Texas Childhood Obesity Research Demonstration Research Articles

Adiposity And Cardiovascular Health And The Reallocation Of Waking Activities In Preschool Children With Overweight

Physical activity and sedentary behaviors differentially relate to health outcomes in children. Isotemporal substitution provides opportunities to evaluate the relation of hypothetical time replacement scenarios across intensity categories with health. Few isotemporal studies have been conducted among preschool-aged youth and ethnically diverse populations. PURPOSE: To examine the relation of reallocation of waking activity behaviors on 1) adiposity and 2) cardiovascular health indicators among preschool-aged youth (ages 2-5 years) with overweight participating in Texas Childhood Obesity Research Demonstration (TX CORD), a low-income, majority Hispanic cohort. METHODS: Participants wore an ActiGraph wGT3X-BT monitor (waist) and attended health assessments. Valid wear time was defined as ≥10 hours between 06:00-22:59 hours on ≥3 days (≥1 weekend). Adiposity measures were percentage of the 95th percentile (%BMIp95), fat mass, fat mass index, waist circumference, and waist-to-hip ratio. Cardiovascular measures were resting systolic (SBP) and diastolic (DBP) blood pressure, and heart rate. Covariates included age, sex, ethnicity, and socioeconomic status. Isotemporal substitution modeling was employed to address the study purpose. RESULTS: Complete data were available for 131 children (Mean age = 4.3±1.1, 53% female, 87% Hispanic, 31% ≤49% income to poverty ratio). For boys, reallocating 15 minutes of sedentary, light, or moderate intensity activity to vigorous intensity activity was significantly associated with beneficial reductions in all adiposity indicators; for girls, these relations were statistically null. For boys and girls, reallocating 15 minutes of sedentary (-5.0 SBP, -3.7 DBP), light (-4.3 SBP, -3.2 DBP), or moderate intensity activity (-7.3 SBP, -5.5 DBP) to vigorous intensity activity was significantly associated with favorable cardiovascular indicators. CONCLUSIONS: Substituting vigorous for lower intensity physical activity is associated with several favorable adiposity and cardiovascular health outcomes among preschool children with overweight and obesity. Teaching caregivers how to engage young children in vigorous intensity is needed, especially as overweight children spend more time sedentary and less time in higher intensity activities.

Who benefits from the intervention? Correlates of successful BMI reduction in the Texas Childhood Obesity Demonstration Project (TX‐CORD)

Many childhood obesity intervention studies report mean outcomes but do not explore the variation in responses and the characteristics of those who respond well. To identify child and family characteristics associated with improvement in the primary outcome, %BMIp95 , of the Texas Childhood Obesity Research Demonstration project (TX-CORD). The 12-month TX-CORD secondary prevention study randomized 549 children, ages 2 to 12 years, with BMI ≥85th percentile to the intensive intervention vs. the comparison program, with measurements at baseline, 3-, and 12-months. A growth mixture model was used to identify mutually exclusive latent %BMIp95 trajectories. Latent class regression tested associations between baseline characteristics and latent class membership. A 2-class solution emerged after accounting for the effect of intervention randomization. Latent Class 1 participants (86% of sample) were characterized by mild-to-moderate obesity and demonstrated a significantly greater response to the intensive intervention between 0 and 3 months (slope-on-group = -0.931, p = 0.03). A rebound between 3 and 12 months was not significantly different between arms. Latent Class 2 participants (14%), who had severe obesity, demonstrated no difference in response between intervention groups. Characteristics associated with Class 1 membership included younger age (2-5 years vs. 6-12 years: OR 3.70, p = .035) and lower maternal BMI category (< 35 kg/m2 vs. ≥ 35 kg/m2 : OR 7.14, p < .0001). The optimal target population for the intensive intervention are children who have milder obesity, are younger, and do not have a mother with severe obesity. Children with severe obesity may require different approaches.

Using Process Evaluation for Implementation Success of Preschool‐Based Programs for Obesity Prevention: The TX Childhood Obesity Research Demonstration Study

Through the Texas Childhood Obesity Research Demonstration study, we implemented and evaluated a system-oriented model of primary and secondary prevention approaches to mitigate obesity among low-income Texas children aged 2 to 12 years. Primary prevention included implementing the Coordinated Approach To Child Health Early Childhood (CATCH EC) program in Head Start preschools. In this paper, we describe the methods and results of CATCH EC program process evaluation over 2years of implementation. We used a quasi-experimental design with serial cross-sectional data collected from Head Start centers across intervention and comparison catchment areas in Houston and Austin, Texas (intervention: N = 12 centers in 2012-2013 [Year 1], N = 12 in 2013-2014 [Year 2]; comparison: N = 13 centers in Year 1, N = 12 in Year 2). Process evaluation included center director and teacher surveys conducted in both years of implementation. We developed indices for implementation of CATCH EC and non-CATCH health events at the centers. Implementation scores were higher among intervention centers as compared to comparison centers across both years of implementation, and these differences were statistically significant (p < .01). There was also high variability in program implementation in intervention centers across both years ranging from 55% to 95%. These implementation index strategies may inform future evaluation of preschool-based obesity prevention program implementation.

Development and use of an index for measuring implementation of a weight management program in children in primary care clinics in Texas

BackgroundThe Texas Childhood Obesity Research Demonstration study was an integrated, systems-oriented intervention that incorporated primary and secondary obesity prevention approaches targeting multiple sectors, including primary care clinics, to address childhood obesity. The primary care clinic component included the American Academy of Pediatrics’ Next Steps weight management counseling materials that support brief healthy lifestyle-focused visits. The current study describes the methodology and assesses the implementation of the Next Steps program in the participating primary care clinics, as well as the association of implementation with enrollment of children with overweight and obesity in the secondary prevention intervention.MethodsThe study used a serial cross-sectional study design to collect data from 11 primary care clinics in Houston (n = 5) and Austin (n = 6), Texas, in 2013–2014. Responses of primary care providers on 42 self-reported survey questions assessing acceptability, adoption, appropriateness, and feasibility of the program were utilized to create a mean standardized clinic implementation index score. Provider scores were aggregated to represent Next Steps implementation scores at the clinic level. A mixed effects logistic regression test was conducted to determine the association between program implementation and the enrollment of children in the secondary prevention.ResultsMean implementation index score was lower at Year 2 of implementation (2014) than Year 1 (2013) although the decrease was not significant [63.2% (12.2%) in 2013 vs. 55.3% (16.5%) in 2014]. There were no significant associations between levels of implementation of Next Steps and enrollment into TX CORD secondary prevention study.ConclusionsThe development of an index using process evaluation measures can be used to assess the implementation and evaluation of provider-based obesity prevention tools in primary care clinics.

Impact of the Coordinated Approach to Child Health Early Childhood Program for Obesity Prevention among Preschool Children: The Texas Childhood Obesity Research Demonstration Study

This study presents the impact of a 2-year implementation of Coordinated Approach to Child Health Early Childhood (CATCH EC), a preschool-based healthy nutrition and physical activity program, on child BMI z-scores, BMI percentiles, diet, physical activity, and sedentary behaviors among 3- to 5-year old children across Head Start centers in Houston and Austin, Texas. We used a quasi-experimental study design with serial cross-sectional data collection (Intervention catchment area: n = 12 centers, 353 parent-child dyads in Year 1; n = 12 centers, 365 parent-child dyads; Comparison catchment area: n = 13 centers in year 1, 319 parent child dyads; and n = 12 centers, 483 parent-child dyads in year 2). Child height and weight were measured and parent self-report surveys were conducted at year 1 (fall 2012) and year 2 (spring 2014). In year 1, 34.8% of the children were overweight or obese, 74% were Hispanic, and >80% reported an annual household income of <$25,000. In year 2, 32.2% were overweight or obese, 72% were Hispanic, and 82.3% reported an annual income of <$25,000. Results demonstrated significantly lower child BMI z-scores [β = -0.26 (95% confidence interval, CI: -0.50 to -0.01), p = 0.041] and BMI percentiles [β = -6.5 (95% CI: -12.4 to -0.69), p = 0.028] from year 1 to 2 follow-up among those in intervention Head Start centers, compared to those in the comparison centers. There were no significant between-group changes in child dietary, physical activity, or screen time behaviors. Implementation of a preschool-based obesity prevention program can be modestly effective in lowering the prevalence of child overweight in low-income populations.

Improvement in Primary Care Provider Self-Efficacy and Use of Patient-Centered Counseling To Address Child Overweight and Obesity after Practice-Based Changes: Texas Childhood Obesity Research Demonstration Study.

The Texas Childhood Obesity Research Demonstration project, a multicenter, multisystem approach to childhood overweight and obesity (OW/OB), included training and materials to support primary care clinics (PCCs) in addressing child OW/OB in the office. This study evaluated the impact over 24 months of brief training and practice-based support on primary care providers' (PCPs) perceived self-efficacy and practice behaviors. The PCPs at five Houston and seven Austin PCCs completed questionnaires at baseline (2012, n = 36), 12 months (2013, n = 30), and 24 months (2014, n = 34) follow-up. Mixed-effects linear regression models were used to compare changes in self-efficacy (15 items, responses 1-4: not at all confident to very confident) and practice behaviors (30 items, responses 0-4: never to always) in obesity-related screening and counseling, and to assess association between prior training and these outcomes. Self-efficacy items for identification of (2.9 [0.1] vs. 3.3 [0.1]) and counseling about (2.8 [0.1] vs. 3.4 [0.1]) OW/OB-related parenting practices, and setting behavioral goals (2.9 [0.2] vs. 3.3 [0.2]) improved significantly (p < 0.05) between baseline and 24-month follow-up. Self-efficacy items with "confident" mean baseline scores that further improved included determining child OW/OB (3.6 [0.1] vs. 3.9 [0.1]) and interpreting BMI (3.6 [0.1] vs. 3.9 [0.1]). At all measurements, PCPs reported frequently addressing medical problems and lifestyle behaviors. Use of patient-centered counseling techniques, which was low at baseline, increased significantly, including asking permission before discussing lifestyle (1.5 [0.3] vs. 2.4 [0.3]). Prior training was associated with improved self-efficacy. The improvement in PCPs' self-efficacy and patient-centered counseling to address childhood OW/OB supports implementation of brief training and practice support in clinics that serve Medicaid-eligible children.

Dietary Intake, Attitudes toward Healthy Food, and Dental Pain in Low-Income Youth.

Few studies have examined the relation between food consumption and related attitudes and dental pain among children. The objective of this study is to examine the associations of healthy and unhealthy food items, attitudes toward healthy food, and self-efficacy of eating healthy with dental pain among children. A cross-sectional analysis was performed using child survey data from the Texas Childhood Obesity Research Demonstration (TX CORD) project. Fifth-grade students ( n = 1,020) attending 33 elementary schools in Austin and Houston, Texas, completed the TX CORD Child Survey, a reliable and valid survey instrument focused on nutrition and physical activity behaviors. All nutrition questions ask about the number of times food and beverage items were consumed on the previous day. Dental pain was reported as mouth or tooth pain in the past 2 wk that made their mouth hurt so much that they could not sleep at night. Mixed-effects logistic regression models were used to test the association between 10 unhealthy food items, 9 healthy food items, 2 health attitudes, and self-efficacy with dental pain. All models controlled for sociodemographic variables. In total, 99 (9.7%) students reported dental pain. Dental pain was associated with intake of the following unhealthy items: soda, fruit juice, diet soda, frozen desserts, sweet rolls, candy, white rice/pasta, starchy vegetables, French fries/chips, and cereal (adjusted odds ratio [AOR], 1.27-1.81, P < 0.01). The intake of other vegetables (AOR, 1.56; P < 0.01), a healthy item, and the attitude that healthy food tastes good (AOR, 1.59; P = 0.04) were also positively associated with dental pain. The attitude of eating healthier leads to fewer health problems (AOR, 0.50) and self-efficacy for healthy eating (AOR, 0.44) were negatively associated with dental pain ( P < 0.01). Interventions should focus on improving oral health by reducing intake of unhealthy foods and educating children and families on the importance of diet as a means of reducing dental caries. Knowledge Transfer Statement: The results of this study can be used to inform researchers on potential food items and psychosocial measures to examine in low-income, minority populations for longitudinal research. These results would also be useful to educators who could incorporate oral health care and nutrition education into school curriculums.

Associations Between Parent-Perceived Neighborhood Safety and Encouragement and Child Outdoor Physical Activity Among Low-Income Children.

A growing body of research has examined the relationship between perceived neighborhood safety and parental encouragement for child physical activity (PA), yet these potential predictors have not been studied together to predict child outdoor PA. The purpose of this study is to examine these predictors and parent- and child-reported child outdoor PA. The Texas Childhood Obesity Research Demonstration study collected data from fifth-grade students attending 31 elementary schools across Austin and Houston and their parents (N = 748 parent-child dyads). Mixed-effects linear and logistic regressions stratified by gender and adjusted for sociodemographic covariates assessed associations among parental-perceived neighborhood safety, parental encouragement for child's outdoor PA, and parent- and child-reported child's outdoor PA. Parental-perceived neighborhood safety was significantly associated with encouraging outdoor PA (P = .01) and child-reported child's outdoor PA in boys, but not in girls. Significant associations were found between parental encouragement and child-reported outdoor PA for girls (P < .05) and parent-reported outdoor PA (P < .01) for boys and girls. Parent encouragement of PA and neighborhood safety are potential predictors of child outdoor PA and could be targeted in youth PA interventions.

Predictors of Severe Obesity in Low-Income, Predominantly Hispanic/Latino Children: The Texas Childhood Obesity Research Demonstration Study.

IntroductionThe objective of this study was to identify predictors of severe obesity in a low-income, predominantly Hispanic/Latino sample of children in Texas.MethodsThis cross-sectional analysis examined baseline data on 517 children from the secondary prevention component of the Texas Childhood Obesity Research Demonstration (TX CORD) study; data were collected from September 2012 through February 2014. Self-administered surveys were used to collect data from parents of children who were aged 2 to 12 years, had a body mass index (BMI) in the 85th percentile or higher, and resided in Austin, Texas, or Houston, Texas. Multivariable logistic regression models adjusted for sociodemographic covariates were used to examine associations of children’s early-life and maternal factors (large-for-gestational-age, exclusive breastfeeding for ≥4 months, maternal severe obesity [BMI ≥35.0 kg/m2]) and children’s behavioral factors (fruit and vegetable consumption, physical activity, screen time) with severe obesity (BMI ≥120% of 95th percentile), by age group (2–5 y, 6–8 y, and 9–12 y).ResultsAcross all ages, 184 (35.6%) children had severe obesity. Among children aged 9 to 12 years, large-for-gestational-age at birth (odds ratio [OR] = 2.31; 95% confidence interval [CI], 1.13–4.73) was significantly associated with severe obesity. Maternal severe obesity was significantly associated with severe obesity among children aged 2 to 5 years (OR = 2.67; 95% CI, 1.10–6.47) and 9 to 12 years (OR = 4.12; 95% CI, 1.84–9.23). No significant association was observed between behavioral factors and severe obesity in any age group.ConclusionIn this low-income, predominantly Hispanic/Latino sample of children, large-for-gestational-age and maternal severe obesity were risk factors for severe obesity among children in certain age groups. Promoting healthy lifestyle practices during preconception and prenatal periods could be an important intervention strategy for addressing childhood obesity.

Strategies to Recruit a Diverse Low-Income Population to Child Weight Management Programs From Primary Care Practices.

Purpose and ObjectivesPrimary care practices can be used to engage children and families in weight management programs. The Texas Childhood Obesity Research Demonstration (TX CORD) study targeted patients at 12 primary care practices in diverse and low-income areas of Houston, Texas, and Austin, Texas for recruitment to a trial of weight management programs. This article describes recruitment strategies developed to benefit both families and health care practices and the modification of electronic health records (EHRs) to reflect recruitment outcomes.Intervention ApproachTo facilitate family participation, materials and programs were provided in English and Spanish, and programs were conducted in convenient locations. To support health care practices, EHRs and print materials were provided to facilitate obesity recognition, screening, and study referral. We provided brief training for providers and their office staffs that covered screening patients for obesity, empathetic communication, obesity billing coding, and use of counseling materials.Evaluation MethodsWe collected EHR data from 2012 through 2014, including demographics, weight, and height, for all patients aged 2 to 12 years who were seen in the 12 provider practices during the study’s recruitment phase. The data of patients with a body mass index (BMI) at or above the 85th percentile were compared with the same data for patients who were referred to the study and patients who enrolled in the study. We also examined reasons that patients referred to the study declined to participate.ResultsOverall, 26% of 7,845 patients with a BMI at or above the 85th percentile were referred to the study, and 27% of referred patients enrolled. Enrollment among patients with a BMI at or above the 85th percentile was associated with being Hispanic and with more severe obesity than with patients of other races/ethnicities or less severe obesity, respectively. Among families of children aged 2 to 5 years who were referred, 20% enrolled, compared with 30% of families of older children (>5 y to 12 y). Referral rates varied widely among the 12 primary care practices, and referral rates were not associated with EHR modifications.Implications for Public HealthEngagement and recruitment strategies for enrolling families in primary care practice in weight management programs should be strengthened. Further study of factors associated with referral and enrollment, better systems for EHR tools, and data on provider and office adherence to study protocols should be examined. EHRs can track referral and enrollment to capture outcomes of recruitment efforts.

Best Practices and Barriers to Obesity Prevention in Head Start: Differences Between Director and Teacher Perceptions.

IntroductionPractices and barriers to promoting healthy eating and physical activity at Head Start centers may influence children’s energy balance behaviors. We examined differences between directors’ and teachers’ perspectives on best practices and barriers to promoting healthy eating and physical activity in Head Start centers.MethodsWe conducted a cross-sectional study of directors (n = 23) and teachers (n = 113) at 23 Head Start centers participating in the baseline assessment of the Texas Childhood Obesity Research Demonstration study. Participants completed surveys about practices and barriers to promoting healthy eating and physical activity. Multilevel regression models examined differences between director and teacher responses.ResultsMore than half of directors and teachers reported meeting most best practices related to nutrition and physical activity; few directors or teachers (<25%) reported conducting physical activity for more than 60 minutes a day, and less than 40% of teachers helped children attend to satiety cues. Significantly more directors than teachers reported meeting 2 nutrition-related best practices: “Teachers rarely eat less healthy foods (especially sweets, salty snacks, and sugary drinks) in front of children” and “Teachers talk to children about trying/enjoying new foods” (P < .05). No barrier to healthy eating or physical activity was reported by more than 25% of directors or teachers. Significantly more teachers than directors reported barriers to healthy eating, citing lack of food service staff support, limited time, and insufficient funds (P < .05).ConclusionMore barriers to healthy eating were reported than were barriers to physical activity indicating that more support may be needed for healthy eating. Differences between responses of directors and teachers may have implications for future assessments of implementation of best practices and barriers to implementation related to nutrition and physical activity in early care and education centers.

The utility of Geographical Information Systems (GIS) in systems-oriented obesity intervention projects: the selection of comparable study sites for a quasi-experimental intervention design--TX CORD.

The Texas Childhood Obesity Research Demonstration project (TX CORD) uses a systems-oriented approach to address obesity that includes individual and family interventions, community-level action, as well as environmental and policy initiatives. Given that randomization is seldom possible in community-level intervention studies, TX CORD uses a quasi-experimental design. Comparable intervention and comparison study sites are needed to address internal validity bias. TX CORD was designed to be implemented in low-income, ethnically diverse communities in Austin and Houston, Texas. A three-stage Geographical Information System (GIS) methodology was used to establish and ascertain the comparability of the intervention and comparison study sites. Census tract (stage 1) and school (stage 2) data were used to identify spatially exclusive geographic areas that were comparable. In stage 3, study sites were compared on demographic characteristics, socioeconomic status (SES), food assets, and physical activity (PA) assets. Student's t-test was used to examine significant differences between the selected sites. The methodology that was used resulted in the selection of catchment areas with demographic and socioeconomic characteristics that fit the target population: ethnically diverse population; lower-median household income; and lower home ownership rates. Additionally, the intervention and comparison sites were statistically comparable on demographic and SES variables, as well as food assets and PA assets. This GIS approach can provide researchers, program evaluators, and policy makers with useful tools for both research and practice. Area-level information that allows for robust understanding of communities can enhance analytical procedures in community health research and offer significant contributions in terms of community assessment and engagement.

Incorporating Primary and Secondary Prevention Approaches To Address Childhood Obesity Prevention and Treatment in a Low-Income, Ethnically Diverse Population: Study Design and Demographic Data from the Texas Childhood Obesity Research Demonstration (TX CORD) Study

There is consensus that development and evaluation of a systems-oriented approach for child obesity prevention and treatment that includes both primary and secondary prevention efforts is needed. This article describes the study design and baseline data from the Texas Childhood Obesity Research Demonstration (TX CORD) project, which addresses child obesity among low-income, ethnically diverse overweight and obese children, ages 2-12 years; a two-tiered systems-oriented approach is hypothesized to reduce BMI z-scores, compared to primary prevention alone. Our study aims are to: (1) implement and evaluate a primary obesity prevention program; (2) implement and evaluate efficacy of a 12-month family-centered secondary obesity prevention program embedded within primary prevention; and (3) quantify the incremental cost-effectiveness of the secondary prevention program. Baseline demographic and behavioral data for the primary prevention community areas are presented. Baseline data from preschool centers, elementary schools, and clinics indicate that most demographic variables are similar between intervention and comparison communities. Most families are low income (≤$25,000) and Hispanic/Latino (73.3-83.8%). The majority of parents were born outside of the United States. Child obesity rates exceed national values, ranging from 19.0% in preschool to 35.2% in fifth-grade children. Most parents report that their children consume sugary beverages, have a television in the bedroom, and do not consume adequate amounts of fruits and vegetables. Interventions to address childhood obesity are warranted in low-income, ethnically diverse communities. Integrating primary and secondary approaches is anticipated to provide sufficient exposure that will lead to significant decreases in childhood obesity.