Healthy Habits, Happy Homes

Healthy Habits, Happy HomesRandomized Trial to Improve Household Routines for ObesityPrevention Among Preschool-Aged ChildrenJess Haines, PhD, MHSc, RD; Julia McDonald, MS, MPH; Ashley O’Brien, LCSW, MPH; Bettylou Sherry, PhD, RD;Clement J. Bottino, MD; Marie Evans Schmidt, PhD; Elsie M. Taveras, MD, MPH

IMPORTANCE Racial/ethnic and socioeconomic disparities exist across risk factors forchildhood obesity.

OBJECTIVE To examine the effectiveness of a home-based intervention to improvehousehold routines known to be associated with childhood obesity among a sample oflow-income, racial/ethnic minority families with young children.

DESIGN Randomized trial.

SETTING The intervention was delivered in the families’ homes.

PARTICIPANTS The study involved 121 families with children aged 2 to 5 years who had atelevision (TV) in the room where he or she slept; 111 (92%) had 6-month outcome data (55intervention and 56 control). The mean (SD) age of the children was 4.0 (1.1) years; 45% wereoverweight/obese. Fifty-two percent of the children were Hispanic, 34% were black, and 14%were white/other. Nearly 60% of the families had household incomes of $20 000 or less.

INTERVENTIONS The 6-month intervention promoted 4 household routines, family meals,adequate sleep, limiting TV time, and removing the TV from the child’s bedroom, using (1)motivational coaching at home and by phone, (2) mailed educational materials, and (3) textmessages. Control subjects were mailed materials focused on child development.

MAIN OUTCOMES AND MEASURES Change in parent report of frequency of family meals(times/wk), child sleep duration (hours/d), child weekday and weekend day TV viewing(hours/d), and the presence of a TV in the room where the child slept from baseline to 6months. A secondary outcome was change in age- and sex-adjusted body mass index(calculated as weight in kilograms divided by height in meters squared).

RESULTS Compared with control subjects, intervention participants had increased sleepduration (0.75 hours/d; 95% CI, 0.06 to 1.44; P = .03), greater decreases in TV viewing onweekend days (−1.06 hours/d; 95% CI, −1.97 to −0.15; P = .02), and decreased body massindex (−0.40; 95% CI, −0.79 to 0.00; P = .05). No significant intervention effect was foundfor the presence of a TV in the room where the child slept or family meal frequency.

CONCLUSIONS AND RELEVANCE Our results suggest that promoting household routines,particularly increasing sleep duration and reducing TV viewing, may be an effective approachto reduce body mass index among low-income, racial/ethnic minority children. Longer-termstudies are needed to determine maintenance of behavior change.

TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01565161

JAMA Pediatr. doi:10.1001/jamapediatrics.2013.2356Published online September 9, 2013.

Editorial

Supplemental content atjamapediatrics.com

Author Affiliations: Authoraffiliations are listed at the end of thisarticle.

Corresponding Author: Elsie M.Taveras, MD, MPH, Division ofGeneral Pediatrics, Department ofPediatrics, Pediatric PopulationHealth Management, MassachusettsGeneral Hospital for Children, 100Cambridge Street, 15th Fl, Mail CodeM100C1570, Boston, MA 02114([email protected]).

Research

Original Investigation

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T he prevalence of overweight and obesity among youngchildren in the United States is high.1 Racial/ethnic mi-nority children and those living in low-income house-

holds bear a disproportionate share of the burden of over-weight status,1,2 making development of effective interventionstrategies for these high-risk populations particularly urgent.Racial/ethnic and socioeconomic disparities also exist acrossmany known risk factors for childhood overweight andobesity.3-8 Interventions that are able to address the dispari-ties in obesity-related risk factors may help curb the increasein overweight and obesity among racial/ethnic minority chil-dren and those living in low-income households.

Among a national sample of preschool-aged children, An-derson and Whitaker9 found that children who were exposedto 3 household routines (ie, regularly eating dinner as a fam-ily, adequate nighttime sleep, and limiting screen time) hadsubstantially lower obesity rates than children who were notexposed to those routines. The findings were similar across ra-cial/ethnic groups and across socioeconomic status. Ander-son and Whitaker’s findings suggest that promotion of thesehousehold routines may be an effective way to prevent child-hood obesity among racial/ethnic minority and low-incomefamilies. While a number of home-based obesity preventioninterventions have been implemented in very early infancy,10-14

to our knowledge, few obesity interventions for older chil-dren have been delivered in the home where household rou-tines occur.15-17 No home-based interventions have ad-dressed all of these household routines.

The purpose of this study was to assess the extent to whicha home-based intervention, compared with a mailed controlcondition focused on healthful development, resulted in im-provements in household routines that may be preventive ofchildhood overweight and obesity among racial/ethnic minor-ity and low-income families with children aged 2 to 5 years.We also examined the impact of the intervention on changein child body mass index (BMI, calculated as weight in kilo-grams divided by height in meters squared).

MethodsStudy Design and ParticipantsHealthy Habits, Happy Homes is a randomized trial.18 InSupplement, eFigure 1 provides a schematic of the study de-sign. Between June 1, 2011, and February 1, 2012, we recruitedfamilies from 4 community health centers that serve primar-ily low-income and racial/ethnic minority families in thegreater Boston area. Participants were families with childrenaged 2 to 5 years who had a television (TV) in the room wherethe child slept (verified by staff at home visit). We excluded (1)parents who were unable to respond to interviews in Englishor Spanish; (2) families who planned to move from the area; (3)parents who were younger than 18 years of age; and (4) chil-dren who had a chronic health condition such as severe cere-bral palsy.

Using patient records from individual health centers, weidentified 1467 potentially eligible families. We mailed a let-ter to each parent introducing the study and inviting them to

participate and included an opt-out telephone number shouldthe family choose not to participate. We telephoned familieswho did not refuse additional contact beginning 7 days aftermailing the letter. Of the 1467 potentially eligible families, re-search assistants attempted telephone contact with 1148, dur-ing which time they described the study, screened for eligi-bility, collected contact information, and scheduled a homevisit to collect baseline data and obtain written consent. Fami-lies were enrolled once we obtained their baseline data andwritten consent. Of the 500 parents who could be contactedand were eligible for the study, 121 enrolled in the study (re-sponse rate = 24%).

For simplicity, we determined our required sample sizeusing one of our targeted routines—TV viewing. To detect a 1.2-hour reduction in TV viewing per day19 with a 2-sided 5% sig-nificance level and a power of 80%, we determined that asample size of 60 participants per condition was necessary,based on an anticipated dropout rate of 10%.

To assign enrolled families to the intervention or controlcondition, we used a stratified block randomization scheme.Stratum was recruitment site blocked by child sex; conditionwas assigned by blocks of 4 in each strata. Our statistical pro-grammer used a computerized routine to randomly assign thestratified blocks to the intervention and control condition. As-signments were implemented through sealed sequentiallynumbered individual envelopes that the research assistantopened following the completion of baseline assessments.

All baseline and 6-month follow-up data were obtainedduring a home visit. Participants received $40 for completingthe baseline visit and $50 for completing the 6-month fol-low-up visit. All study activities were approved by the Har-vard Pilgrim Health Care human subjects committee.

Treatment GroupsFamilies randomized to the control condition received 4monthly mailed packages that included educational materi-als on reaching developmental milestones during early child-hood and low-cost incentives (eg, coloring books). The edu-cational materials were adapted from the Centers for DiseaseControl and Prevention’s “Developmental Milestones” (http://www.cdc.gov/ncbddd/actearly/milestones/index.html). Ma-terials focused on milestones for each age group organized bydevelopmental domain (social/emotional, language, cogni-tive, and motor).

InterventionThe Healthy Habits, Happy Homes intervention is a home-based intervention that uses individually tailored counselingby health educators to encourage behavior change. The inter-vention was informed by findings from focus groups with 74racial/ethnic minority parents of young children.20 Major com-ponents of the intervention included (1) motivational coach-ing by a health educator during 4 home visits and 4 healthcoaching telephone calls, (2) mailed educational materials(eFigure 2 in Supplement) and incentives, and (3) weekly textmessages on adoption of household routines.

We trained 4 bilingual health educators to use motiva-tional interviewing21-23 during the home visits and coaching

Research Original Investigation Healthy Habits, Happy Homes

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calls. Each home visit included (1) a check-in to review prog-ress and setbacks to behavior change, (2) discussion of behav-ior change goals and collaborative goal setting, and (3) a con-crete activity or tool the parent could use to support behaviorchange. Table 1 provides an overview of the home visit, mailededucational materials and incentives, and sample text mes-sages for each unit. The monthly coaching calls were de-signed to assess participants’ progress on making changes, pro-vide support for challenges that arose, and reinforce studymessages. The intervention focused on promotion of 4 house-hold behaviors: eating meals together as a family, obtainingadequate sleep, limiting TV time, and removing the TV fromthe child’s bedroom. Although the intervention was de-signed to change behaviors related to excess weight gain, child’sweight was not discussed in the intervention; instead, the in-tervention focused on promotion of the key household behav-iors with particular attention to achieving the goals in low-resource home environments.

In addition to the coaching home visits and calls, par-ents received text messages twice weekly for 16 weeksand then weekly for the last 8 weeks of the program(Table 1). Those participants without a cell phone that couldaccept texts (n = 11) received mailed postcards with thesame information.

Outcome MeasuresOur main outcomes were change, from baseline to follow-up,in 4 behaviors: eating meals together as a family, child’s sleepduration, child’s TV viewing time, and presence of a TV in theroom where the child slept. Using surveys at baseline and fol-low-up, we asked parents to report the number of days at leastsome of the family ate a meal together in the past 7 days.24 Tomeasure sleep duration, we asked parents to quantify the av-erage amount of daily sleep their child obtained including naps,and separately asked about bedtime and wake time in the pastmonth.25-27 To measure TV viewing time, we asked parents toreport separately the number of hours their child watched TVon an average weekday and weekend day in the past month.28

We also asked whether the child had a TV in the room wherehe or she slept.29

As a secondary outcome, we assessed change in child BMI.Trained research assistants measured child height using aSchorr board and child weight using a calibrated electronicscale. We then calculated child BMI and age-specific and sex-specific percentiles using the Centers for Disease Control andPrevention references.30 We chose BMI itself as the anthropo-metric outcome rather than BMI z score because publishedstudies have indicated that while the BMI z score is optimalfor assessing adiposity on a single occasion, BMI is preferablefor measuring change in adiposity.31

We kept detailed records of completed home visits andcalls. To assess parents’ satisfaction with the intervention, weasked parents in the intervention group during the follow-upsurvey to rate how satisfied they were with the program com-ponents and how helpful each component was in guiding theirapproach to their child’s behaviors. We also asked parentswhether they would recommend the program to their familyand friends.

Statistical MethodsWe first performed univariate analyses of variables of inter-est to examine baseline distributions of characteristics by in-tervention status and to examine distributional assump-tions. In intent-to-treat complete case analyses, we usedregression models to examine differences from baseline to6-month follow-up between the intervention and controlgroups. For continuous measures, we used linear regression,and for dichotomous outcomes, we used logistic regressionmodels. We performed all analyses using SAS version 9.2 (SASInstitute).

ResultsThe Figure details the participant flow in the Healthy Habits,Happy Homes study. We randomized 121 parent-child dyads

Table 1. Overview of the Home Visit, Mailed Educational Materials, and Text Messages for the Healthy Habits, Happy Homes Intervention

Unit Home Visit ContentMailed EducationMaterials Sample Text Message

Creatingroutines inyour home

Introduction and goal setting;activity: creating a daily sched-ule; handouts: overview ofgoals, implementing routines

Incentives: coloring book, stickers;newsletter: Sleep for Better Health

How could you add more family meals to your week? (Think aboutbreakfast, lunch, or dinner. Sit at a table, turn the TV off, and enjoyyour meal together.); Try the 3 Bs: bath, book, and bed! Routines makebedtime easier for parents and children.

Sleep for bet-ter health

Check-in; activity: bedtime rou-tine clock; handout: sleep tips

Incentives: Goodnight Moon book,art kit); newsletter: Limiting Your TVTime

Well-rested children make for happier parents (2-5 y olds need 11+hours of sleep, and enough sleep can make for better moods and betterlearning); Mommy, I can’t sleep... TV at bedtime makes it harder forkids to relax and go to sleep. For quiet time at the end of the day, read abook or sing softly.

Limiting yourchild’s inac-tive time

Check-in; activity: “fitnessdice”; handout: limiting TV

Incentives: mitt and ball set, Beren-stain Bears, too much TV, waterbottle; newsletter: Get Active

Think about this: children with a TV in their bedroom watch an averageof almost 1.5 h more/d than those without a TV in the bedroom; play-time for your child can be cooking or clean-up time for you (encourageher to do puzzles, look at books, or build with blocks instead of watch-ing TV)

Eating bettertogether

Check-in; activity: sometimesanytime food cards; handouts:healthy snacking, cooking withyour child

Incentives: laminated placemat, cup,and plate set; newsletter: Sugar-Sweetened Beverages

Healthy drinks, such as water and low-fat milk, in the fridge will helpyour child make healthy choices, fruit slices in a pitcher of water makeit pretty and fun; use a calendar and fun stickers to keep track of howmany fruits and vegetables your child eats. And remember, your kidslearn from you, so start crunching!

Abbreviation: TV, television.

Healthy Habits, Happy Homes Original Investigation Research

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to the intervention (n = 62) or the control condition (n = 59).Two participants withdrew from the study and 8 were lost tofollow-up. A total of 111 (92% of those enrolled at baseline) com-pleted the 6-month follow-up assessments. Table 2 shows base-line characteristics of our study sample overall and by inter-vention assignment. The mean (SD) age of the children was 4.0(1.1) years; 45% were overweight or obese at baseline. Nearly60% of the study sample had annual household incomes at orbelow $20 000. Children in the study were predominantly His-panic (52%) or black (34%), and 80% co-slept with their par-ents. There were no substantive group differences at baselinein health behaviors or BMI.

Table 3 shows baseline and 6-month follow-up levels of ourbehavioral and BMI outcomes by intervention arm. Fre-quency of eating family dinners remained relatively un-changed in both the intervention and control families with nointervention effect. We observed an intervention effect for child

sleep duration; at 6 months, child sleep duration increased by0.56 hours/d in the intervention group and decreased by 0.19hours/d in the control group, yielding a difference of 0.75hours/d (95% CI, 0.06 to 1.44; P = .03). We observed larger de-creases in weekend TV viewing among children in the inter-vention group compared with the control group (−1.06 hours/d;95% CI, −1.97 to −0.15; P = .02). Weekday TV viewing also de-creased more among children in the intervention, but this dif-ference was not statistically significant. Families in both theintervention (20%) and control (12%) conditions reported re-moving the TV from the room where their child slept, with nosignificant intervention effect (P = .29).

At 6 months, child BMI had decreased by a mean of 0.18in the intervention group and increased by 0.21 in the controlgroup, yielding a difference of −0.40 (95% CI, −0.79 to 0.00;P = .05).

We aimed for participants to complete 4 home visits and4 phone calls with a health educator by 6 months. Among the62 families randomized to intervention, 48 (77%) completedall 4 home visits. Fewer families completed the phone calls;23 (37%) completed all 4 phone calls. Among the 55 interven-tion families who completed the process survey at follow-up,89% reported being “satisfied” or “very satisfied” with the pro-gram as a whole; 98% were “satisfied” or “very satisfied” withthe counseling received during home visits; and 98% were “sat-isfied” or “very satisfied” with the counseling received dur-ing coaching calls. Nearly all parents (98%) reported they wouldrecommend the program to friends and family.

DiscussionIn this 6-month follow-up of a home-based randomized trial,we found that a multicomponent intervention that uses indi-vidually tailored counseling focused on improving house-hold routines increased children’s sleep duration and re-duced children’s TV viewing on weekends. We found that,compared with control subjects, children who participated inthe intervention decreased their BMI.

To our knowledge, the Healthy Habits, Happy Homes studyis the first home-based randomized trial to address key house-hold routines related to obesity risk among young children. Re-cent reviews of obesity prevention interventions among youngchildren have identified the paucity of home-based interven-tions and have called for interventions that are appropriatelytailored for families.32,33 Our use of motivational interview-ing by trained health educators allowed families to identify andwork on the challenges and barriers of key relevance to them.We also designed our intervention based on findings from ourformative research with racially/ethnically diverse, low-income parents of young children to ensure our interventionwas contextually appropriate for these high-risk popula-tions. Our use of mobile technology to encourage behaviorchange is also novel; to our knowledge, few studies have ex-amined the use of mobile technology to encourage the adop-tion of healthful weight-related behaviors.34,35 Our results sug-gest such an approach is feasible among ethnically/raciallydiverse, low-income families. Future studies should be de-

Figure. Participant Flow for the Healthy Habits, Happy Homes Study

1467 Were pre-eligible

4 Opted out

315 Missed contact window

1148 Attempted contacts duringrecruitment window

190 With disconnected/wrong numbers

458 Were ineligible29860491734

With no TV in bedroomPlanning to moveBecause of languageBecause of ageFor other reasons

174 Declined to participate

163 Did not get in contact

163 Pre-enrolled

39 Did not complete baseline assessment

3 Were ineligible at baseline visit (no TV in bedroom)

121 Families in total enrolled

62 In intervention group 59 In control group

12

WithdrewLost to follow-up

56 Completed follow-up

16

WithdrewLost to follow-up

55 Completed follow-up

TV indicates television.




signed to specifically examine the effectiveness of text mes-sages in supporting healthful weight-related behavior changeamong families with young children.

We found that our intervention had a significant effect onchild sleep duration. Despite strong evidence that sleep du-ration and quality are associated with obesity risk in youngchildren,25,27 few published intervention studies have fo-cused on increasing preschool-aged children’s sleep.36,37 Ourresults suggest that a home-based intervention that uses mo-tivational interviewing to elicit change in household routinescan be used to increase child sleep duration. Empirical evi-dence of the inverse association between TV viewing andsleep38,39 suggests that household routines related to both sleepand TV viewing may be needed to achieve a change in childsleep duration.

In our intervention, the mean difference (intervention vscontrol) in TV viewing on weekend days was −1.06 hours at 6months. This magnitude of effect is higher than 2 of the 3 in-

tervention studies that have successfully decreased TV view-ing/screen time among preschool-aged children40,41; the thirdintervention measured total screen time only, making a di-rect comparison of the effect for TV viewing difficult.42 We didfind a smaller, nonsignificant difference (−0.31) in TV view-ing on weekdays. It is possible that parents have more free timeon the weekends and therefore are better able to implementlimits on children’s TV viewing. Further investigation into howbarriers to limiting TV viewing may differ on weekends andweekdays is warranted.

Our intervention did not have a significant interventioneffect on the presence of a TV in the room where the child slept.There are 2 factors that could have contributed to these non-significant findings. First, it is possible that our intervention,which focused on household routines, was not intensive or spe-cific enough to change this behavior. It is possible that a moreintensive and targeted approach, such as financial incen-tives, may be needed to motivate families to give up a TV. Sec-

Table 2. Baseline Characteristics and Behaviors of Participants in the Healthy Habits, Happy Homes StudyOverall and by Intervention Assignment

Overall(n = 111)

Intervention(n = 55)

Control(n = 56)

Child characteristics, mean (SD)

Age, y 4.1 (1.1) 4.1 (1.1) 4 (1.1)

BMI 17.4 (2.4) 17.3 (2.1) 17.4 (2.7)

BMI z score 0.91 (1.18) 0.95 (1.12) 0.88 (1.24)

Behaviors/Routines, mean (SD)

Sleep, h/d 10.4 (1.5) 10.4 (1.6) 10.5 (1.4)

TV, h/d 2.5 (1.5) 2.5 (1.6) 2.5 (1.5)

Family meals, times/wk 6.3 (2.0) 6.5 (1.8) 6.1 (2.2)

Sex, No (%)

Female 53 (47.7) 24 (43.6) 29 (51.8)

Male 58 (52.3) 31 (56.4) 27 (48.2)

Race/ethnicity, No. (%)

Black 37 (33.3) 16 (29.1) 21 (37.5)

Hispanic 57 (51.4) 33 (60.0) 24 (42.9)

Other 17 (15.3) 6 (10.9) 11 (19.6)

BMI category, No. (%)

<85th percentile 58 (53.7) 27 (51.9) 31 (55.4)

85th-<95th percentile 29 (26.9) 13 (25.0) 16 (28.6)

>95th percentile 21 (19.4) 12 (23.1) 9 (16.1)

Parent and household characteristics, mean (SD)

Maternal BMI 27.9 (6.1) 27 (5.8) 28.7 (6.4)

Highest parent education, No. (%)

<High school 18 (16.8) 11 (20.4) 7 (13.2)

High school graduate 40 (37.4) 17 (31.5) 23 (43.4)

≥Some college 49 (45.8) 26 (48.1) 23 (43.4)

Married or cohabitating, No. (%)

Married/cohabiting 54 (48.6) 28 (50.9) 26 (46.4)

Not married 57 (51.4) 27 (49.1) 30 (53.6)

Household income, No. (%), $

≤20 000 54 (55.1) 28 (62.2) 26 (49.1)

20 001 to 50 000 34 (34.7) 14 (31.1) 20 (37.7)

>50 000 10 (10.2) 3 (6.7) 7 (13.2)

Children co-sleep with parents 80 (72) 43 (78) 37 (66)

Abbreviations: BMI, body mass index(calculated as weight in kilogramsdivided by height in meters squared);TV, television.




ond, in our sample, most parents (80%) reported that their chil-dren sleep with them. It is possible that parents are not willingto remove the TV from their own room. Future research shouldexplore strategies to motivate parents to remove the TV froma room where they sleep with their child.

Our intervention had no effect on the frequency of familymeals. The frequency of family meals was fairly high amongour sample, approximately 6 times per week, which may haveresulted in our participants having little “room to move” withregard to this behavior. The wording of our question, whichdefined family meals as “at least some of the family ate to-gether” may have contributed to this ceiling effect. Becauseour intervention had an effect on child BMI despite not chang-ing family meal frequency, our results suggest that changingthe frequency of family meals may not be a necessary strat-egy for reducing obesity risk among low-income, racially/ethnically diverse families. Rollins et al43 explored the asso-ciation between family meal frequency and obesity levelsamong a national sample of children aged 6 to 11 years andfound that the influence of family meals on weight status maydiffer by race/ethnicity and income; they found no associa-tion between the frequency of family meals and obesity preva-lence among Hispanic and black girls and found a positive as-sociation between the frequency of family meals and obesityrates among Hispanic boys from low-education households.

Similar results have been found among adolescents.44 Fur-ther research on how the association between obesity risk andfamily meal frequency and quality may differ by race/ethnicity and/or income is needed.

At 6 months, the mean difference in BMI for the inter-vention vs control groups was −0.40. This magnitude ofeffect was similar to a recent community-based obesity pre-vention intervention for Latino American families withpreschool-aged children (Salud Con La Familia) in which theadjusted mean difference was −0.59 (95% CI, −0.94 to −0.25)at 3 months.45 Like our intervention, the Salud Con LaFamilia intervention was culturally tailored and addressedfamily meals and TV viewing. It is unclear as to the inter-vention effect of Salud Con La Familia on these householdroutines as these data were not provided. Our findings sug-gest that a home-based intervention that uses motivationalinterviewing to elicit change in household routines, in par-ticular around TV viewing and sleep duration, is effective inreducing child’s BMI.

When interpreting our results, several limitationsshould be considered. First, our intervention targeted low-income and racial/ethnic minority parents. Thus, our inter-vention may not generalize to more socioeconomicallyadvantaged populations. Second, of the 500 families wecontacted, only 121 (24%) enrolled in the study. Thus, it is

Table 3. Change in Behavioral and BMI Outcomes From Baseline to 6 Months by Intervention Assignment

Mean (SD)

Difference β (95% CI) P ValueBaseline 6 Months Change

Behavioral outcomesFamily meals,times/wk

Intervention 6.1 (2.16) 5.87 (2.29) −0.23 (2.66)0.29 (−0.69 to 1.27) .56

Control 6.54 (1.84) 6.03 (2.12) −0.52 (2.53)

Sleep, h/d

Intervention 10.52 (1.42) 11.07 (1.45) 0.56 (1.6)0.75 (0.06 to 1.44) .03

Control 10.38 (1.63) 10.16 (1.6) −0.19 (2)

TV, h/d

Intervention 2.45 (1.46) 1.64 (1.04) −0.82 (1.46)−0.54 (−1.22 to 0.15) .12

Control 2.46 (1.64) 2.2 (1.85) −0.28 (2.09)

TV on weekdays, h/d

Intervention 2.4 (1.48) 1.59 (1.04) −0.81 (1.52)−0.31 (−0.98 to 0.37) .37

Control 2.45 (1.85) 1.95 (1.88) −0.5 (2.03)

TV on weekends, h/d

Intervention 2.56 (1.96) 1.77 (1.5) −0.79 (1.93)−1.06 (−1.97 to −0.15) .02

Control 2.48 (2.01) 2.77 (2.37) 0.26 (2.79)

TV in bedroom, No.(%)

Intervention 55 (100.0) 44 (80.0) 11 (20.0)1.75 (0.62 to 4.91)a .29

Control 56 (100.0) 49 (87.5) 7 (12.5)

BMI outcomes

Child BMIb

Intervention 17.34 (2.11) 17.16 (1.99) −0.18 (0.98)−0.40 (−0.79 to 0.00) .05

Control 17.36 (2.73) 17.57 (3.22) 0.21 (1.07)

Child BMI z score

Intervention 0.95 (1.12) 0.89 (1.05) −0.06 (0.63)−0.17 (−0.40 to 0.07) .17

Control 0.88 (1.24) 0.98 (1.07) 0.11 (0.61)

Abbreviations: BMI, body mass index(calculated as weight in kilogramsdivided by height in meters squared);TV, television.a Odds ratio (95% CI).b Adjusted for child age and sex.




unclear how these results would generalize to those whodid not take up the intervention. Third, although, wherepossible, we used validated measures to assess our behav-ioral outcomes, we used parental report rather than objec-tive measures. Thus, it is possible that parents could exag-gerate improvements in behaviors. However, our effect onBMI, an objective measure, and the fact that parents in theintervention arm did not report an increase in family meals,a key intervention target, argues against exaggerated

reports of behavior change. Fourth, the follow-up periodwas only 6 months, therefore, it is unknown whether thesechanges in behavior and BMI were sustained.

In summary, after 6 months, we found that the HealthyHabits, Happy Homes intervention improved sleep durationand TV viewing behaviors, as well as decreased BMI among ra-cially/ethnically diverse children from low-income house-holds. Future studies with a longer follow-up are needed to de-termine maintenance of these behavior changes.

ARTICLE INFORMATION

Accepted for Publication: March 13, 2013.

Published Online: September 9, 2013.doi:10.1001/jamapediatrics.2013.2356.

Author Affiliations: Obesity Prevention Program,Department of Population Medicine, HarvardMedical School and Harvard Pilgrim Health CareInstitute, Boston, Massachusetts (McDonald,O’Brien, Taveras); Department of Pediatrics,Massachusetts General Hospital, Boston,Massachusetts (Taveras); Department of FamilyRelations and Applied Nutrition, University ofGuelph, Guelph, Ontario, Canada (Haines); Divisionof Nutrition, Physical Activity, and Obesity, NationalCenter for Chronic Disease Prevention and HealthPromotion, Centers for Disease Control andPrevention, Atlanta, Georgia (Sherry); Division ofGeneral Pediatrics, Children’s Hospital Boston,Boston, Massachusetts (Bottino, Schmidt).

Author Contributions: Dr Taveras had full access tothe study data and takes responsibility for theintegrity of the data and accuracy of data analysis.Study concept and design: All authors.Acquisition of data: McDonald, O’Brien.Analysis and interpretation of data: Haines,McDonald, O’Brien, Sherry, Schmidt, Taveras.Drafting of the manuscript: Haines, McDonald,Bottino, Taveras.Critical revision of the manuscript for importantintellectual content: McDonald, O’Brien, Sherry,Bottino, Schmidt.Statistical analysis: McDonaldObtained funding: Haines, Schmidt, Taveras.Administrative, technical, or material support:McDonald, O’Brien, Bottino.Study supervision: Haines, McDonald, Sherry,Taveras.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by theCenters for Disease Control and Prevention and theNational Center for Chronic Disease Prevention andHealth Promotion (Prevention Research Centersgrant 1U48DP00194).

Role of the Sponsors: The sponsors had no role inthe design and conduct of the study; collection,management, analysis, and interpretation of thedata; and preparation, review, or approval of themanuscript; and decision to submit the manuscriptfor publication.

Disclaimer: The findings and conclusions in thisarticle are those of the authors and do notnecessarily represent the official position of theCenters for Disease Control and Prevention.

Additional Contributions: We thank theparticipants of the Healthy Habits, Happy Homesstudy and the 4 health centers that supported thestudy: Dimock Community Health Center, Roxbury

Comprehensive Community Health Centers, andthe Cambridge and Somerville offices of CambridgeHealth Alliance. We also thank the research staffwho helped make the study happen including KarenTroncoso, BA, BSc, Amy Louer, BA, StephanieFerisin, MHP, Elizabeth Cespedes, MPH, JhoanaYactayo, BSc, and Katherine Calderon. Additionally,we thank Jan Jernigan, PhD, of the Centers forDisease Control and Prevention for her ongoingcontribution to the development of the HealthyHabits, Happy Homes program materials andintervention structure.

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Healthy Habits, Happy Homes