Roberto P. Treviño

Risk factors for type 2 diabetes in a sixth- grade multiracial cohort: the HEALTHY study

OBJECTIVE HEALTHY is a 3-year middle school intervention program designed to reduce risk factors for type 2 diabetes. The prevalence of diabetes risk factors at baseline in a cohort of 6,358 sixth-grade students is reported. RESEARCH DESIGN AND METHODS Forty-two schools at seven U.S. sites were randomly assigned to intervention or control. Students participated in baseline data collection during fall of 2006. RESULTS Overall, 49.3% of children had BMI ≥85th percentile, 16.0% had fasting blood glucose ≥100 mg/dl (<1% had fasting blood glucose ≥126 mg/dl), and 6.8% had fasting insulin ≥30 μU/ml. Hispanic youth were more likely to have BMI, glucose, and insulin levels above these thresholds than blacks and whites. CONCLUSIONS Sixth-grade students in schools with large minority populations have high levels of risk factors for type 2 diabetes. The HEALTHY intervention was designed to modify these risk factors to reduce diabetes incidence.

Effect of the Bienestar Health Program on Physical Fitness in Low-Income Mexican American Children.

Once considered an adult onset disease, type 2 diabetes is increasingly being diagnosed in low-income Mexican American children. Studies have suggested that most of those so diagnosed were overweight, reported low levels of physical activity, and were generally unaware of their disease. The Bienestar Health Programwas designed to reduce risk factors associated with the onset of type 2 diabetes. A major focus of the curriculum is health and physical education. A comparison of intervention and control group students resulted in a significant difference in physical fitness change scores (p < .003) after an 8-month intervention. This study suggests that it is possible to improve the physical fitness of low-income Mexican American preadolescent children through a comprehensive school-based health program.

Shifts in BMI Category and Associated Cardiometabolic Risk: Prospective Results From HEALTHY Study

OBJECTIVES: To evaluate shifts across BMI categories and associated changes in cardiometabolic risk factors over 2.5 years in an ethnically diverse middle school sample. METHODS: As part of HEALTHY, a multisite school-based study designed to mitigate risk for type 2 diabetes, 3993 children participated in health screenings at the start of sixth and end of eighth grades. Assessments included anthropometric measures, blood pressure, and glucose, insulin, and lipids. Students were classified as underweight, healthy weight, overweight, obese, or severely obese. Mixed models controlling for school intervention status and covariates were used to evaluate shifts in BMI category over time and the relation between these shifts and changes in risk factors. RESULTS: At baseline, students averaged 11.3 (±0.6) years; 47.6% were boys, 59.6% were Hispanic, and 49.8% were overweight or obese. Shifts in BMI category over time were common. For example, 35.7% of youth who were overweight moved to the healthy weight range, but 13% in the healthy weight range became overweight. BMI shifts were not associated with school intervention condition, household education, or youth gender, race/ethnicity, pubertal status, or changes in height. Increases in BMI category were associated with worsening of cardiometabolic risk factors, and decreases were associated with improvements. Boys who increased BMI category were more vulnerable to negative risk factor changes than girls. CONCLUSIONS: There are substantial shifts across BMI categories during middle school that are associated with clinically meaningful changes in cardiometabolic risk factors. Programs to promote decreases in BMI and prevent increases are clearly warranted.

Identifying Barriers That Hinder Onsite Parental Involvement in a School-Based Health Promotion Program

We investigated whether barriers to onsite parental involvement in the Bienestar Health Program Parent Component could be identified and whether participation rates could be increased by addressing these barriers. All nonparticipating parents of fourth-grade students of San Antonio Independent School District from 4 schools, which were selected randomly from 20 intervention schools in Bienestar, were invited to take part in this study. A total of 47 of 223 (21%) parents engaged in one of four focus groups offered. Parents identified barriers to their involvement in Bienestar that fit into five descriptive categories: (a) low value, (b) high cost, (c) competing family demands, (d) concerns about the program design, and (e) social role norms. The Bienestar Parent Component was then modified according to the focus group findings, which resulted in a marked increase in parental involvement from 17% to 37% overall. These findings suggest that even when parents are involved in the initial design of parent-friendly and culturally sensitive programs, as was the case for Bienestar, maximizing parental involvement may require additional assessment, identification, and remediation of barriers.

Diabetes Risk, Low Fitness, and Energy Insufficiency Levels among Children from Poor Families

BACKGROUND Low-income populations have higher rates of type 2 diabetes and it is the hope of the investigators to increase support for the dissemination of evidence-based prevention programs aimed at children from poor families. OBJECTIVE To determine the prevalence of high blood glucose, obesity, low fitness, and energy insufficiency levels among children from poor families. DESIGN The cross-sectional study conducted in fall 2001 used fasting capillary glucose, body mass index, body fat, step test, and three 24-hour dietary recalls to assess diabetes risk factor levels. SUBJECTS Participants were 1,402 fourth-grade students aged 8 to 10 years. The racial/ethnic backgrounds were 80% Mexican American, 10% African American, 5% Asian American, and 5% non-Hispanic white. STATISTICAL ANALYSIS PERFORMED All data were analyzed for descriptive statistics and frequencies of distribution. Means were computed by sex for all diabetes risk factors and t test conducted to determine differences between sexes. RESULTS Nearly 75% of participants lived in households with <USD 20,400 annual income. Although 44% of students were energy insufficient, 33% were obese, and 7% had high blood glucose levels. Most of these students had marginal to unacceptable fitness levels and consumed high energy-dense and low nutrient-dense foods. CONCLUSIONS Children living in poverty have high levels of diabetes risk factors and need early detection and intervention programs. Prudent advice might be to increase physical activity and intake of nutrient-dense foods rather than to restrict energy intake.

Improving Quality of Food Frequency Questionnaire Response in Low-Income Mexican American Children

The authors evaluated the validity and reliability of the Block Kids Food Frequency Questionnaire (BKFFQ) and the Block Kid Screener (BKScreener) in Mexican American children living along the Texas–Mexico border who participated in the National Institutes of Health–funded Proyecto Bienestar Laredo. The Bienestar/NEEMA health program is a school-based diabetes and obesity control program, and the Proyecto Bienestar Laredo is the translation of the Bienestar/NEEMA health program to 38 elementary schools in Laredo, Texas. Par ticipants included 2,376 eight-year-old boys (48%) and girls (52%) from two school districts in Laredo. Two Food Frequency Questionnaire (BKFFQ and BKScreener) dietary intakes were collected, and an expert panel of nutritionist assigned a classification response quality of “Good,” “Questionable,” and “Poor,” based on playfulness (systematic or nonrandom) patterns and completion rates. In addition, both instruments were assessed for reliability (test–retest) in 138 students from a San Antonio School District. Children’s height, weight, percentage body fat, reported family history of diabetes, and Texas Assessments of Knowledge and Skills in reading and mathematics scores were collected. This study showed that for Mexican American children living along the Texas–Mexico border, within the time constraints of the classroom, BKScreener yielded better data than the BKFFQ.

Association between Frequency of Ready-to-Eat Cereal Consumption, Nutrient Intakes, and Body Mass Index in Fourth- to Sixth-Grade Low-Income Minority Children

BACKGROUND The consumption of non-ready-to-eat cereal and ready-to-eat cereal (RTEC) breakfasts have been associated with increased nutrient intakes and lower body mass index (BMI). These relationships have not been examined in low-income minority children. OBJECTIVES To evaluate, in low-income minority children, whether there is a relationship among the frequency of RTEC consumption and nutrient intakes measured at baseline, and whether there is a relationship between the frequency of RTEC and BMI controlling for age, sex, ethnicity, and energy intake. DESIGN A longitudinal study design where a cohort was followed for 3 years. SUBJECTS/SETTING Participants were 625 fourth- through sixth-grade, low-income children living in San Antonio, Texas, and enrolled in the control arm of the Bienestar Diabetes Prevention Programs cluster randomized trial. Three multiple-pass 24-hour dietary recalls were collected at the beginning of their fourth-grade year and at the end of their fifth- and sixth-grade years. Childrens age, sex, ethnicity, and height and weight (used to calculate BMI) were collected between August 2001 and May 2004. STATISTICAL ANALYSES PERFORMED Descriptive and inferential statistical analyses were performed. The frequency of breakfast consumption was examined using a 6×4 cross-tabulation table with χ(2) test to establish categorical differences. The degree of association between BMI percentile and frequency of RTEC consumption adjusted for age, sex, ethnicity, and nutrition-related parameters were calculated using a partial correlation multivariate linear model analysis. RESULTS There was a significant positive relationship between the frequency of RTEC consumption and nutrient intakes measured at baseline. There was also a significant inverse relationship between frequency of RTEC consumption and BMI percentile over the cumulative 3-year period controlling for age, sex, ethnicity, and energy intake. CONCLUSIONS Children who frequently consumed RTEC had greater intakes of essential nutrients at baseline and significantly lower BMI over a 3-year period.

Cardiometabolic Risk Assessments by Body Mass Index z -Score or Waist-to-Height Ratio in a Multiethnic Sample of Sixth-Graders

Convention defines pediatric adiposity by the body mass index z-score (BMIz) referenced to normative growth charts. Waist-to-height ratio (WHtR) does not depend on sex-and-age references. In the HEALTHY Study enrollment sample, we compared BMIz with WHtR for ability to identify adverse cardiometabolic risk. Among 5,482 sixth-grade students from 42 middle schools, we estimated explanatory variations (R 2) and standardized beta coefficients of BMIz or WHtR for cardiometabolic risk factors: insulin resistance (HOMA-IR), lipids, blood pressures, and glucose. For each risk outcome variable, we prepared adjusted regression models for four subpopulations stratified by sex and high versus lower fatness. For HOMA-IR, R 2 attributed to BMIz or WHtR was 19%–28% among high-fatness and 8%–13% among lower-fatness students. R 2 for lipid variables was 4%–9% among high-fatness and 2%–7% among lower-fatness students. In the lower-fatness subpopulations, the standardized coefficients for total cholesterol/HDL cholesterol and triglycerides tended to be weaker for BMIz (0.13–0.20) than for WHtR (0.17–0.28). Among high-fatness students, BMIz and WHtR correlated with blood pressures for Hispanics and whites, but not black boys (systolic) or girls (systolic and diastolic). In 11-12 year olds, assessments by WHtR can provide cardiometabolic risk estimates similar to conventional BMIz without requiring reference to a normative growth chart.

Accuracy of self-reported energy intakes in low-income urban 4th grade minority children

We examined the accuracy of self‐reported energy intake (rEI) in low‐income, urban minority school‐aged children at risk for obesity and associated diabetes utilizing a relatively new, simple previously published prediction equation for identifying inaccurate reports of dietary energy intake. Participants included 614 nine‐year‐old boys (51%) and girls (49%). Three 24‐h dietary recalls were collected. Childrens height, weight (used to calculate BMI), and percent body fat (%BF) were measured. Physical fitness, reported family history of diabetes, and ethnicity were also collected. A previously published prediction equation was used to determine the validity of rEIs in these children to identify under‐, plausible‐, and over‐reporters. Additionally, we examined the question of whether there is a difference in reporting by sex, ethnicity, BMI, and %BF. On average, 18% of the children were at risk of being overweight, 43% were already overweight at baseline, yet these children reported consuming fewer calories on average than recommended guidelines. Additionally, reported caloric intake in this cohort was negatively associated with BMI and %BF. Using the previously described methods, 49% of participants were identified as under‐reporters, whereas 39 and 12% were identified as plausible‐ and over‐reporters, respectively. On average, children reported caloric intakes that were almost 100% of predicted energy requirement (pER) when the sedentary category was assigned. Inactivity and excessive energy intake are important contributors to obesity. With the rising rates of obesity and diabetes in children, accurate measures of energy intake are needed for better understanding of the relationship between energy intake and health outcomes.

HEALTHY Study School Food Service Revenue and Expense Report

BACKGROUND Food service directors have a concern that federal reimbursement is not meeting the demands of increasing costs of healthier meals. The purpose of this article is to report the food option changes and the annual revenues and expenses of the school food service environment. METHODS The HEALTHY study was a 3-year (2006 to 2009) randomized, cluster-designed trial conducted in 42 middle schools at 7 field centers. The schools selected had at least 50% of students who were eligible for free or reduced-price lunch or who belonged to a minority group. A randomly assigned half of the HEALTHY schools received a school health intervention program consisting of 4 integrated components: nutrition, physical activity, behavioral knowledge and skills, and social marketing. The nutrition component consisted of changing the meal plans to meet 5 nutrition goals. Revenue and expense data were collected from income statements, federal meal records, à la carte sale sheets, school store sale sheets, donated money/food records, and vending machines. RESULTS Although more intervention schools reached the nutritional goals than control schools, revenues and expenses were not significantly different between groups. CONCLUSION The HEALTHY study showed no adverse effect of school food policies on food service finances.