Obesity Interventions in Underserved Populations: What ... · Obesity Interventions in Underserved Populations: What What Works and What Doesn't Works and What Doesn't ... Angela

Obesity Interventions in Obesity Interventions in Underserved PopulationsUnderserved Populations ::What What Works and What Doesn'tWorks and What Doesn't

Marian L. Fitzgibbon, Ph.D.Marian L. Fitzgibbon, Ph.D.Professor Professor of Medicine of Medicine and and

Health Policy and AdministrationHealth Policy and AdministrationUniversity University of Illinois at Chicagoof Illinois at Chicago

[email protected]@uic.edu

CoCo--InvestigatorsInvestigators

�� Michael Berbaum, PhDMichael Berbaum, PhD�� Joanna Buscemi, PhDJoanna Buscemi, PhD�� Carol Carol BraunschweigBraunschweig, PhD, PhD�� Alan Dyer, PhDAlan Dyer, PhD

Barbara Barbara FieseFiese, PhD, PhD�� Barbara Barbara FieseFiese, PhD, PhD�� Katherine Katherine KauferChristoffelKauferChristoffel, MD, MPH, MD, MPH�� YoonsangYoonsang Kim, PhD, MPHKim, PhD, MPH�� Angela Kong, PhD, MPH, RDAngela Kong, PhD, MPH, RD�� Angela OdomsAngela Odoms--Young, PhD Young, PhD �� Melinda Stolley, PhDMelinda Stolley, PhD

Presentation OutlinePresentation Outline�� IntroductionIntroduction

�� Treating obesity in adultsTreating obesity in adults�� ORBITORBIT

�� Preventing obesity in childrenPreventing obesity in children�� HipHip--Hop to Hop to Health Jr.Health Jr.�� HipHip--Hop to Hop to Health Jr.Health Jr.�� TeacherTeacher--Delivered HipDelivered Hip--Hop to HealthHop to Health�� NiñosNiños FelicesFelices, , NiñosNiños SanosSanos�� Chicago Family Food SurveyChicago Family Food Survey

�� Retaining hardRetaining hard--toto--reach participants: lessons reach participants: lessons learnedlearned

�� Future directionsFuture directions

1999

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 1999, 2009

(*BMI ≥≥≥≥30, or about 30 lbs. overweight for 5’4” person)

2009

1990

Source: Behavioral Risk Factor Surveillance System, CDC.

2009

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

AgeAge--Adjusted Prevalence of Overweight and Adjusted Prevalence of Overweight and Obesity Obesity in U.S. in U.S. Women Aged 20 Years and Women Aged 20 Years and

Older, NHANES 2011Older, NHANES 2011--1212

63.2

82.0

56.6

77.2

44.450

60

70

80

90

Pre

vale

nce,

%

32.8

44.4

0

10

20

30

40

Overweight/Obese (BMI ≥ 25) Obese (BMI ≥ 30)

Pre

vale

nce,

%

Non-Hispanic White Non-Hispanic Black Hispanic

FlegalFlegal et al. et al. JAMA 2014JAMA 2014; 311:806; 311:806--14.14.

Obesity Reduction Black Obesity Reduction Black Intervention Trial (ORBIT)Intervention Trial (ORBIT)

NCI CA105051NCI CA105051

ORBIT Study Design/Participant FlowORBIT Study Design/Participant Flow

Eligibility Interview (N=690)

Baseline Interview (N=217)

Randomization (N=213)

Intervention Group (N=107) Control Group (N=106)6-Month

Weight LossIntervention

12-MonthMaintenance Intervention

Intervention Group (N=107) Control Group (N=106)

6-Month Follow-up (N=100) 6-Month Follow-up (N=97)

18-Month Follow-up (N=93) 18-Month Follow-up (N=97)

ControlNewsletters

ControlNewsletters

ORBIT Intervention: Weight LossORBIT Intervention: Weight Loss

�� Months 1Months 1--66�� Classes twice per weekClasses twice per week

��1 skill1 skill--building + exercisebuilding + exercise��1 exercise only1 exercise only��1 exercise only1 exercise only

�� Motivational interviewing (MI) once per monthMotivational interviewing (MI) once per month

ORBIT Intervention: MaintenanceORBIT Intervention: Maintenance�� Months 7Months 7--1212

�� Exercise plus Exercise plus ““Our TimeOur Time”” group support twice per group support twice per weekweek

�� MI once per monthMI once per month�� Newsletter every other monthNewsletter every other month

�� Months 13Months 13--1515�� Months 13Months 13--1515�� Exercise once per weekExercise once per week�� MI once per monthMI once per month�� Newsletter every other monthNewsletter every other month

�� Months 16Months 16--1818�� MI once per monthMI once per month�� Newsletter every other monthNewsletter every other month

BMI and Weight at BaselineBMI and Weight at Baseline

Intervention(N=107)

Mean (SD)

Control(N=106)

Mean (SD)

All(N=213)

Mean (SD)

BMI (kg/m2) 38.7 (5.5) 39.8 (5.8) 39.2 (5.7)

Weight (kg) 103.9 (15.7) 105.9 (17.4) 104.9 (16.6)Weight (kg) 103.9 (15.7) 105.9 (17.4) 104.9 (16.6)

Obesity category, n (%)

30-<35 kg/m2 36 (34%) 27 (25%) 63 (30%)63 (30%)

35-<40 kg/m2 31 (29%) 26 (25%) 57 (27%)57 (27%)

≥ 40 kg/m2 40 (37%) 53 (50%) 93 (44%)93 (44%)

Weight and BMI Change after 6Weight and BMI Change after 6 --Month Month Weight Loss ProgramWeight Loss Program

Unadjusted Change at 6 Months, Mean (SD)

Difference between groups

in adjusted mean change

(95% CI)a paIntervention

(N=100) Control(N=97) (95% CI)a pa(N=100) (N=97)

Weight (kg)

-3.04 (4.93) 0.22 (3.72) -3.27(-4.50 to -2.05)

<.001

BMI (kg/m2)

-1.14 (1.88) 0.10 (1.37) -1.24(-1.71 to -0.78)

<.001

a From analysis of covariance with change as the dependent variable, controlling From analysis of covariance with change as the dependent variable, controlling for baseline value for baseline value and cohort. and cohort. Only participants with weight measurements at 6 Only participants with weight measurements at 6 months were included in months were included in the analysis. the analysis.

Weight and BMI Change after 18Weight and BMI Change after 18 --Month Month Weight Loss/Maintenance ProgramWeight Loss/Maintenance Program

Unadjusted Change at 18 Months, Mean (SD)

Difference between groups

in adjusted mean change

(95% CI)a paIntervention

(N=93) Control(N=97) (95% CI)a pa(N=93) (N=97)

Weight (kg)

-2.26 (7.42) 0.51 (5.69) -2.83(-4.71 to -0.95)

.003

BMI (kg/m2)

-0.86 (2.79) 0.22 (2.07) -1.13(-1.83 to -0.43)

.002

a From analysis of covariance with change as the dependent variable, controlling From analysis of covariance with change as the dependent variable, controlling for baseline value for baseline value and cohort. and cohort. Only participants with weight measurements at 18 Only participants with weight measurements at 18 months were included in months were included in the analysis. the analysis.

ConclusionsConclusions

�� Women in the intervention group lost Women in the intervention group lost significantly more weight than women in the significantly more weight than women in the control group during the 6control group during the 6--month weight month weight loss program (loss program (--3.0 3.0 vsvs 0.2 kg, p < .001).0.2 kg, p < .001).loss program (loss program (--3.0 3.0 vsvs 0.2 kg, p < .001).0.2 kg, p < .001).

�� Some weight was reSome weight was re--gained during the gained during the maintenance phase, but weight loss was maintenance phase, but weight loss was still greater in the intervention group than in still greater in the intervention group than in the control group at 18 months (the control group at 18 months (--2.3 2.3 vsvs 0.5 0.5 kg, p = .003).kg, p = .003).

Conclusions Conclusions ““The enterprise of treating obesity is The enterprise of treating obesity is necessary. Obese individuals need and necessary. Obese individuals need and deserve help. The long odds of developing deserve help. The long odds of developing highly effective treatments do not rule out highly effective treatments do not rule out the possibility that a breakthrough will come the possibility that a breakthrough will come the possibility that a breakthrough will come the possibility that a breakthrough will come somewhere at some point. With that said, if somewhere at some point. With that said, if the goal is to have fewer people struggling the goal is to have fewer people struggling with obesity, and to reduce the associated with obesity, and to reduce the associated societal costs, prevention must be the societal costs, prevention must be the priority.priority.””KD Brownell. The humbling experience of treating obesity: Should we persist or desist? Behaviour Research and Therapy. 2010;48:717-19.

Prevalence of Obesity* Among Children and Prevalence of Obesity* Among Children and Adolescents, 1963 to 2012Adolescents, 1963 to 2012

10

15

20

25

Pre

vale

nce

(%)

*BMI ≥ 95th percentile for age and sex.Ogden et al. JAMA 2002;288:1728-32. Hedley et al. JAMA 2004;291:2847-50. Ogden et al. JAMA 2010;303:242-9. Ogden et al. JAMA 2014;311:806-14.

0

5

1963-1970

1971-1974

1976-1980

1988-1994

1999-2002

2007-2008

2011-2012

Pre

vale

nce

(%)

Age 6-11 Age 12-19

Prevalence of Obesity* in Children by Prevalence of Obesity* in Children by Racial/Ethnic Group, NHANES 2011Racial/Ethnic Group, NHANES 2011--1212

13.1

19.6

11.3

23.822.1

16.7

26.1

22.6

15

20

25

30

Pre

vale

nce

(%)

*BMI ≥ 95th percentile for age and sex. Ogden et al. JAMA 2014;311:806-14.

3.5

11.3

0

5

10

2-5 years 6-11 years 12-19 years

Pre

vale

nce

(%)

Non-Hispanic White Non-Hispanic Black Hispanic

Advantages of PreschoolAdvantages of Preschool--Based Based ProgramsPrograms

�� Potential for interrupting trajectory to Potential for interrupting trajectory to obesity in young childrenobesity in young children

�� Continuous contact with childrenContinuous contact with childrenContinuous contact with childrenContinuous contact with children

�� Inclusion of minority and lowInclusion of minority and low--income income childrenchildren

�� No cost to parentsNo cost to parents

�� Parental trust in school settingParental trust in school setting

PreschoolPreschool--Based Intervention StudiesBased Intervention Studies

Efficacy trial (HipEfficacy trial (Hip--Hop to Hop to Health Jr.)Health Jr.)Effective for Black childrenEffective for Black children

Ineffective for Latino childrenIneffective for Latino children

Black childrenBlack children Latino childrenLatino children

Effectiveness trialEffectiveness trial(Teacher(Teacher--DeliveredDeliveredHipHip--Hop to Health)Hop to Health)

Pilot study of intervention Pilot study of intervention with enhanced parent with enhanced parent

componentcomponent(Obesity Prevention in (Obesity Prevention in

Latino Families)Latino Families)

Black childrenBlack children Latino childrenLatino children

Efficacy TrialEfficacy Trial

HipHip--Hop to Hop to Health Jr.Health Jr.

(NHLBI HL58871)(NHLBI HL58871)

�� Randomized controlled trialRandomized controlled trial�� Randomized controlled trialRandomized controlled trial

�� Program taught in Head Start preschools Program taught in Head Start preschools by trained interventionists on study staffby trained interventionists on study staff

Study Design and Participant FlowStudy Design and Participant Flow12 Catholic Charities Head Start Sites12 Catholic Charities Head Start SitesPredominantly AfricanPredominantly African--American PreschoolsAmerican Preschools

Randomization by SchoolRandomization by School

Intervention Schools (N=6)Intervention Schools (N=6) Control Schools (N=6)Control Schools (N=6)

Baseline Interview (N=197)Baseline Interview (N=197) Baseline Interview (N=212)Baseline Interview (N=212)

14 Week Intervention14 Week Intervention 14 Week Control Curriculum14 Week Control Curriculum

PostPost--Intervention Interview Intervention Interview (N=179)(N=179)

PostPost--Intervention Interview Intervention Interview (N=183)(N=183)

11--Year FollowYear Follow--up (N=143)up (N=143) 11--Year FollowYear Follow--up (N=146)up (N=146)

22--Year FollowYear Follow--up (N=146)up (N=146) 22--Year FollowYear Follow--up (N=154)up (N=154)Children with interview data but no anthropometric data at followChildren with interview data but no anthropometric data at follow--up are up are not shown.not shown.

Weight Control Intervention:Weight Control Intervention:HipHip--Hop to Hop to Health Jr.Health Jr.

�� A schoolA school--based weight control intervention based weight control intervention (not a weight loss intervention)(not a weight loss intervention)

�� Emphasizes healthy eating and increased Emphasizes healthy eating and increased �� Emphasizes healthy eating and increased Emphasizes healthy eating and increased physical activityphysical activity

�� Designed for preschoolDesigned for preschool--aged minority aged minority children (3children (3--5 years old)5 years old)

Weight Control Intervention Weight Control Intervention (cont(cont ’’’’’’’’d)d)

�� 14 weeks 14 weeks –– different theme each weekdifferent theme each week

�� 3 classes per week3 classes per week

�� 40 minutes long40 minutes long�� 40 minutes long40 minutes long�� 1515--20 minutes interactive healthy eating 20 minutes interactive healthy eating

and/or exercise activityand/or exercise activity�� 20 minutes of continuous physical activity20 minutes of continuous physical activity

Weekly ThemesWeekly ThemesWeekWeek LessonLesson WeekWeek LessonLesson

11 Go, Go, Grow vs. Grow vs. Slow FoodsSlow Foods

88 ProteinProtein

22 Food PyramidFood Pyramid 99 Heart Healthy ExerciseHeart Healthy Exercise

33 PortionsPortions 1010 Instead of TV, I Could…Instead of TV, I Could…33 PortionsPortions 1010 Instead of TV, I Could…Instead of TV, I Could…

44 GrainsGrains 1111 Grooving, MovingGrooving, Moving

55 FruitsFruits 1212 Healthy SnacksHealthy Snacks

66 VegetablesVegetables 1313 Healthy Me, Part 1Healthy Me, Part 1

77 MilkMilk 1414 Healthy Me, Part 2Healthy Me, Part 2

Overweight and Obesity in Children Overweight and Obesity in Children at at BaselineBaseline

CategoryBMI

Percentilea

PredominantlyAA Schools

N (%)

PredominantlyLatino Schools

N (%)

Underweight < 5th 4 ( 1%)4 ( 1%) 4 ( 1%)4 ( 1%)Underweight < 5th 4 ( 1%)4 ( 1%) 4 ( 1%)4 ( 1%)

Normal weight 5th to <85th 266 (65%)266 (65%) 215 (54%)215 (54%)

Overweight 85th to <95th 75 (18%) 76 (19%)

Obese ≥ 95th 64 (16%) 106 (26%)

a BMI percentiles for age and sex are based on the 2000 Centers for Disease Control (CDC) growth charts for children and are calculated using a SAS program provided by CDC.

Overweight and Obesity in Overweight and Obesity in Parents/Caregivers Parents/Caregivers at at BaselineBaseline

CategoryBMI Range

(kg/m2)

PredominantlyAA Schools

N (%)

PredominantlyLatino Schools

N (%)

Underweight < 18.5< 18.5 6 ( 2%)6 ( 2%) 2 ( 1%)2 ( 1%)Underweight < 18.5< 18.5 6 ( 2%)6 ( 2%) 2 ( 1%)2 ( 1%)

Normal weight 18.5 18.5 to <25to <25 66 (22%)66 (22%) 72 (23%)72 (23%)

Overweight 25 to <3025 to <30 83 (28%) 114 (37%)

Obesity class I Obesity class I 30 to <3530 to <35 65 (22%) 68 (22%)

Obesity class II Obesity class II 35 to < 4035 to < 40 34 (11%) 37 (12%)

Obesity class IIIObesity class III ≥ 40≥ 40 45 (15%) 17 ( 5%)

AdjustedAdjusted aa Child BMI and BMI Z Score Child BMI and BMI Z Score Change at 1Change at 1 --Year FollowYear Follow --upup(Predominantly AA Preschools)(Predominantly AA Preschools)

ChangeChangeINTINT

(N=143)(N=143)MeanMean

CONCON(N=146)(N=146)

MeanMeanDifference (INTDifference (INT--CON)CON)

(95% CI)(95% CI) pp

BMI, kg/mBMI, kg/m22 0.020.02 0.640.64 --0.62 (0.62 (--0.95 0.95 to to --0.280.28)) .002.002

AdjustedAdjustedbb BMI, BMI,

kg/mkg/m22

0.060.06 0.590.59 --0.53 (0.53 (--0.91 0.91 to to --0.140.14)) .012.012

BMI Z scoreBMI Z score --0.060.06 0.130.13 --0.19 (0.19 (--0.35 0.35 to to --0.030.03)) .024.024

AdjustedAdjustedbb BMI BMI

Z scoreZ score

--0.080.08 0.160.16 --0.23 (0.23 (--0.38 0.38 to to --0.090.09)) .006.006

a a Adjusted for group randomization by Head Start site using SAS Adjusted for group randomization by Head Start site using SAS Proc Mixed.Proc Mixed.b b Adjusted for baseline age quartile, baseline BMI, and Head Adjusted for baseline age quartile, baseline BMI, and Head Start site. Start site.

AdjustedAdjusted aa Child BMI and BMI Z Score Child BMI and BMI Z Score Change at 2Change at 2 --Year FollowYear Follow --upup(Predominantly AA Preschools)(Predominantly AA Preschools)

ChangeChangeINTINT


CON CON (N=154)(N=154)

MeanMeanDifference (INTDifference (INT--CON)CON)

(95% CI)(95% CI) pp

BMI, kg/mBMI, kg/m22 0.480.48 1.141.14 --0.65 (0.65 (--1.09 1.09 to to --0.210.21)) .008.008

AdjustedAdjustedbb BMI, BMI,

kg/mkg/m22

0.540.54 1.081.08 --0.54 (0.54 (--0.98 0.98 to to --0.100.10)) .022.022

BMI Z scoreBMI Z score 0.020.02 0.160.16 --0.14 (0.14 (--0.25 0.25 to to --0.030.03)) .021.021

AdjustedAdjustedbb BMI BMI

Z scoreZ score

0.000.00 0.170.17 --0.18 (0.18 (--0.31 0.31 to to --0.040.04)) .015.015

a a Adjusted for group randomization by Head Start site using SAS Adjusted for group randomization by Head Start site using SAS Proc Mixed.Proc Mixed.b b Adjusted for baseline age quartile, baseline BMI, and Head Adjusted for baseline age quartile, baseline BMI, and Head Start site. Start site.


�� In the 12 predominantly AfricanIn the 12 predominantly African--American American preschools, children in the intervention preschools, children in the intervention group showed smaller BMI and BMI Z group showed smaller BMI and BMI Z score increases than children in the score increases than children in the control group at both 1control group at both 1--year and 2year and 2--year year control group at both 1control group at both 1--year and 2year and 2--year year followfollow--up.up.

�� In the 12 predominantly Latino schools, In the 12 predominantly Latino schools, there were no significant differences there were no significant differences between groups in BMI or Z score at between groups in BMI or Z score at followfollow--up.up.

Conclusions (contConclusions (cont ’’’’’’’’d)d)

�� The next step for AfricanThe next step for African--American American children: an effectiveness trial.children: an effectiveness trial.�� Will the intervention be effective when Will the intervention be effective when

delivered by trained classroom teachers delivered by trained classroom teachers instead of interventionists on the study staff?instead of interventionists on the study staff?instead of interventionists on the study staff?instead of interventionists on the study staff?

�� The next step for Latino children: piloting a The next step for Latino children: piloting a program with a parent intervention.program with a parent intervention.�� Is it feasible to add a parent intervention to a Is it feasible to add a parent intervention to a

schoolschool--based program? Does it appear to based program? Does it appear to improve the efficacy of the program?improve the efficacy of the program?

Effectiveness TrialEffectiveness Trial

TeacherTeacher--Delivered Delivered HipHip--Hop to HealthHop to Health

(NHLBI HL081645)(NHLBI HL081645)

�� Randomized controlled trialRandomized controlled trial�� Program taught by classroom teachers in Program taught by classroom teachers in

Chicago Public Schools (CPS) preschoolsChicago Public Schools (CPS) preschools

Study Design and Participant FlowStudy Design and Participant FlowTeacherTeacher--Delivered HipDelivered Hip--Hop to HealthHop to Health

18 CPS Preschools18 CPS Preschools(predominantly African(predominantly African--American,American, 2 classrooms each)2 classrooms each)



Baseline Assessment (N=325)Baseline Assessment (N=325) Baseline Assessment (N=293)Baseline Assessment (N=293)

14 Week Intervention14 Week Intervention 14 Week Control Curriculum14 Week Control Curriculum

PostPost--Intervention AssessmentIntervention Assessment(N=309)(N=309)

PostPost--Intervention AssessmentIntervention Assessment(N=280)(N=280)

OneOne--Year FollowYear Follow--upup(N=285)(N=285)


Changes in Weight Control Changes in Weight Control InterventionIntervention

�� 2 classes per week (+1 optional class)2 classes per week (+1 optional class)

�� Some weekly themes changedSome weekly themes changed

�� CDCD�� CDCD�� Songs about nutrition/exerciseSongs about nutrition/exercise�� 2 complete exercise sessions2 complete exercise sessions


Category BMI Percentile Rangea N (%)

Underweight < 5th percentile 6 (1%)

Normal weight 5th to <85th percentile 405 (66%)Normal weight 5th to <85th percentile 405 (66%)

Overweight 85th to <95th percentile 125 (20%)

Obese ≥ 95th percentile 82 (13%)


Overweight and Obesity in Overweight and Obesity in Parents/Caregivers at Parents/Caregivers at BaselineBaseline

CategoryCategory BMI Range (kg/mBMI Range (kg/m22)) N (%)N (%)

Underweight Underweight < 18.5< 18.5 5 ( 1%)5 ( 1%)

Normal weightNormal weight 18.5 18.5 to <25to <25 89 (22%)89 (22%)Normal weightNormal weight 18.5 18.5 to <25to <25 89 (22%)89 (22%)

Overweight Overweight 25 to <3025 to <30 100 (24%)100 (24%)

Obesity class I Obesity class I 30 to <3530 to <35 85 (21%)85 (21%)

Obesity class II Obesity class II 35 to < 4035 to < 40 60 (15%)60 (15%)

Obesity class IIIObesity class III ≥ 40≥ 40 73 (18%)73 (18%)

AdjustedAdjusted aa Child Child ActivityActivity bb PostPost--intervention intervention ((ActiGraphActiGraph Accelerometer)Accelerometer)

ActivityActivityINTINT


CONCON(N=94)(N=94)MeanMean

Difference,Difference,INTINT--CONCON

Mean (95% CI)Mean (95% CI) pp

MVPA, MVPA, min/daymin/day

109.9 102.5 7.46 (1.41 to 13.51) .02

Moderate, Moderate, 79.0 74.2 4.78 (0.10 to 9.45) .05Moderate, Moderate, min/daymin/day

79.0 74.2 4.78 (0.10 to 9.45) .05

Vigorous, Vigorous, min/daymin/day

31.0 28.2 2.83 (0.36 to 5.29) .03

Counts/minCounts/min 672.6 640.1 32.6 (-1.8 to 66.9) .06

a a Adjusted for baseline value, baseline age (years), school, and classroom.Adjusted for baseline value, baseline age (years), school, and classroom.bb Valid record: worn Valid record: worn ≥ 8 hours/day for for ≥ 4 days. NHANES definition of time worn. NHANES definition of time worn.

MVPA: MVPA: ≥ 420 counts/15 s; vigorous activity: 420 counts/15 s; vigorous activity: ≥ 842 counts/15 s (Pate et al. 842 counts/15 s (Pate et al. Obesity 2006;14:2000Obesity 2006;14:2000--6).6).

AdjustedAdjusted aa Change from Baseline toChange from Baseline to1 Year Post1 Year Post--interventionintervention

ChangeChange INTINTMean (SE)Mean (SE)

CONCONMean (SE)Mean (SE)

INTINT--CONCONMean (SE)Mean (SE) pp

BMI, kg/mBMI, kg/m22 0.30 (0.08)0.30 (0.08) 0.43 (0.08)0.43 (0.08) --0.13 (0.11)0.13 (0.11) .26.26

BMI Z scoreBMI Z score 0.08 (0.04)0.08 (0.04) 0.10 (0.04)0.10 (0.04) --0.01 (0.06)0.01 (0.06) .83.83BMI Z scoreBMI Z score 0.08 (0.04)0.08 (0.04) 0.10 (0.04)0.10 (0.04) --0.01 (0.06)0.01 (0.06) .83.83

TV, hr/dTV, hr/d --0.03 (0.10)0.03 (0.10) --0.21 (0.11)0.21 (0.11) 0.18 (0.15)0.18 (0.15) .23.23

Screen time, Screen time, hr/dhr/d

0.22 (0.16)0.22 (0.16) 0.08 (0.16)0.08 (0.16) 0.14 (0.22)0.14 (0.22) .52.52

Healthy Healthy Eating IndexEating Index

0.63 (1.01)0.63 (1.01) --3.01 (1.11)3.01 (1.11) 3.64 (1.50)3.64 (1.50) .02.02

a From multilevel models with a random intercept and random time trend at student and classroom levels, adjusted for baseline age.

HEI Components: HEI Components: AdjustedAdjusted aa Change from Change from Baseline to 1 Year PostBaseline to 1 Year Post--interventionintervention

ChangeChange INTINTMean (SE)Mean (SE)

CONCONMean (SE)Mean (SE)

INTINT--CONCONMean (SE)Mean (SE) pp

Total fruitTotal fruit --0.16 (0.16)0.16 (0.16) --0.92 (0.18)0.92 (0.18) 0.76 (0.24)0.76 (0.24) .003.003

Whole fruitWhole fruit --0.04 (0.23)0.04 (0.23) --0.91 (0.25)0.91 (0.25) 0.87 (0.34)0.87 (0.34) .02.02

Saturated fatSaturated fat 0.12 (0.34)0.12 (0.34) 0.02 (0.38)0.02 (0.38) 0.11 (0.51)0.11 (0.51) .84.84Saturated fatSaturated fat 0.12 (0.34)0.12 (0.34) 0.02 (0.38)0.02 (0.38) 0.11 (0.51)0.11 (0.51) .84.84

Whole grainWhole grain 0.12 (0.18)0.12 (0.18) 0.78 (0.20)0.78 (0.20) --0.67 (0.27)0.67 (0.27) .02.02

Tot vegetableTot vegetable 0.27 (0.15)0.27 (0.15) --0.09 (0.16)0.09 (0.16) 0.37 (0.22)0.37 (0.22) .11.11

VegVeg: : dkdk green/ green/ orange/legumeorange/legume

0.34 (0.13)0.34 (0.13) 0.01 (0.15)0.01 (0.15) 0.33 (0.20)0.33 (0.20) .11.11

SoFAASSoFAAS 0.93 (0.48)0.93 (0.48) --0.75 (0.53)0.75 (0.53) 1.68 (0.71)1.68 (0.71) .02.02

a From multilevel models with a random intercept and random time trend at student and classroom levels, adjusted for baseline age.


�� There was not a significant difference There was not a significant difference between groups in BMI change or BMI Z between groups in BMI change or BMI Z score change from baseline to 1score change from baseline to 1--year year followfollow--up.up.followfollow--up.up.

�� There were differences between groups in There were differences between groups in secondary outcome measures.secondary outcome measures.�� Healthy Eating Index score change from Healthy Eating Index score change from

baseline to 1baseline to 1--year followyear follow--upup�� Activity postActivity post--intervention (not measured at 1intervention (not measured at 1--

year followyear follow--up)up)

Conclusions (contConclusions (cont ’’’’’’’’d)d)

�� Teacher training required more time and Teacher training required more time and direct supervision than expected.direct supervision than expected.

�� Even after training, classroom teachers Even after training, classroom teachers may not be able to deliver the intervention may not be able to deliver the intervention may not be able to deliver the intervention may not be able to deliver the intervention at the same intensity level as specially at the same intensity level as specially trained childhood educators on the study trained childhood educators on the study staff.staff.

FamilyFamily --Based PilotBased Pilot

Niños FelicesNiños FelicesNiños SanosNiños Sanos

(NCI CA121423)(NCI CA121423)

�� Randomized controlled trial (pilot)Randomized controlled trial (pilot)�� FamilyFamily--based interventionbased intervention�� ChildrenChildren’’s program and parentss program and parents’’ program program

taught by trained bilingual interventionists taught by trained bilingual interventionists on study staffon study staff

Study Design and Participant FlowStudy Design and Participant FlowNiños Felices Niños SanosNiños Felices Niños Sanos

4 CPS Preschools4 CPS Preschools(predominantly Latino,(predominantly Latino, 2 classrooms each)2 classrooms each)



Baseline Interview (N=72)Baseline Interview (N=72) Baseline Interview (N=74)Baseline Interview (N=74)Baseline Interview (N=72)Baseline Interview (N=72) Baseline Interview (N=74)Baseline Interview (N=74)

Children: 14Children: 14--Week InterventionWeek InterventionParents: 6Parents: 6--Week InterventionWeek Intervention

1414--Week Control CurriculumWeek Control CurriculumNo Parent InterventionNo Parent Intervention

PostPost--Intervention InterviewIntervention Interview(N=71)(N=71)

PostPost--Intervention InterviewIntervention Interview(N=72)(N=72)



Cultural ChallengesCultural Challenges

Beliefs about healthy weight for infants are Beliefs about healthy weight for infants are moderated by race/ethnicity, agemoderated by race/ethnicity, age, SES., SES.

Parent InterventionParent Intervention

�� Six weeksSix weeks

�� 90 minutes each week90 minutes each week�� Didactic session (45 minutes)Didactic session (45 minutes)

Exercise session (45 minutes)Exercise session (45 minutes)�� Exercise session (45 minutes)Exercise session (45 minutes)


Category BMI Percentile Rangea N (%)

Underweight < 5th percentile 3 ( 2%)

Normal weight 5th to <85th percentile 76 (52%)

Overweight 85th to <95th percentile 36 (25%)

Obese ≥ 95th percentile 31 (21%)


Overweight and Obesity in Overweight and Obesity in Parents/Caregivers at Parents/Caregivers at BaselineBaseline

CategoryCategory BMI Range (kg/mBMI Range (kg/m22)) N (%)N (%)

Underweight Underweight < 18.5< 18.5 0 ( 0%)0 ( 0%)

Normal weightNormal weight 18.5 18.5 to <25to <25 21 (22%)21 (22%)Normal weightNormal weight 18.5 18.5 to <25to <25 21 (22%)21 (22%)

Overweight Overweight 25 to <3025 to <30 31 (32%)31 (32%)

Obesity class I Obesity class I 30 to <3530 to <35 25 (26%)25 (26%)

Obesity class II Obesity class II 35 to < 4035 to < 40 13 (13%)13 (13%)

Obesity class IIIObesity class III ≥ 40≥ 40 7 (7%)7 (7%)

AdjustedAdjusted aa Child BMI and BMI Z Score Change Child BMI and BMI Z Score Change Year 1Year 1

ChangeChangeINTINT


CONCON(N=67)(N=67)MeanMean

Difference,Difference,INTINT--CONCON(95% CI)(95% CI) pp

BMI change, BMI change, -0.51 -0.68 0.17 (-0.45 to 0.80) .35BMI change, BMI change, kg/mkg/m22

-0.51 -0.68 0.17 (-0.45 to 0.80) .35

BMI Z score BMI Z score changechange

-0.51 -0.54 0.03 (-0.28 to 0.34) .70

a a Adjusted for school and classroom using SAS Adjusted for school and classroom using SAS Proc Mixed.Proc Mixed.


�� This was a pilot, so we did not expect to This was a pilot, so we did not expect to see a statistically significant difference see a statistically significant difference between groups in BMI or BMI Z score. between groups in BMI or BMI Z score.

�� Parent attendance was low.Parent attendance was low.�� Parent attendance was low.Parent attendance was low.�� In earlier focus groups, Latina parents had In earlier focus groups, Latina parents had

expressed interest in a schoolexpressed interest in a school--based based intervention for parents.intervention for parents.

�� Relatively few parents were employed fullRelatively few parents were employed full--time (24%).time (24%).

Longitudinal StudyLongitudinal Study

Chicago Family Chicago Family Food SurveyFood Survey

(NCI CA149400)(NCI CA149400)

�� Longitudinal studyLongitudinal study

�� WIC participants assessed before and WIC participants assessed before and after changes in the WIC food package after changes in the WIC food package

Study Design and Participant FlowStudy Design and Participant FlowChicago Family Food SurveyChicago Family Food Survey

100 did not participate in 100 did not participate in longitudinal studylongitudinal study

12 WIC clinics and food centers12 WIC clinics and food centers

CrossCross--sectional study (N=398 dyads)sectional study (N=398 dyads)

New WIC food package introducedNew WIC food package introduced longitudinal studylongitudinal studyNo permission for contact: 9No permission for contact: 9Refused: 12Refused: 12Unable to contact: 35Unable to contact: 35Passive refusal: 44Passive refusal: 44

New WIC food package introducedNew WIC food package introducedLongitudinal study begins (N=298)Longitudinal study begins (N=298)

66--Month Interview (N=295)Month Interview (N=295)



MeasuresMeasures�� Parent and child demographicsParent and child demographics�� Home and car ownership/availabilityHome and car ownership/availability�� Household compositionHousehold composition�� Acculturation, language, birthplaceAcculturation, language, birthplace�� History of breastfeedingHistory of breastfeeding�� History of breastfeedingHistory of breastfeeding�� Child height and weightChild height and weight�� Food security (USDA short form)Food security (USDA short form)�� Home food availability in last weekHome food availability in last week

�� Fruits and vegetablesFruits and vegetables�� Dairy and grainsDairy and grains

Measures (contMeasures (cont ’’’’’’’’d)d)�� 2424--hour diet recallhour diet recall�� Food stamps/SNAP in last 6 monthsFood stamps/SNAP in last 6 months�� Child Feeding Questionnaire (Birch)Child Feeding Questionnaire (Birch)�� Child eating practicesChild eating practices

�� Eating while watching TV, at regular timeEating while watching TV, at regular time, etc., etc.�� Child careChild care�� Child careChild care

�� Preschool, relatives in other householdsPreschool, relatives in other households�� Food stores where usually shopFood stores where usually shop

�� Perception of food availability/costPerception of food availability/cost�� Food preferences: fruits and vegetablesFood preferences: fruits and vegetables�� Nutrition knowledgeNutrition knowledge�� Perceived Stress Scale (short form)Perceived Stress Scale (short form)

Child Overweight and Obesity at BaselineChild Overweight and Obesity at Baseline

BMI Percentile Rangea

AAb

N=136Hisp b

N=139

Underweight < 5th 5% 3%

Normal weight 5th to <85th 63% 58%

Overweight 85th to <95th 15% 18%

Obese ≥ 95th 17% 22%


b Parent’s race

Change in Child BMI and BMI Z Score at Change in Child BMI and BMI Z Score at 6 Months6 Months

Baseline 6 months

Mean (SD) Mean (SD) pa

AA (n=125)

BMI, kg/m2 16.9 (1.7) 16.7 (1.8) .15BMI, kg/m2 16.9 (1.7) 16.7 (1.8) .15

BMI Z score 0.46 (1.29) 0.55 (1.33) .34

Hispanic (n=128)

BMI, kg/m2 17.4 (2.2) 17.2 (2.3) .13

BMI Z score 0.77 (1.23) 0.85 (1.26) .34

a From paired t-test.

Change in Food Security at 6 MonthsChange in Food Security at 6 Months

Baseline 6 months pa

AA (n=127) <.001

High or marginal 58% 78%

Low 30% 16%

Very low 12% 6%Very low 12% 6%

Hispanic (n=135) .44

High or marginal 44% 51%

Low 43% 34%

Very low 13% 15%

a From Mantel-Haenszel test.

Change in Home Food Availability Change in Home Food Availability at 6 Months: Hispanic Dyadsat 6 Months: Hispanic Dyads

Mean (SD) Mean (SD) or N (%)or N (%)

BaselineBaseline 6 Months6 Months ChangeChange ppaa

FruitsFruits 12.4 (4.0)12.4 (4.0) 11.9 (3.8)11.9 (3.8) --0.57 (3.68)0.57 (3.68) .07.07

Fruit juicesFruit juices 2.6 (0.9)2.6 (0.9) 2.5 (1.1)2.5 (1.1) --0.07 (1.16)0.07 (1.16) .47.47

VegetablesVegetables 14.9 (4.3)14.9 (4.3) 15.4 (3.9)15.4 (3.9) 0.43 (3.38)0.43 (3.38) .13.13

Whole grainWhole grain 1.9 (0.7)1.9 (0.7) 2.2 (0.7)2.2 (0.7) 0.29 (0.93)0.29 (0.93) <.001<.001

Milk, 2%, Milk, 2%, 1%, nonfat1%, nonfat

100 (70%)100 (70%) 132 (92%)132 (92%) 32 (22%)32 (22%) <.001<.001

Milk, wholeMilk, whole 65 (45%)65 (45%) 27 (19%)27 (19%) --38 (38 (--27%)27%) <.001<.001

a From McNemar’s test for milk and paired t-tests for other variables. N=143.Questionnaire listed 25 fruits, 4 juices, 25 vegetables, 3 whole-grain items.

Change in Home Food Availability Change in Home Food Availability at 6 Months: Africanat 6 Months: African --American DyadsAmerican Dyads

Mean (SD) Mean (SD) or N (%)or N (%)

BaselineBaseline 6 Months6 Months ChangeChange ppaa

FruitsFruits 8.6 (4.2)8.6 (4.2) 9.2 (3.9)9.2 (3.9) 0.58 (3.54)0.58 (3.54) .06.06

Fruit juicesFruit juices 2.3 (1.0)2.3 (1.0) 2.7 (1.0)2.7 (1.0) 0.38 (1.12)0.38 (1.12) <.001<.001

VegetablesVegetables 11.5 (4.5)11.5 (4.5) 12.9 (4.2)12.9 (4.2) 1.36 (3.62)1.36 (3.62) <.001<.001

Whole grainWhole grain 1.5 (0.9)1.5 (0.9) 1.9 (0.9)1.9 (0.9) 0.48 (0.98)0.48 (0.98) <.001<.001

Milk, 2%, Milk, 2%, 1%, nonfat1%, nonfat

64 (49%)64 (49%) 101 (78%)101 (78%) 37 (28%)37 (28%) <.001<.001

Milk, wholeMilk, whole 83 (64%)83 (64%) 54 (42%)54 (42%) --29 (29 (--22%)22%) <.001<.001

a From McNemar’s test for milk and paired t-tests for other variables. N=143.Questionnaire listed 25 fruits, 4 juices, 25 vegetables, 3 whole-grain items.

Change in Diet at 6 MonthsChange in Diet at 6 MonthsHispanicHispanic AfricanAfrican--AmericanAmerican

ChangeChange ppaa ChangeChange ppaa

MothersMothers N=132N=132 N=121N=121

Energy, kcalEnergy, kcal -9.43 (744) .88 -23.0 (978) .80

Fat, % kcalFat, % kcal -1.86 (11.43) .06 0.24 (12.02) .83

SFA, % kcalSFA, % kcal -0.95 (5.11) .03 0.35 (5.77) .51SFA, % kcalSFA, % kcal

Fiber, g/1000 kcalFiber, g/1000 kcal 0.57 (6.25) .30 0.25 (4.01) .49

ChildrenChildren N=121N=121 N=90N=90

Energy, kcalEnergy, kcal 90 (552) .07 174 (585) .006

Fat, % kcalFat, % kcal -1.44 (10.89) .15 0.88 (10.01) .40

SFA, % kcalSFA, % kcal -1.18 (4.99) .01 -0.41 (4.44) .39

Fiber, g/1000 kcalFiber, g/1000 kcal 1.00 (5.58) .05 0.12 (3.19) .72

a From paired t-tests. Mean (SD).

Change in Diet at 18 MonthsChange in Diet at 18 MonthsHispanicHispanic AfricanAfrican--AmericanAmerican

Change (%)Change (%) ppaa Change (%)Change (%) ppaa

MothersMothers N=109N=109 N=83N=83

Energy, kcalEnergy, kcal -1.2% .76 -6.7% .21

Fat, % kcalFat, % kcal -4.3% .24 -3.0% .38

SFA, % kcalSFA, % kcal -9.0% .05 -5.1% .22

Fiber, g/1000 kcalFiber, g/1000 kcal 12.9% .10 7.4% .22

ChildrenChildren N=89N=89 N=64N=64

Energy, kcalEnergy, kcal 14.9% .004 20.9% .003

Fat, % kcalFat, % kcal -10.5% .002 5.0% .27

SFA, % kcalSFA, % kcal -15.3% <.001 -3.6% .55

Fiber, g/1000 kcalFiber, g/1000 kcal 17.1% .03 5.7% .38

a From GEE, controlling for age at 18 mon, gender (children), voucher amount, SNAP, BMI at 18 mon, acculturation (Hispanics).

Change in Diet Quality at 18 MonthsChange in Diet Quality at 18 MonthsHealthy Eating IndexHealthy Eating Index --2005 Score2005 Score

BaselineBaseline 18 Months18 MonthsChange Change

(%)(%)ppaa

MothersMothers

HispanicHispanic 57.3 (1.3)57.3 (1.3) 58.1 (1.5)58.1 (1.5) 1.4%1.4% .62.62

AAAA 43.7 (1.3)43.7 (1.3) 46.2 (1.3)46.2 (1.3) 5.8%5.8% .13.13

ChildrenChildren

HispanicHispanic 55.6 (1.9)55.6 (1.9) 59.6 (1.9)59.6 (1.9) 7.2%7.2% .02.02

AAAA 51.8 (1.8)51.8 (1.8) 53.6 (1.8)53.6 (1.8) 3.5%3.5% .32.32

a From GEE, controlling for age at 18 mon, gender (children), voucher amount, SNAP, BMI at 18 mon, acculturation (Hispanics).

Food Group Intake Before and 18 Months After Food Food Group Intake Before and 18 Months After Food Package RevisionsPackage Revisions

Odoms-Young AM, et al. Public Health Nutrition. 2014;17(1):83–93.

Conclusions: Changes at 6 MonthsConclusions: Changes at 6 Months

�� Children’s BMI and BMI Z scoreChildren’s BMI and BMI Z score

�� No significant changes at the 6No significant changes at the 6--month visit.month visit.

�� Food securityFood security

�� AfricanAfrican--Americans: higher food security Americans: higher food security �� AfricanAfrican--Americans: higher food security Americans: higher food security reported at the 6reported at the 6--month visit.month visit.

�� Hispanics: no significant change.Hispanics: no significant change.

Conclusions: Changes at 6 Months: Conclusions: Changes at 6 Months: Home Food AvailabilityHome Food Availability

�� Fruits and vegetablesFruits and vegetables�� AfricanAfrican--Americans reported more fruit juices and Americans reported more fruit juices and

vegetables at 6 months. No significant change in vegetables at 6 months. No significant change in number of fruits.number of fruits.

�� Hispanics reported no significant change at 6 monthsHispanics reported no significant change at 6 months�� Hispanics reported no significant change at 6 monthsHispanics reported no significant change at 6 months

�� WholeWhole--grain itemsgrain items�� Both groups reported more wholeBoth groups reported more whole--grain items at 6 grain items at 6

months.months.

�� MilkMilk�� Both groups were more likely to have lowBoth groups were more likely to have low--fat milk and fat milk and

less likely to have highless likely to have high--fat milk in the home at 6 fat milk in the home at 6 months.months.

Conclusions: Changes at 6 Months: Conclusions: Changes at 6 Months: Nutrient IntakeNutrient Intake

�� Hispanic childrenHispanic children�� Less saturated fat (% kcal)Less saturated fat (% kcal)�� More fiberMore fiber

�� AfricanAfrican--American childrenAmerican children�� Higher energy intakeHigher energy intake

�� Hispanic mothersHispanic mothers�� Less saturated fat (% kcal)Less saturated fat (% kcal)

�� AfricanAfrican--American mothersAmerican mothers�� No significant changes in energy or nutrient intakeNo significant changes in energy or nutrient intake

Conclusions: Changes at 18 Months: Conclusions: Changes at 18 Months: Nutrient Intake and Diet QualityNutrient Intake and Diet Quality

�� Hispanic childrenHispanic children�� Higher energy intakeHigher energy intake�� Less fat and saturated fat (% kcal)Less fat and saturated fat (% kcal)�� More fiberMore fiber�� Higher HEIHigher HEI--2005 score2005 score�� Higher HEIHigher HEI--2005 score2005 score

�� AfricanAfrican--American childrenAmerican children�� Higher energy intakeHigher energy intake

�� Mothers (Hispanic and AfricanMothers (Hispanic and African--American)American)�� No significant changesNo significant changes

Conclusions: Changes at 18 Months: Conclusions: Changes at 18 Months: Food Group IntakeFood Group Intake

�� Whole milkWhole milk�� All groups were less likely to drink whole milk at 18 months All groups were less likely to drink whole milk at 18 months

(Hispanic and African(Hispanic and African--American mothers and children).American mothers and children).

�� ReducedReduced--fat milkfat milk�� Children were more likely to drink reducedChildren were more likely to drink reduced--fat milk at 18 fat milk at 18 �� Children were more likely to drink reducedChildren were more likely to drink reduced--fat milk at 18 fat milk at 18

months. The change was not significant for mothers.months. The change was not significant for mothers.

�� Fruit juice and sweetened beveragesFruit juice and sweetened beverages�� Hispanic mothers were less likely to drink fruit juice.Hispanic mothers were less likely to drink fruit juice.

�� AfricanAfrican--American children were more likely to drink sugarAmerican children were more likely to drink sugar--sweetened beverages.sweetened beverages.

�� Fruit, vegetables, whole grainsFruit, vegetables, whole grains�� No significant changesNo significant changes

Family EATS Pilot StudyFamily EATS Pilot Study�� Rationale: Rationale: Participation in family meals may be Participation in family meals may be

beneficial, but quality of family mealtime interactions beneficial, but quality of family mealtime interactions likely likely moderates effect.moderates effect.

�� Primary purpose: Primary purpose: To assess family interactions during To assess family interactions during mealtimes among a sample of 30 lowmealtimes among a sample of 30 low--income Hispanic, income Hispanic, African American, and nonAfrican American, and non--Hispanic White families with Hispanic White families with a preschool a preschool aged child.aged child.

�� Aim 1. Aim 1. To examine the relationships between mealtime To examine the relationships between mealtime behaviors, race/ethnicity, and behaviors, race/ethnicity, and child BMI.child BMI.

�� Aim 2. Aim 2. To assess family factors (perceived stress, To assess family factors (perceived stress, financial strain, chaos, mealtime climate, food financial strain, chaos, mealtime climate, food insecurity, parental feeding style, television viewing, insecurity, parental feeding style, television viewing, child food preferences, dietary intake) that influence child food preferences, dietary intake) that influence mealtime behaviors.mealtime behaviors.

Family 1Family 1

Parents are at the table. High engagement, lots of conversation.

Family 2Family 2

Mother is on the phone in the next room. The oldest child controls the table.

Mealtime Interactions: ABC Mealtime Mealtime Interactions: ABC Mealtime Coding Coding

Behaviors Definition Examples

Action Behaviors that take someone physically away from the meal

•Answer the door/phone•Play with something nearby•Use the bathroom

Behavior Control Directed at modifying (e.g. stopping or directing) others’ behavior

•“Get your elbows off the table”•Please use your indoor voice”•“Move over”•“Put this back on the stove”•“Put this back on the stove”

Mealtime Communication

All non-behavior-control exchanges pertaining to the meal

•Discussion about food served•Discussion of mealtime chores•“Please pass the …..”

InterpersonalCommunication

Aimed at giving or receiving information to or from others

•Friendly joking•Discussions about feelings or beliefs/interests separate from meal served

Critical Communication

Critical statements in response to another’s behavior

•“You’re annoying”•“You always forget to put your dishes away”

Demographics, Mothers and ChildrenDemographics, Mothers and ChildrenHispanic

N=10AA

N=10WhiteN=10

MothersAge, yr 33.7 (6.7) 35.6 (8.3) 32.5 (6.0)Education, yr 9.7 (2.2) 12.9 (1.9) 14.0 (1.5)HS grad 4 (40%) 9 (90%) 10 (100%)Income (median) 15,000 15,000 30,000Income (median) 15,000 15,000 30,000Married/live w. partner 9 (90%) 3 (30%) 6 (60%)Works full-time 0 (0%) 2 (20%) 2 (20%)SNAP, last 6 mo 0 (0%) 8 (80%) 6 (60%)Acculturationa 1.0 (0.1) -- --ChildrenFemale 5 (50%) 4 (40%) 6 (60%)Age, mo 53.4 (3.0) 55.5 (3.3) 53.9 (2.5)

Mean (SD) or N (%). aMarin scale: 1=least acculturated, 5=most acculturated.

Body Mass Index, Parents and ChildrenBody Mass Index, Parents and Children

Hispanic AA WhiteParentsa N=9 N=9 N=9BMI, kg/m2 30.9 (6.0) 33.6 (7.1) 31.3 (8.5)

Overweight 4 (44%) 3 (33%) 3 (33%)Obese 4 (44%) 5 (56%) 4 (44%)

Childrenb N=10 N=9 N=10BMI, kg/m2 16.9 (1.7) 18.0 (2.8) 17.7 (3.4)

Overweight 2 (20%) 1 (11%) 2 (20%)Obese 1 (10%) 4 (44%) 3 (30%)

Mean (SD) or N (%).a Overweight = 25-<30 kg/m2; obese = ≥ 30 kg/m2.b Overweight = 85th-<95th percentile; obese = ≥ 95th percentile.

Mealtime Interactions by Mealtime Interactions by Race/Ethnicity Race/Ethnicity

2.4%

4.9%

20.1%

10.8%

15.3%

22.5%15.9%

25.2%

0.08% 0.29% 0.64%

60%

70%

80%

90%

100%Critical Communication

Interpersonal Communication

Meal Time Communication

Behavioral Control*

40.9%

65.4%

52.0%

6.5%4.9%

0%

10%

20%

30%

40%

50%

Hispanic (n=10) AA (n=9) White (n=10)

Control*

Action

*p value=.0019Hispanic vs. AA

*p value=.0043 AA vs. NHW

5.0%

3.7% 5.3%4.8%

13.9%

11.0% 12.8%14.6%

25.3%17.7% 17.2%

27.4%

0.2% 0.2% 0.2% 0.1%

60%

70%

80%

90%

100%

Critical Communication Interpersonal Communication

Meal Time

Mealtime Interactions by BMI Status

49.5%53.1% 49.5% 52.3%

5.0% 4.8%

0%

10%

20%

30%

40%

50%

Parent BMI <30

Parent BMI >=30

Child BMI <85th%ile

Child BMI >=85th%ile

Meal Time Communication

Behavioral Control

Action

Retaining Traditionally Hard to Retaining Traditionally Hard to Reach Participants: Reach Participants:

Lessons LearnedLessons Learned

Importance of RetentionImportance of Retention

�� High attrition can lead to introduction of High attrition can lead to introduction of bias and bias and decreased generalizability.decreased generalizability.

�� Attrition is a significant problem in lowAttrition is a significant problem in low--income and income and minority populations.minority populations.income and income and minority populations.minority populations.�� Transportation challengesTransportation challenges�� Transient living situationsTransient living situations�� Distrust of researchDistrust of research�� Inconsistent contact informationInconsistent contact information�� Language barriersLanguage barriers

RetentionRetention�� Efficacy trialEfficacy trial (N=409)

�� PostPost--intervention (14 weeks): 89%intervention (14 weeks): 89%�� 12 months: 71%12 months: 71%�� 24 months: 73%24 months: 73%

�� Effectiveness trial (N=618)Effectiveness trial (N=618)�� Effectiveness trial (N=618)Effectiveness trial (N=618)�� PostPost--intervention (14 weeks): 95%intervention (14 weeks): 95%�� 12 months: 88%12 months: 88%

�� Chicago Family Food Chicago Family Food SurveySurveyaa (N=298)(N=298)�� 12 months: 91%12 months: 91%�� 18 months: 89%18 months: 89%

a The longitudinal study began with the 6-month visit.

Key Retention Strategies: Key Retention Strategies: Efficacy TrialEfficacy Trial

�� Collaboration with a communityCollaboration with a community--based based organization (Head Start)organization (Head Start)

�� Continuity of data collection locations Continuity of data collection locations �� Continuity of data collection locations Continuity of data collection locations (preschools)(preschools)

�� Collection of detailed contact informationCollection of detailed contact information

�� Provision of monetary compensationProvision of monetary compensation

�� Detailed participant tracking/search Detailed participant tracking/search protocolprotocol

Additional Retention Strategies: Additional Retention Strategies: Effectiveness TrialEffectiveness Trial

�� Staff continuityStaff continuity�� Ensured that data collectors could be consistently Ensured that data collectors could be consistently

available during preschool hoursavailable during preschool hours�� Used small, consistent data collection teamsUsed small, consistent data collection teams�� Used small, consistent data collection teamsUsed small, consistent data collection teams�� Hired staff who could commit to staying with the Hired staff who could commit to staying with the

study through followstudy through follow--up data collectionup data collection

�� Benefits of staff continuityBenefits of staff continuity�� Allowed longAllowed long--term relationshipterm relationship--building between building between

staff and participants, leading to greater truststaff and participants, leading to greater trust�� Improved retention of detailed information about Improved retention of detailed information about

hardhard--toto--reach familiesreach families

Additional Retention Strategies: Additional Retention Strategies: Effectiveness Trial (cont’d)Effectiveness Trial (cont’d)

�� Strategic hiring of data collection staffStrategic hiring of data collection staff�� Prioritized experience in communityPrioritized experience in community--based based

social service positionssocial service positions�� Created fullCreated full--time, longertime, longer--term jobs with term jobs with

benefits to encourage retention and give data benefits to encourage retention and give data collectors a multicollectors a multi--faceted understanding of the faceted understanding of the studystudy

�� Weekly allWeekly all--staff meetings to encourage staff meetings to encourage problemproblem--solvingsolving

Additional Retention Strategies: Additional Retention Strategies: CFFS (WIC)CFFS (WIC)

�� InIn--home data collection protocol for followhome data collection protocol for follow--up visitsup visits�� WIC sites not daily destinations, unlike WIC sites not daily destinations, unlike WIC sites not daily destinations, unlike WIC sites not daily destinations, unlike

preschoolspreschools�� Home visit offered in initial scheduling callHome visit offered in initial scheduling call�� Only home visit offered to participant who Only home visit offered to participant who

missed scheduled WIC site visitmissed scheduled WIC site visit

�� Increased focus on staff diversity trainingIncreased focus on staff diversity training


�� It is important to plan for successful It is important to plan for successful retention from retention from the start.the start.�� Staffing needs and participant incentives Staffing needs and participant incentives

should be considered when developing the should be considered when developing the should be considered when developing the should be considered when developing the grant proposal.grant proposal.

�� Retention strategies will vary depending Retention strategies will vary depending on the setting, population, and on the setting, population, and study study design.design.

Future DirectionsFuture Directions

HipHip--Hop at HomeHop at Home

�� Randomized controlled trial Randomized controlled trial

�� FamilyFamily--based interventionbased intervention�� FamilyFamily--based interventionbased intervention

�� Professionally developed app for teachers Professionally developed app for teachers and parents/children and parents/children

Summary Summary

�� Weight control programs for young children Weight control programs for young children need to involve parents.need to involve parents.�� Many parents are unable or unwilling to Many parents are unable or unwilling to

participate in classes held in school during the participate in classes held in school during the school day.school day.school day.school day.

�� We must continue to understand more about We must continue to understand more about the context in which people make daythe context in which people make day--toto--day day lifestyle decisions.lifestyle decisions.

�� Healthy eating and physical activity must be Healthy eating and physical activity must be easily integrated into everyday life. easily integrated into everyday life.

AcknowledgmentsAcknowledgments�� ORBIT participantsORBIT participants

�� Teachers, principals, parents, and children Teachers, principals, parents, and children who participated in our preschoolwho participated in our preschool--based based obesity prevention studiesobesity prevention studies

�� CFFS participants and WIC center CFFS participants and WIC center �� CFFS participants and WIC center CFFS participants and WIC center personnelpersonnel

�� Chicago Public SchoolsChicago Public Schools

�� Catholic CharitiesCatholic Charities

�� NCI and NHLBINCI and NHLBI

�� Kraft FoodsKraft Foods

Acknowledgments (contAcknowledgments (cont ’’’’’’’’d)d)

�� Cheryl BittnerCheryl Bittner

�� Lara BlumsteinLara Blumstein

�� Maria Maria CáceresCáceres

�� Christine Christine RanieriRanieri

�� Leo RestrepoLeo Restrepo

�� Aida RodriguezAida Rodriguez

�� Lupe CompeanLupe Compean

�� Sandra GomezSandra Gomez

�� Sylvia Sylvia MurallesMuralles

�� Kathryn O’Kathryn O’MalleyMalley

�� Linda SchifferLinda Schiffer

�� Sarah Ford Sarah Ford ThompsonThompson

�� Yolanda VegaYolanda Vega

The solution of adult problems The solution of adult problems tomorrow depends in large tomorrow depends in large measure upon the way our measure upon the way our children grow children grow up today. up today. There is There is no greater insight into the future no greater insight into the future no greater insight into the future no greater insight into the future than recognizing that, when we than recognizing that, when we save children, we save children, we save save ourselves. ourselves.

Margaret MeadMargaret Mead

Thank You!Thank You!Thank You!Thank You!

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