Cynthia D. Schwarz

Factors Influencing the Implementation of School Wellness Policies in the United States, 2009

Introduction The quality of school wellness policy implementation varies among schools in the United States. The objective of this study was to characterize the school wellness policy environment nationally and identify factors influencing the quality and effectiveness of policy implementation. Methods We invited school administrators from 300 high schools to complete a questionnaire; 112 administrators responded. We performed a 2-step cluster analysis to help identify factors influencing the implementation of school wellness policies. Results Eighty-two percent of schools reported making staff aware of policy requirements; 77% established a wellness committee or task force, 73% developed administrative procedures, and 56% trained staff for policy implementation. Most commonly reported challenges to implementation were lack of time or coordination of policy team (37% of respondents) and lack of monetary resources (33%). The core domains least likely to be implemented were communication and promotion (63% of respondents) and evaluation (54%). Cluster 1, represented mostly by schools that have taken action toward implementing policies, had higher implementation and effectiveness ratings than Cluster 2, which was defined by taking fewer actions toward policy implementation. In Cluster 1, accountability was also associated with high ratings of implementation quality and effectiveness. Conclusion The development of organizational capacity may be critical to ensuring an environment that promotes high-quality policy implementation. Assessing, preventing, and addressing challenges; establishing clear definitions and goals; and requiring accountability for enacting policy across all core domains are critical to ensuring high-quality implementation.

Postpartum Teens’ Breakfast Consumption is Associated with Snack and Beverage Intake and Body Mass Index

Addressing high-risk dietary patterns among postpartum teens may help reduce weight retention and prevent intergenerational obesity. The objective of this study was to describe the relationship between breakfast consumption and outcomes of snack and beverage intake and body mass index (BMI) among postpartum teens. During 2007-2009, 1,330 postpartum teens across 27 states participated in a cross-sectional, baseline assessment of a group-randomized, nested cohort study. Participants were enrolled in the Parents as Teachers Teen Program and completed a 7-day recall of breakfast, snack, and beverage consumption. BMI was calculated from heights and weights obtained by on-site staff. Sample descriptives were compared across breakfast consumption frequency groupings by one-way analysis of variance tests or χ² tests. General linear models assessed relationships between breakfast consumption and measures of snack and sweetened beverage intake, water consumption, and BMI-for-age percentile. Almost half (42%) of the sample consumed breakfast fewer than 2 days per week. Those who ate breakfast 6 to 7 days/week consumed 1,197 fewer kilocalories per week from sweet and salty snacks, 1,337 fewer kilocalories per week from sweetened drinks, and had a lower BMI compared to those who ate breakfast fewer than 2 days per week (P < 0.05). Consumption of fruit, vegetables, milk, water, and cereal as a snack were higher among regular breakfast consumers (P < 0.05). Although breakfast consumption among postpartum teens is low, those who regularly consume breakfast had healthier snacking behaviors and weight. Interventions are needed to encourage breakfast consumption among teen mothers.

A Randomized Trial of Weight Change in a National Home Visiting Program

INTRODUCTION Clinical trials have demonstrated significant impact in reducing weight and incidence of type 2 diabetes mellitus. However, the intensity of these trials limits their scalability to real world settings. The purpose of this study was to embed a lifestyle intervention for overweight and obese mothers within the routine practice of a parent education, home visiting organization. DESIGN Pragmatic trial that used a stratified random design. SETTING/PARTICIPANTS Overweight or obese mothers of preschool children located across St. Louis, Missouri, enrolled in Parents As Teachers, a home visiting organization reaching women and children nationwide. INTERVENTION A lifestyle intervention derived from the Diabetes Prevention Program was embedded within Parents As Teachers entitled Healthy Eating and Active Living Taught at Home (HEALTH). MAIN OUTCOME MEASURES Outcomes included the proportion of women that achieved 5% weight loss at 24 months and improvements in clinical and behavioral outcomes at 12 and 24 months. Participants were enrolled from 2012 to 2014 and data analysis began in 2016. RESULTS Women in the usual care versus intervention group were significantly less likely to achieve 5% weight loss at 24 months (11% vs 26%, p=0.01). At 12 months, there was a 2.8-kg difference in weight between groups (p=0.0006), and by 24 months a 4.7-kg difference in weight (3.2 [SD=7.6] kg vs -1.5 [SD=8.3] kg, p=0.002); group differences in waist circumference were also evident by 12 months (2.1 [SD=8.4] cm vs -0.7 [SD=9.8] cm, p=0.04) and 24 months (3.8 [SD=10.6] cm vs -2.5 [SD=9.1] cm, p=0.005), as were improvements in behavioral outcomes. There was no difference in blood pressure between groups. CONCLUSIONS HEALTH achieved modest but clinically significant weight loss outcomes, and reduced weight gain in mothers of young children. The scalability of this embedded intervention offers the potential to reach mothers in Parents As Teachers programs nationally. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT01567033.

Postpartum Teens’ Perception of the Food Environments at Home and School

Background. An environment that supports healthy eating is one factor to prevent obesity. However, little is known about postpartum teen’s perceptions of their home and school environments and how this relates to dietary behaviors. Purpose. This study explores the relationship between home and school environments and dietary behaviors for postpartum teens. Design. Conducted cross-sectionally during 2007-2009 across 27 states and included 889 postpartum teens enrolled in Parents as Teachers Teen Program. Data included measures of sociodemographics and perceptions of school and home food environments. A 7-day recall of snack and beverage frequency assessed dietary behaviors. Logistic regression explored associations between baseline environment measures and dietary behaviors at baseline and postintervention (approximately 5 months after baseline) for the control group. Results. Respondents reported greater access and selection (i.e., variety of choices) of healthy foods and beverages at home than school. At baseline, fruit and vegetable intake was associated with home selection (1.9, 95% confidence interval [CI: 1.3, 2.9]) and availability (1.8, 95% CI [1.3, 2.6]), sweet snack consumption was associated with selection (1.5, 95% CI [1.0, 2.1]), and total snack consumption and sugar-sweetened beverage intake were associated with selection (snack: 2.1, 95% CI [1.5, 3.0]; beverage: 1.7, 95% CI [1.2, 2.4]) and availability (snack: 2.1, 95% CI [1.4, 3.1]; beverage: 1.5, 95% CI [1.0, 2.3]). Water intake at baseline and at the postintervention for control group teens was associated with selection (1.6, 95% CI [1.1, 2.2]). No significant associations were identified between the school environment and dietary behaviors. Conclusions. Interventions should target improvements in the home environment for high-risk, postpartum teens.

Influence of Home and School Environments on Specific Dietary Behaviors Among Postpartum, High-Risk Teens, 27 States, 2007-2009

Introduction The objective of this study was to determine whether perceptions of the home and school food environments are related to food and beverage intakes of postpartum teens. Methods Our study was a baseline, cross-sectional analysis of 853 postpartum teens enrolled in a weight-loss intervention study across 27 states from 2007 through 2009. Eight-item scales assessed perceived accessibility and availability of foods and beverages in school and home environments. Associations between environments and intakes were assessed by using χ2 and using logistic regression with generalized estimating equations (GEE), respectively. Results Overall, 52% of teens perceived their school food environment as positive, and 68% of teens perceived their home food environment as positive. A positive school environment was independently associated with fruit consumption and 100% fruit juice consumption. A positive home environment was independently associated with fruit, vegetable, and water consumption and infrequent consumption of soda and chips (χ2 P < .05). Having only a positive school environment was associated with fruit consumption (GEE odds ratio [OR], 3.1; 95% confidence interval [CI], 1.5–6.5), and having only a positive home environment was associated with fruit (GEE OR, 2.9; 95% CI, 1.6–5.6), vegetable (GEE OR, 3.1; 95% CI, 1.5–6.2), and water (GEE OR, 2.6; 95% CI, 1.7–4.0) consumption and infrequent consumption of soda (GEE OR, 0.5; 95% CI, 0.3–0.7). Results for positive home and school environments were similar to those for positive home only. Conclusion Home and school environments are related to dietary behaviors among postpartum teens, with a positive home environment more strongly associated with healthful behaviors.

Impact of a Healthy Weight Intervention Embedded Within a National Home Visiting Program on the Home Food Environment

Purpose: To determine whether a lifestyle intervention embedded within Parents as Teachers (PAT), a national child development and parenting home visiting program, helped families make food-related home environment changes. Design: Secondary data analysis of a stratified randomized pragmatic trial. (Trial Registration: This study is registered at www.clinicaltrials.gov NCT01567033). Setting: Participant homes in St. Louis, Missouri. Subjects: Women (n = 179 with pre-post data, of 230 with baseline) participating in standard PAT, with overweight or obesity, and at least one preschool child with BMI percentile ≥60%. Intervention: PAT + Healthy Eating and Active Living Taught at Home (HEALTH), embedded elements of the Diabetes Prevention Program within the standard PAT curriculum. PAT + HEALTH addressed specific behaviors that impact caloric intake (e.g., sugar-sweetened beverages), focusing on behavioral and environmental strategies. Consistent with PAT practice, the frequency, number, and focus (i.e., time spent on intervention components) of home visits were determined by the familys needs; dose structure was flexible [on average intervention: 23 (SD = 9), usual care: 13 (SD = 6) visits]. Measures: Food availability/accessibility and distractions in the home were assessed with items drawn largely from the HomeSTEAD Survey. Analysis: Generalized estimating equations (GEEs) were used to test equality of changes between baseline and 24 months in the intervention and usual care groups. Results: The only significant difference in the pattern of change between usual care and intervention was soda availability/accessibility (p = 0.013). Conclusion: This embedded intervention successfully reduced availability/accessibility of sugar-sweetened beverages in the home. However, given the limited impact on other food-related home environment factors, future interventions could seek to more effectively intervene on all aspects of the home environment.

A formative study to understand perspectives of families eligible for a pediatric obesity program: a qualitative study

BackgroundRaising Well® (RW) was initiated in 2015 by Envolve PeopleCare™ at the request of health plans seeking a solution to work with families on Medicaid that have a child with overweight or obesity. RW uses expert clinical coaches via phone contact to deliver an educational intervention promoting lifestyle change to families with at least one overweight or obese child in an eligible Medicaid health plan. This gives RW significant potential for reach and population impact. This project aimed to understand how to maximize this impact by exploring perspectives of RW, using a conceptual framework informed by the Conceptual Model of Implementation Research, including assessment of the feasibility, acceptability, and appropriateness of RW; determining satisfaction among those experiencing coaching; identifying reasons individuals do not participate; and developing recommendations to enhance interest and participation.MethodsSemi-structured interviews were conducted with 70 RW-eligible families across four states, who were described as: active participants, respondents who dropped or stopped RW, and RW non-participants. Following the interviews, the transcripts were coded inductively and deductively using a grounded theory approach, considering themes from the conceptual framework; themes also emerged from the data.ResultsFrom this sample, 19 families reported to be active coaching participants, 24 had dropped coaching, and 27 were RW non-participants. A number of themes were identified. Feasibility themes included coaches’ flexibility and willingness to work with the family’s schedule. Acceptability themes suggest providing actionable strategies tailored to the family’s context and needs, beyond just nutrition information and tips, early in the coaching relationship so the family perceives a benefit for continued participation. With regard to appropriateness, families were also interested in other methods of communication including email, texting, and in person visits. Access to resources for activity and healthy eating in their local community was also recommended.ConclusionsRW has the potential to improve health and promote wellness. To enhance the impact of this program, RW could incorporate these findings to promote feasibility, acceptability, and appropriateness and improve program implementation. Strategies may include modifying the information provided or the mode of delivering the information.

Abstract A26: Relative influence of home and school environments on specific dietary behaviors among postpartum, high-risk teens

Background: Nearly one third of adolescent girls are overweight or obese, and this risk is significantly heightened for postpartum, high-risk teenagers. Interventions among this difficult to reach population are critical for the prevention of obesity and related health effects, including several types of epithelial cancers. Targeting the home and school environment, where teens spend most of their time, may be particularly effective at reducing behaviors associated with obesity. Previously, in a study of high-risk postpartum teens, we found a greater influence of the perceived home food environment (vs. school) on total calories consumed from food and beverage groups. Here we aim to build upon these findings, looking at consumption of specific food and beverage items and the relative influence of school and home food environments, and whether relationships vary by baseline body mass index (BMI). Methods: This is a cross-sectional, baseline analysis of 875 girls enrolled in the Balance Adolescent Lifestyle Activities and Nutrition Choices for Energy (BALANCE) study, a weight loss intervention designed to prevent obesity among postpartum, high-risk adolescents across 26 states. A total of 8 items were used to assess perceived healthful school and home food environments, respectively, on a 5-point Likert Scale. Ratings were averaged and dichotomized to generate an overall environment score. To assess the relative influence of home and school environment, we created the following categories: 0,“negative school & home”; 1, “positive school only” 2, ”positive home only” 3, ”positive school & home”. Frequency of specific food and beverage items were collapsed into binary categories to reflect infrequent (0-3 days/week) and frequent (4-7 days/week) consumption. Height and weight were obtained by trained staff and used to calculate BMI-for-age (dichotomized as normal [ Results: Among 875 postpartum teens, a positive home environment was significantly associated with decreased consumption of chips and increased consumption of fruit and vegetables (p Conclusions: In this understudied population of postpartum teens, the home environment was associated with healthy dietary behaviors. Results indicated that having a positive home environment was enough to influence behavior and for many items, the added benefit of a positive school environment was relatively low. Improving the home environment may be particularly important among this population of teen moms who are at increased risk for obesity and who are in a position to pass down their food behaviors to their children. Citation Format: Megan A. Clarke, Rachel G. Tabak, Cynthia D. Schwarz, Debra L. Haire-Joshu, Corinne E. Joshu. Relative influence of home and school environments on specific dietary behaviors among postpartum, high-risk teens. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr A26.