1.015], p = 0.60). After adjusting for all potentially confounding variables with a significant association (p ≤ 0.05) on both health literacy and breastfeeding, the multivariable model showed no association between health literacy and breastfeeding (OR = 0.984 [CI 0.963-1.007], p = 0.170).

CONCLUSION

Surprisingly, we found no association between health literacy and breastfeeding behavior in our study. Therefore, future research with comparable measurements of health literacy and breastfeeding is required to validate this result and to identify reasons for early breastfeeding cessation.

Pathways linking parental health literacy with health behaviours directed at the child: a scoping review

Health literacy (HL) is thought to be crucial for the management of the manifold demands relating to child health which parents are faced with. Albeit many studies have investigated parental HL and health behaviours (HBs) directed at the child, knowledge about the pathways which link parental HL with HB is scarce. The aim of this scoping review was to identify and comprehensively describe the variety of pathways linking parental HL with HBs directed at the child which were empirically analysed in previous studies. Following established scoping review methods database searches were conducted in MEDLINE, EMBASE, PsycINFO and WebofScience on 5 March 2020. Eligibility criteria included primary, empirical studies assessing parental HL and HB directed at the child in the general parent population. Titles and abstracts were screened independently by six reviewers for potentially relevant publications and data were extracted using standardized data extraction forms. The search identified 6916 articles for title and abstract screening. After full-text review, 50 studies were included in this review. Most studies (N = 24) assumed a direct association between HL and HBs and only few studies (N = 4) used more complex models investigating different pathways or mediation and/or moderation models. Overall, the evidence on the underlying pathways linking parental HL and HBs directed at the child is mixed and fairly limited. Therefore, hypothesis-driven research and integration of results into theoretical frameworks is needed for advancing both the research on HL and public health practice.

Relationship between maternal healthy eating literacy and healthy meal provision in families in Japan

This study examined the effects of maternal healthy eating literacy (HEL) on healthy meal provision in Japanese families. We conducted an online cross-sectional survey with 1899 mothers of pre-school children. Participants were divided into two groups based on their median score of eating out and consuming convenience foods, and demographic variables were compared between these groups. We assessed associations between HEL and healthy meal provision using Pearson's correlation coefficient (r) and multiple linear regression with healthy meal provision as the dependent variable and HEL as the independent variable, adjusting for age, education, work styles, household income, number of children and whether participants lived with a partner. Mothers exhibiting high scores on eating out/consuming convenience foods were more likely to be employed (p = 0.004), have only one child (p = 0.034), have lower education (p=0.011) and exhibit lower healthy meal provision (p < 0.001) and HEL scores (p < 0.001). In addition, HEL was associated with healthy meal provision (β = 0.34, p < 0.001). Among mothers with higher scores on eating out/consuming convenience foods, HEL was associated with healthy meal provision (β = 0.32, p < 0.001). This study suggests that maternal HEL is associated with healthy meal provision regardless of the degree of eating out/consuming convenience food. Thus, interventions to improve maternal HEL can help mothers to provide healthy meals when they eat out or consume convenience foods as family meals.

A Longitudinal Analysis Examining the Associations of Tummy Time With Active Playtime, Screen Time, and Sleep Time

BACKGROUND

Evidence links tummy time (ie, the time spent in awake prone positioning that is encouraged and supervised by an adult) to infants' health outcomes such as gross motor and total development. However, the associations between tummy time and other movement and sleep behaviors as the child develops remain unknown. The aim of this study was to examine whether early introduction and practice of tummy time within the first 6 months of age were associated with active and outdoor playtime, screen time, and nocturnal sleep time of children when they were 12 and 24 months old.

METHODS

A longitudinal analysis was conducted using data extracted from an Australian trial. Using telephone surveys with mothers, demographic data were collected from third trimester of pregnancy and tummy time data were collected at 6 months of age. Data on playtime, screen time, and nocturnal sleep duration as dependent variables were collected at 12 and 24 months of age. Multiple logistic regression models were built to investigate the associations.

RESULTS

Children who started tummy time within 4 weeks of age were more likely to have >10 hours sleep at night at 12 months (adjusted odds ratio 1.54, 95% confidence interval, 1.08-2.19). They were more likely to have >3 hours per day of outdoor play and have <1 hour per day of screen time at 24 months. Children who practiced tummy time every day were more likely to have >2 hours per day of active play at 12 months and have <1 hour per day of screen time at 24 months.

CONCLUSIONS

Starting tummy time earlier and frequently was associated with more favorable movement and sleep of young children at 12 and 24 months of age.

Measurement of screen time among young children aged 0-6 years: A systematic review

The impact of screen-based devices on children's health and development cannot be properly understood without valid and reliable tools that measure screen time within the evolving digital landscape. This review aimed to summarize characteristics of measurement tools used to assess screen time in young children; evaluate reporting of psychometric properties; and examine time trends related to measurement and reporting of screen time. A systematic review of articles published in English across three databases from January 2009 to April 2020 was undertaken using PROSPERO protocol (registration: CRD42019132599) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Included articles measured screen time as outcome, exposure, or confounder in children 0-6 years. The search identified 35,868 records, 1035 full-text articles were screened for eligibility, and 622 met inclusion criteria. Most measures (60%) consisted of one to three items and assessed duration of screen time on a usual day. Few measures assessed content (11%) or coviewing (7%). Only 40% of articles provided a citation for the measure, and only 69 (11%) reported psychometric properties-reliability n = 58, validity n = 19, reliability and validity n = 8. Between 2009 and 2019, the number of published articles increased from 28 to 71. From 2015, there was a notable increase in the proportion of articles published each year that assessed exposure to mobile devices in addition to television. The increasing number of published articles reflects increasing interest in screen time exposure among young children. Measures of screen time have generally evolved to reflect children's contemporary digital landscape; however, the psychometric properties of measurement tools are rarely reported. There is a need for improved measures and reporting to capture the complexity of children's screen time exposures.

A qualitative study of providers' perceptions of parental feeding practices of infants and toddlers to prevent childhood obesity

Background

With a recent focus on establishing US Dietary Guidance for children ages 0 to 2 years old, the objective of this qualitative study was to determine misconceptions and barriers that prevent parents from implementing early childhood feeding and obesity prevention practices as reported by healthcare, community-based, and education providers.

Methods

Trained researchers conducted one-on-one qualitative phone interviews, using a semi-structured script, with early childhood health and education providers working with families of young children. Interviews were audiotaped, transcribed verbatim, and analyzed using the classic analysis approach. Transcripts were coded by researchers and analyzed for themes.

Results

Providers (n = 21) reported commonly observed obesogenic practices including overfeeding tendencies, early initiation of solids or less optimal feeding practices, lack of autonomy and self-regulation by child, and suboptimal dietary patterns. Sources of parental misconceptions about feeding were often related to cultural, familial, and media influences, or lack of knowledge about optimal feeding practices for infants or toddlers.

Conclusions

Providers indicated a need for engaging and consistent child feeding and obesity prevention education materials appropriate for diverse cultural and literacy levels of parents, with detailed information on transitioning to solid foods. Early education and community-based providers reported limited access to evidence-based educational materials more so than healthcare providers. It is an opportune time to develop reputable and evidence-based child feeding guidance that is readily available and accessible for parents of infants and toddlers to prevent early childhood obesity.

A Health-Literacy Intervention for Early Childhood Obesity Prevention: A Cluster-Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Children who become overweight by age 2 have greater risk of long-term obesity and health problems. The study aim was to assess the effectiveness of a primary care-based intervention on the prevalence of overweight at age 24 months.

METHODS

In a cluster-randomized trial, sites were randomly assigned to the Greenlight intervention or an attention-control arm. Across 4 pediatric residency clinics, we enrolled infant-caregiver dyads at the 2-month well-child visit. Inclusion criteria included parent English- or Spanish-speaking and birth weight ≥1500 g. Designed with health-literacy principles, the intervention included a parent toolkit at each well-child visit, augmented by provider training in clear-health communication. The primary outcome was proportion of children overweight (BMI ≥85th percentile) at age 24 months. Secondary outcomes included weight status (BMI z score).

RESULTS

A total of 459 intervention and 406 control dyads were enrolled. In total, 49% of all children were overweight at 24 months. Adjusted odds for overweight at 24 months (treatment versus control) was 1.02 (95% confidence interval [CI]: 0.63 to 1.64). Adjusted mean BMI z score differences (treatment minus control) were -0.04 (95% CI: -0.07 to -0.01), -0.09 (95% CI: -0.14 to -0.03), -0.19 (-0.33 to -0.05), -0.20 (-0.36 to -0.03), -0.16 (95% CI: -0.34 to 0.01), and 0.00 (95% CI -0.21 to 0.21) at 4, 6, 12, 15, 18, and 24 months, respectively.

CONCLUSIONS

The intervention resulted in less weight gain through age 18 months, which was not sustained through 24 months. Clinic-based interventions may be beneficial for early weight gain, but greater intervention intensity may be needed to maintain positive effects.

Parental health literacy and nutrition literacy affect child feeding practices: A cross-sectional study

BACKGROUND

Health literacy (HL) and nutrition literacy (NL) are important issues to consider, in the provision of health care to children and the establishment of healthy eating behaviors.

AIM

The study investigates the possible role of HL and NL levels of Greek parents, in parental Feeding Practices (PFP).

METHODS

This is a cross-sectional study which was conducted in the urban area of the Attica region, Greece. The sample consisted of 402 parents (68.4% mothers). Parents completed the Greek version of Comprehensive Parental Feeding Questionnaire, the European Health Literacy Questionnaire 47 and the Greek version of the Nutrition Literacy Scale. Sociodemographic and anthropometric characteristics were also assessed. The non-parametric tests Mann-Whitney and Kruskal Wallis, the chi-square test and linear regression models were applied.

RESULTS

The median for HL and NL were 33.69 and 24.00, respectively. Mothers applied the "child control" practice more frequently than fathers (p = 0.015). Linear regression analysis revealed that HL was associated positively with "healthy eating guidance" and "monitoring" (p = 0.009 and p < 0.0001, respectively) and negatively with "emotion regulation/food as reward" and "child control" (p = 0.037 and p = 0.015, respectively). NL was associated positively only with "healthy eating guidance" (p = 0.009), positively but marginally with "monitoring" (p = 0.051) and negatively with "emotion regulation/food as reward" (p = 0.020).

CONCLUSIONS

Higher parental levels of HL and NL are significantly positively associated with better parental feeding practices in Greece.

Cultural Adaptation of Health Literacy Measures: Translation Validation of the Newest Vital Sign in Arabic-Speaking Parents of Children With Type 1 Diabetes in Kuwait

PURPOSE

The purpose of the study was to assess the feasibility of use and reliability of the Arabic version of the Newest Vital Sign (NVS-Ar) in parents of children with type 1 diabetes (T1D).

METHODS

The final translated version of NVS-Ar was administered to 175 adult caregivers of children with T1D who are native Arabic speakers. The association between NVS-Ar scores for the parents/legal guardians and A1C for their children was assessed. The internal consistency was evaluated by Cronbach's α, and reliability was assessed by test-retest method.

RESULTS

The median (interquartile range) score was 4.0 (3-5). The internal consistency of the NVS-Ar was moderate (α = .58). The intraclass correlation coefficient was .61. There was no correlation between NVS-Ar score and A1C (Spearman's ρ = .055; P = .62). Furthermore, there was significant inverse association between adequate health literacy and optimal glycemic control among the children, which remained evident even after adjusting for the duration of T1D, age, or education of the parents/guardians. However, it lost statistical significance after adjustment for treatment regimen.

CONCLUSION

Study findings indicate that the NVS is unlikely to be a predictive tool for functional health literacy in Arabic settings and that there is a need to properly translate and validate other tools such as the Test of Functional Health Literacy in Adults or, alternatively, to develop a reliable tool.

Health literacy as a determinant of childhood and adult obesity: a systematic review

OBJECTIVES

To assess whether Health Literacy (HL) acts as a determinant of obesity in adults and children by synthesizing the results of recent scientific evidence.

CONTENT

This is a systematic qualitative review following the MOOSE guidelines. A systematic, computer-assisted literature search via PubMed scientific database, between January 1st, 2000, and September 30th 2020, was conducted. Only cross-sectional epidemiologic research studies that were published in the English language, investigating HL's possible role as a determinant of childhood and adult obesity, were included.

SUMMARY

After screening 725 citations from the PubMed database, 39 (n=39) studies in total were included in this literature review; Four (n=4) studies were conducted in the children population, seven (n=7) studies were performed in children-parent/caregiver dyads, and 28 studies (n=28) enrolled adults. There is significant evidence that HL knowledge and skills determine the consequent management of obesity and BMI rates in children and adult populations.

OUTLOOK

Despite policies and action plans put in place by countries globally, overweight and obesity continue to be a pressing public health issue and one of the critical drivers of non-communicable diseases, constituting a health, social and economic burden worldwide. Health Literacy as an essential health policy and promotion agenda item and a critical empowerment strategy could increase children's and adults' control over their overall health and awareness to overcome obesity issues. Initiatives to improve HL levels could be useful tools in managing the obesity epidemic, starting from integrating HL in the school curriculum and further in family and community action plans.

Parental neglect of feeding in obese individuals. A review of scientific evidence and its application among Saudi population

Human beings encountered malnutrition during the twentieth century and obesity in the very next century. This is how the future will look when the present becomes a slice of history. Obesity is threatening the healthy being of many youngsters throughout the world. Environmental influences have indicated to effect even genetically safe subjects among which parental neglect seems to be most alarming. Two extensively and globally investigated variables, the feeding style and the physical activity, provide some hope in its prevention. Despite the high rise of obesity prevalence in Saudi Arabia, there is scant research on these topics. The purpose of this review is to present a comprehensive assessment of these 2-obesity associated parental variables. The composed literature could provide an insight to the dominant surge of obesity in the Arab nations and stimulate research on current parenting practices in the Kingdom.

Health Literacy and Physical Activity: A Systematic Review

BACKGROUND

The importance of health literacy (HL) in health promotion is increasingly clear and acknowledged globally, especially when addressing noncommunicable diseases. This paper aimed to collect and summarize all current data from observational studies generating evidence of the association between HL and physical activity (PA) and to analyze intervention studies on the promotion of PA to ascertain whether HL moderates the efficacy of such intervention.

METHODS

A comprehensive systematic literature search of observational studies investigating the association between HL and PA was performed. Intervention studies on the promotion of PA that also measured the HL levels of participants and its effect on the outcome of the intervention were also identified.

RESULTS

Of the 22 studies included in this review, 18 found a significant positive association between high HL and high levels of PA. The only intervention study among them indicated that HL was not a significant moderator of the intervention's effectiveness.

CONCLUSION

HL can enable individuals to make deliberate choices about their PA and thus contribute to preventing many chronic noncommunicable diseases. That said, low levels of HL do not seem to influence the efficacy of health promotion interventions.

Influence of Parental Physical Activity and Screen Time on the BMI of Adult Offspring in a Saudi Population

Saudi Arabia is witnessing a drastic rise in adult obesity. Geographic limitations hamper somatic activities to counter this rise. Parental physical inactivity in the region has never been addressed. This study’s purpose is to determine the differences between parent and adult child (the subjects here) levels of physical activity (PA) and screen time (ST) between normal weight and obese adults in the Saudi Arabian population. Two hundred and forty adult subjects (18 to 35 years) were screened for their body mass index (BMI) values (18.5 ≤ 25 as normal and 25 ≤ 30) or above as overweight/obese), followed by their congregation into normal weight (N) (n = 150) and overweight/obese (Ov/Ob) (n = 90) groups. A self-reported questionnaire assessed parenting practices, while a physical activity record diary calculated existing levels of PA and ST. Statistical significance was determined by a chi-squared test (p < 0.01) and BMI correlation was found by Pearson’s correlation coefficient. Maternal age (87.8% ≤ 20 years in the Ov/Ob group (Gp) and consanguineous marriage (88.9% in the Ov/Ob Gp) showed significant differences. A high prevalence of inactivity was observed among families (father 53.3%, mother 53.3%, subject 80.0%) in the Ov/Ob Gp. Higher amounts of ST (76.7% ≥ 9 h/day) were found in the Ov/Ob Gp, which significantly differed. Differences in the parent and child levels of PA and ST exist between normal weight and obese Saudi Arabian adults. Physically active parents having adult children inspire them to develop healthy physical behaviors which counter the development of obesity. Consanguineous marriage and early maternal age may be associated with progressive adult obesity.

Wakeful Prone "Tummy Time" During Infancy: How Can We Help Parents?

AIMS

This study's purpose is to present facilitators and barriers for wakeful prone positioning or "tummy time" during infancy by exploring the personal perspectives of infant caregivers attempting to provide daily tummy time.

METHODS

The study was qualitative in design, using thematic analysis to identify major and minor themes from semi-structured interviews. The Capability, Opportunity, Motivation - Behavior Model provided a conceptual framework for the interview guide and categorization of major themes.

RESULTS

Within capability, opportunity, and motivation, the major themes of self-efficacy, scheduling, variations, siblings, committed adult help, social responses of acquaintances, and caregiver enjoyment could be barriers or facilitators, depending on the context. Optimized physical circumstances, caregiver interest, perceived benefits to the infant, pride and accomplishment, and obligation were identified as facilitators only. Barriers included negative infant affect.

CONCLUSIONS

These results offer preliminary guidance in a knowledge gap: tummy time support that addresses the self-identified concerns of infant caregivers.

Unintentional error in formula preparation and its simulated impact on infant weight and adiposity

BACKGROUND

Accelerated weight gain in infancy is a public health issue and is likely due to feeding behaviours.

OBJECTIVES

To test the accuracy of individuals to dispense infant formula as compared with recommended serving sizes and to estimate the effect of dispensing inaccuracy on infant growth.

METHODS

Fifty-three adults dispensed infant formula powder for three servings of 2, 4, 6, and 8 fl oz bottles, in random order. The weight of dispensed infant formula powder was compared with the recommended serving size weight on the nutrition label. A novel mathematical model was used to estimate the impact of formula dispensing on infant weight and adiposity.

RESULTS

Nineteen percent of bottles (20 of 636) prepared contained the recommended amount of infant formula powder. Three percent were underdispensed, and 78% of bottles were overdispensed, resulting in 11% additional infant formula powder. Mathematical modelling feeding 11% above energy requirements exclusively for 6 months for male and female infants suggested infants at the 50th percentile for weight at birth would reach the 75th percentile with increased adiposity by 6 months.

CONCLUSIONS

Inaccurate measurement of infant formula powder and overdispensing, which is highly prevalent, specifically, may contribute to rapid weight gain and increased adiposity in formula-fed infants.

Exploring the Relationship between Maternal Health Literacy, Parenting Self-Efficacy, and Early Parenting Practices among Low-Income Mothers with Infants

OBJECTIVE

To explore the association of maternal health literacy (MHL), parenting self-efficacy and early parenting practices among low-income mothers with infants.

DESIGN

A cross-sectional, descriptive correlational design.

PARTICIPANTS

Low-income mothers (N=186) with infants.

METHODS

Face-to-face interviews were conducted using English and Spanish versions of questionnaires by trained bilingual research assistants. The Newest Vital Sign (NVS) screening tool was used to measure MHL.

RESULTS

Nearly three-quarters (72%) of mothers were rated as having low MHL. In the bivariate analysis, MHL was positively correlated with education, household income, language, social support, parenting self-efficacy, and early parenting practices, but negatively correlated with number of children. The study findings demonstrate that parenting self-efficacy had a mediating effect on MHL and early parenting practices among mothers with infants.

CONCLUSION

Results suggest that future research is needed to advance MHL in low-income mothers and to inform potential HL interventions for this target population.

Effects of Contextual Economic Factors on Childhood Obesity

OBJECTIVES

To examine the association between changes in contextual economic factors on childhood obesity in the US.

METHODS

We combined data from 2003, 2007, and 2011/2012 National Surveys of Children's Health for 129,781 children aged 10-17 with 27 state-level variables capturing general economic conditions, labor supply, and the monetary or time costs of calorie intake, physical activity, and cigarette smoking. We employed regression models controlling for demographic factors and state and year fixed effects. We also examined heterogeneity in economic effects by household income.

RESULTS

Obesity risk increased with workforce proportion in blue-collar occupations, urban sprawl, female labor force participation, and number of convenience stores but declined with median household income, smoking ban in restaurants, and full service restaurants per capita. Most effects were specific to low income households, except for density of supercenters/warehouse clubs which was significantly associated with higher overweight/obesity risk only in higher income households.

CONCLUSIONS FOR PRACTICE

Changes in state-level economic factors related to labor supply and monetary or time cost of calorie intake may affect childhood obesity especially for children in low-income households. Policymakers should consider these effects when designing programs aimed at reducing childhood obesity.

Health Literacy: Implications for Child Health

Health literacy is an important issue to consider in the provision of health-care to children. Similar to the adult population, most parents face health literacy challenges. Of particular concern, 1 in 4 parents have low health literacy, greatly affecting their ability to use health information to make health decisions for their child. High expectations are placed on parents and children to achieve effective disease management and positive health outcomes in the context of complex health-care systems and disease treatment regimens. Low health literacy affects parent acquisition of knowledge, attitudes, and behaviors, as well as child health outcomes across the domains of disease prevention, acute illness care, and chronic illness care. The effect of low health literacy is wide ranging, including 1) poor nutrition knowledge and behaviors, 2) higher obesity rates, 3) more medication errors, 4) more emergency department use, and 5) poor asthma knowledge, behaviors, and outcomes. Health-care providers can mitigate the effects of health literacy by seeking to align health-care demands with the health literacy skills of families. Effective health literacy-informed interventions provide insights into methods that can be used by providers and health systems to improve health outcomes. Health literacy-informed communication strategies should be used with all families in a "universal precautions approach" because all parents likely benefit from clear communication. As scientific advances are made in disease prevention and management, unless families understand how to follow provider recommendations, the benefit of these advances will not be realized and disparities in outcomes will be exacerbated.

Reducing pediatric caries and obesity risk in South Asian immigrants: randomized controlled trial of common health/risk factor approach

Background

This paper describes the design and methods of a multi-phase study to reduce early childhood caries and obesity in vulnerable South Asian (SA) immigrants in the United States. Early childhood caries and obesity are the most common diseases of early childhood. Risk factors for both diseases are rooted in early childhood feeding practices such as bottle feeding and intake of sweets and sweetened beverages. The Common Health/Risk Factor Approach to addressing oral health is widely promoted by the WHO and other policy makers. This approach recognizes links between oral health and other diseases of modernity. Our CHALO! (“Child Health Action to Lower Obesity and Oral health risk”--from a Hindi word meaning "Let's go!") study targets SA families at high risk for early childhood caries and obesity. CHALO! addresses common risk factors associated with these two common diseases of childhood.

Methods

This two part project includes a randomized controlled trial, and a Knowledge Translation campaign. A randomized controlled trial will enroll n =  360 families from pediatric practices serving South Asians in the New York metro area. The intervention group will receive home visits by SA community health workers at 6, 8, 10, 12, 14, and 16 months of age. Controls will receive culturally tailored educational material. Primary outcomes-- cariogenic and obesogenic feeding practices at 6, 12, and 18 months-- will be assessed with the MySmileBuddy iPad based tool. Secondary outcomes include: oral hygiene practices, anthropometrics, and caries incidence at 18 months. A public education campaign will focus on both families and health care providers.

Discussion

There are few Common Health/Risk Factor Approach published studies on obesity and oral health risk in children, despite health morbidity and costs associated with both conditions. CHALO! comprises a multi-level interventions designed to promote culturally competent, sustainable change.

Trial registration

ClinicalTrials.govNCT03077425.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5317-9) contains supplementary material, which is available to authorized users.

Prevalence of breast-feeding and exclusive breast-feeding at 48 h after birth and up to the sixth month in Cyprus: the BrEaST start in life project

OBJECTIVE

To assess the prevalence and sociodemographic determinants of breast-feeding (BF) and exclusive breast-feeding (EBF) in Cyprus up to the sixth month.

DESIGN

Cross-sectional and longitudinal descriptive study. BF and EBF were estimated based on mothers' self-reported BF status in line with Step 7 of the WHO/UNICEF Baby-Friendly Hospital Initiative questionnaire and based on 24 h recall.

SETTING

Maternity wards in all public hospitals and twenty-nine (of thirty-five) private maternity clinics nationwide.

SUBJECTS

Consecutive sample of 586 mothers recruited within 48 h from birth, followed up by telephone interview at the first, fourth and sixth month.

RESULTS

Although 84·3 % of mothers initiated BF before discharge, prevalence of BF at the sixth month was 32·4 %, with the highest reduction observed between the first and fourth months. Prevalence of EBF at 48 h was 18·8 % and fell gradually to 5·0 % at the sixth month. Mothers with higher educational attainment or higher family income were more likely to breast-feed until the sixth month. In terms of EBF, an association was observed only with education, which persisted until the sixth month. Other than social gradient, mode of delivery was the strongest determinant of BF initiation, exclusivity and continuation. Mothers who gave birth vaginally were three to four times more likely to initiate BF (OR=3·1; 95 % CI 1·7, 5·4) and EBF (OR=4·3; 95 % CI 2·7, 6·8).

CONCLUSIONS

The low prevalence of BF and EBF in Cyprus, together with the fact that caesarean section rates are currently among the highest in Europe, suggest the need for further research to understand this multidimensional phenomenon and for interdisciplinary policy action to protect, promote and support BF.

Validity of the toddler feeding questionnaire for measuring parent authoritative and indulgent feeding practices which are associated with stress and health literacy among Latino parents of preschool children

Understanding the contribution of parental feeding practices to childhood obesity among Latino children is a solution-oriented approach that can lead to interventions supporting healthy childhood growth and lowering rates of obesity. The purpose of this study was to confirm the reliability and validity of the Toddler Feeding Questionnaire (TFQ) to measure parental feeding practices among a sample of Spanish-speaking parent-preschool child pairs (n = 529), and to test the hypothesis that parent characteristics of body mass index (BMI), stress, and health literacy are associated with more indulgent and less authoritative feeding practices. Standardized parent-report questionnaires were completed during baseline interviews in a randomized controlled trial of an obesity prevention intervention. The TFQ includes subscales for indulgent practices (11 items), authoritative practices (7 items), and environmental influences (6 items) with response options scored on a 5-point Likert scale and averaged. Factor analysis confirmed a three-factor structure. Internal consistency was good for indulgent (α = 0.66) and authoritative (α = 0.65) practices but lower for environmental (α = 0.48). Spearman correlation showed indulgent practices and environmental influences were associated with unhealthy child diet patterns, whereas authoritative practices were associated with a healthier child diet. Multivariate linear regression showed higher parent stress was associated with higher indulgent and lower authoritative scores; higher parent health literacy was positively associated with indulgent scores. These results indicate the TFQ is a valid measure of authoritative and indulgent parent feeding practices among Spanish-speaking parents of preschool-age children and that stress and health literacy, potentially modifiable parent characteristics, could be targeted to support healthy feeding practices.

Proportion of infants meeting the Australian 24-hour Movement Guidelines for the Early Years: data from the Melbourne InFANT Program

BACKGROUND

Little information is available on the movement behaviours of infants, despite evidence that these are important for development. The release of new Australian 24-hour Movement Guidelines provides an opportunity to document the current state of movement behaviours in infants relative to these guidelines. The aim of this study was to report the prevalence of 4 month old Australian infants meeting the 24-hour Movement Guidelines, individually, and in combination, and to describe associations with individual characteristics.

METHODS

Maternal report baseline data from the Melbourne Infant Feeding, Activity and Nutrition Trial Program were used to determine prevalence of infants meeting physical activity (30 min of tummy time per day), sedentary behaviour (no more than 1 h at a time kept restrained; zero screen time), and sleep guidelines (14-17 h for 0-3 month olds or 12-16 h for 4-11 month olds). Prevalence of infants meeting combined guidelines was also described. The odds of meeting guidelines based on infant and family characteristics was determined.

RESULTS

Data are reported for 455 infants with a mean age of 3.6 months (SD = 1.0). The proportion of infants meeting each of the guidelines was 29.7% for tummy time, 56.9% for kept restrained, 27.9% for screen time, 58.7% for sleep and 3.5% for the combined guidelines (i.e. meeting all four guidelines). A significantly higher proportion of girls than boys met the screen time guideline (32.5% versus 24.0%, p = 0.04) and the combined guidelines (5.7% versus 1.6%, p = 0.01). Few associations were observed between infant and family characteristics and proportion of infants meeting individual guidelines.

CONCLUSIONS

Very few infants met all of the guidelines contained in the new Australian 24-hour Movement Guidelines suggesting there is much room for improvement in movement behaviours from early life. Fewer infants met the tummy time and screen time guidelines hence these appear to be the behaviours requiring most attention. Parents and others providing care to infants require support and strategies to assist them in adhering to the guidelines to ensure optimal health and development for the youngest in our population.

Depressive Symptoms and Length of U.S. Residency Are Associated with Obesity among Low-Income Latina Mothers: A Cross-Sectional Analysis

Latinos are the largest minority population group in the United States (U.S.), and low-income Latina women are at elevated risk of depression and obesity. Thus, the prevention of these two problems is a pressing public health concern in this population. Both depressive symptoms and obesity are modifiable factors that can be addressed by culturally relevant interventions. However, the association between depressive symptoms and obesity in Latina immigrant women is not well understood. Therefore, this cross-sectional study examined the association between depressive symptoms and obesity among Latina women of childbearing age (15–44). Participants (n = 147) were low-income, predominantly immigrant Latina mothers enrolled in the Latina Mothers′ Child Feeding Practices and Style Study. Women were eligible to participate if they self-identified as Latina; were enrolled in or eligible for the Special Supplemental Nutrition Program for Women, Infants and Children program; had a child between ages two and five years; and were living in the U.S. for at least one year, and residing in Rhode Island. Enrolled participants completed a survey in their language of preference (English or Spanish) administered by bilingual interviewers. About one-third (34%) of participants were classified as having obesity (BMI ≥ 30 kg/m²), 28.3% had elevated depressive symptoms (CES-D ≥ 16), and 70.1% were immigrants. Women with elevated depressive symptoms had increased odds of having obesity (odds ratio (OR) = 2.80, 95% confidence interval (CI): 1.24–6.33). Additionally, among immigrants, length of U.S. residency was associated with increased odds of obesity (OR = 1.05, 95% CI: 1.02–1.09). Findings underscore the need for screening and culturally relevant interventions designed to address both depressive symptoms and obesity among low-income Latina women of childbearing age. Furthermore, findings highlight the importance of taking into account the length of residency in the U.S. when designing interventions targeting Latina immigrants.

Television During Meals in the First 4 Years of Life

The development of children's mealtime television (TV) habits has not been well studied. We assessed whether mealtime TV habits established in infancy will persist into early childhood. We analyzed data collected through parent surveys at birth and at 6-month intervals from a randomized controlled trial. We used t-tests, χ² tests, and a multivariable logistic regression to determine if family characteristics were associated with mealtime TV. A McNemar test was used to assess whether mealtime TV exposure changed over time. College-educated fathers and families with an annual income >$50 000 were associated with less-frequent TV exposure during children's mealtimes. It was found that 84% of children retained their level of exposure to TV during mealtimes from the first 24 months through 48 months of life. Clinicians should counsel families about mealtime TV use within the first 2 years of life because these habits seem to develop early and persist into at least early childhood.

[What are the determinants of childhood obesity? : A literature review as part of the project "Nationwide Monitoring of Childhood Obesity Determinants"]

BACKGROUND

Obesity can impair health even in childhood and unfold negative health consequences through an individual's lifespan. In Germany, to date, a systematic and periodically updated synopsis of the multifaceted determinants of childhood obesity is lacking. In this paper, we present the results of a systematic literature review on childhood obesity determinants, which was conducted over the course of the implementation of nationwide monitoring.

METHODS

The review was carried out in three steps. Initially, a search for etiological models of childhood obesity was conducted. Based on these results, a systematic review of reviews on childhood obesity determinants was carried out. Finally, the results were verified by taking international guidelines on childhood obesity into account.

RESULTS

In total, 21 etiological models, 75 reviews and 7 guidelines were identified. Over 60 determinants were extracted from these publications and were summarized into the following categories: nutritional behavior, physical activity behavior, sleeping pattern, biological determinants and diseases, prenatal and early childhood determinants, psycho-social determinants, food environment, moveability/walkability, setting and social environment, health promotion and prevention, socioeconomic, demographic, and sociocultural determinants.

CONCLUSION

This review demonstrates the complex patterns of childhood obesity determinants in correspondence with a socio-ecological approach. The review will form the basis for the monitoring-system "Nationwide Monitoring of Childhood Obesity Determinants", which will be implemented at the Robert Koch Institute by the end of 2017.

Randomized controlled trial of an early child obesity prevention intervention: Impacts on infant tummy time

OBJECTIVE

To describe infant activity at 3 months old and to test the efficacy of a primary care-based child obesity prevention intervention on promoting infant activity in low-income Hispanic families.

METHODS

This study was a randomized controlled trial (n = 533) comparing a control group of mother-infant dyads receiving standard prenatal and pediatric primary care with an intervention group receiving "Starting Early," with individual nutrition counseling and nutrition and parenting support groups coordinated with prenatal and pediatric visits. Outcomes included infant activity (tummy time, unrestrained floor time, time in movement-restricting devices). Health literacy was assessed using the Newest Vital Sign.

RESULTS

Four hundred fifty-six mothers completed 3-month assessments. Infant activity results were: 82.6% ever practiced tummy time; 32.0% practiced tummy time on the floor; 34.4% reported unrestrained floor time; 56.4% reported ≥1 h/d in movement-restricting devices. Inadequate health literacy was associated with reduced tummy time and unrestrained floor time. The intervention group reported more floor tummy time (OR 2.16, 95% CI 1.44-3.23) and unrestrained floor time (OR 1.69, 95% CI 1.14-2.49) compared to controls. No difference in the time spent in movement-restricting devices was found.

CONCLUSIONS

Tummy time and unrestrained floor time were low. Primary care-based obesity prevention programs have potential to promote these activities.

Emphasizing the child in child health literacy research

Child health literacy is a 'hot topic' of late, as researchers and practitioners work to attain an equitable and healthy future. Health literacy emphasizes the wide range of skills that people need to access, understand, evaluate and use health information to promote good health. In light of the recognition that health literacy is an important determinant of health for adults, addressing child health literacy early on is essential to maximize future health outcomes. Meeting children's specific needs arguably includes the delivery of information that can be easily accessed and understood by younger age groups. While much academic discourse pertains to the importance of building parental health literacy, there is less literature that explicitly focuses on child-centred health literacy. On the premise that health literacy is an asset, this paper provides an argument for investing in children's health literacy by working with children to encourage meaningful contributions in research and practice.

Parental Health Literacy and Outcomes of Childhood Nephrotic Syndrome

OBJECTIVE

Determine the association of parental health literacy with treatment response among children with nephrotic syndrome.

METHODS

This was a cohort study of children aged 1-18 with nephrotic syndrome and their parent. Health literacy was measured using the validated Short Test of Functional Health Literacy in Adults assessing reading comprehension and numeracy. Outcomes included initial relapse-free period, frequently relapsing disease, relapse rate, second-line medication use, and complete remission after therapy.

RESULTS

Of 190 parents, 80% had adequate health literacy (score >67 of 100), and higher scores were not correlated with higher education. Almost all achieved perfect numeracy scores (>86%); numeracy was not associated with outcomes. After adjusting for immigration, education, and income, higher reading comprehension scores (tertile 3) compared with lower scores (tertile 1) were significantly associated with lower risk of first relapse (hazard ratio 0.67, 95% confidence interval [CI] 0.48-0.94, P trend = .02), lower odds of frequently relapsing disease (odds ratio [OR] 0.38, 95% CI 0.21-0.70, P trend = .002), lower relapse rate (rate ratio 0.77, 95% CI 0.73-0.80, P trend < .001), and higher odds of complete remission after both initial steroids and cyclophosphamide (OR 2.07, 95% CI 1.36-3.16, P trend = .003; OR 5.97, 95% CI 2.42-14.7, P trend < .001).

CONCLUSIONS

Lower parental health literacy, specifically reading comprehension, is associated with higher relapse rates among children with nephrotic syndrome and fewer achieving complete remission. This underscores the importance of assessing and targeting health literacy for chronic management of childhood-onset diseases.

[Health literacy in childhood and adolescence: An overview and current state of research]

BACKGROUND

Health literacy is multidisciplinary and brings together many concepts, and is of increasing importance for disease protection, health promotion, and prevention, and for health policy within Europe. Although its importance is increasingly recognised, adults are mostly the target audience, whereas children and adolescents, in addition to education and schools, have so far been neglected.

OBJECTIVES

The aim is to give an overview of the state of the art in childhood and adolescence health literacy research, and to identify any existing gaps.

MATERIALS

A literature review has been performed to identify the relevant research data.

RESULTS

Limitations in developmental and age-adjusted conceptual frameworks and a lack of prevalence data, however, significantly impede our understanding of the meaning of health literacy in children and adolescents. School health promotion programmes could serve as a platform for effective health literacy education, beginning in early childhood.

CONCLUSIONS

In addition to compatibility with a broader literacy perspective, the proximity to several theories of health promotion and defined concepts, and the importance of school health promotion and education, it is vital to focus research on current gaps in the understanding of health literacy determinants, health literacy as a determinant of health, and in terms of the design and systematic implementation of intervention programmes.

Infant Sleep and Parent Health Literacy

OBJECTIVE

Child sleep problems are prevalent and have been linked to poor behavior, worse school performance, and obesity. Low health literacy (HL) is associated with suboptimal parenting practices and worse health outcomes, but the relationship between parent HL and child sleep-related issues is not known. We examined the association between parent HL and child sleep-related issues.

METHODS

This was a cross-sectional analysis of data from caregivers enrolled in a cluster randomized trial of a primary care-based child obesity prevention program in 4 pediatric clinics. Parent HL was assessed using the Short Test of Functional Health Literacy in Adults. At the 9-month well-child visit, sleep-related factors were assessed: presence of TV in room where child sleeps, regular naptimes and bedtimes (≥5 days/wk), low daytime and nighttime sleep duration (>1 SD below mean on the basis of national data). Multiple logistic regression analyses were performed.

RESULTS

We enrolled 557 caregivers of 9-month-old children (49.7% Hispanic, 26.9% black, 56.2% <$20,000 annual income); 49.6% reported having a TV in the room where their child sleeps; 26.6% did not have regular naptimes norbedtimes. Median sleep duration was 2.3 (interquartile range, 1.5-3.0) hours (daytime), and 9.0 (interquartile range, 8.0-10.0) hours (night) (30.2% low daytime; 20.3% low nighttime sleep duration). Children of parents with low HL were more likely to have a bedroom TV (66.7% vs 47.7%, P = .01; adjusted odds ratio, 2.2; 95% confidence interval, 1.1-4.3) and low night-time sleep (37.0% vs 18.5%; P = .002; adjusted odds ratio, 2.4; 95% confidence interval, 1.2-4.8).

CONCLUSIONS

Low parent HL is associated with TV in the bedroom and low night sleep duration. Additional study is needed to further explore these associations and intervention strategies to address child sleep problems.

Pediatric Obesity in Early Childhood: A Physician Screening Tool

Obesity is a public health crisis and continues to affect youth of increasingly younger ages. With significant medical and psychosocial comorbidities, it is critical that front-line providers feel confident in their abilities to assess, and appropriately refer, children and families to subspecialties to aid in weight management treatment. This article describes the development and utility of a 1-page screening tool for pediatricians and other providers. Utilizing research, clinical experience, and consensus opinion, a brief tool was developed that could be incorporated into medical visits to facilitate medical care decisions and management of pediatric obesity.

Effects of parent and child behaviours on overweight and obesity in infants and young children from disadvantaged backgrounds: systematic review with narrative synthesis

Background

Despite the crucial need to develop targeted and effective approaches for obesity prevention in children most at risk, the pathways explaining socioeconomic disparity in children’s obesity prevalence remain poorly understood.

Methods

We conducted a systematic review of the literature that investigated causes of weight gain in children aged 0–5 years from socioeconomically disadvantaged or Indigenous backgrounds residing in OECD countries. Major electronic databases were searched from inception until December 2015. Key words identified studies addressing relationships between parenting, child eating, child physical activity or sedentary behaviour and child weight in disadvantaged samples.

Results

A total of 32 articles met the inclusion criteria. The Mixed Methods Appraisal Tool quality rating for the studies ranged from 25 % (weak) to 100 % (strong). Studies predominantly reported on relationships between parenting and child weight (n = 21), or parenting and child eating (n = 12), with fewer (n = 8) investigating child eating and weight. Most evidence was from socio-economically disadvantaged ethnic minority groups in the USA. Clustering of diet, weight and feeding behaviours by socioeconomic indicators and ethnicity precluded identification of independent effects of each of these risk factors.

Conclusions

This review has highlighted significant gaps in our mechanistic understanding of the relative importance of different aspects of parent and child behaviours in disadvantaged population groups.

Electronic supplementary material

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Educational intervention to improve the health outcomes of children with sickle cell disease

INTRODUCTION

Although sickle cell disease (SCD) is the most common single gene disorder worldwide, caregivers of children do not have adequate knowledge about the illness and its management. The purpose of this study was to assess the efficacy of education along with tailored written materials in changing the behaviors of caregivers to help them provide better care for children with SCD.

METHODS

A preintervention and postintervention quasi-experimental design was used. A convenience sample of 43 caregivers of 57 children were asked to complete a questionnaire related to their knowledge of SCD before and after educational sessions. The educational sessions (the intervention) were provided to caregivers at the Children's Cancer Center in Lebanon by one registered nurse, one certified pediatric nurse practitioner, and one pediatric hematologist. Emergency department (ED) visits and hospitalizations were compared 2 months before and 2 months after the intervention.

RESULTS

A statistically significant increase was found in the knowledge of caregivers about the cause, symptoms, and management of the disease. A statistically significant decrease occurred in the number of hospitalizations before and after the intervention but not in the number of visits to the ED. Multiple regression analysis found that none of the background variables were related to knowledge, ED visits, or hospitalizations.

CLINICAL IMPLICATIONS

Education and written materials written in a simple language that is understood by 5th-graders were beneficial in improving the knowledge of caregivers and in decreasing the number of hospitalizations of children with SCD.