Children's Healthy Living (CHL) Program for remote underserved minority populations in the Pacific region: rationale and design of a community randomized trial to prevent early childhood obesity

Acculturation and Health Status in the Children's Healthy Living Program in the Pacific Region

Acculturation/enculturation has been found to impact childhood health and obesity status. The objective of this study is to use cross-sectional data to examine the association between proxies of adult/caregiver acculturation/enculturation and child health status (Body Mass Index [BMI], waist circumference [WC], and acanthosis nigricans [AN]) in the U.S.-Affiliated Pacific Islands (USAPI), Alaska, and Hawai'i. Study participants were from the Children's Healthy Living (CHL) Program, an environmental intervention trial and obesity prevalence survey. Anthropometric data from 2-8 year olds and parent/caregiver questionnaires were used in this analysis. The results of this study (n = 4121) saw that those parents/caregivers who identified as traditional had children who were protected against overweight/obesity (OWOB) status and WC > 75th percentile (compared to the integrated culture identity) when adjusted for significant variables from the descriptive analysis. AN did not have a significant association with cultural classification. Future interventions in the USAPI, Alaska, and Hawai'i may want to focus efforts on parents/caregivers who associated with an integrated cultural group as an opportunity to improve health and reduce child OWOB prevalence.

Social determinants of health literacy among parents and caregivers in the US-Affiliated Pacific

Health literacy is understudied in the US-Affiliated Pacific (USAP), where local populations have historically experienced social marginalization and disproportionate health inequities caused by the social determinants of health (SDOH). This cross-sectional study analyzed several SDOH indicators-acculturation, use of food assistance programs and demographic characteristics (race and ethnicity, household income, primary language spoken at home and educational attainment)-and their relationship to health literacy among 1305 parents/caregivers of young children ages 2-8 years old who participated in the Children's Healthy Living (CHL) program in Alaska, American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Guam, and Hawai'i. Significantly increased odds of low health literacy were found among parents/caregivers with households where a language other than English was the primary language compared to English-only households (OR = 1.86, 95% CI = 1.22, 2.82), household income of <$35 000 compared to ≥$35 000 (OR = 2.15, 95% CI = 1.13, 4.07), parents/caregivers of Asian children compared to parents/caregivers of White children (OR = 2.68, 95% CI = 1.05, 6.84), parent/caregivers with less than or some high school education compared to high school completion (1st- to 8th-grade OR = 4.46, 95% CI = 2.09, 9.52; 9th- to 11th-grade OR 1.87, 95% CI = 1.06, 3.30) and parent/caregivers with acculturation status defined as marginalized as compared to integrated (OR = 2.31, 95% CI = 1.09, 4.86). This study indicates that some USAP parents/caregivers may lack the capacity to acquire health information, utilize health resources, and navigate health decision making. Future efforts to understand and improve health literacy in the USAP should be population specific, thoroughly assess personal and organizational health literacy, and inventory community health care capacity.

Mapa V, Boushey CJ. Diet Quality of Young Children in the US-Affiliated Pacific's Children's Healthy Living (CHL) Program

BACKGROUND

Childhood diet can impact health outcomes over the life course. Few studies have assessed dietary quality among infants and children in the US-Affiliated Pacific (USAP) region.

OBJECTIVE

The aim of this study was to examine the differences in diet quality among Pacific children in the Children's Healthy Living (CHL) program by Pacific jurisdiction and by their World Bank Income Group (WBIG) level.

DESIGN

This cross-sectional study used dietary records collected from 2012 to 2015.

PARTICIPANTS/SETTING

Data were collected on 2- to 8-year-old children (n = 3,529) enrolled in the Children's Healthy Living Program for Remote Underserved Minority Populations in the Pacific region, conducted in the USAP jurisdictions of Alaska, Hawai'i, American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Guam, Federated States of Micronesia (FSM islands include Chuuk, Kosrae, Pohnpei, Yap), Republic of the Marshall Islands (RMI), and Republic of Palau.

MAIN OUTCOME MEASURE

Diet quality was assessed using the Healthy Eating Index-2005 (HEI-2005). This HEI version was commensurate with the time of dietary data collection for the CHL project and previous studies, thus allowing cross-study comparisons.

STATISTICAL ANALYSIS PERFORMED

Means of total HEI-2005 scores between jurisdictions and their WBIG level were compared using linear models, with and without adjustment for age, sex, and dietary energy.

RESULTS

Differences in mean HEI-2005 scores among children were found between jurisdictions and their WBIG level. Alaska had the highest adjusted mean score (63.3). RMI had the lowest adjusted mean score (50.1). By WBIG, lower-middle income jurisdictions had the lowest adjusted mean HEI-2005 score (56.0), whereas high income jurisdictions had the highest adjusted mean HEI-2005 score (60.5).

CONCLUSIONS

Variation in children's diet quality was found between USAP jurisdictions, notably between jurisdictions of different WBIG levels. Future research is needed to deepen understanding of these differences in diet quality by WBIG level, such as whether differences may be attributable to the jurisdictions' varying food systems, and possibly explained by the nutrition transition. Understanding childhood diet quality in this region can inform approaches for nutrition programs in the Pacific region.

Implementation models and frameworks used to guide community-based physical activity programs for children: a scoping review

BACKGROUND

The implementation of community-based programs is key to effective, sustainable initiatives that can support population-level changes in children's physical activity. The purpose of this scoping review was to explore the implementation models and frameworks used to develop (process models), explore (determinant frameworks), and/or evaluate (evaluation frameworks) community-based physical activity programs for children. Also, the foundational components of the implementation models and frameworks and practical application in real-world settings were described.

METHODS

The methodological framework developed by Arksey and O'Malley (2005) and the updated recommendations from Levac, Colquhoun and O'Brien (2010) were used to search, identify, and summarize applicable studies. This review also met the requirements in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Scoping Reviews Checklist (PRISMA-ScR). A detailed search of six databases and three academic journals was conducted. Information about the article, the program, and the implementation model/framework were extracted and summarized.

RESULTS

The search retrieved 42,202 articles, of which 27 met the inclusion criteria. Eleven process models, one determinant framework, and two evaluation frameworks were identified. Nineteen components were developed from the models and frameworks. Tailoring, situational analysis, and element identification were common components among the identified models and frameworks.

CONCLUSIONS

Since the execution of interventions is vital for creating successful health-promoting initiatives, researchers and program developers should consider using implementation models and frameworks to guide their community-based physical activity programs. Further research examining the application of new and existing implementation models and frameworks in developing, exploring, and evaluating community-level programs is warranted.

Prevalence and socio-demographic distributions of meeting RMI Guidelines for Healthy Living among elementary school children in Majuro, Republic of Marshall Islands: a cross-sectional population-based survey

Background

Childhood obesity is high in Republic of Marshall Islands (RMI). We report the prevalence and socio-demographic distribution of selected obesity-related risk factors among children in Majuro, RMI.

Methods

Sixteen elementary schools were approached and students and parents in Grades 1, 3, and 5 invited to participate in this cross-sectional population-based survey. Accelerometry and a questionnaire were used to collect data on children's physical activity (PA), sleep, screen time and dietary behaviours. Descriptive statistics and mixed-effects logistic regression were used to examine differences in the proportions of children meeting selected RMI Healthy Living Guidelines by sex, school grade and school sector.

Findings

Thirteen schools and 958 children were recruited, of which 892 (52.2% girls; mean age 9.3 ± 1.8 years) provided useable data. Around 90% met the PA, 29% screen time, 13% sleep, 69% sugar-sweetened beverage and 56% highly processed food guidelines. The proportion meeting individual guidelines was higher among children in Grade 1 compared with Grade 5. Being a girl (0.27; 95% CI 0.16, 0.46) was associated with lower odds of meeting the PA recommendation. Compared with children from Grade 1, those in Grade 5 had lower odds of meeting the PA (0.28; 95% CI 0.15, 0.55), screen time (0.60; 95% CI 0.40, 0.89), sleep duration (0.33; 95% CI 0.18, 0.59), sugar-sweetened beverage (0.35; 95% CI 0.23, 0.53), and consumption of highly processed foods recommendations (0.49; 95% CI 0.33, 0.72).

Interpretation

While most children in RMI are adequately active, resources are needed to promote healthier levels of screen time, sleep, sugar-sweetened beverage and highly processed food consumption, especially among older children.

Funding

This study was funded by World Diabetes Foundation; Canvasback Missions, RMI; NHMRC Australia (APP1176858); Pacific Community.

Diet and Acanthosis Nigricans over a Two-Year Period in Children of the Pacific Region

BACKGROUND

The impact that dietary carbohydrates have on children developing type 2 diabetes remains controversial. Furthermore, there are limited pediatric longitudinal studies on changes in body mass index (BMI) and diet related to the development of acanthosis nigricans (AN), a risk factor associated with type 2 diabetes.

METHODS

Two 24 h dietary records were collected for 558 children, 2-8 years of age, at baseline and at a 2-year follow-up. Data on age, sex, BMI, and the presence of AN were also collected at each time point from the Children's Healthy Living Program. Logistic regression was used to determine factors associated with the presence of AN at follow-up. Multinominal regression was used to determine factors associated with changes in AN status. Linear regression was used to measure the associations between changes in dietary intake and in the Burke Score for AN.

RESULTS

AN was present in 28 children at baseline and 34 children at follow-up. Adjusting for the presence of AN at baseline, age, sex, study group, baseline BMI, change in BMI z-score, time between assessments, and baseline intake, an increase from baseline for each teaspoon of sugar and serving of carbohydrate-rich food increased the risk for having AN at follow-up by 9% and 8%, respectively (p ≤ 0.05). An increased intake of added sugar (teaspoons) increased the risk of developing AN by 13% (p ≤ 0.01) and an increase in servings of foods rich in starch increased the risk of developing AN by 12% (p ≤ 0.01) compared to children who never had AN. Increasing the intake of fruit was also associated with decreased Burke Scores using multiple regression. However, the intake of energy and macronutrients were not associated with AN.

CONCLUSIONS

Added sugar and foods rich in starch were independently associated with the occurrence of AN, suggesting the type of carbohydrates consumed is a factor in AN occurrence.

Children's Dietary Intake by Early Care and Education Setting in the US Affiliated Pacific

OBJECTIVE

Examine differences in dietary intake of children aged 2-5 years in early care and education (ECE) setting in the US Affiliated Pacific (USAP).

DESIGN

Secondary analysis of cross-sectional data collected by the Children's Healthy Living program.

PARTICIPANTS

Children (n = 1,423) with complete dietary records and information on the ECE setting.

MAIN OUTCOME MEASURES

Dietary intake by ECE setting; Head Start (HS), other ECE (OE), and no ECE.

ANALYSIS

Comparison of mean dietary intake across ECE settings and multivariate logistic regression to evaluate ECE setting and likelihood for meeting dietary reference intake (DRI).

RESULTS

Children in HS and OE settings had a significantly higher intake of several food groups and nutrients, compared with no ECE; vegetables (0.4 cup-equivalents per thousand kcals [CETK] vs 0.3 CETK; P < 0.001), fruits (0.8 CETK vs 0.6 CETK; P = 0.001), milk (0.9 CETK for HS and 1.0 CETK for OE vs 0.8 CETK; P < 0.001). Sixty-five percent of the HS group met DRI and had greater odds of meeting calcium DRI (odds ratio, 1.8; 95% confidence interval, 1.2-2.7) compared with other groups. The OE group had the lowest proportion of children meeting recommended intakes for 19 out of 25 nutrients.

CONCLUSIONS AND IMPLICATIONS

Mean intakes of foods and nutrients for children across the USAP meet some, but not all, recommendations and intakes vary across children attending various ECE setting types. Additional research on the clinical importance of these differences and the impact of the complex food systems in the USAP may identify systematic strategies for improving diet among children.

Food Security is Associated with Higher Diet Quality Among Children of the US-Affiliated Pacific Region

BACKGROUND

The prevalence of food insecurity and its relationship to diet quality are factors impacting the health of persons living across the United States-affiliated Pacific region (USAP).

OBJECTIVES

The aim of this study was to describe characterize the relationship between household food security status and diet quality of 2- to 8-y-old children across jurisdictions in the USAP.

METHODS

Baseline data from 2- to 8-y-olds (n = 3099) enrolled in the Children's Healthy Living Program for Remote Underserved Minority Populations in the Pacific region, an obesity prevention study conducted in communities across Alaska, American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Guam, and Hawaii, and a concomitant prevalence study in communities across the Freely Associated States (FAS) (the Federated States of Micronesia: Kosrae, Pohnpei, Chuuk, Yap; Republic of Marshall Islands; Republic of Palau) were collected in 2012. Caregivers self-reported sociodemographic data and food insecurity. Assisted by their caregiver, children completed two dietary records on nonconsecutive, randomly assigned days. The Healthy Eating Index 2005 (HEI-2005) was used to assess the diet quality. Data were summarized overall and by jurisdiction. Differences in HEI-2005 and HEI component scores among jurisdictions and by household food security status were tested using 1-factor ANOVA.

RESULTS

Half or more of participants from American Samoa, Guam, CNMI, and FAS reported household food insecurity (n = 295, 59.7%; n = 292, 49.9%; n = 267, 54.6%; n = 572, 69.0%, respectively). HEI-2005 scores varied by jurisdiction (P < 0.001) and were significantly lower among FAS participants (54.7 ± 1.2) than among all other jurisdictions (P < 0.05). Total diet quality scores did not differ by food security status (59.9 ± 0.8 food secure compared with 58.3 ± 1.1 food insecure, P = 0.07); however, most diet quality adequacy component scores were significantly higher and moderation component scores significantly lower among participants in food secure households than those in food insecure households.

CONCLUSIONS

Significant differences in children's diet quality and household food security existed across USAP jurisdictions.

Food and Physical Activity Environment in the US-Affiliated Pacific Region: The Children's Healthy Living Program

OBJECTIVE

To describe the quality of food and physical activity (PA) environments by World Bank Income level in jurisdictions from the Children's Healthy Living Program.

DESIGN

Baseline cross-sectional community data were analyzed from 11 jurisdictions categorized by World Bank Income levels to describe exposure to different food and PA outlets. The Children's Healthy Living Program was a multilevel, multijurisdictional prevalence study and community intervention trial that reduced child obesity in the US-Affiliated Pacific region.

SETTING

US-Affiliated Pacific region.

PARTICIPANTS

Food (n = 426) and PA (n = 552) Outlets.

MAIN OUTCOME MEASURES

Physical activity and food scores that reflect the quality of the outlets that support being physically active and healthy eating options, respectively.

ANALYSIS

Descriptive statistics are presented as means ± SD or percentages.

RESULTS

High-income-income level jurisdictions had higher food and PA scores than middle-income level jurisdictions.

CONCLUSIONS AND IMPLICATIONS

The US-Affiliated Pacific region has limited quality food and PA outlets in underserved communities at risk for obesity. The findings in this paper can be used to develop tools and design interventions to improve the food and PA environment to increase a healthier, active lifestyle.

Food Group, Macronutrient Intake, and Metabolic Status in the US-Affiliated Pacific's Children's Healthy Living (CHL) Program

BACKGROUND

The Children's Healthy Living study provided dietary intake information for understudied Native Hawaiian and Other Pacific Islander (NHOPI) young children.

OBJECTIVES

Our objective was to describe food group and macronutrient intakes of NHOPI children in the US-Affiliated Pacific region (USAP), overall and by jurisdiction, income level, and metabolic status.

METHODS

We evaluated 2-8-y-olds (n = 3520) in a cross-sectional cluster sampled study using 2 d of dietary records completed by caregivers using provided tools, quantified by a specially developed food composition table and compared with US dietary recommendations. Overweight and obesity (OWOB) and acanthosis nigricans (AN) assessment (metabolic status) was completed by trained evaluators using standard tools. Demographic data were collected by questionnaire. Regression analysis identified differences in dietary component means by jurisdiction, World Bank income groups (WBIGs), and metabolic status, adjusted for age and sex.

RESULTS

Few children met US recommendations for vegetable (2.4%) and milk (4.1%) food groups. US macronutrient recommendations were generally met. Food group and macronutrient intakes were significantly different by jurisdiction and WBIG. Means for food groups, except meats, and macronutrients, except protein, were higher in overweight/obese (OWOB) compared with healthy-weight children. Grain intake of 7.25 (SE: 0.08) oz was higher (P < 0.05) and milk intake of 0.90 (SE: 0.05) cups was lower (P < 0.05) in children with OWOB compared with those without OWOB [grains: 7.17 (SE: 0.07) oz; and milk: 0.96 (SE: 0.04) cups]. Monounsaturated fat intake of 11.68 (SE: 0.10) % energy was higher in those with OWOB, compared with healthy-weight children [11.56 (SE: 0.08) % energy, P < 0.05].

CONCLUSIONS

Young children's diets in the USAP did not meet milk, vegetable, or fruit intake recommendations. There was variability in dietary patterns across the USAP and by WBIG. Grain intake and monounsaturated fat intake were lower and milk intake was higher in children with better metabolic status.

Family-centred interventions for Indigenous early childhood well-being by primary healthcare services

BACKGROUND

Primary healthcare, particularly Indigenous-led services, are well placed to deliver services that reflect the needs of Indigenous children and their families. Important characteristics identified by families for primary health care include services that support families, accommodate sociocultural needs, recognise extended family child-rearing practices, and Indigenous ways of knowing and doing business. Indigenous family-centred care interventions have been developed and implemented within primary healthcare services to plan, implement, and support the care of children, immediate and extended family and the home environment. The delivery of family-centred interventions can be through environmental, communication, educational, counselling, and family support approaches.

OBJECTIVES

To evaluate the benefits and harms of family-centred interventions delivered by primary healthcare services in Canada, Australia, New Zealand, and the USA on a range of physical, psychosocial, and behavioural outcomes of Indigenous children (aged from conception to less than five years), parents, and families.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 22 September 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), cluster RCTs, quasi-RCTs, controlled before-after studies, and interrupted time series of family-centred care interventions that included Indigenous children aged less than five years from Canada, Australia, New Zealand, and the USA. Interventions were included if they met the assessment criteria for family-centred interventions and were delivered in primary health care. Comparison interventions could include usual maternal and child health care or one form of family-centred intervention versus another.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. overall health and well-being, 2. psychological health and emotional behaviour of children, 3. physical health and developmental health outcomes of children, 4. family health-enhancing lifestyle or behaviour outcomes, 5. psychological health of parent/carer. 6. adverse events or harms. Our secondary outcomes were 7. parenting knowledge and awareness, 8. family evaluation of care, 9. service access and utilisation, 10. family-centredness of consultation processes, and 11. economic costs and outcomes associated with the interventions. We used GRADE to assess the certainty of the evidence for our primary outcomes.

MAIN RESULTS

We included nine RCTs and two cluster-RCTs that investigated the effect of family-centred care interventions delivered by primary healthcare services for Indigenous early child well-being. There were 1270 mother-child dyads and 1924 children aged less than five years recruited. Seven studies were from the USA, two from New Zealand, one from Canada, and one delivered in both Australia and New Zealand. The focus of interventions varied and included three studies focused on early childhood caries; three on childhood obesity; two on child behavioural problems; and one each on negative parenting patterns, child acute respiratory illness, and sudden unexpected death in infancy. Family-centred education was the most common type of intervention delivered. Three studies compared family-centred care to usual care and seven studies provided some 'minimal' intervention to families such as education in the form of pamphlets or newsletters. One study provided a minimal intervention during the child's first 24 months and then the family-centred care intervention for one year. No studies had low or unclear risk of bias across all domains. All studies had a high risk of bias for the blinding of participants and personnel domain. Family-centred care may improve overall health and well-being of Indigenous children and their families, but the evidence was very uncertain. The pooled effect estimate from 11 studies suggests that family-centred care improved the overall health and well-being of Indigenous children and their families compared no family-centred care (standardised mean difference (SMD) 0.14, 95% confidence interval (CI) 0.03 to 0.24; 2386 participants). We are very uncertain whether family-centred care compared to no family-centred care improves the psychological health and emotional behaviour of children as measured by the Infant Toddler Social Emotional Assessment (ITSEA) (Competence domain) (mean difference (MD) 0.04, 95% CI -0.03 to 0.11; 2 studies, 384 participants). We assessed the evidence as being very uncertain about the effect of family-centred care on physical health and developmental health outcomes of children. Pooled data from eight trials on physical health and developmental outcomes found there was little to no difference between the intervention and the control groups (SMD 0.13, 95% CI -0.00 to 0.26; 1961 participants). The evidence is also very unclear whether family-centred care improved family-enhancing lifestyle and behaviours outcomes. Nine studies measured family health-enhancing lifestyle and behaviours and pooled analysis found there was little to no difference between groups (SMD 0.16, 95% CI -0.06 to 0.39; 1969 participants; very low-certainty evidence). There was very low-certainty evidence of little to no difference for the psychological health of parents and carers when they participated in family-centred care compared to any control group (SMD 0.10, 95% CI -0.03 to 0.22; 5 studies, 975 parents/carers). Two studies stated that there were no adverse events as a result of the intervention. No additional data were provided. No studies reported from the health service providers perspective or on outcomes for family's evaluation of care or family-centredness of consultation processes.

AUTHORS' CONCLUSIONS

There is some evidence to suggest that family-centred care delivered by primary healthcare services improves the overall health and well-being of Indigenous children, parents, and families. However, due to lack of data, there was not enough evidence to determine whether specific outcomes such as child health and development improved as a result of family-centred interventions. Seven of the 11 studies delivered family-centred education interventions. Seven studies were from the USA and centred on two particular trials, the 'Healthy Children, Strong Families' and 'Family Spirit' trials. As the evidence is very low certainty for all outcomes, further high-quality trials are needed to provide robust evidence for the use of family-centred care interventions for Indigenous children aged less than five years.

Domains of Capacity Building in Whole-Systems Approaches to Prevent Obesity-A "Systematized" Review

Despite increased awareness of its risks, for the most part, contemporary efforts for obesity prevention have been patchy at best. As such, the burgeoning interest in whole-systems approaches (WSAs) that acknowledge the complex, dynamic nature of overweight and obesity and operate across multiple levels of society is particularly timely. Many components of "community capacity building" (CB), an essential but often neglected aspect of obesity prevention, overlap with "best practice principles" in effective/optimal community-based obesity-prevention initiatives. Rhetoric urging WSAs and community CB in public health abounds although operative and efficacious contemporary examples of these approaches to reducing obesity levels are scarce. The aim of this investigation was to undertake a systematized review of the level of capacity building incorporated in published literature on WSAs targeting obesity to better understand how domains of CB have been incorporated. A PubMed search and a recently published systematic review were utilized to identify WSAs to obesity prevention between 1995-2020. A team-based approach to qualitative thematic data analysis was used to systematically assess and describe each intervention regarding explicit capacity-building practice. Despite not being specifically designed for building capacity, a significant proportion of the WSAs studied in the current report had implemented several CB domains.

Pacific Islands Cohort on Cardiometabolic Health Study: rationale and design

BACKGROUND

Pacific Islanders, including those residing in the US Affiliated Pacific Islands (USAPI), experience some of the highest mortality rates resulting from non-communicable diseases (NCDs) worldwide. The Pacific Island Health Officers' Association declared a Regional State of Health Emergency in 2010 due to the epidemic of NCDs in the USAPI. Obesity, a known risk factor for NCDs, has become an epidemic among both children and adults in Micronesia and other parts of the USAPI. There is some recent information about overweight and obesity (OWOB) among young children in the USAPI, but there is no data looking at the relationship between children and their biological parents. The Pacific Islands Cohort on Cardiometabolic Health (PICCAH) Study aims to collect data on NCD lifestyle factors from two generations of families (n = 600 child-parent dyads or 1,200 participants) living in Guam, Pohnpei, and Palau.

METHODS

The PICCAH Study is an epidemiological study using community-based convenience sampling to recruit participants in USAPI of Guam, Palau, and Pohnpei. The goal is to recruit participant dyads consisting of 1 child plus their biological parent in Guam (500 dyads or 1,000 participants), Pohnpei (50 dyads or 100 participants), and Palau (50 dyads or 100 participants). All participants are having the following information collected: demographic, health, and lifestyle information; anthropometry; diet; physical activity; sleep; acanthosis nigricans; blood pressure; and serum levels of fasting plasma glucose, fasting insulin, glycated hemoglobin, total cholesterol, triglycerides, LDL, and HDL.

DISCUSSION

The PICCAH Study is designed to establish the baseline of a generational epidemiologic cohort with an emphasis on cardiometabolic risk, and to better understand the extent of DM and CVD conditions and related risk factors of those living in the USAPI jurisdictions of Guam, Pohnpei, and Palau. This study also serves to further build research capacity in the underserved USAPI Region.

Effects of a Sleep Health Education Program for Children and Parents on Child Sleep Duration and Difficulties: A Stepped-Wedge Cluster Randomized Clinical Trial

IMPORTANCE

Preschool-aged children often lack sufficient sleep and experience sleep difficulties. A consistent bedtime routine, falling asleep alone, and other sleep practices reduce difficulties and increase sleep duration.

OBJECTIVE

To evaluate the effects of a preschool-based sleep health literacy program on children's sleep duration and difficulties and on parent sleep knowledge, attitudes, self-efficacy, and beliefs 9 and 12 months after the program.

DESIGN, SETTING, AND PARTICIPANTS

This stepped-wedge cluster randomized clinical trial was implemented across the 2018-2019 school year. Head Start preschool personnel delivered interventions and collected outcomes data at baseline and 4 follow-ups. Seven Head Start agencies across New York State were randomized to implement interventions in either fall 2018 or winter and spring 2019. Outcomes were ascertained at 9- and 12-month follow-up. From March 19 through September 28, 2018, Head Start staff recruited (a) English- or Spanish-speaking parents (b) of children 3 years of age on or about September 2018 (c) who planned to remain at the site through the school year. Altogether, 519 parent-child (aged 3 years) dyads completed baseline and (any) follow-up data.

INTERVENTIONS

A 2-week classroom curriculum for children, a 1-hour parent workshop, and 1-on-1 parent discussions at home or school.

MAIN OUTCOMES AND MEASURES

Outcomes were the pre- vs postintervention differences measured at baseline and 9-month follow-up for parent-reported child school-night sleep duration per sleep logs, mild or moderate sleep difficulties per a validated questionnaire, and the total and domain scores for parent sleep knowledge, attitudes, self-efficacy, and beliefs. A modified intention-to-treat analysis excluding participants with only baseline data was used.

RESULTS

The mean (SD) age at enrollment of 519 children was 2.7 (0.1) years, 264 (50.9%) were girls, 196 (37.8%) lived in Spanish-speaking households, and 5 (0.9%) identified as Alaskan Native or American Indian, 17 (3.2%) as Asian American or Pacific Islander, 57 (10.8%) as Black, 199 (37.8%) as White, and 63 (12.0%) as other. Mean sleep durations increased nonsignificantly from baseline by 5.6 minutes (95% CI, -2.3 to 13.6 minutes; P = .17) at 9-month follow-up and by 6.8 minutes (95% CI, 0.2-13.7 minutes; P = .06) at 12-month follow-up. There was a slight improvement in parental knowledge (1.13 unit increase from baseline; 95% CI, 0.13-2.12 units), but no significant outcomes for parent sleep attitudes (0.16 unit increase from baseline; 95% CI, -0.46 to 0.77 units), self-efficacy (-0.13 unit decrease from baseline; 95% CI, -1.02 to 0.76 units) and beliefs (-0.20 unit decrease from baseline; 95% CI, -0.56 to 0.16 units). Intervention effects for child sleep difficulties were not significant (odds ratio, 1.13; 95% CI, 0.62-2.09). Fewer than 1 in 4 parents accurately perceived their child's sleep difficulty at 12 months.

CONCLUSIONS AND RELEVANCE

The findings of this large pragmatic, stepped-wedge cluster randomized clinical trial, albeit largely negative, may have implications for the sustained impact, focus, and potential population-level effects of sleep education programs. Future research should evaluate the effects of more recurrent programming that emphasizes recognition of sleep problems and whether small increments of sleep across months and years in early childhood have meaningful effects.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03556462.

Consumption of Traditional Fruits and Vegetables among Children in the US-Affiliated Pacific Region

Background

Traditional Pacific diets have many health benefits, including maintenance of a healthy weight and prevention of various diseases. Few studies have evaluated the frequency at which traditional diets are consumed in the Pacific, especially among children.

Objectives

This study examined the frequency of traditional and acculturated fruit and vegetable (F&V) intake among children in the US-affiliated Pacific (USAP) region.

Methods

Diet records of 3319 children ages 2 to 8 y old were analyzed for frequency of traditional or acculturated F&V intake within USAP jurisdictions of American Samoa, Commonwealth of the Northern Mariana Islands (CNMI), Federated States of Micronesia (FSM; FSM island states include Chuuk, Kosrae, Pohnpei, and Yap), Guam, Hawaii, Republic of the Marshall Islands (RMI), and Republic of Palau.

Results

Of the 95,304 food items recorded among participating children in the USAP jurisdictions, 15.2% were F&Vs. Of the 10 jurisdictions, children in the islands of Chuuk, Kosrae, Yap, and Pohnpei recorded the highest frequencies of traditional F&V intake relative to their total F&V intake (67.8%, 64.8%, 56.7%, and 52.5%, respectively). American Samoa and RMI recorded moderate frequency of traditional F&V intake (38.9% and 46.4%, respectively), whereas children in Hawaii, Guam, and CNMI recorded the lowest frequencies of traditional F&V intake relative to their total F&V intake (10.4%, 12.4%, and 15.3%, respectively). Children in Hawaii, Guam, Palau, and CNMI recorded high frequencies of acculturated F&V intake (37.8%, 31.2%, 34.5%, and 27.9%, respectively).

Conclusions

Overall, children in the USAP jurisdictions participating in this study recorded a low frequency of F&V intake. The differences in traditional F&V intake found between the USAP islands may be due to variation in economic income level and external influences on social and cultural norms among the island populations and variations of cost, accessibility, and convenience of each category of food to each island's population.

Maintenance Outcomes of the Children's Healthy Living Program on Overweight, Obesity, and Acanthosis Nigricans Among Young Children in the US-Affiliated Pacific Region: A Randomized Clinical Trial

Importance

Few obesity prevention trials among children have demonstrated sustainable outcomes in the long term.

Objectives

To sustain a community-wide decrease in the prevalence of overweight and obesity among young children in the US-affiliated Pacific region.

Design, Setting, and Participants

In the Children's Healthy Living community-randomized clinical trial, hierarchical modeling comparing the change in intervention and control communities accounted for community randomization (community clustering with jurisdictions), and adjusted for the age and sex distribution of the assessed children in a cross-sectional design. The outcome measures were repeated in communities rather than among individual children. A total of 27 communities in 5 jurisdictions (Hawai'i, Alaska, Commonwealth of the Northern Mariana Islands, American Samoa, and Guam) of the US-affiliated Pacific region were included. Participants included children aged 2 to 8 years in the 27 selected communities from October 1, 2012 (4329 in time 1 [baseline]) to August 31, 2015 (4043 in time 2 [intervention end]) and from January 1, 2019, to April 30, 2020 (1469 in time 3 [maintenance period]). Study analysis was completed March 25, 2022.

Interventions

Nineteen activities addressed training, policies, systems, and environments of communities and 6 target behaviors of children (consumption of fruit and vegetables, water, and sugar-sweetened beverages; sleep; physical activity; and screen time) during a 2-year intervention period. Continued partnership with community coalitions, ongoing academic training of community partners, and use of trial data during a 6-year maintenance period.

Main Outcomes and Measures

The primary outcome was measured anthropometry; secondary outcomes were the presence of acanthosis nigricans, dietary intake derived from 2 days of food records, and survey questions on screen time and sleep disturbance.

Results

Among the 9840 children included in the analysis (4866 girls [49.5%] and 4974 boys [50.5%]; 6334 [64.4%] aged 2-5 years), the intervention group showed significant improvements compared with the control group from times 1 to 3 in prevalence of overweight plus obesity (d = -12.60% [95% CI, -20.92% to -4.28%]), waist circumference (d = -1.64 [95% CI, -2.87 to -0.41] cm), and acanthosis nigricans prevalence (d = -3.55% [95% CI, -6.17% to -0.92%]). Significant improvements were also observed from times 2 to 3 in prevalence of overweight plus obesity (d = -8.73% [95% CI, -15.86% to -1.60%]) but not in waist circumference (d = -0.81 [95% CI, -1.85 to 0.23] cm).

Conclusions and Relevance

This randomized clinical trial found that the outcomes of the Children's Healthy Living intervention were maintained and enhanced 6 years after the intervention among young children in the US-affiliated Pacific region. The prevalence of overweight, obesity, and acanthosis nigricans was further reduced in communities, suggesting that multilevel multicomponent interventions may help reduce child overweight and obesity in this region.

Trial Registration

ClinicalTrials.gov Identifier: NCT01881373.

Improving Willingness to Try Fruits and Vegetables and Gross Motor Skills in Preschool Children in Guam

Early childhood interventions have the potential to promote long-term healthy eating and physical activity habits to prevent obesity. However, research studies including indigenous young children are lacking. This study examined the effectiveness of the Food Friends^®: Fun with New Foods™ and Get Movin’ with Mighty Moves™ (FFMM) curricula on willingness to try fruits and vegetables (FV) and gross motor (GM) skills among preschoolers in Guam. A pre-post community-based study included preschoolers from Head Start (HS), gifted and talented education (Pre-GATE), and Pre-Kindergarten programs during school years (SY) 2017–2018 and 2018–2019. In SY2017–2018, the intervention group had a significant increase in imported FV when compared with the other three groups. No significant differences between groups were found on the other FV scales. Regarding gross motor skills, no significant differences between groups were found. In SY2018–2019, the intervention group had a significant increase in all FV scales except imported FV when compared with the enhanced intervention group. With gross motor skills, no significant differences were found between groups on its progress. These results warrant FFMM adaptations for the prevention of obesity among Guam preschoolers.

Development and evaluation of an undergraduate curriculum on non-communicable disease research in Guam: The Pacific Islands Cohort of College Students (PICCS)

Background

The non-communicable disease (NCD) epidemic among Pacific Islanders prompted the declaration of a regional state of NCD emergency throughout the United States-Affiliated Pacific Islands (USAPIs) in 2010. Subsequently, the University of Guam Health Science Program launched a pilot study on NCD research in its undergraduate curriculum modeled after the Pacific Data for Decision Making (DDM) framework – a field epidemiology training program employed in the USAPIs. The primary objective of the research is to conduct annual assessments of student health indicators with plans for longitudinal follow-up. Here, development and evaluation of the undergraduate research curriculum are described.

Methods

The Pacific DDM framework covering knowledge and skills in resourcing, types of data and indicators, data sources, data management, information products, and data dissemination and use were incorporated in undergraduate core courses of the Health Science Program. During the data collection pilot years, 2013 and 2014, a survey containing questions predominantly on NCD risk factors was launched at the university. The survey was administered by upperclassmen in the Health Science Program and evolved into the Pacific Islands Cohort of College Students (PICCS) research study. The initial years were spent developing the infrastructure. Program outputs were tracked annually to measure program success.

Results

Students in the Health Science Program obtained research knowledge and skills through various courses while enrolled in the program. The PICCS data collection continued annually as a cross-sectional survey from 2015 to current. Numerous successes have resulted including student abstracts and publications, acceptances to summer programs and fellowships, a sustained annual health fair for college students, a grant award, and other program-related impacts.

Conclusion

The PICCS framework provided the organizational structure and documented tools, protocols, roles, and responsibilities to enhance consistency and reproducibility. Undergraduate students applied their knowledge and skills to an ongoing study focused on NCD risk factor surveillance of college students. Additionally, multiple research successes have been achieved through the PICCS curriculum. Plans are underway to begin the longitudinal design of the PICCS research study and sustain it through the curriculum, with room for adaptation as courses are updated over time.

Estimating intervention dose of the multilevel multisite children's healthy living program intervention

Increased community collective efficacy (CE), defined as social cohesion among neighbors and their willingness to intervene for common good, is associated with improved community health outcomes. However, processes to increase CE and estimate its dose within an intervention are not well understood. The 2 year Children's Healthy Living (CHL) intervention aimed to improve child behaviors known to affect obesity. We used data from CHL to estimate CE dose and examine its association with a successful outcome from CHL-reduction in children's recreational screen time. Monthly reports from nine intervention communities were quantified, and CE dose was calculated for each community overall, at 4 time intervals (6, 12, 18, and 24 months), and for each CE building block-social bonding, social bridging, social leveraging, empowerment, and civic engagement. CE dose at each time interval and change in screen time was correlated using Spearman's rho. Next, communities were categorized as having a high CE dose or a low CE dose, and differences between four high-dose and five low-dose communities were compared using a two-tailed t-test. The correlation between change in screen time and CE dose was significant (rs = 0.83, p = .003). Significantly more activities facilitating empowerment and civic engagement were conducted in high-dose communities, which were more likely to show improvements in screen time, than in low-dose communities. This method of estimating an intervention's CE dose and examining change over time and effect of CE and its building blocks on intervention outcomes shows promise.

Determination of Child Waist Circumference Cut Points for Metabolic Risk Based on Acanthosis Nigricans, the Children's Healthy Living Program

INTRODUCTION

Waist circumference is a common anthropometric measure for predicting abdominal obesity and insulin resistance. We developed optimal waist circumference cut points for children aged 2 to 8 years in the US-Affiliated Pacific (USAP) region based on the relationship of waist circumference and acanthosis nigricans in this population.

METHODS

We conducted a cross-sectional analysis from the Children's Healthy Living Program's 2012-2013 data on 4,023 children. We used receiver-operating characteristic analysis to determine the sensitivity and specificity for acanthosis nigricans across waist circumference, by sex and age. We determined optimal waist circumference cutoff points corresponding to Youden index (J), (equal to [sensitivity + specificity] - 1), with acanthosis nigricans. We compared these cut points with the 90th percentile.

RESULTS

The 90th-percentile cut points for boys aged 2 to 5 years (58.15 cm) and 6 to 8 years (71.63 cm) were slightly higher than for girls in both age groups (aged 2-5 y, 57.97 cm; 6-8 y: 70.37 cm). The optimal cut points (corresponding to the highest sensitivity and specificity) were as follows: for boys aged 2 to 5 years, 90th percentile (58.25 cm; sensitivity, 48.0%; specificity, 91.5%); for boys aged 6 to 8 years, 78th percentile (63.59 cm; sensitivity, 86.8%; specificity, 82.8%); for girls aged 2 to 5 years, 62nd percentile (53.27 cm; sensitivity, 71.4%; specificity, 63.1%), and for girls aged 6 to 8 years, 80th percentile (63.63 cm; sensitivity, 55.4%; specificity, 82.9%).

CONCLUSION

Among USAP children, waist circumference was a reasonable predictor for acanthosis nigricans. Further analysis is warranted to examine causes of acanthosis nigricans at lower-than-expected waist circumference percentiles. The cut points can be used for early detection of metabolic risk.

Role of social ecological model level on young Pacific children's sugar-sweetened beverage and water intakes: Children's Healthy Living intervention

OBJECTIVE

To examine children's sugar-sweetened beverage (SSB) and water intakes in relation to implemented intervention activities across the social ecological model (SEM) during a multilevel community trial.

DESIGN

Children's Healthy Living was a multilevel, multicomponent community trial that reduced young child obesity (2013-2015). Baseline and 24-month cross-sectional data were analysed from nine intervention arm communities. Implemented intervention activities targeting reduced SSB and increased water consumption were coded by SEM level (child, caregiver, organisation, community and policy). Child SSB and water intakes were assessed by caregiver-completed 2-day dietary records. Multilevel linear regression models examined associations of changes in beverage intakes with activity frequencies at each SEM level.

SETTING

US-Affiliated Pacific region.

PARTICIPANTS

Children aged 2-8 years (baseline: n 1343; 24 months: n 1158).

RESULTS

On average (± sd), communities implemented 74 ± 39 SSB and 72 ± 40 water activities. More than 90 % of activities targeted both beverages together. Community-level activities (e.g. social marketing campaign) were most common (61 % of total activities), and child-level activities (e.g. sugar counting game) were least common (4 %). SSB activities across SEM levels were not associated with SSB intake changes. Additional community-level water activities were associated with increased water intake (0·62 ml/d/activity; 95 % CI: 0·09, 1·15) and water-for-SSB substitution (operationalised as SSB minus water: -0·88 ml/d/activity; 95 % CI: -1·72, -0·03). Activities implemented at the organization level (e.g. strengthening preschool wellness guidelines) and policy level (e.g. SSB tax advocacy) also suggested greater water-for-SSB substitution (P < 0·10).

CONCLUSIONS

Community-level intervention activities were associated with increased water intake, alone and relative to SSB intake, among young children in the Pacific region.

Childhood Obesity Evidence Base Project: A Systematic Review and Meta-Analysis of a New Taxonomy of Intervention Components to Improve Weight Status in Children 2-5 Years of Age, 2005-2019

Objective: To evaluate the efficacy of childhood obesity interventions and conduct a taxonomy of intervention components that are most effective in changing obesity-related health outcomes in children 2-5 years of age. Methods: Comprehensive searches located 51 studies from 18,335 unique records. Eligible studies: (1) assessed children aged 2-5, living in the United States; (2) evaluated an intervention to improve weight status; (3) identified a same-aged comparison group; (4) measured BMI; and (5) were available between January 2005 and August 2019. Coders extracted study, sample, and intervention characteristics. Effect sizes [ESs; and 95% confidence intervals (CIs)] were calculated by using random-effects models. Meta-regression was used to determine which intervention components explain variability in ESs. Results: Included were 51 studies evaluating 58 interventions (N = 29,085; mean age = 4 years; 50% girls). Relative to controls, children receiving an intervention had a lower BMI at the end of the intervention (g = 0.10, 95% CI = 0.02-0.18; k = 55) and at the last follow-up (g = 0.17, 95% CI = 0.04-0.30; k = 14; range = 18-143 weeks). Three intervention components moderated efficacy: engage caregivers in praise/encouragement for positive health-related behavior; provide education about the importance of screen time reduction to caregivers; and engage pediatricians/health care providers. Conclusions: Early childhood obesity interventions are effective in reducing BMI in preschool children. Our findings suggest that facilitating caregiver education about the importance of screen time reduction may be an important strategy in reducing early childhood obesity.

Prevalence and Predictors of Overweight and Obesity among Young Children in the Children's Healthy Living Study on Guam

This study is part of the Children's Healthy Living program in U.S. Affiliated Pacific region. The objectives were to estimate overweight and obesity (OWOB) prevalence and identify possible related risk factors among ethnic groups in Guam. In 2013, 865 children (2-8 years) were recruited via community-based sampling from select communities in Guam. Children's demographic and health behavior information; dietary intake; and anthropometric measurements were collected. Logistic regression, odds ratio, t-tests, and chi-square tests were used to determine differences and assess covariates of OWOB. The results indicate that 58% of children were living below the poverty level, 80% were receiving food assistance, and 51% experienced food insecurity. The majority of children surveyed did not meet recommendations for: sleep duration (59.6%), sedentary screen-time (83.11%), or fruit (58.7%) and vegetable (99.1%) intake, and consumed sugar sweetened beverages (SSB) (73.7%). OWOB affected 27.4% of children. Children affected by OWOB in this study were statistically more likely (p = 0.042) to suffer from sleep disturbances (p = 0.042) and consume marginally higher amounts (p value = 0.07) of SSB compared to children with healthy weight. Among Other Micronesians, children from families who considered themselves 'integrated' into the culture were 2.05 (CI 0.81-5.20) times more likely to be affected by OWOB. In conclusion, the OWOB prevalence among 2-8-year-olds in Guam was 27.4%; and compared with healthy weight children, children with OWOB were more likely to have educated caregivers and consume more SSBs. Results provide a basis for health promotion and obesity prevention guidance for children in Guam.

The Affordability of a Thrifty Food Plan-based Market Basket in the United States-affiliated Pacific Region

In an effort to characterize food costs in the United States (US)-affiliated Pacific Region, a first-time food cost survey was conducted in March 2014. A market basket survey was developed using an adaptation of the US Department of Agriculture Thrifty Food Plan. Surveys were conducted in the states of Alaska and Hawai'i; Portland, Oregon; the US-affiliated Pacific Islands of American Samoa (American Samoa); Commonwealth of the Northern Mariana Islands; the island of Pohnpei within the Federated States of Micronesia; Guam; Republic of the Marshall Islands; and Republic of Palau. Urban and rural communities were included. Multiple stores in multiple communities were surveyed in each jurisdiction. Food retailers (N = 74) ranged from convenience markets to supermarkets. Not all foods in the market basket survey were available in each of the communities. Inspection of available income data also showed that food costs represented a higher percentage of household income for American Samoa than those of Alaska, Hawai'i, and Portland. Thrifty Food Plan weighted weekly totals for the region ranged from $181.90 to $264.30. Weighting was based on the amount of the item converted to grams required for the Thrifty Food Plan menu. These food costs are significantly higher than those of Portland ($142.00) for the survey period. Protein foods, grains, vegetables, fruit, and dairy were the 5 most costly components, in descending order. Food affordability was assessed by comparing food costs across jurisdictions and examining estimated food costs to reported average jurisdiction incomes. The survey is intended to help inform public health policy and educational programs in the region. A locally adapted food survey would benefit future analyses, regional policy, and educational efforts.

Trends in Health Behavior Patterns Among U.S. Adults, 2003-2015

Background

Over the last two decades, considerable resources from U.S. federal and philanthropic entities were dedicated to improving preventive and reducing chronic disease risk behaviors.

Purpose

Given the population health efforts to improve health behaviors in adults, this study explored how health behavior patterns shifted over the years by exploring multiple health behavior patterns.

Methods

Data were obtained from the odd years between 2002 and 2016 Behavioral Risk Factor Surveillance System. Latent class analyses including fruit and vegetables, physical activity, cigarette smoking, and heavy and binge drinking were conducted for each year.

Results

Three-class models best fit the data and were most interpretable. Each year included Healthy or Physically Active (preventive behaviors, no risk behaviors), Apathetic (no preventive/risk behaviors), and Binge-drinking groups. Gender and age consistently distinguished the Healthy/Physically Active groups from the Apathetic and Binge-drinking groups across the years.

Conclusions

This study confirms health behavior clusters exist and have been stable across time. This is encouraging as trends have not gotten worse, but there is room for improvement. Repetition of the groups across years suggests that despite population-level interventions, a large segment of the U.S. population at risk for chronic diseases are not engaging in preventive health.

Interventions for preventing obesity in children

BACKGROUND

Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review.

OBJECTIVES

To determine the effectiveness of a range of interventions that include diet or physical activity components, or both, designed to prevent obesity in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of diet or physical activity interventions, or combined diet and physical activity interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse events, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to 12 years, and 13 to 18 years for zBMI and BMI.

MAIN RESULTS

We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that diet combined with physical activity interventions, compared with control, reduced BMI (mean difference (MD) -0.07 kg/m2, 95% confidence interval (CI) -0.14 to -0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD -0.11, 95% CI -0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD -0.22 kg/m2, 95% CI -0.44 to 0.01) or zBMI (diet alone: MD -0.14, 95% CI -0.32 to 0.04; physical activity alone: MD 0.01, 95% CI -0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD -0.10 kg/m2, 95% CI -0.14 to -0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD -0.02, 95% CI -0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that diet combined with physical activity interventions, compared with control, reduced zBMI (MD -0.05 kg/m2, 95% CI -0.10 to -0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD -0.03, 95% CI -0.06 to 0.01) or BMI (-0.02 kg/m2, 95% CI -0.11 to 0.06).Children aged 13 to 18 years: There is very low-certainty evidence that physical activity interventions, compared with control reduced BMI (MD -1.53 kg/m2, 95% CI -2.67 to -0.39; 4 RCTs; n = 720); and low-certainty evidence for a reduction in zBMI (MD -0.2, 95% CI -0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that diet combined with physical activity interventions, compared with control, had no effect on BMI (MD -0.02 kg/m2, 95% CI -0.10 to 0.05); or zBMI (MD 0.01, 95% CI -0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions: Two RCTs reported data directly comparing diet with either physical activity or diet combined with physical activity interventions for children aged 6 to 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update.

AUTHORS' CONCLUSIONS

Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physical activity do not appear to be effective in children of this age. In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that diet combined with physical activity interventions may be effective. Importantly, this updated review also suggests that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities.The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.

Diabetes Prevention and Care Programs in the US-Affiliated Pacific Islands: Challenges, Innovation, and Recommendations for Effective Scale-Up

PURPOSE OF REVIEW

This review describes some of the unique challenges faced by the US-Affiliated Pacific Islands (USAPIs) in addressing diabetes prevention and care and presents innovative population-level strategies that have been employed to address them.

RECENT FINDINGS

Challenges include an unhealthy food environment and a strained health care infrastructure, both compounded by geography. Innovations in addressing these challenges include attempts to modify the food environment, a focus on early life prevention, and task shifting among the health workforce. Many of the successful interventions share a focus on culture, community, and capacity building. Although the USAPIs are uniquely challenged by environmental, structural, and health system barriers, there have been a number of innovative and successful strategies employed that highlight the resilience of these island nations in addressing their current disease burden when provided with the opportunity and resources to do so. Health policies to protect, support, and promote diabetes prevention and care are essential and may be informed by the interventions described.

Challenges and Lessons Learned from Multi-Level Multi-Component Interventions to Prevent and Reduce Childhood Obesity

Multi-level multi-component (MLMC) strategies have been recommended to prevent and reduce childhood obesity, but results of such trials have been mixed. The present work discusses lessons learned from three recently completed MLMC interventions to inform future research and policy addressing childhood obesity. B’more Healthy Communities for Kids (BHCK), Children’s Healthy Living (CHL), and Health and Local Community (SoL) trials had distinct cultural contexts, global regions, and study designs, but intervened at multiple levels of the socioecological model with strategies that address multiple components of complex food and physical activity environments to prevent childhood obesity. We discuss four common themes: (i) How to engage with community partners and involve them in development of intervention and study design; (ii) build and maintain intervention intensity by creating mutual promotion and reinforcement of the intervention activities across the multiple levels and components; (iii) conduct process evaluation for monitoring, midcourse corrections, and to engage stakeholder groups; and (iv) sustaining MLMC interventions and its effect by developing enduring and systems focused collaborations. The paper expands on each of these themes with specific lessons learned and presents future directions for MLMC trials.

Effect of the Children's Healthy Living Program on Young Child Overweight, Obesity, and Acanthosis Nigricans in the US-Affiliated Pacific Region: A Randomized Clinical Trial

IMPORTANCE

Pacific Islanders have among the highest rates of obesity and type 2 diabetes in the world. Targeting children is critical for primary prevention.

OBJECTIVES

To prevent young child overweight and obesity and to improve health in the US-Affiliated Pacific region via the Children's Healthy Living Program.

DESIGN, SETTING, AND PARTICIPANTS

In this multijurisdictional, multilevel, multicomponent community randomized clinical trial, where all evaluable children were analyzed according to the random assignment of their community, hierarchical difference-in-difference models accounted for the community randomization, community clustering with jurisdictions, and these models were adjusted for the age and sex distribution of the community. The setting was 27 communities in 5 jurisdictions (Alaska, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, and Hawaii). Participants were 4329 children (time 1) and 4042 children (time 2) aged 2 to 8 years in 27 selected communities from October 7, 2012, to October 25, 2015. Data analysis was completed in June 2018.

INTERVENTIONS

Nineteen activities addressed policy, environment, messaging, training, and 6 target behaviors (sleep time, screen time, physical activity, fruits and vegetables, water, and sugar-sweetened beverages).

MAIN OUTCOMES AND MEASURES

Primary outcomes were body size measurements. Secondary outcomes were acanthosis nigricans, sleep quality and duration, dietary intake, physical activity, and other questionnaire reponses.

RESULTS

The study included 27 communities and 8371 evaluable children (mean [SD] age, 5.4 [1.8] years; 50.9% male [n = 4264]). Data analysis included 952 children in the intervention group and 930 children in the control group aged 2 to 5 years at time 1; 825 children in the intervention group and 735 children in the control group aged 2 to 5 years at time 2; 565 children in the intervention group and 561 children in the control group aged 6 to 8 years at time 1; and 517 children in the intervention group and 560 children in the control group aged 6 to 8 years at time 2. The intervention communities showed significant improvement compared with control communities in overweight and obesity prevalence (effect size [d] = -3.95%; 95% CI, -7.47% to -0.43%), waist circumference (d = -0.71 cm; 95% CI, -1.37 to -0.05 cm), and acanthosis nigricans prevalence (d = -2.28%; 95% CI, -2.77% to -1.57%). Age and sex subgroup analysis revealed greater difference among the intervention communities in acanthosis nigricans prevalence in the group aged 2 to 5 years (-3.99%) vs the group aged 6 to 8 years (-3.40%), and the interaction was significant (d = 0.59%, P < .001), as well as the smaller difference in the group aged 2 to 5 years (-0.10%) vs the group aged 6 to 8 years (-1.07%) in screen time (d = -0.97 hour per day, P = .01).

CONCLUSIONS AND RELEVANCE

The intervention reduced the prevalence of young child overweight and obesity and acanthosis nigricans. Comprehensive, effective, and sustainable interventions are needed to improve child health in the US-Affiliated Pacific region.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01881373.

Evaluation of complex community-based childhood obesity prevention interventions

BACKGROUND

Multi-setting, multi-component community-based interventions have shown promise in preventing childhood obesity; however, evaluation of these complex interventions remains a challenge.

OBJECTIVE

The objective of the study is to systematically review published methodological approaches to outcome evaluation for multi-setting community-based childhood obesity prevention interventions and synthesize a set of pragmatic recommendations.

METHODS

MEDLINE, CINAHL and PsycINFO were searched from inception to 6 July 2017. Papers were included if the intervention targeted children ≤18 years, engaged at least two community sectors and described their outcome evaluation methodology. A single reviewer conducted title and abstract scans, full article review and data abstraction. Directed content analysis was performed by three reviewers to identify prevailing themes.

RESULTS

Thirty-three studies were included, and of these, 26 employed a quasi-experimental design; the remaining were randomized control trials. Body mass index was the most commonly measured outcome, followed by health behaviour change and psychosocial outcomes. Six themes emerged, highlighting advantages and disadvantages of active vs. passive consent, quasi-experimental vs. randomized control trials, longitudinal vs. repeat cross-sectional designs and the roles of process evaluation and methodological flexibility in evaluating complex interventions.

CONCLUSIONS

Selection of study designs and outcome measures compatible with community infrastructure, accompanied by process evaluation, may facilitate successful outcome evaluation.

Collecting wrappers, labels, and packages to enhance accuracy of food records among children 2-8 years in the Pacific region: Children's Healthy Living Program (CHL)

The aim was to describe differences in dietary outcomes based on the provision of food wrappers, labels or packages (WLP) to complement data from dietary records (DR) among children from the US Affiliated Pacific. The WLP were intended to aid food coding. Since WLP can be associated with ultra-processed foods, one might expect differences in sodium, sugar, and other added ingredients to emerge. Dietary intakes of children (2-8 y) in Alaska, Hawai'i, Commonwealth of the Northern Mariana Islands, and Guam were collected using parent/caregiver completed 2-day DR. Parents were encouraged to collect WLP associated with the child's intake. Trained staff entered data from the DRs including the WLP when available using PacTrac3, a web application. Of the 1,868 DRs collected and entered at the time of this report, 498 (27%) included WLP. After adjusting for confounders (sex, age, location, education, food assistance), the DRs with WLP had significantly higher amounts of energy (kcal), total fat, saturated fat, added sugar, and sodium. These results suggest the inclusion of WLP enhanced the dietary intake data. The intake of energy, fat, added sugar and sodium derived from processed foods and foods consumed outside the home was better captured in children who had WLP.

Areca (betel) nut chewing practices of adults and health behaviors of their children in the Freely Associated States, Micronesia: Findings from the Children's Healthy Living (CHL) Program

BACKGROUND

Chewing areca (betel) nut has been deemed carcinogenic. The practice has become a public health concern in Micronesia. The Children's Healthy Living (CHL) Program included an areca (betel) nut questionnaire in a survey of household characteristics in the Freely Associated States (FAS). This paper describes areca (betel) nut chewing practices of adults and the health behaviors of their children.

METHODS

A cross-section of 1200 children (2-8 year-olds) and their caregivers in Chuuk, Kosrae, Pohnpei, Republic of Palau, Republic of the Marshall Islands (RMI), and Yap were recruited. Socio-demographics, adult areca (betel) nut chewing practices, and other health behaviors of children and adults were assessed. Child anthropometric measurements were collected to estimate weight status.

RESULTS

The FAS areca (betel) nut chewing prevalence was 42%, ranging from 3% (RMI) to 94% (Yap). Among chewers, 84% added tobacco, 97% added slaked lime, 85% added betel leaf, and 24% mixed the components with alcohol. Among FAS children, 95% practiced daily teeth-brushing and 53% visited the dentist annually. Compared to non-chewing households, areca (betel) nut chewing households were more likely to have very young children enrolled, more highly educated adults, and members that used tobacco and alcohol.

CONCLUSION

The FAS areca (betel) nut chewing prevalence (42%) is above the world prevalence of 10-20%, with wide variability across the islands. The oral health findings in this study may inform future oral cancer prevention programs or policies. Regular monitoring of areca (betel) nut use is needed to measure the impact of such programs or policies.

Empowering One Community at a Time for Policy, System and Environmental Changes to Impact Obesity

Objective

This article describes Mayors Mentoring Mayors (3M), an initiative of the Arkansas Coalition for Obesity Prevention (ArCOP), which expanded to five states to become the signature community initiative of the Mid-South Transdisciplinary Collaborative Center (Mid-South TCC) for Health Disparities Research.

Methods

The 3M program is an extension of the Growing Healthy Communities (GHC) program, which sought to build capacity within communities to reduce obesity by implementing policy, system and environmental (PSE) changes that support healthy living. GHC where the mayor was involved had the most significant changes toward better health. These mayors were recruited to share their successes, lessons learned, and best practices with their colleagues through a series of Lunch & Learns. Following the GHC and 3M models, a multi-state approach to expand 3M to five additional states was developed. ArCOP partnered with the Mid-South TCC to recruit mayors in the five states.

Results

Five Lunch & Learn events were held across Arkansas between March and May 2015, with a total of 98 participants (40 mayors, 37 community leaders, 21 guests). Each regional Lunch & Learn had 1-2 host mayor(s) in attendance, with a total of 9 host mayors. For the 3M regional expansion project, eight GHC Recognition Applications from five states were submitted. Five communities, designated as Emerging, were funded to implement GHC projects.

Conclusion

ArCOP successfully engaged mayors, elected officials, and stakeholders who can influence policy across Arkansas as well as in an additional five states in the Mid-South TCC region to implement obesity PSE prevention strategies.

Para I Famagu'on-Ta: Fruit and Vegetable Intake, Food Store Environment, and Childhood Overweight/Obesity in the Children's Healthy Living Program on Guam

This cross-sectional study examined the: (1) association between food store environment (FSE), fruit and vegetable (FV) availability and access, and prevalence of early childhood overweight/obesity (COWOB); and (2) influence of young child actual FV intake on the relationship between the FSE and early COWOB prevalence. Anthropometric and socio-demographic data of children (2 to 8 years; N=466) in baseline communities on Guam participating in the Children's Healthy Living (CHL) Program community trial were included. CDC year 2000 growth charts were used to calculate BMI z-scores and categories. FSE factors (fresh FV scores, store type) were assessed using the CX3 Food Availability and Marketing Survey amended for CHL. ArcGIS maps were constructed with geographic coordinates of participant residences and food stores to calculate food store scores within 1 mile of participant's residences. A sub-sample of participants (n = 355) had Food and Activity Log data to calculate FV and energy intakes. Bivariate correlations and logistic regression evaluated associations. Of 111 stores surveyed, 73% were small markets, 16% were convenience stores, and 11% were large grocery/supermarkets. Supermarkets/large grocery stores averaged the highest FV scores. Most participants did not meet FV intake recommendations while nearly half exceeded energy intake recommendations. Living near a small market was negatively correlated with BMI z-score (r = - 0.129, P < .05) while living near a convenience store was positively correlated with BMI z-score (r = 0.092, P < .05). Logistic regression analysis yielded non-significant associations. The high density of small markets may be an opportunity for FSE intervention but further investigation of Guam's FSE influence on health is needed.

Dual burden of malnutrition in US Affiliated Pacific jurisdictions in the Children's Healthy Living Program

BACKGROUND

Few data are available on dual burden of under and over nutrition of children in the Pacific region. The objective was to examine prevalence of stunting at birth and current stunting and their relationship to obesity in US Affiliated Pacific (USAP) jurisdictions.

METHODS

Cross sectional survey with cluster sampling by community. 5558, 2-8 years olds were measured in 51 communities in 11 USAP jurisdictions. The main outcome measures were stunting at birth, current stunting and obesity by body mass index. Prevalences of stunting at birth, current stunting and obesity were determined, adjusting for age distribution and community clustering. Differences by among age, sex, race and jurisdiction income levels were evaluated by chi-square analysis. Relationships of stunting at birth and current stunting with obesity were examined using a hierarchical model accounting for the study design.

RESULTS

Prevalences were stunting at birth 6.8% (Standard Error, SE = 0.9%), current stunting 1.4% (SE = 0.2%) and obesity 14.03.8% (SE = 0.9%). Obesity was highest in upper middle income jurisdictions (UMIJ) at 17.5%. Stunting at birth differed by race (p = 0.0001) with highest prevalence among Native Hawaiian/Pacific Islanders (10.7%). Prevalence of stunting at birth was different by jurisdiction income level with 27.5% in lower middle income jurisdictions (LMIJ), and 22.2% in UMIJ, and 5.5% in higher than high income jurisdictions (HIJ) at 5.5% (p < 0.0001). Prevalence of current stunting was higher in LMIJ than HIJ (p = 0.001), although children with current stunting were less likely to have been stunted at birth. The association between stunting at birth and current stunting was negative (OR = 0.19, 95% CI: 0.05-0.69).

CONCLUSIONS

Currently stunted children were marginally less likely to be obese than not stunted children in the USAP, where the prevalence of current stunting is low. Stunting (at birth and current) was highest in LMIJ, while UMIJ jurisdictions had the highest dual burden of malnutrition (that is the highest combination of both stunting at birth and obesity).

TRIAL REGISTRATION

National Institutes for Health clinical trial # NCT01881373 (clinicaltrials.gov).

New mobile methods for dietary assessment: review of image-assisted and image-based dietary assessment methods

For nutrition practitioners and researchers, assessing dietary intake of children and adults with a high level of accuracy continues to be a challenge. Developments in mobile technologies have created a role for images in the assessment of dietary intake. The objective of this review was to examine peer-reviewed published papers covering development, evaluation and/or validation of image-assisted or image-based dietary assessment methods from December 2013 to January 2016. Images taken with handheld devices or wearable cameras have been used to assist traditional dietary assessment methods for portion size estimations made by dietitians (image-assisted methods). Image-assisted approaches can supplement either dietary records or 24-h dietary recalls. In recent years, image-based approaches integrating application technology for mobile devices have been developed (image-based methods). Image-based approaches aim at capturing all eating occasions by images as the primary record of dietary intake, and therefore follow the methodology of food records. The present paper reviews several image-assisted and image-based methods, their benefits and challenges; followed by details on an image-based mobile food record. Mobile technology offers a wide range of feasible options for dietary assessment, which are easier to incorporate into daily routines. The presented studies illustrate that image-assisted methods can improve the accuracy of conventional dietary assessment methods by adding eating occasion detail via pictures captured by an individual (dynamic images). All of the studies reduced underreporting with the help of images compared with results with traditional assessment methods. Studies with larger sample sizes are needed to better delineate attributes with regards to age of user, degree of error and cost.

Multi-Level, Multi-Component Approaches to Community Based Interventions for Healthy Living-A Three Case Comparison

There is increasing interest in integrated and coordinated programs that intervene in multiple community settings/institutions at the same time and involve policy and system changes. The purpose of the paper is to analyse three comparable cases of Multi Level, Multi Component intervention programs (ML-MC) from across the world in order to give recommendations for research, policy and practice in this field. Through the comparison of three cases: Health and Local Community (SoL-program), Children's Healthy Living (CHL) and B'More Healthy Communities for Kids (BHCK), this paper examines the potential of ML-MC community-based public health nutrition interventions to create sustainable change. The paper proposes methodology, guidelines and directions for future research through analysis and examination strengths and weaknesses in the programs. Similarities are that they engage and commit local stakeholders in a structured approach to integrate intervention components in order to create dose and intensity. In that way, they all make provisions for post intervention impact sustainability. All programs target the child and family members' knowledge, attitudes, behavior, the policy level, and the environmental level. The study illustrates the diversity in communities as well as diversity in terms of which and how sites and settings such as schools, kindergartens, community groups and grocery stores became involved in the programs. Programs are also different in terms of involvement of media stakeholders. The comparison of the three cases suggests that there is a need to build collaboration and partnerships from the beginning, plan for sufficient intensity/dose, emphasize/create consistency across levels and components of the intervention, build synchronization across levels, and plan for sustainability.

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.

Quality assurance of data collection in the multi-site community randomized trial and prevalence survey of the children's healthy living program

BACKGROUND

Quality assurance plays an important role in research by assuring data integrity, and thus, valid study results. We aim to describe and share the results of the quality assurance process used to guide the data collection process in a multi-site childhood obesity prevalence study and intervention trial across the US Affiliated Pacific Region.

METHODS

Quality assurance assessments following a standardized protocol were conducted by one assessor in every participating site. Results were summarized to examine and align the implementation of protocol procedures across diverse settings.

RESULTS

Data collection protocols focused on food and physical activity were adhered to closely; however, protocols for handling completed forms and ensuring data security showed more variability.

CONCLUSIONS

Quality assurance protocols are common in the clinical literature but are limited in multi-site community-based studies, especially in underserved populations. The reduction in the number of QA problems found in the second as compared to the first data collection periods for the intervention study attest to the value of this assessment. This paper can serve as a reference for similar studies wishing to implement quality assurance protocols of the data collection process to preserve data integrity and enhance the validity of study findings.

TRIAL REGISTRATION

NIH clinical trial #NCT01881373.

Prevalence of obesity and acanthosis nigricans among young children in the children's healthy living program in the United States Affiliated Pacific

Estimate prevalence of obesity and acanthosis nigricans (AN) among children in United States Affiliated Pacific (USAP) jurisdictions.Cross-sectional measurement of weight, height, and AN in 5775, 2 to 8 years old in 51 communities-Hawai'i, Alaska, Commonwealth of the Northern Mariana Islands, Guam, American Samoa, Palau, Republic of the Marshall Islands (RMI), 4 Federated States of Micronesia (Pohnpei, Yap, Kosrae, Chuuk). Analyses weighted to jurisdiction-specific sex and age distributions accounting for clustering of communities within jurisdictions.Prevalence of obesity was 14.0%, overweight 14.4%, healthy weight 68.9%, and underweight 2.6%, higher in males (16.3%) than females (11.6%), higher among 6 to 8 years old (16.3%) than 2 to 5 years old (12.9%), highest in American Samoa (21.7%), and absent in RMI. In total, 4.7% of children had AN, with no sex difference, higher in 6 to 8 years old (6.8%) than 2 to 5 years old (3.5%) and highest in Pohnpei (11.9%), and absent in Alaska. Obesity was highly associated with AN (odds ratio = 9.25, 95% confidence interval = 6.69-12.80), with the strongest relationships among Asians, followed by Native Hawaiians and Pacific Islanders (NHPI).Obesity, age, and Asian and NHPI race were positively associated with AN.

"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.

Promoting Sleep Health Among Families of Young Children in Head Start: Protocol for a Social-Ecological Approach

Inadequate or poor quality sleep in early childhood impairs social-emotional and cognitive function via effects on the developing brain and increases obesity risk via hormonal and endocrine effects. The prevalence of short sleep duration, behavioral sleep problems, and sleep-disordered breathing among children aged 3 to 5 years is 20% to 50%. Healthy sleep habits increase sleep duration and prevent behavioral sleep problems. Awareness of sleep-disordered breathing symptoms leads to its timely treatment. We designed a study that aims to empower families whose children are in early childhood programs with the knowledge and skills needed to obtain healthy sleep and to recognize a sleep problem. We used the social-ecological framework to guide individual, interpersonal, organizational, community, and policy interventions. This study builds on the Sweet Dreamzzz, Inc, Early Childhood Sleep Education Program (ECSEP) in Head Start. A stepped-wedge-cluster randomized trial will test effects on child, parent, and classroom outcomes; a policy evaluation will assess the impact of knowledge-translation strategies. The study has 3 aims. The first is to adapt educational materials into multimedia formats and build the capacity of Head Start agencies to implement the study. The second aim is to enroll 540 parent-child dyads in a primary prevention trial of sleep health promotion in Head Start and to analyze effects on children's sleep duration (primary outcome); parents' knowledge, attitudes, self-efficacy, and behavior; and children's sleep difficulties. The third aim is to conduct a secondary prevention feasibility study of screening and guidance for sleep problems. Secondary outcomes are changes in classroom behaviors and policies. Integrating sleep health literacy into early childhood programs could affect the life-course development of millions of children.

Measurement of obesity prevention in childcare settings: A systematic review of current instruments

OBJECTIVE

The incidence of childhood obesity is highest among children entering kindergarten. Overweight and obesity in early childhood track through adulthood. Programs increasingly target children in early life for obesity prevention. However, the published literature lacks a review on tools available for measuring behaviour and environmental level change in child care. The objective is to describe measurement tools currently in use in evaluating obesity-prevention in preschool-aged children.

METHODS

Literature searches were conducted in PubMed using the keywords "early childhood obesity," "early childhood measurement," "early childhood nutrition" and "early childhood physical activity." Inclusion criteria included a discussion of: (1) obesity prevention, risk assessment or treatment in children ages 1-5 years; and (2) measurement of nutrition or physical activity.

RESULTS

One hundred thirty-four publications were selected for analysis. Data on measurement tools, population and outcomes were abstracted into tables. Tables are divided by individual and environmental level measures and further divided into physical activity, diet and physical health outcomes. Recommendations are made for weighing advantages and disadvantages of tools.

CONCLUSION

Despite rising numbers of interventions targeting obesity-prevention and treatment in preschool-aged children, there is no consensus for which tools represent a gold standard or threshold of accuracy.

Influence of Teachers' Personal Health Behaviors on Operationalizing Obesity Prevention Policy in Head Start Preschools: A Project of the Children's Healthy Living Program (CHL)

OBJECTIVE

To quantify the Head Start (HS) teacher mediating and moderating influence on the effect of a wellness policy intervention.

DESIGN

Intervention trial within a larger randomized community trial.

SETTING

HS preschools in Hawaii.

PARTICIPANTS

Twenty-three HS classrooms located within 2 previously randomized communities.

INTERVENTION

Seven-month multi-component intervention with policy changes to food served and service style, initiatives for employee wellness, classroom activities for preschoolers promoting physical activity (PA) and healthy eating, and training and technical assistance.

MAIN OUTCOME MEASURES

The Environment and Policy Assessment and Observation (EPAO) classroom scores and teacher questionnaires assessing on knowledge, beliefs, priorities, and misconceptions around child nutrition and changes in personal health behaviors and status were the main outcome measures.

ANALYSIS

Paired t tests and linear regression analysis tested the intervention effects on the classroom and mediating and moderating effects of the teacher variables on the classroom environment.

RESULTS

General linear model test showed greater intervention effect on the EPAO score where teachers reported higher than average improvements in their own health status and behaviors (estimate [SE] = -2.47 (0.78), P < .05).

CONCLUSIONS AND IMPLICATIONS

Strategies to improve teacher health status and behaviors included in a multi-component policy intervention aimed at child obesity prevention may produce a greater effect on classroom environments.

Recruitment Strategies and Lessons Learned from the Children's Healthy Living Program Prevalence Survey

The US Affiliated Pacific region's childhood obesity prevalence has reached epidemic proportions. To guide program and policy development, a multi-site study was initiated, in collaboration with partners from across the region, to gather comprehensive information on the regional childhood obesity prevalence. The environmental and cultural diversity of the region presented challenges to recruiting for and implementing a shared community-based, public health research program. This paper presents the strategies used to recruit families with young children (n = 5775 for children 2 - 8 years old) for obesity-related measurement across eleven jurisdictions in the US Affiliated Pacific Region. Data were generated by site teams that provided summaries of their recruitment strategies and lessons learned. Conducting this large multi-site prevalence study required considerable coordination, time and flexibility. In every location, local staff knowledgeable of the community was hired to lead recruitment, and participant compensation reflected jurisdictional appropriateness (e.g., gift cards, vouchers, or cash). Although recruitment approaches were site-specific, they were predominantly school-based or a combination of school- and community-based. Lessons learned included the importance of organization buy-in; communication, and advance planning; local travel and site peculiarities; and flexibility. Future monitoring of childhood obesity prevalence in the region should consider ways to integrate measurement activities into existing organizational infrastructures for sustainability and cost-effectiveness, while meeting programmatic (e.g. study) goals.

Head Start Wellness Policy Intervention in Hawaii: A Project of the Children's Healthy Living Program

BACKGROUND

The increased prevalence of childhood overweight and obesity across the United States and the Pacific has become a serious public health concern, with especially high prevalence among Native Hawaiian and Pacific Islander (NHPI) children. This study aimed to measure the effect of a Head Start (HS) policy intervention for childhood obesity prevention.

METHODS

Twenty-three HS classrooms located in Hawaii participated in the trial of a 7-month policy intervention with HS teachers. Classroom- and child-level outcome assessments were conducted, including: the Environment and Policy Assessment and Observations (EPAO) of the classroom environment; plate waste observations to assess child intake of fruit and vegetables; and child growth.

RESULTS

The intervention showed a positive and significant effect on classroom EPAO physical activity (PA) and EPAO total scores. Although mean BMI z-score (zBMI) increased at postintervention for both intervention (mean = 0.60; standard deviation [SD], 1.16; n = 114) and delayed-intervention groups (mean = 0.35; SD, 1.17; n = 132), change in zBMI was not significantly different between the groups (p = 0.50; p = 0.48).

CONCLUSIONS

These findings contribute evidence on the potential for HS wellness policy to improve the PA environment of HS classrooms. More research is needed to link these policy changes to other child outcomes.

Assessing intervention fidelity in a multi-level, multi-component, multi-site program: the Children's Healthy Living (CHL) program

Addressing complex chronic disease prevention, like childhood obesity, requires a multi-level, multi-component culturally relevant approach with broad reach. Models are lacking to guide fidelity monitoring across multiple levels, components, and sites engaged in such interventions. The aim of this study is to describe the fidelity-monitoring approach of The Children's Healthy Living (CHL) Program, a multi-level multi-component intervention in five Pacific jurisdictions. A fidelity-monitoring rubric was developed. About halfway during the intervention, community partners were randomly selected and interviewed independently by local CHL staff and by Coordinating Center representatives to assess treatment fidelity. Ratings were compared and discussed by local and Coordinating Center staff. There was good agreement between the teams (Kappa = 0.50, p < 0.001), and intervention improvement opportunities were identified through data review and group discussion. Fidelity for the multi-level, multi-component, multi-site CHL intervention was successfully assessed, identifying adaptations as well as ways to improve intervention delivery prior to the end of the intervention.

Anthropometric measurement standardization in the US-affiliated pacific: Report from the Children's Healthy Living Program

OBJECTIVES

Anthropometric standardization is essential to obtain reliable and comparable data from different geographical regions. The purpose of this study is to describe anthropometric standardization procedures and findings from the Children's Healthy Living (CHL) Program, a study on childhood obesity in 11 jurisdictions in the US-Affiliated Pacific Region, including Alaska and Hawai'i.

METHODS

Zerfas criteria were used to compare the measurement components (height, waist, and weight) between each trainee and a single expert anthropometrist. In addition, intra- and inter-rater technical error of measurement (TEM), coefficient of reliability, and average bias relative to the expert were computed.

RESULTS

From September 2012 to December 2014, 79 trainees participated in at least 1 of 29 standardization sessions. A total of 49 trainees passed either standard or alternate Zerfas criteria and were qualified to assess all three measurements in the field. Standard Zerfas criteria were difficult to achieve: only 2 of 79 trainees passed at their first training session. Intra-rater TEM estimates for the 49 trainees compared well with the expert anthropometrist. Average biases were within acceptable limits of deviation from the expert. Coefficient of reliability was above 99% for all three anthropometric components.

CONCLUSIONS

Standardization based on comparison with a single expert ensured the comparability of measurements from the 49 trainees who passed the criteria. The anthropometric standardization process and protocols followed by CHL resulted in 49 standardized field anthropometrists and have helped build capacity in the health workforce in the Pacific Region. Am. J. Hum. Biol. 28:364-371, 2016. © 2015 Wiley Periodicals, Inc.

Overweight and Obesity Prevalence among Public School Children in Guam

BACKGROUND

The Government of Guam passed Public Law 28-87, which established the collection of child Body Mass Index (BMI) measurements in the Guam Department of Education (GDOE). This paper aimed to analyze the BMI data and report the childhood obesity prevalence on Guam.

METHODS

Secondary analysis was performed on a repeated cross-section of 106,827 children in the GDOE from 2010 to 2014. Age- and sex-specific prevalence estimates and 95% Confidence Intervals (CI) by weight status were calculated for each year. Test for trends in the high weight status were performed.

RESULTS

The childhood obesity prevalence was 23.1% (95% CI, 22.9%-23.4%). It declined from 23.6% (95% CI, 23.1%-24.1%) in 2010-2011 to 22.6% (95% CI, 22.1%-23.0%) in 2013-2014 (p=.007).

CONCLUSION

Childhood obesity on Guam has declined, though it remains higher than the U.S. Mainland. Continued BMI data collection is needed to monitor childhood obesity and measure the impact of Public Law 28-87.