Marie K. Fialkowski

Children’s Healthy Living (CHL) Program for remote underserved minority populations in the Pacific region: rationale and design of a community randomized trial to prevent early childhood obesity

BackgroundAlthough surveillance data are limited in the US Affiliated Pacific, Alaska, and Hawaii, existing data suggest that the prevalence of childhood obesity is similar to or in excess of other minority groups in the contiguous US. Strategies for addressing the childhood obesity epidemic in the region support the use of community-based, environmentally targeted interventions. The Children’s Healthy Living Program is a partnership formed across institutions in the US Affiliated Pacific, Alaska, and Hawaii to design a community randomized environmental intervention trial and a prevalence survey to address childhood obesity in the region through affecting the food and physical activity environment.Methods/DesignThe Children’s Healthy Living Program community randomized trial is an environmental intervention trial in four matched-pair communities in American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, and Hawaii and two matched-pair communities in Alaska. A cross-sectional sample of children (goal n = 180) in each of the intervention trial communities is being assessed for outcomes at baseline and at 24 months (18 months post-intervention). In addition to the collection of the participant-based measures of anthropometry, diet, physical activity, sleep and acanthosis nigricans, community assessments are also being conducted in intervention trial communities. The Freely Associated States of Micronesia (Federated States of Micronesia, and Republics of Marshall Islands and Palau) is only conducting elements of the Children’s Healthy Living Program sampling framework and similar measurements to provide prevalence data. In addition, anthropometry information will be collected for two additional communities in each of the 5 intervention jurisdictions to be included in the prevalence survey. The effectiveness of the environmental intervention trial is being assessed based on the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework.DiscussionThe Children’s Healthy Living Program environmental trial is designed to focus on capacity building and to maximize the likelihood of sustainable impact on childhood obesity-related behaviors and outcomes. The multiple measures at the individual, community, and environment levels are designed to maximize the likelihood of detecting change. This approach enhances the likelihood for identifying and promoting the best methods to promote health and well-being of the children in the underserved US Affiliated Pacific Region.Trial registrationNIH clinical trial # NCT01881373

Systematic Review of Prevalence of Young Child Overweight and Obesity in the United States–Affiliated Pacific Region Compared With the 48 Contiguous States: The Children’s Healthy Living Program

We estimated overweight and obesity (OWOB) prevalence of children in US-Affiliated Pacific jurisdictions (USAP) of the Childrens Healthy Living Program compared with the contiguous United States. We searched peer-reviewed literature and government reports (January 2001-April 2014) for OWOB prevalence of children aged 2 to 8 years in the USAP and found 24 sources. We used 3 articles from National Health and Nutrition Examination Surveys for comparison. Mixed models regressed OWOB prevalence on an age polynomial to compare trends (n = 246 data points). In the USAP, OWOB prevalence estimates increased with age, from 21% at age 2 years to 39% at age 8 years, increasing markedly at age 5 years; the proportion obese increased from 10% at age 2 years to 23% at age 8 years. The highest prevalence was in American Samoa and Guam.

Evaluation of Dietary Assessment Tools Used to Assess the Diet of Adults Participating in the Communities Advancing the Studies of Tribal Nations Across the Lifespan Cohort

BACKGROUND Accurate assessment of dietary intake is essential for researchers and public health practitioners to make advancements in public health. This is especially important in Native Americans who display disease prevalence rates that are dramatically higher than the general US population. OBJECTIVE To evaluate three dietary assessment tools: dietary records, a food frequency questionnaire (FFQ), and a shellfish assessment survey among Native American adults from the Communities Advancing the Studies of Tribal Nations Across the Lifespan (CoASTAL) cohort. DESIGN The CoASTAL cohort was composed of randomly selected individuals from three tribal registries of Pacific Northwest Tribal Nations. This cross-sectional study used data from the baseline of CoASTAL and was restricted to the non-pregnant adults (aged 18 years or older) who completed the shellfish assessment survey (n=500), an FFQ (n=518), dietary records (n=444), weight measures (n=493), and height measures (n=496). Paired t tests, Pearson correlation coefficients, and percent agreement were used to evaluate the dietary records and the FFQ with and without accounting for plausibility of reported energy intake (rEI). Sensitivity and specificity as well as Spearman correlation coefficients were used to evaluate the shellfish assessment survey and the FFQ compared to dietary records. RESULTS Statistically significant correlations between the FFQ and dietary records for selected nutrients were not the same by sex. Accounting for plausibility of rEI for the dietary records and the FFQ improved the strength of the correlations for percent energy from protein, energy from carbohydrate, and calcium for both men and women. In addition, the association between rEI (dietary records and FFQ) and weight became significant when the sample was limited to plausible rEI. The shellfish assessment survey was found to similarly assess shellfish consumption in comparison to the FFQ. CONCLUSIONS These results support the benefit of multiple measures of diet, including regional and culturally specific surveys, especially among Native Americans. Accounting for plausibility of rEI may ensure more accurate estimations of dietary intakes.

Estimated Nutrient Intakes from Food Generally Do Not Meet Dietary Reference Intakes among Adult Members of Pacific Northwest Tribal Nations

Diet is influential in the etiology of chronic diseases in many populations including Native Americans. The objective of this report is to present the first comprehensive dietary survey, to our knowledge, of a representative sample of nonpregnant adults from Pacific Northwest tribal nations participating in the Communities Advancing the Studies of Tribal Nations Across the Lifespan (CoASTAL) cohort. Only participants who completed 1-4 d of dietary records and had weights and heights measured in the laboratory were eligible for this analysis (n = 418). Mean nutrient intakes were stratified by gender for the total sample, those with plausibly reported energy intakes (rEI), and those with implausibly rEI. Estimates of nutrient intakes were compared with Dietary Reference Intakes (DRI). Nutrient estimates from NHANES 2001-2002 were used as a reference. Among both men and women, total fat contributed 34-37% of energy intake and saturated fat contributed 11-12% of energy intake. Daily cholesterol intakes ranged from 262 to 442 mg. A majority of men and women were not meeting recommendations for vitamins A, C, and E, magnesium, and sodium. For a majority of the nutrients examined, plausibility resulted in higher mean estimates. The CoASTAL cohort nutrient profile is similar to NHANES 2001-2002, with a majority of DRI recommendations not being met. Adequate dietary intake information may be more important for this population, because Native Americans experience a disproportionate burden for diseases.

The Relevancy of Community-Based Methods: Using Diet within Native American and Alaska Native Adult Populations as an Example

The rates of obesity, diabetes, and heart disease in Native Americans and Alaska Natives far exceed that of the general US population. There are many postulating reasons for these excessive rates including the transition from a traditional to a contemporary diet. Although information on the dietary intakes of Native American and Alaska Native communities are limited, there seems to be a consensus that the Native American and Alaska Native diet is high in total fat, saturated fat, cholesterol, and sodium. Further information on the diet needs to be attained so that dietary interventions can effectively be implemented in these communities. An approach that is community based is proposed as the best solution to understanding the Native diet and developing culturally tailored interventions to sustainably improve diet. Clin Trans Sci 2012; Volume 5: 295–300

Dietary patterns are associated with dietary recommendations but have limited relationship to BMI in the Communities Advancing the Studies of Tribal Nations Across the Lifespan (CoASTAL) cohort

OBJECTIVE Traditional food systems in indigenous groups have historically had health-promoting benefits. The objectives of the present study were to determine if a traditional dietary pattern of Pacific Northwest Tribal Nations (PNwT) could be derived using reduced rank regression and if the pattern would be associated with lower BMI and current Dietary Reference Intakes. DESIGN The baseline data from the Communities Advancing the Studies of Tribal Nations Across the Lifespan (CoASTAL) cohort were used to derive dietary patterns for the total sample and those with plausibly reported energy intakes. SETTING Pacific Northwest Coast of Washington State, USA. SUBJECTS Adult PNwT members of the CoASTAL cohort with laboratory-measured weight and height and up to 4 d of dietary records (n 418). RESULTS A traditional dietary pattern did not evolve from the analysis. Moderate consumption of a sweet drinks dietary pattern was associated with lower BMI while higher consumption of a vegetarian-based dietary pattern was associated with higher BMI. The highest consumers of the vegetarian-based dietary pattern were almost six times more likely to meet the recommendations for dietary fibre. CONCLUSIONS Distinct dietary patterns were found. Further exploration is needed to confirm whether the lack of finding a traditional pattern is due to methodology or the loss of a traditional dietary pattern among this population. Longitudinal assessment of the CoASTAL cohorts dietary patterns needs to continue.

Anthropometric measurement standardization in the US‐affiliated pacific: Report from the Children's Healthy Living Program

Anthropometric standardization is essential to obtain reliable and comparable data from different geographical regions. The purpose of this study is to describe anthropometric standardization procedures and findings from the Childrens Healthy Living (CHL) Program, a study on childhood obesity in 11 jurisdictions in the US‐Affiliated Pacific Region, including Alaska and Hawai‘i.

Ethnicity and acculturation: do they predict weight status in a longitudinal study among Asian, Hispanic, and non-Hispanic White early adolescent females?

Background The prevalence of overweight and obesity among adolescents has increased over the past decade. Prevalence rates are disparate among certain racial and ethnic groups. This study sought to longitudinally examine the relationship between overweight status (≥85th percentile according to the Centers for Disease Control and Prevention growth charts) and ethnic group, as well as acculturation (generation and language spoken in the home) in a sample of adolescent females. Methods Asian (n=160), Hispanic (n=217), and non-Hispanic White (n=304) early adolescent girls participating in the multistate calcium intervention study with complete information on weight, ethnicity, and acculturation were included. Multiple methods of assessing longitudinal relationships (binary logistic regression model, linear regression model, Cox proportional-hazards regression analysis, and Kaplan–Meier survival analysis) were used to examine the relationship. Results The total proportion of girls overweight at baseline was 36%. When examining by ethnic group, the proportion varied with Hispanic girls having the highest percentage (46%) in comparison to their Asian (23%) and Non-Hispanic White (35%) counterparts. Although the total proportion of overweight was 36% at 18 months, the variation across the ethnic groups remained with the proportion of Hispanic girls becoming overweight (55%) being greater than their Asian (18%) and non-Hispanic White (34%) counterparts. However, regardless of the statistical approach used, there were no significant associations between overweight status and acculturation over time. Conclusion These unexpected results warrant further exploration into factors associated with overweight, especially among Hispanic girls, and further investigation of acculturation’s role is warranted. Identifying these risk factors will be important for developing targeted obesity prevention initiatives.

Misreporting of Dietary Intake Affects Estimated Nutrient Intakes in Low-Income Spanish-Speaking Women

Misreporting of dietary intake affects the validity of data collected and conclusions drawn in studies exploring diet and health outcomes. One consequence of misreporting is biological implausibility. Little is known regarding how accounting for biological implausibility of reported intake affects nutrient intake estimates in Hispanics, a rapidly growing demographic in the United States. Our study explores the effect of accounting for plausibility on nutrient intake estimates in a sample of Mexican-American women in northern California in 2008. Nutrient intakes are compared with Dietary Reference Intake recommendations, and intakes of Mexican-American women in a national survey are presented as a reference. Eighty-two women provided three 24-hour recalls. Reported energy intakes were classified as biologically plausible or implausible using the reported energy intakes to total energy expenditure cutoff of <0.76 or >1.24, with low-active physical activity levels used to estimate total energy expenditure. Differences in the means of nutrient intakes between implausible (n=36) and plausible (n=46) reporters of energy intake were examined by bivariate linear regression. Estimated energy, protein, cholesterol, dietary fiber, and vitamin E intakes were significantly higher in plausible reporters than implausible. There was a significant difference between the proportions of plausible vs implausible reporters meeting recommendations for several nutrients, with a larger proportion of plausible reporters meeting recommendations. Further research related to misreporting in Hispanic populations is warranted to explore the causes and effects of misreporting in studies measuring dietary intake, as well as actions to be taken to prevent or account for this issue.

Using the ANGELO Model To Develop the Children's Healthy Living Program Multilevel Intervention To Promote Obesity Preventing Behaviors for Young Children in the US-Affiliated Pacific Region

BACKGROUND Almost 40% of children are overweight or obese by age 8 years in the US-Affiliated Pacific, inclusive of the five jurisdictions of Alaska, Hawaii, American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands. This article describes how the Childrens Healthy Living (CHL) Program used the ANGELO (Analysis Grid for Environments/Elements Linked to Obesity) model to design a regional intervention to increase fruit and vegetable intake, water consumption, physical activity, and sleep duration and decrease recreational screen time and sugar-sweetened beverage consumption in young children ages 2-8 years. METHODS Using the ANGELO model, CHL (1) engaged community to identify preferred intervention strategies, (2) reviewed scientific literature, (3) merged findings from community and literature, and (4) formulated the regional intervention. RESULTS More than 900 community members across the Pacific helped identify intervention strategies on importance and feasibility. Nine common intervention strategies emerged. Participants supported the idea of a regional intervention while noting that cultural and resource differences would require flexibility in its implementation in the five jurisdictions. Community findings were merged with the effective obesity-reducing strategies identified in the literature, resulting in a regional intervention with four cross-cutting functions: (1) initiate or strengthen school wellness policies; (2) partner and advocate for environmental change; (3) promote CHL messages; and (4) train trainers to promote CHL behavioral objectives for children ages 2-8 years. These broad functions guided intervention activities and allowed communities to tailor activities to maximize intervention fit. CONCLUSIONS Using the ANGELO model assured that the regional intervention was evidence based while recognizing jurisdiction context, which should increase effectiveness and sustainability.