Alexandra K. Adams

Dietary Intakes and Physical Activity among Preschool-Aged Children Living in Rural American Indian Communities before a Family-Based Healthy Lifestyle Intervention

OBJECTIVE To report dietary intake and physical activity among preschool-aged children living in rural American Indian communities before participation in a family-based healthy lifestyle intervention and to compare data to current age-specific recommendations. SUBJECTS/DESIGN One hundred thirty-five preschool-aged children, living in rural American Indian communities, provided diet and physical activity data before participating in a 2-year randomized healthy lifestyle intervention. Three 24-hour dietary recalls assessed nutrient and food and added sugar intake, which were compared to the National Academy of Sciences Dietary Reference Intakes, the US Department of Agricultures MyPyramid, and American Heart Association recommendations. Time watching television and moderate plus vigorous activity was compared to MyPyramid and American Academy of Pediatrics recommendations. STATISTICAL ANALYSIS Nutrient, food group, added sugar intake, and time watching television and in moderate or vigorous activity were compared to recommendations by computing the percent of recommendations met. Nonparametric tests identified differences in diet and physical activity among age groups and normal and overweight children (body mass index <85th and > or = 85th percentile). RESULTS Average nutrient intakes met recommendations whereas food group intakes did not. Mean fruit and vegetable intakes for 2- to 3-year-olds were 0.36 c/day fruit and 0.45 c/day vegetables and, for 4- to 5-year-olds, 0.33 c/day fruit and 0.48 c/day vegetables. Both age groups reported consuming more than 50 g added sugar, exceeding the recommendation of 16 g. Overweight vs normal weight children reported significantly more sweetened beverage intake (8.0+/-0.10 vs 5.28+/-0.08 oz/day, P<0.01). On average, all children reported watching television 2.0 hours/day and significant differences were observed for total television viewing and nonviewing time between overweight and normal weight children (8.52+/-0.6 vs 6.54+/-0.6 hours/day, P<0.01). All children engaged in <20 minutes/day of moderate or vigorous activity. CONCLUSIONS Overall, children in this sample did not meet MyPyramid recommendations for fruits or vegetables and exceed added sugar intake recommendations. Television viewing time and time when the television was on in the home was highly prevalent along with low levels of moderate or vigorous activity. The Healthy Children Strong Families intervention we studied has potential for improving nutrition and physical activity among preschool-aged children living in rural American Indian communities.

Constructs of Health and Environment Inform Child Obesity Prevention in American Indian Communities

Objective: Obesity prevention efforts have had limited success in American Indian (AI) populations. More effective prevention programs might be designed using insights into linkages between parental health beliefs, environmental constraints and healthy lifestyle choices.

Impact of exercise and dietary fatty acid composition from a high-fat diet on markers of hunger and satiety.

To compare the effects of both dietary fatty acid composition and exercise vs. sedentary conditions on circulating levels of hunger and satiety hormones. Eight healthy males were randomized in a 2 × 2 crossover design. The four treatments were 3 days of HF diets (50% of energy) containing high saturated fat (22% of energy) with exercise (SE) or sedentary (SS) conditions, and high monounsaturated fat (30% of energy) with exercise (UE) or sedentary (US) conditions. Cycling exercise was completed at 45% of VO(2)max for 2h daily. On the third HF day, 20 blood samples were drawn over a 24h period for each hormone (leptin, insulin, ghrelin, and peptide YY (PYY)). A visual analog scale (VAS) was completed hourly between 0800 and 2200. Average 24h leptin and insulin levels were lower while 24h PYY was higher during exercise vs. sedentary conditions. FA composition did not differentially affect 24h hormone values. VAS scores for hunger and fullness did not differ between any treatment but did correlate with ghrelin, leptin, and insulin. High saturated or unsaturated fat diets did not differ with respect to markers of hunger or satiety. Exercise decreased 24h leptin and insulin while increasing PYY regardless of FA composition.

Familial and individual predictors of obesity and insulin resistance in urban Hispanic children

High intake of sugar‐sweetened beverages (SSB) has been suggested to contribute to the pediatric obesity epidemic, however, how the home food environment influence childrens intake of SSB among Hispanic families is still poorly understood.

Effects of dietary fatty acid composition on 24-h energy expenditure and chronic disease risk factors in men

BACKGROUND A high-fat (HF) diet and sedentary lifestyle are implicated in the development of obesity. Controlled feeding studies and measures of short-term resting energy expenditure (REE) have suggested that the type of dietary fat may alter energy expenditure (EE). OBJECTIVE The objective was to examine the effects of an HF diet rich in either monounsaturated or saturated fatty acids (FAs) and of exercise on EE and chronic disease risk factors. DESIGN Eight healthy men [age: 18-45 y; body mass index (in kg/m(2)): 22 +/- 3] were randomly assigned in a 2 x 2 crossover design to 1 of 4 treatments: HF diet (50% of energy) with a high amount of saturated fat (22% of energy) plus exercise (SE) or a sedentary (SS) condition or a diet high in monounsaturated fat (30% of energy) plus exercise (UE) or a sedentary (US) condition. The subjects spent 5 d in a metabolic chamber and cycled at 45% of maximal oxygen uptake for 2 h each day during the exercise visits. Respiratory gases and urinary nitrogen were measured to determine 24-h EE. Resting metabolic rate was measured on days 2, 4, and 6. RESULTS Average 24-h EE was not different with respect to dietary FA composition (3202 +/- 146, 3208 +/- 151, 2240 +/- 82, and 2270 +/- 104 for SE, UE, SS, and US, respectively). Total and LDL cholesterol and blood pressure were significantly greater after the SE and SS treatments than after the UE and US treatments. CONCLUSION Resting metabolic rate and 24-h EE were not significantly different after short-term exposure to an HF diet rich in monounsaturated FAs or after exposure to a diet rich in saturated FAs in healthy, nonobese men.

Correlates of physical activity in young American Indian children: lessons learned from the Wisconsin Nutrition and Growth Study.

BACKGROUND Obesity is a serious and growing health problem in American Indian (AI) children. Our study, the Wisconsin Nutrition and Growth Study, aimed to understand the prevalence and contributing factors to pediatric obesity in Wisconsin tribes and provide the foundation for intervention design. OBJECTIVE This article focuses on associations among age, gender, and 3 measures of weight status with proxy-reported physical activity and TV/screen time in 3 to 8 year-old AI children. DESIGN/METHODS In a cross-sectional design, 581 AI children (49.1% female, aged 3-8 years) participated in health screenings that included height, weight, waist circumference, percent body fat, and a caregiver survey on demographics and health, with questions on physical activity and TV/screen time. RESULTS Forty-five percent of children were overweight or obese. Boys were significantly more obese and had higher levels of body fat than girls. There were no differences in weight category across age groups. Boys participated in significantly more weekly sports than girls and sports participation was somewhat higher in younger children. Body mass index and waist circumference were not significantly correlated with TV/screen time or with the 3 activity measures (sports participation, outdoor play time, or physical education classes). Hours of outdoor play significantly predicted child body fat percentage controlling for maternal body mass index and child age and gender. CONCLUSIONS Young AI children in Wisconsin have high rates of overweight/obesity starting at a very early age, and outdoor play may play a significant role in mediating body fat. There is a need to develop obesity-prevention interventions at early ages.

The Healthy Children, Strong Families intervention promotes improvements in nutrition, activity and body weight in American Indian families with young children

Objective American Indian children of pre-school age have disproportionally high obesity rates and consequent risk for related diseases. Healthy Children, Strong Families was a family-based randomized trial assessing the efficacy of an obesity prevention toolkit delivered by a mentor v. mailed delivery that was designed and administered using community-based participatory research approaches. Design During Year 1, twelve healthy behaviour toolkit lessons were delivered by either a community-based home mentor or monthly mailings. Primary outcomes were child BMI percentile, child BMI Z-score and adult BMI. Secondary outcomes included fruit/vegetable consumption, sugar consumption, television watching, physical activity, adult health-related self-efficacy and perceived health status. During a maintenance year, home-mentored families had access to monthly support groups and all families received monthly newsletters. Setting Family homes in four tribal communities, Wisconsin, USA. Subjects Adult and child (2–5-year-olds) dyads (n 150). Results No significant effect of the mentored v. mailed intervention delivery was found; however, significant improvements were noted in both groups exposed to the toolkit. Obese child participants showed a reduction in BMI percentile at Year 1 that continued through Year 2 (P<0·05); no change in adult BMI was observed. Child fruit/vegetable consumption increased (P=0·006) and mean television watching decreased for children (P=0·05) and adults (P=0·002). Reported adult self-efficacy for health-related behaviour changes (P=0·006) and quality of life increased (P=0·02). Conclusions Although no effect of delivery method was demonstrated, toolkit exposure positively affected adult and child health. The intervention was well received by community partners; a more comprehensive intervention is currently underway based on these findings.

Community-Responsive Interventions to Reduce Cardiovascular Risk in American Indians

American Indian and Alaska Native (AI/AN) populations bear a heavy burden of cardiovascular disease (CVD), and they have the highest rates of risk factors for CVD, such as cigarette smoking, obesity, and diabetes, of any U.S. population group. Yet, few randomized controlled trials have been launched to test potential preventive interventions in Indian Country. Five randomized controlled trials were initiated recently in AI/AN communities to test the effectiveness of interventions targeting adults and/or children to promote healthy behaviors that are known to impact biological CVD risk factors. This article provides a context for and an overview of these five trials. The high burden of CVD among AI/AN populations will worsen unless behaviors and lifestyles affecting CVD risk can be modified. These five trials, if successful, represent a starting point in addressing these significant health disparities.

Healthy Children, Strong Families 2: A randomized controlled trial of a healthy lifestyle intervention for American Indian families designed using community-based approaches:

Background/Aims Few obesity prevention trials have focused on young children and their families in the home environment, particularly in underserved communities. Healthy Children, Strong Families 2 is a randomized controlled trial of a healthy lifestyle intervention for American Indian children and their families, a group at very high risk of obesity. The study design resulted from our long-standing engagement with American Indian communities, and few collaborations of this type resulting in the development and implementation of a randomized clinical trial have been described. Methods Healthy Children, Strong Families 2 is a lifestyle intervention targeting increased fruit and vegetable intake, decreased sugar intake, increased physical activity, decreased TV/screen time, and two less-studied risk factors: stress and sleep. Families with young children from five American Indian communities nationwide were randomly assigned to a healthy lifestyle intervention (Wellness Journey) augmented with social support (Facebook and text messaging) or a child safety control group (Safety Journey) for 1 year. After Year 1, families in the Safety Journey receive the Wellness Journey, and families in the Wellness Journey start the Safety Journey with continued wellness-focused social support based on communities’ request that all families receive the intervention. Primary (adult body mass index and child body mass index z-score) and secondary (health behaviors) outcomes are assessed after Year 1 with additional analyses planned after Year 2. Results To date, 450 adult/child dyads have been enrolled (100% target enrollment). Statistical analyses await trial completion in 2017. Lessons learned Conducting a community-partnered randomized controlled trial requires significant formative work, relationship building, and ongoing flexibility. At the communities’ request, the study involved minimal exclusion criteria, focused on wellness rather than obesity, and included an active control group and a design allowing all families to receive the intervention. This collective effort took additional time but was critical to secure community engagement. Hiring and retaining qualified local site coordinators was a challenge but was strongly related to successful recruitment and retention of study families. Local infrastructure has also been critical to project success. Other challenges included geographic dispersion of study communities and providing appropriate incentives to retain families in a 2-year study. Conclusion This multisite intervention addresses key gaps regarding family/home-based approaches for obesity prevention in American Indian communities. Healthy Children, Strong Families 2’s innovative aspects include substantial community input, inclusion of both traditional (diet/activity) and less-studied obesity risk factors (stress/sleep), measurement of both adult and child outcomes, social networking support for geographically dispersed households, and a community selected active control group. Our data will address a literature gap regarding multiple risk factors and their relationship to health outcomes in American Indian families.

Understanding community and family barriers and supports to physical activity in American Indian children.

Increasing physical activity (PA) in children and adults is necessary to prevent or ameliorate chronic diseases such as obesity, type 2 diabetes and cardiovascular disease. Interventions designed to increase PA at the individual and community level through policy and environmental change are essential. American Indian (AI) communities face a disproportionate burden of chronic disease and are eager to work on multi-level methods for disease prevention. 1 Over the past 10 years our research group has been partnering with multiple AI communities in northern Wisconsin on research to understand barriers and supports to healthy lifestyles and PA. Methods have included the WINGS epidemiological work and parental questionnaires 2 (see this issue), key informant interviews and focus groups 3-4 , PhotoVoice/GIS mapping, accelerometry/direct observation 5 , and environmental assessment. An intervention, Healthy Children, Strong Families, and Supportive Communities, is underway and focuses both on the family environment and aiding individuals in making healthy choices. 6 The intervention also assists communities in making community level changes to support healthy lifestyles. Our journey with these communities to understand the prevalence of obesity and cardiovascular disease and the role of attitude and environment in order to aid intervention design has taught us many valuable lessons. The framework of our work has been community based participatory research 7-8 , and tribal members were involved at all stages of the research whenever possible. In this commentary, discussion of the lessons learned from each of these methods is divided into 3 realms: community views and suggestions, objective measurement, and environmental assessment. Some methods cross more than one realm. These notes from the field may help other communities as they travel a similar journey toward wellness. Community Views and Suggestions During the WINGS study, the parent survey for parents of 3-8 year old children included an open ended question seeking suggestions for changes in the community that might encourage healthier lifestyles. 2 Caregivers provided 90 suggestions of how to promote healthy lifestyles in their community. Fifty-six of those suggestions specifically mentioned physical activity related changes. Common themes noted by caregivers were the desire for more family oriented activities, more activities and sports directed at younger children, parents needing to spend more time with children in activities, and needing more facilities for younger children/families. Our key informant and focus group work showed the importance of understanding parental views of health in order to intervene in increasing PA. Parents had a view of health