S. Sonia Arteaga

Challenge! Health Promotion/Obesity Prevention Mentorship Model Among Urban, Black Adolescents

OBJECTIVES: The objective of this study was to evaluate a 12-session home/community-based health promotion/obesity prevention program (Challenge!) on changes in BMI status, body composition, physical activity, and diet. METHODS: A total of 235 black adolescents (aged 11–16 years; 38% overweight/obese) were recruited from low-income urban communities. Baseline measures included weight, height, body composition, physical activity (PA), and diet. PA was measured by 7-day play-equivalent physical activity (≥1800 activity counts per minute). Participants were randomly assigned to health promotion/obesity prevention that is anchored in social cognitive theory and motivational interviewing and was delivered by college-aged black mentors or to control. Postintervention (11 months) and delayed follow-up (24 months) evaluations were conducted. Longitudinal analyses used multilevel models with random intercepts and generalized estimating equations, controlling for baseline age/gender. Stratified analyses examined baseline BMI category. RESULTS: Retention was 76% over 2 years; overweight/obese status declined 5% among intervention adolescents and increased 11% among control adolescents. Among overweight/obese youth, the intervention reduced total percentage of body fat and fat mass and increased fat-free mass at delayed follow-up and increased play-equivalent physical activity at postintervention but not at delayed follow-up. Intervention adolescents declined significantly more in snack/dessert consumption than control adolescents at both follow-up evaluations. CONCLUSIONS: At postintervention, there were intervention effects on diet and PA but not BMI category or body composition. At delayed follow-up, dietary changes were sustained and the intervention prevented an increase in BMI category. Body composition was improved for overweight/obese youth. Changes in body composition follow changes in diet and PA and may not be detected immediately after intervention.

The need for targeted weight-control approaches in young women and men.

In this issue of the American Journal of Preventive Medicine, Brown et al.1 investigate the role that pregnancy plays in 10-year weight gain among a cohort of Australian women who were initially aged 18–23 years. Their results, based on women who were mostly nulliparous and unmarried at baseline, are consistent with previous findings suggesting that childbearing is a significant predictor of later weight gain.2–4 More than 40% of pregnant women in the U.S. gain weight in excess of recommended amounts; the IOM recently updated their guidelines for how much weight women should gain during pregnancy.5 Once gained, excess pregnancy weight is difficult to lose and may be associated with an increased risk of developing obesity, diabetes, and cardiovascular disease (CVD) later in life.6,7 Given that women who enter pregnancy overweight or obese are at higher risk of adverse pregnancy outcomes, such as preeclampsia, gestational diabetes, fetal macrosomia, cesarean delivery8 and postpartum weight retention,6 it would be beneficial for women to attain a healthy weight before they consider pregnancy. However, about 50% of U.S. women of childbearing age are overweight or obese,9 and nearly 50% of pregnancies are unplanned.10 Few researchers have tried to disentangle the role of pregnancy from other factors. Brown et al.1 also conclude that living with a partner but not having a child is associated with higher 10-year weight gain than not having a partner and child. In another recent study, young adults who transitioned from being single or dating to cohabitating or married were more likely to become obese over the next 5–6 years than those not making that transition.11 These two findings suggest that living with a partner itself in addition to pregnancy puts young women at higher risk of obesity. The results of a research by The and Gordon-Larsen11 apply also to young men, but the relationship between parenting and weight gain among men is less well studied. Early adulthood is a time of life-changing events, such as moving away from family and entering the work force, in addition to marriage and parenting. The changing social and environmental context associated with these life changes may profoundly affect weight gain for both young women and men. Indeed, young adults gain 1–2 pounds per year, with the largest weight gain—almost 3 pounds/year—occurring between the ages of 20 and 29 years.12 Excess weight gain early in adulthood is associated with later, more adverse levels of CVD risk factors, such as hypertension, dyslipidemia, and diabetes.13,14 Despite the high risk for weight gain early in adulthood and the subsequent increased risk of adverse outcomes, few studies have tested behavioral interventions aimed at young adults. A few studies have focused on preventing excessive weight gain during pregnancy15–18 or returning to pre-pregnancy weight19,20 but for the most part, these studies have been small, with high attrition and limited generalizability. A similarly small number of studies have targeted weight control among young adults in general.21–23 Although eligible for adult weight-loss studies, young adult participants usually have less weight loss and higher attrition rates than older participants.24 In general, the interventions tested to date have had varying success, suggesting that a better understanding of influences and barriers is pivotal in developing interventions that will appeal to young adults. As with older adults, influences on obesity-related behaviors—particularly dietary intake and physical activity—are multi-factorial, including physiology, family, peers, community, culture, and the environment. However, such influences may differ in their importance to young adults. For example, young adults may be more sensitive to peer pressure, have fewer economic resources, and may be less motivated to adopt healthy behaviors because they perceive health consequences to be distal. New parents may face unique barriers, such as time and energy constraints due to balancing child care, work, and home responsibilities. On the other hand, pregnant women and new parents may be more motivated to control their own weight if they realize that such changes may also benefit their children’s health.25 The National Heart, Lung, and Blood Institute and the Eunice Kennedy Shriver National Institute of Child Health and Human Development recently funded six studies that may begin to fill the interventional research gap related to weight control in young adults. Recognizing that weight-control approaches will need to be targeted toward this age group, each study will conduct formative research to refine the proposed intervention, recruitment, retention, and adherence strategies. Incorporating what was learned during the formative phase, each study will conduct a 2-year RCT to test the efficacy of the behavioral interventions that address weight loss, prevention of weight gain, or prevention of excessive peripartum weight gain. Specific target populations include pregnant and postpartum women, community college or university students, and young adults trying to quit smoking. The trials will have racial/ethnic, gender, and socioeconomic diversity across the study populations. While the interventions build on proven approaches for older adults, they are adapted to be more appealing to young adults. To do this, most plan to use technology-driven methods such as mobile phones, social networks, Internet programs, and web-based curricula. The use of technology to deliver interventions may also reduce participant burden, a critical consideration for pregnant women and new parents. These interventions have the potential to be practical, cost-effective, and easily disseminated on a broad scale if they are proven efficacious. Successful interventions can not only help young adults achieve and maintain a healthy weight, but may prevent or delay the development of many chronic diseases and other obesity-related adverse outcomes. Moreover, by improving health behaviors in adults of childbearing age, these interventions may lead to healthier behaviors and weights for the next generation of children.

Statistical Design Features of the Healthy Communities Study

The Healthy Communities Study is designed to assess relationships between characteristics of community programs and policies targeting childhood obesity and childrens BMI, diet, and physical activity. The study involved a complex data collection protocol implemented over a 2-year period (2013-2015) across a diverse sample of 130 communities, defined as public high school catchment areas. The protocol involved baseline assessment within each community that included in-person or telephone interviews regarding community programs and policies and in-home collection of BMI, nutritional, and physical activity outcomes from a sample of up to 81 children enrolled in kindergarten through eighth grade in public schools. The protocol also involved medical record reviews to establish a longitudinal trajectory of BMI for an estimated 70% of participating children. Staged sampling was used to collect less detailed measures of physical activity and nutrition across the entire sample of children, with a subset assessed using more costly, burdensome, and detailed measures. Data from the Healthy Community Study will be analyzed using both cross-sectional and longitudinal models that account for the complex design and correct for measurement error and bias using a likelihood-based Markov-chain Monte Carlo methodology. This methods paper provides insights into the complex design features of the Healthy Communities Study and may serve as an example for future large-scale studies that assess the relationship between community-based programs and policies and health outcomes of community residents.

Operational Implementation of the Healthy Communities Study: How Communities Shape Children’s Health

The Healthy Communities Study (HCS) is examining how characteristics of community programs and policies targeting childhood obesity are related to childhood diet, physical activity, and obesity outcomes. The study involves selected districts and public schools in 130 communities; families recruited through schools; and data collected at the community, school, household, and child levels. Data collection took place in two waves-Wave 1 in Spring 2012 and Wave 2 from 2013 to 2015-with analysis to be completed by August 2016. This paper describes operational elements of the HCS, including recruitment activities, field operations, training of data collectors, human subjects protection, and quality assurance and quality control procedures. Experienced trainers oversaw and conducted all training, including training of (1) district and school recruitment staff; (2) telephone interviewers for household screening and recruitment; (3) field data collectors for conducting household data collection; and (4) community liaisons for conducting key informant interviews, document abstraction, and community observations. The study team developed quality assurance and quality control procedures that were implemented for all aspects of the study. Planning and operationalizing a study of this complexity and magnitude, with multiple functional teams, required frequent communication and strong collaboration among all study partners to ensure timely and effective decision making.

Weight Status Measures Collected in the Healthy Communities Study: Protocols and Analyses.

The Healthy Communities Study is one of the largest studies to assess the relationship between characteristics of community programs and policies to prevent childhood obesity and obesity-related outcomes. The purpose of this paper is to describe the protocol that was developed for collecting the anthropometric data for the study and the procedures for analyzing the data. Data were collected from 2013 to 2015 and analyses will be completed by mid-2016. During in-home visits, Healthy Communities Study staff collected height, weight, and waist circumference measurements from child participants and height and weight measurements from adult participants. The protocol for obtaining these measurements was adapted from the protocol used by the National Health and Nutrition Examination Survey, with modifications to accommodate assessments conducted in homes rather than in a Mobile Examination Center. In addition to anthropometric data from in-home visits, the Healthy Communities Study collected retrospective height and weight measurements from the medical records of child participants. These data were used to calculate trajectories of BMI and BMI z-scores. The study implemented procedures for ensuring the accuracy of the in-home measurements and abstracted medical data. These procedures included automatically checking the ranges on entered data, reviewing data for end-digit patterns, and abstracting selected medical records using two independent abstractors to assess agreement. The collection of longitudinal height and weight measures will allow researchers to address several pressing questions related to how characteristics of community programs and policies are associated with obesity-related outcomes among children.

Community Policies and Programs to Prevent Obesity and Child Adiposity

INTRODUCTION Evidence regarding impact of community policies and programs (CPPs) to prevent child obesity is limited, and which combinations of strategies and components are most important is not understood. The Healthy Communities Study was an observational study to assess relationships of characteristics and intensity of CPPs with adiposity, diet, and physical activity in children, taking advantage of variation across the U.S. in community actions to prevent child obesity. The study examined the association of CPPs to prevent child obesity with measured BMI and waist circumference, hypothesizing that communities with more-comprehensive CPPs would have children with lower adiposity. METHODS The study included 130 communities selected by probability-based sampling or because of known CPPs targeting child obesity. Data were collected at home visits on 5,138 children during 2013-2015. CPPs were scored for multiple attributes to create a CPP intensity score. A CPP target behavior score reflected the number of distinct target behaviors addressed. Scores were standardized with the smallest observed score across communities being 0 and the largest 1. Multilevel regression analysis in 2016 adjusted for community, household, and individual characteristics. RESULTS Higher CPP target behavior score was significantly associated with lower BMI and waist circumference in a dose-response relationship, with magnitude for the past 3 years of CPPs of 0.843 (p=0.013) for BMI and 1.783 cm (p=0.020) for waist circumference. CONCLUSIONS This study provides plausible evidence that comprehensive CPPs targeting a greater number of distinct physical activity and nutrition behaviors were associated with lower child adiposity.

Overview of the obesity intervention taxonomy and pooled analysis working group.

The National Heart, Lung, and Blood Institute and the National Institutes of Health Office of Disease Prevention convened a meeting on August 29-30, 2013 entitled “Obesity Intervention Taxonomy and Pooled Analysis.” The overarching goals of the meeting were to understand how to decompose interventions targeting behavior change, and in particular, those that focus on obesity and to combine data from groups of related intervention studies to supplement what can be learned from the individual studies. This paper summarizes the workshop recommendations and provides an overview of the two other papers that originated from the workshop and that address decomposition of behavioral change interventions and pooling of data across diverse studies within a consortium.

College Mentors A View From the Inside of an Intervention to Promote Health Behaviors and Prevent Obesity Among Low-Income, Urban, African American Adolescents

This article examined the views of college mentors who administered Challenge!—a home- and community-based health promotion/overweight prevention intervention that effectively reduced the progression to overweight among African American adolescents. In-depth qualitative interviews among 17 mentors (81%) conducted 1 year following the intervention yielded four primary findings: (a) the importance of a strong mentor–mentee relationship often extending beyond the issues of diet and physical activity, (b) concern at the adversities the adolescents faced (e.g., poverty and household instability); (c) the personal impact of the mentoring process on the mentors’ own dietary and physical activity behavior and career choices; and (d) recommendations regarding subsequent mentoring programs. In summary, college students are a valuable resource as mentors for low-income, African American adolescents and provide insights into the success of health promotion/overweight prevention interventions.

Association between community characteristics and implementation of community programmes and policies addressing childhood obesity: the Healthy Communities Study: Community characteristics and programmes

Little is known about whether characteristics of communities are associated with differential implementation of community programmes and policies to promote physical activity and healthy eating. This study examines associations between community characteristics (e.g. region and race/ethnicity) and the intensity of community programmes and policies implemented to prevent childhood obesity. It explores whether community characteristics moderate the intensity of community efforts to prevent childhood obesity.

Measuring the intensity of community programs and policies for preventing childhood obesity in a diverse sample of US communities: the Healthy Communities Study: Intensity of community programs and policies

Efforts to address the critical public health problem of childhood obesity are occurring across the USA; however, little is known about how to characterize the intensity of these efforts.