Meliha Salahuddin

Strategies to recruit a diverse low-income population to child weight management programs from primary care practices

Purpose and Objectives Primary care practices can be used to engage children and families in weight management programs. The Texas Childhood Obesity Research Demonstration (TX CORD) study targeted patients at 12 primary care practices in diverse and low-income areas of Houston, Texas, and Austin, Texas for recruitment to a trial of weight management programs. This article describes recruitment strategies developed to benefit both families and health care practices and the modification of electronic health records (EHRs) to reflect recruitment outcomes. Intervention Approach To facilitate family participation, materials and programs were provided in English and Spanish, and programs were conducted in convenient locations. To support health care practices, EHRs and print materials were provided to facilitate obesity recognition, screening, and study referral. We provided brief training for providers and their office staffs that covered screening patients for obesity, empathetic communication, obesity billing coding, and use of counseling materials. Evaluation Methods We collected EHR data from 2012 through 2014, including demographics, weight, and height, for all patients aged 2 to 12 years who were seen in the 12 provider practices during the study’s recruitment phase. The data of patients with a body mass index (BMI) at or above the 85th percentile were compared with the same data for patients who were referred to the study and patients who enrolled in the study. We also examined reasons that patients referred to the study declined to participate. Results Overall, 26% of 7,845 patients with a BMI at or above the 85th percentile were referred to the study, and 27% of referred patients enrolled. Enrollment among patients with a BMI at or above the 85th percentile was associated with being Hispanic and with more severe obesity than with patients of other races/ethnicities or less severe obesity, respectively. Among families of children aged 2 to 5 years who were referred, 20% enrolled, compared with 30% of families of older children (>5 y to 12 y). Referral rates varied widely among the 12 primary care practices, and referral rates were not associated with EHR modifications. Implications for Public Health Engagement and recruitment strategies for enrolling families in primary care practice in weight management programs should be strengthened. Further study of factors associated with referral and enrollment, better systems for EHR tools, and data on provider and office adherence to study protocols should be examined. EHRs can track referral and enrollment to capture outcomes of recruitment efforts.

Predictors of Severe Obesity in Low-Income, Predominantly Hispanic/Latino Children: The Texas Childhood Obesity Research Demonstration Study

Introduction The objective of this study was to identify predictors of severe obesity in a low-income, predominantly Hispanic/Latino sample of children in Texas. Methods This cross-sectional analysis examined baseline data on 517 children from the secondary prevention component of the Texas Childhood Obesity Research Demonstration (TX CORD) study; data were collected from September 2012 through February 2014. Self-administered surveys were used to collect data from parents of children who were aged 2 to 12 years, had a body mass index (BMI) in the 85th percentile or higher, and resided in Austin, Texas, or Houston, Texas. Multivariable logistic regression models adjusted for sociodemographic covariates were used to examine associations of children’s early-life and maternal factors (large-for-gestational-age, exclusive breastfeeding for ≥4 months, maternal severe obesity [BMI ≥35.0 kg/m2]) and children’s behavioral factors (fruit and vegetable consumption, physical activity, screen time) with severe obesity (BMI ≥120% of 95th percentile), by age group (2–5 y, 6–8 y, and 9–12 y). Results Across all ages, 184 (35.6%) children had severe obesity. Among children aged 9 to 12 years, large-for-gestational-age at birth (odds ratio [OR] = 2.31; 95% confidence interval [CI], 1.13–4.73) was significantly associated with severe obesity. Maternal severe obesity was significantly associated with severe obesity among children aged 2 to 5 years (OR = 2.67; 95% CI, 1.10–6.47) and 9 to 12 years (OR = 4.12; 95% CI, 1.84–9.23). No significant association was observed between behavioral factors and severe obesity in any age group. Conclusion In this low-income, predominantly Hispanic/Latino sample of children, large-for-gestational-age and maternal severe obesity were risk factors for severe obesity among children in certain age groups. Promoting healthy lifestyle practices during preconception and prenatal periods could be an important intervention strategy for addressing childhood obesity.

Associations Between Parent-Perceived Neighborhood Safety and Encouragement and Child Outdoor Physical Activity Among Low-Income Children

BACKGROUND A growing body of research has examined the relationship between perceived neighborhood safety and parental encouragement for child physical activity (PA), yet these potential predictors have not been studied together to predict child outdoor PA. The purpose of this study is to examine these predictors and parent- and child-reported child outdoor PA. METHODS The Texas Childhood Obesity Research Demonstration study collected data from fifth-grade students attending 31 elementary schools across Austin and Houston and their parents (N = 748 parent-child dyads). Mixed-effects linear and logistic regressions stratified by gender and adjusted for sociodemographic covariates assessed associations among parental-perceived neighborhood safety, parental encouragement for childs outdoor PA, and parent- and child-reported childs outdoor PA. RESULTS Parental-perceived neighborhood safety was significantly associated with encouraging outdoor PA (P = .01) and child-reported childs outdoor PA in boys, but not in girls. Significant associations were found between parental encouragement and child-reported outdoor PA for girls (P < .05) and parent-reported outdoor PA (P < .01) for boys and girls. CONCLUSIONS Parent encouragement of PA and neighborhood safety are potential predictors of child outdoor PA and could be targeted in youth PA interventions.

The effect of prenatal maternal cigarette smoking on children’s BMI z -score with SGA as a mediator

BackgroundThe goal of this study was to assess the effect of prenatal maternal cigarette smoking on children’s BMI z-score trajectories, and to evaluate whether small-for-gestational-age (SGA) acts as a potential mediator between prenatal maternal cigarette smoking and child’s BMI z-score at 4 years of age.MethodsGroup-based trajectory modeling (GBTM) methods were employed to describe and classify developmental BMI z-score trajectories (the outcome of interest) in children from 9 months to 4 years of age (n = 5221) in the Early Childhood Longitudinal Study, Birth Cohort (ECLS-B) study (2001–2005). Further analysis examined whether the identified BMI z-score trajectories varied with the exposure, prenatal maternal cigarette smoking. Mediation analyses were utilized to examine whether being SGA (binary measure) acted as a potential mediator in the relationship between prenatal maternal cigarette smoking and BMI z-score among 4-year-old children.ResultsUsing GBTM, two BMI z-score trajectory groups were identified: normal BMI z-score (57.8%); and high BMI z-score (42.2%). Children of mothers who smoked cigarettes during pregnancy were 2.1 times (RR 95% CI: 1.1–4.0, P value = 0.023) more at risk of being in the high BMI z-score trajectory group. Prenatal cigarette smoking was positively related to SGA at birth, but SGA was inversely related to BMI z-score at 4 years. The direct effect (0.19, 95% CI: 0.18, 0.19; P value < 0.001) of maternal cigarette smoking status during pregnancy on BMI z-score among 4-year-old children was stronger and in the opposite direction of the indirect effect (−0.04, 95% CI: −0.04, −0.04; P value < 0.001) mediated through SGA.ConclusionsIn this study, prenatal maternal cigarette smoking was positively associated with the high BMI z-score group, as well with SGA. The effects of prenatal smoking on BMI z-score at 4 years appears to act through pathways other than SGA.

Maternal risk factor index and cesarean delivery among women with nulliparous, term, singleton, vertex deliveries, Texas, 2015

BACKGROUND Cesarean delivery accounts for over one-third of the ~400 000 annual births in Texas, with first-time cesarean accounting for 20% of the overall cesareans. We examined associations of maternal medical comorbidities with cesarean delivery among nulliparous, term, singleton, vertex (NTSV) deliveries in Texas. METHODS Nulliparous, term, singleton, vertex deliveries to women aged 15-49 years were identified using the 2015 Texas birth file (Center for Health Statistics, Texas Department of State Health Services). A risk factor index was constructed (score range 0-4), including preexisting/gestational diabetes mellitus, preexisting/gestational hypertension/eclampsia, infertility treatment, smoking during pregnancy, and prepregnancy overweight/obesity, and categorized as 0, 1, 2, and 3+ based on the number of risk factors present. Multivariable logistic regression analyses were conducted to examine associations between the categorized risk factor index and cesarean delivery, overall and by maternal race and ethnicity. RESULTS Among the 114 535 NTSV deliveries in Texas in 2015, 27.2% were by cesarean. The most prevalent maternal risk among all deliveries was prepregnancy overweight/obesity (42.4%). The odds of cesarean delivery increased significantly with increasing number of risk factors [one risk factor: 1.72 (95% CI 1.67-1.78); two risk factors: 2.58 (95% CI 2.46-2.71); and three or more risk factors: 3.91 (95% CI 3.45-4.44)]. DISCUSSION In Texas in 2015, nearly half of NTSV deliveries had at least one maternal risk factor and the odds of cesarean delivery were significantly elevated for women with a higher risk index score. The findings from this study highlight the need for intervening during the preconception and interconception period as intrapartum care practices have an important influence on birth outcomes.

The associations of large-for-gestational-age and infant feeding practices with children's body mass index z-score trajectories: the Early Childhood Longitudinal Study, Birth Cohort

Very few studies have examined if high birth weight and infant feeding practices have implications for the trajectory of body mass index (BMI) growth across the early childhood period. The goal of this study was to assess if large‐for‐gestational‐age (LGA) and infant feeding practices (exclusive breastfeeding for 6 months, and early introduction of complementary food prior to 4 months) are associated with BMI z‐score trajectories over the early childhood period. Group‐based trajectory modelling (GBTM) methods were employed to describe and classify developmental BMI z‐score trajectories (the outcome of interest) in children from 9 months to 4 years of age (n = 4497) born to prenatal non‐smoking mothers in the Early Childhood Longitudinal Study, Birth Cohort (2001–2005). Further analyses examined if the identified BMI z‐score trajectories varied systematically with the exposures, LGA and specific infant feeding practices, after accounting for sociodemographic and other early‐life factors. Two BMI z‐score trajectory groups were identified: normal BMI z‐score (56.2%) and high BMI z‐score (43.8%). Children who were LGA infants had 2.3 times (risk ratio 95% confidence interval: 1.2, 4.5) greater risk of being in high BMI z‐score group relative to normal BMI z‐score group. BMI z‐score trajectory groups did not differ by infant feeding practices, after controlling for LGA at birth. Membership in the high BMI z‐score group was associated with LGA, but not with infant feeding practices. Healthcare professionals should provide early obesity counselling to parents of LGA infants so that parents can take appropriate obesity prevention measures for their children.