Hot Papers in the Literature

A mixed-methods evaluation of school-based active living programs

Am J Prev Med. 2012 Nov;43(5 Suppl 4):S395–S398.

McCreary LL, Park CG, Gomez L, Peterson S, Pino D, McElmurry BJ.

Background: School-based programs to combat childhood obesity often lack resources to incorporate strong evaluation components. This paper describes a collaborative evaluation conducted by partners implementing Active Living by Design (ALbD) programs at one Chicago elementary school.

Purpose: To assess ALbD program outcomes by triangulating various forms of evidence gathered while implementing these programs.

Methods: An exploratory, mixed-methods design was used to collect and analyze data from numerous physical activity initiatives implemented at the school from 2004 to 2009. The researchers triangulated quantitative (student BMI data, student standardized test and discipline data, classroom physical activity logs, and student physical activity knowledge surveys) and qualitative (classroom physical activity logs and open-ended teacher surveys questions) findings to assess outcomes.

Results: Students continuously enrolled at this school from Grades 1 through 4, those most exposed to ALbD activities over time, had significantly lower BMI after 4 years, compared with peers who transferred to the school after Grade 1. Student achievement on standardized tests improved between 2004 (prior to initiating ALbD activities) and 2008. Visits to the Disciplinary Office dropped dramatically over the 4-year period. Teacher interviews and surveys and classroom Take 10! Program activity logs revealed that the program was implemented enthusiastically by all grades. The Physical Activity Knowledge Survey revealed a significant increase in physical activity knowledge after instituting these activities.

Conclusions: Collaborative efforts to amass and analyze a variety of data demonstrated the effects of implementing a variety of health promotion activities in one school, documenting the growth of a "culture of health" in that school community.

PMID: 23079273 [PubMed - in process]

Enhancing self-regulation as a strategy for obesity prevention in Head Start preschoolers: The Growing Healthy study

BMC Public Health. 2012 Nov 30;12(1):1040. [Epub ahead of print]

Miller AL, Horodynski MA, Herb HE, Peterson KE, Contreras D, Kaciroti N, Staples-Watson J, Lumeng JC.

Background: Nearly one in five 4-year-old children in the United States are obese, with low-income children almost twice as likely to be obese as their middle/upper-income peers. Few obesity prevention programs for low-income preschoolers and their parents have been rigorously tested, and effects are modest. We are testing a novel obesity prevention program for low-income preschoolers built on the premise that children who are better able to self-regulate in the face of psychosocial stressors may be less likely to eat impulsively in response to stress. Enhancing behavioral self-regulation skills in low-income children may be a unique and important intervention approach to prevent childhood obesity.

Methods/design: The Growing Healthy study is a randomized controlled trial evaluating two obesity prevention interventions in 600 low-income preschoolers attending Head Start, a federally-funded preschool program for low-income children. Interventions are delivered by community-based, nutrition-education staff partnering with Head Start. The first intervention (n=200), Preschool Obesity Prevention Series (POPS), addresses evidence-based obesity prevention behaviors for preschool-aged children and their parents. The second intervention (n=200) comprises POPS in combination with the Incredible Years Series (IYS), an evidence-based approach to improving self-regulation among preschool-aged children. The comparison condition (n=200) is Usual Head Start Exposure. We hypothesize that POPS will yield positive effects compared to Usual Head Start, and that the combined intervention (POPS+IYS) addressing behaviors well-known to be associated with obesity risk, as well as self-regulatory capacity, will be most effective in preventing excessive increases in child adiposity indices (body mass index, skinfold thickness). We will evaluate additional child outcomes using parent and teacher reports and direct assessments of food-related self-regulation. We will also gather process data on intervention implementation, including fidelity, attendance, engagement, and satisfaction.

Discussion: The Growing Healthy study will shed light on associations between self-regulation skills and obesity risk in low-income preschoolers. If the project is effective in preventing obesity, results can also provide critical insights into how best to deliver obesity prevention programming to parents and children in a community-based setting like Head Start in order to promote better health among at-risk children. Trial registration number: Clinicaltrials.gov Identifier: NCT01398358.

PMID: 23194185 [PubMed - as supplied by publisher]

Joint association of physical activity/screen time and diet on CVD risk factors in 10-year-old children

Front Med. 2012 Dec;6(4):428–435.

Drenowatz C, Carlson JJ, Pfeiffer KA, Eisenmann JC.

The increasing prevalence of childhood overweight and obesity has been associated with an increased risk for cardiovascular disease (CVD). While several studies examined the effect of single behaviors such as physical activity (PA), sedentary behavior or diet on CVD risk, there is a lack of research on combined associations, specifically in children. Therefore, the purpose of this study was to examine the joint association of PA or screen time (ST) and diet on CVD risk factors in children. PA, ST and diet were assessed via questionnaire in 210 fifth grade students (age: 10.6±0.4 years). The healthy eating index (HEI) was subsequently calculated as indicator for diet quality. Height, weight, % body fat, and resting blood pressure were measured according to standard procedures and blood samples obtained via fingerprick were assayed for blood lipids. Total cholesterol HDL ratio (TC:HDL), mean arterial pressure (MAP), and % body fat were used as indicators of CVD risk. 55% of children did not meet current PA recommendations on at least 5 days/week and 70% exceeded current recommendations for ST. Further, only 2.5% possessed a “good” diet (HEI>80). There was no significant association of PA or ST and diet on CVD risk score. Neither TC:HDL, MAP, and % body fat nor the total CVD risk score was significantly correlated with diet, PA, or ST. Children in the high PA group, however, had significantly better diet scores. Despite the fact that self-reported PA, ST, or dietary intake were not directly related to CVD risk in this sample, higher activity levels were associated with a healthier diet and lower ST indicating an overall healthier lifestyle of this subgroup.

PMID: 23224418 [PubMed - in process]

A qualitative study of the aspirations and challenges of low-income mothers in feeding their preschool-aged children

Int J Behav Nutr Phys Act. 2012 Nov 16;9(1):132.

Herman AN, Malhotra K, Wright G, Fisher JO, Whitaker RC.

Background: The prevalence of obesity among preschool-aged children has increased, especially among those in low-income households. Two promising behavioral targets for preventing obesity include limiting children's portion sizes and their intake of foods high in solid fats and/or added sugars, but these approaches have not been studied in low-income preschoolers in the home setting. The purpose of this study was to understand the contextual factors that might influence how low-income mothers felt about addressing these behavioral targets and mothers' aspirations in feeding their children.

Methods: We recruited 32 English-speaking women in Philadelphia, Pennsylvania who were eligible for the Supplemental Nutrition Assistance Program and who were the biologic mothers of children 36 to 66 months of age. Each mother participated in 1 of 7 focus groups and completed a brief socio-demographic questionnaire. Focus group questions centered on eating occasions, foods and drinks consumed in the home, and portion sizes. Each focus group lasted 90 minutes and was digitally recorded and transcribed verbatim. Three authors independently identified key themes and supporting quotations. Themes were condensed and modified through discussion among all authors.

Results: Thirty-one mothers identified themselves as black, 15 had a high school education or less, and 22 lived with another adult. Six themes emerged, with three about aspirations mothers held in feeding their children and three about challenges to achieving these aspirations. Mothers' aspirations were to: 1) prevent hyperactivity and tooth decay by limiting children's sugar intake, 2) use feeding to teach their children life lessons about limit setting and structure, and 3) be responsive to children during mealtimes to guide decisions about portions. Especially around setting limits with sweets and snack, mothers faced the challenges of: 1) being nagged by children's food requests, 2) being undermined by other adults in the family, and 3) having bad memories from childhood that made it hard to deny children's food requests.

Conclusions: Although the primary aspirations of low-income mothers in feeding their preschool-aged children were not focused on children's weight, these aspirations were compatible with obesity prevention strategies to limit children's portion sizes and their intake of solid fats and/or added sugars.

PMID: 23157723 [PubMed - as supplied by publisher]

Factors predicting severe childhood obesity in kindergarteners

Int J Obes (Lond). 2013 Jan; 37(1):31–39.

Flores G, Lin H.

Background: Severe obesity has increased >300% in US children since 1976, and is associated with multiple cardiovascular risk factors and high adult obesity rates.

Objective: The objective of this study was to identify predictors of severe obesity in kindergarteners.

Methods: Multivariable logistic regression and recursive partitioning analysis (RPA) were used to identify prenatal/pregnancy, infant, and early childhood predictors of severe kindergarten obesity (body mass index (BMI) ≥99th percentile) in the Early Childhood Longitudinal Study Birth Cohort, a nationally representative longitudinal study that followed children from birth through kindergarten.

Results: For the 6800 children, the severe kindergarten obesity prevalence was 5.7%, with higher adjusted odds for crossing the 85th percentile of BMI at 2 years old (odds ratio (OR), 8.0; 95% confidence interval (CI), 4.1-15.7), preschool age (OR, 7.9; 95% CI, 4.9–12.8) and 9 months old (OR, 1.8; 95% CI, 1.2–2.6); maternal severe obesity (OR, 3.4; 95% CI, 1.9–5.8) and gestational diabetes (OR, 2.9; 95% CI, 1.5–5.5); drinking tea or coffee between meals/before bedtime at 2 years old (OR, 3.3; 95% CI, 1.3–8.5); Latino (OR, 2.3; 95% CI, 1.4–3.7) and multiracial (OR, 2.3; 95% CI, 1.1–4.8) race/ethnicity; and drinking sugary beverages at kindergarten age at least weekly (OR, 2.3; 95% CI, 1.4–3.7). Ever-attending center-based daycare (OR, 0.3; 95% CI, 0.1–0.9), eating fruit at least weekly at kindergarten age (OR, 0.3; 95% CI, 0.1–0.7), and maternal history of a prior newborn birth weight≥4000 g (OR, 0.1; 95% CI, 0.02–0.6) were associated with reduced odds of severe obesity. RPA identified low severe obesity prevalence (1.9%) for non-85th BMI-percentile preschool crossers and high severe obesity (56–80%) for predictor clusters which included crossing the 85th BMI percentile at earlier ages, low parental education, specific maternal age cutoffs, preschooler bedtime rules, and outside walking/play frequency for 9-month-olds.

Conclusions: Certain parental, prenatal/pregnancy, infant, and early childhood factors, both alone and in combination, are potent predictors of severe obesity in kindergarteners.

PMID: 23147114 [PubMed - in process]

A longitudinal study of food insecurity on obesity in preschool children

J Acad Nutr Diet. 2012 Dec;112(12):1949–1958.

Metallinos-Katsaras E, Must A, Gorman K.

Background: Obesity and its co-occurrence with household food insecurity among low-income families is a public health concern, particularly because both are associated with later adverse health consequences.

Objective: Our aim was to examine the relationship between household food insecurity with and without hunger in infancy and later childhood with weight status at 2 to 5 years.

Design: This longitudinal study uses household food-security status, weight, and height data collected at the first infancy and last child (2 to 5 years) Special Supplemental Nutrition Program for Women, Infants, and Children visits. Household food security was based on parent/caretaker responses to a four-question subscale of the 18-item Core Food Security Module. Obesity was defined as sex-specific body mass index for age ≥95th percentile.

Participants/setting: A diverse (58.6% non-white) low-income sample of 28,353 children participating in the Massachusetts Special Supplemental Nutrition Program for Women, Infants, and Children (2001–2006); 24.9% of infants and 23.1% of children lived in food-insecure households and 17.1% were obese at their last child visit.

Statistical analysis: Multivariate logistic regression analyses assessed the association between household food-security status during the infant and child visits, and risk of preschool obesity, while controlling for child race/Hispanic ethnicity, sex, child and household size, maternal age, education, and prepregnancy weight. Interactions between these covariates and household food-security status were also examined. In cases of multiple comparisons, a Bonferroni correction was applied.

Results: Persistent household food insecurity without hunger was associated with 22% greater odds of child obesity (odds ratio=1.22; 95% CI 1.06 to 1.41) compared with those persistently food secure (P<0.05). Maternal prepregnancy weight status modified this association with children of underweight (adjusted odds ratio=3.22; 95% CI 1.70 to 6.11; P=0.003) or overweight/obese (adjusted odds ratio=1.34; 95% CI 1.11 to 1.62; P=0.03) mothers experiencing greater odds of child obesity with persistent household food insecurity without hunger compared with those with persistent household food security.

Conclusions: These results suggest that persistent household food insecurity without hunger is prospectively related to child obesity, but that these associations depend on maternal weight status. Vulnerable groups should be targeted for early interventions to prevent overweight and obesity later in life.

PMID: 23174682 [PubMed - in process]

Physical activity and BMI: Evidence from the Panel Study of Income Dynamics Child Development Supplement

J Sch Health. 2012 Nov;82(12):553–559.

Hohensee CW, Nies MA.

Background: This study assessed the association between amount of physical activity and body mass index (BMI) percentile among middle and high school children. Total daily physical activity needs to include both in and out of school physical activity.

Methods: A secondary data analysis was performed on 1306 children drawn from the Panel Study of Income Dynamics Child Development Supplement (CDS III, 2007). The dependent variable in this study was BMI percentile, while the independent variable was physical activity. The multinomial logistic regression model was used to assess the associations between physical activity and BMI percentile controlling for age, gender, race/ethnicity, parental income, and neighborhood safety.

Results: Children who engaged in low daily physical activity levels had 1.8 times the odds of being obese versus normal weight than those who engaged in moderate levels [odds ratio (OR)=1.80, confidence interval (CI)=1.31, 2.48]. African-American children had 1.6 times the odds of being obese than normal weight (OR=1.55, CI=0.99, 2.43) and Hispanic children had approximately 1.8 times the odds of being obese than normal weight in comparison to non-Hispanic white children (OR=1.79, CI=1.00, 3.21). Females had about 1.5 times the odds of being overweight than normal weight than males (OR=1.49, CI=1.04, 2.13).

Conclusions: This study suggests that the accumulation of 30 minutes or more of daily physical activity may be effective in decreasing obesity prevalence among middle and high school-aged children.

PMID: 23151117 [PubMed - in process]

Early predictors of obesity and cardiovascular risk among American Indian children

Matern Child Health J. 2012 Dec;16(9):1879–1886.

Lindberg SM, Adams AK, Prince RJ.

American Indian (AI) children have the highest rates of obesity among ethnic groups in the United States, and rates continue to increase. This study was designed to examine the effects of prenatal and early postnatal factors on AI children's body mass index (BMI) trajectories, adiposity, and cardiovascular risk markers during early childhood. We screened 471 AI children (ages 5–8) from three Wisconsin tribes. Screenings included anthropometric and body fat measures and non-fasting lipid and glucose via fingerstick blood samples. Tribal records from Women Infants and Children (WIC) programs and clinic charts provided data on children's BMI trajectories, maternal prenatal factors, and the early postnatal feeding environment. Forty-seven percent of children were overweight or obese. Analysis of growth trajectories showed that children's BMI category was largely determined within the 1 year of life. Significant predictors of children's BMI category at age 1 included macrosomia (OR 4.38), excess gestational weight gain (OR 1.64) and early termination of breastfeeding (OR 1.66). Children who were overweight/obese at age 1 had greater odds of being overweight (OR 3.42) or obese (OR 3.36), and having unhealthy levels of body fat (OR 2.95) and LDL cholesterol (OR 1.64) at ages 5–8. Children's BMI category is determined in the early post-natal environment, within the 1 year of life, by factors including excess gestational weight gain and early termination of breastfeeding. In turn, children's BMI category at age 1 predicts the emergence of cardiovascular risk markers in early childhood.

PMID: 22527771 [PubMed - in process]

PMCID: PMC3438386 [Available on 2013/12/1]

Clinical tracking of severely obese children: A new growth chart

Pediatrics. 2012 Dec;130(6):1136–1140.

Gulati AK, Kaplan DW, Daniels SR.

The 2000 Centers for Disease Control and Prevention growth charts are unable to accurately define and display BMI percentiles beyond the 97th percentile. At Children's Hospital Colorado, we created new growth charts that allow clinicians to track and visualize BMI values in severely obese children. This growth chart defines a child's BMI as a “percentage of the 95th percentile.” It has the potential to allow clinicians to define subgroups of severe obesity, monitor trends in obese children, and measure treatment success or failure.

PMID: 23129082 [PubMed - in process]

Obesity disparities among elementary-aged children: Data from school-based BMI surveillance

Pediatrics. 2012 Dec;130(6):1102–1109.

Bailey-Davis L, Horst M, Hillemeier MM, Lauter A.

Objectives: To examine 3-year trends and spatial clustering in the prevalence of obesity among elementary-aged children in Pennsylvania.

Methods: Height and weight were measured for ∼980 000 children between ages 5 and 12 years, corresponding to kindergarten through grade 6 in 3 consecutive school years (2006–2007, 2007–2008, 2008–2009). These data were obtained at the school district level and reported to the Pennsylvania Department of Health in response to a state mandate requiring public schools to conduct annual surveillance of student growth. Analyses at the school district level (n=501) regarding obesity prevalence (BMI≥95th percentile) according to age and gender were conducted to examine associations over time and in relation to population density, geographic boundaries, and a calculated family distress index.

Results: The mean prevalence of obesity remained stable over 3 years at ∼17.6% of elementary-aged children. However, within the state, significant differences in the prevalence of obesity were identified. Schools in the most rural areas had adjusted obesity prevalence over 2 percentage points higher than urban schools. Consistent with secular findings for the nation in general, students with families living in socioeconomic distress exhibited upward trends in obesity risk.

Conclusions: School-based surveillance elucidates the disparate risk of obesity for younger students living in the most rural areas, a key finding for primarily rural states. Preventive interventions are needed to reach the most rural children with an emphasis on families where parents are single, are unemployed, have a lower income, and lower educational attainment.

PMID: 23147975 [PubMed - in process]

No association between childcare and obesity at age 4 in low-income Latino children

Pediatr Obes. 2012 Dec 13. doi: 10.1111/j.2047-6310.2012.00125.x. [Epub ahead of print]

Zahir N, Heyman MB, Wojcicki JM.

Background: Previous studies have found an association between early entry to childcare and risk for overweight and obesity at 3 years of age. These studies, however, have been conducted primarily with higher income White populations or have found increased risk in the children of educated mothers.

Objective: To assess the relationship between timing of entry to childcare and duration of childcare and pediatric overweight and obesity in a high risk population.

Methods: Using data from a longitudinal cohort of low-income Latino children in San Francisco, we evaluated the association between time of entry to childcare, hours in childcare, and risk for overweight and obesity at age 4. Similarly, we evaluated the relationship between these same childcare parameters and body mass index Z score and risk of having a waist circumference (WC) percentile≥90th at 4 years of age.

Results: In contrast with previous studies, we found no association between being in childcare at 4 years of age or number of hours per week in childcare and risk for childhood overweight, obesity or WC≥90th percentile at age 4. Additionally, we found no association between age of entry to childcare (≤6 months or ≤12 months of age) with risk for overweight or obesity at age 4. Future studies need to further evaluate the differential impact of childcare on early childhood obesity in relation to race/ethnicity and lower socioeconomic status.

Conclusion: Low-income children may not be at increased risk for obesity in relation to early childcare exposure.

PMID: 23239621 [PubMed - as supplied by publisher]

Proximity to supermarkets associated with higher body mass index among overweight and obese preschool-age children

Prev Med. 2012 Dec 5. pii: S0091-7435(12)00601-9. doi: 10.1016/j.ypmed.2012.11.023. [Epub ahead of print]

Fiechtner L, Block J, Duncan DT, Gillman MW, Gortmaker SL, Melly SJ, Rifas-Shiman SL, Taveras EM.

Objective: The objective of this study is to examine associations of proximity to food establishments with body mass index (BMI) among preschool-age children.

Methods: We used baseline data from 438 children ages 2–6.9 years with a BMI≥85th percentile participating in a RCT in Massachusetts from 2006 to 2009. We used a geographic information system to determine proximity to six types of food establishments: 1) convenience stores, 2) bakeries, coffee shops, candy stores, 3) full service restaurants, 4) large supermarkets, 5) small supermarkets, and 6) fast-food restaurants. The main outcome was child's BMI.

Results: Children's mean (SD) BMI was 19.2 (2.4) kg/m²; 35% lived ≤1 mile from a large supermarket, 42% lived >1 to 2 miles, and 22% lived >2 miles. Compared to children living >2 miles from a large supermarket, those who lived within 1 mile had a BMI 1.06 kg/m² higher. Adjustment for socioeconomic characteristics and distance to fast-food restaurants attenuated this estimate to 0.77 kg/m². Living in any other distance category from a large supermarket and proximity to other food establishments were not associated with child BMI.

Conclusions: Living closer to a large supermarket was associated with higher BMI among preschool-age children who were overweight or obese.

PMID: 23219681 [PubMed - as supplied by publisher]

Reframing family-centred obesity prevention using the Family Ecological Model

Public Health Nutr. 2012 Oct 22:1–9. [Epub ahead of print]

Davison KK, Jurkowski JM, Lawson HA.

Objective: According to the Family Ecological Model (FEM), parenting behaviours are shaped by the contexts in which families are embedded. In the present study, we utilize the FEM to guide a mixed-methods community assessment and summarize the results. Additionally, we discuss the utility of the FEM and outline possible improvements.

Design: Using a cross-sectional design, qualitative and quantitative methods were used to examine the ecologies of parents' cognitions and behaviours specific to children's diet, physical activity and screen-based behaviours. Results were mapped onto constructs outlined in the FEM.

Setting: The study took place in five Head Start centres in a small north-eastern city. The community assessment was part of a larger study to develop and evaluate a family-centred obesity prevention programme for low-income families.

Subjects: Participants included eighty-nine low-income parents/caregivers of children enrolled in Head Start.

Results: Parents reported a broad range of factors affecting their parenting cognitions and behaviours. Intrafamilial factors included educational and cultural backgrounds, family size and a lack of social support from partners. Organizational factors included staff stability at key organizations, a lack of service integration and differing school routines. Community factors included social connectedness to neighbours/friends, shared norms around parenting and the availability of safe public housing and play spaces. Policy- and media-related factors included requirements of public assistance programmes, back-to-work policies and children's exposure to food advertisements.

Conclusions: Based on these findings, the FEM was refined to create an evidence-based, temporally structured logic model to support and guide family-centred research in childhood obesity prevention.

PMID: 23089267 [PubMed - as supplied by publisher]