NCCOR Supported Early Childcare Research and Resources

CACFP Child Feeding Childcare Centers Childcare Homes Childcare Menus Environmental, Policy and System Approaches Farm to Preschool Food Security Head Start Health Disparities Health Literacy Infancy Parental Perceptions of Weight Parental Stress Physical Activity Prenatal and Postpartum Preschool-Aged Screen Time Sleep Water and Beverages

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Child and Adult Care Food Program (CACFP)

Schwartz MB, et al. Comparing current practice to recommendations for the Child and Adult Care Food Program. Child Obes . 2015;11(5):491- 498.

All centers provided access to all required lunch components, but not all components were served (i.e., placed on the child's plate). Vegetables were significantly less likely to be served than meat or grains. Compared with CACFP recommended portion sizes, servings of meat and grain were high, whereas milk was low. Compared with IOM recommendations, average calorie consumption was appropriate, but saturated fat, protein, and sodium intake were high and dietary fiber was low. Meals that offered children both a fruit and a vegetable led to significantly higher produce consumption than meals that offered only one fruit or one vegetable. Child care centers generally comply with current CACFP regulations, but do not provide lunches consistent with the 2011 IOM recommendations for saturated fat, protein, fiber, and sodium. Decreased use of beef and cheese and increased provision of whole grains, fruits, and vegetables are recommended.

Ritchie LD, et al. Participation in the Child and Adult Care Food Program is associated with more nutritious foods and beverages in child care. Child Obes . 2012;8(3):224-229.

CACFP sites in general, and Head Start centers in particular, served more fruits, vegetables, milk, and meat/meat alternatives, and fewer sweetened beverages and other sweets and snack-type items than non-CACFP sites. Reported barriers to providing nutritious foods included high food costs and lack of training. CACFP participation may be one means by which reimbursement for food can be increased and food offerings improved. Further research should investigate whether promoting CACFP participation can be used to provide healthier nutrition environments in child care and prevent obesity in young children.

Monsivais P & Johnson DB. Improving nutrition in home child care: Are food costs a barrier? Public Health Nutr . 2012;15(2):370-376.

In bivariate analyses, higher daily food expenditures were associated with higher total food energy and higher nutritional quality of menus. Controlling for energy and other covariates, higher food expenditures were strongly and positively associated with number of portions of whole grains and fresh produce served (P = 0·001 and 0·005, respectively), with lower energy density and with higher mean nutrient adequacy of menus overall (P = 0·003 and 0·032, respectively). The results indicate that improving the nutritional quality of foods in child care may require higher food spending.

Monsivais P, et al. More nutritious food is served in child-care homes receiving higher federal food subsidies. J

The two groups of providers were socioeconomically and demographically similar with comparable professional backgrounds. However, higher reimbursement providers had significantly greater menu expenditures than the lower reimbursement group ($2.36 vs $1.96/child/day; P=0.031). Reimbursement level was not associated with a difference in calories,

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Am Diet Assoc . 2011;111(5):721-726. ID: 63046

but menus of higher reimbursement providers showed a significantly higher mean nutritional adequacy (64.5% vs 56.3%; P=0.033). The finding that reimbursement rates were positively associated with food expenditures and the nutritional quality of foods served suggests that raising CACFP reimbursements can improve child nutrition.

Child Feeding

Wood CT, et al. Association between bottle size and formulate intake in 2-month-old infants. Acad Pediatr . 2016;16(3):254-259.

Of 865 participants in the Greenlight study, 44% (n = 378; 21.8% white, 40.6% black, 35.3% Hispanic, 2.4% other) of infants were exclusively formula fed at 2 months. Median volume per day was 30 oz (interquartile range 12), and 46.0% of infants were fed with large bottles. Adjusted for covariates, parents using larger bottles reported feeding 4 oz more formula per day (34.2 oz, 95% confidence interval 33.5-34.9 vs 29.7 oz, 95% confidence interval 29.2-30.3, P = .03). Among exclusively formula-fed infants, use of a larger bottle is associated with parental report of more formula intake compared to infants fed with smaller bottles. If infants fed with larger bottles receive more formula, these infants may be overfed and consequently at risk for obesity.

Wood, CT, et al. Confirmatory factor analysis of the Infant Feeding Styles Questionnaire in Latino families. Appetite . 2016;100:118-125.

Of 303 parents completing the IFSQ, 84% were born outside the US, and 74% completed the IFSQ in Spanish. Reliability coefficients ranged from 0.28 to 0.61 for the laissez-faire sub-constructs and from 0.58 to 0.83 for the pressuring, restrictive, and responsive sub-constructs. Results for all coefficients were similar between participants responding to an English and Spanish version of the IFSQ. Goodness of fit indices ranged from CFI 0.82-1 and RMSEA 0.00-0.31, and the model performed best in pressuring-soothing (CFI 1.0, RMSEA 0.00) and restrictive-amount (CFI 0.98, RMSEA 0.1) sub-constructs. In a sample of Latino families, pressuring, restrictive, and responsive constructs performed well. The modified IFSQ in both English and Spanish-speaking Latino families may be used to assess parenting behaviors related to early obesity risk in this at-risk population.

Anstey EH, et al. Five-year progress update on the Surgeon General’s Call to Action to Support Breastfeeding, 2011. J Women Health . 2016;25(8):768-776.

In 2011, Surgeon General Regina Benjamin issued a Call to Action to Support Breastfeeding (Call to Action) in an effort to mobilize families, communities, clinicians, healthcare systems, and employers to take action to improve support for breastfeeding. The Call to Action identified 20 key action steps to address society-wide breastfeeding barriers in six areas: mothers and families, communities, healthcare, employment, research, and public health infrastructure. This report highlights major federal activities that show progress toward answering the Call to Action in the first 5 years since its launch.

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Anderson, SE & Keim, SA. Parent-child interaction, self-regulation, and obesity prevention in early childhood. Curr Obes Rep . 2016;5(2):192-200.

This paper describes the epidemiologic evidence linking parent-child relationships, self-regulation, and weight status with a focus on early childhood. The emotional quality of parent-child interactions may influence children's risk for obesity through multiple pathways. Prospective studies linking observer ratings of young children's self-regulation, particularly inhibitory control, to future weight status are discussed. Although findings are preliminary, promoting positive relationships between parents/caregivers and young children holds promise as a component of efforts to prevent childhood obesity. Multi-disciplinary collaborations between researchers with training in developmental science and child health should be encouraged.

Carnell, S; Pryor, K; Mais, L A; Warkentin, S; Benson, L; Cheng, R. Lunch-time food choices in preschoolers: Relationships between absolute and relative intakes of different food categories, and appetitive characteristics and weight. Physiology & Behavior . 2016;162:151-60.

Despite differing preload conditions, children showed remarkable consistency of intake patterns across all five meals with day-to-day intra-class correlations in absolute and percentage intake of each food category ranging from 0.78 to 0.91. Higher CEBQ-SR was associated with lower mean intake of all food categories across all five meals, with the weakest association apparent for snack foods. Higher CEBQ-FR was associated with higher intake of white bread and fruits and vegetables, and higher CEBQ-EF was associated with greater intake of all categories, with the strongest association apparent for white bread. Analyses of intake of each food group as a percentage of total intake, treated here as an index of the child's choice to consume relatively more or relatively less of each different food category when composing their total lunch-time meal, further suggested that children who were higher in CEBQ-SR ate relatively more snack foods and relatively less fruits and vegetables, while children with higher CEBQ-EF ate relatively less snack foods and relatively more white bread. Higher absolute intakes of white bread and snack foods were associated with higher BMI z score. CEBQ sub-scale associations with food intake variables were largely unchanged by controlling for daily metabolic needs. However, descriptive comparisons of lunch intakes with expected amounts based on metabolic needs suggested that overweight/obese boys were at particularly high risk of overeating. Parents' reports of children's appetitive characteristics on the CEBQ are associated with differential patterns of food choice as indexed by absolute and relative intake of various food categories assessed on multiple occasions in a naturalistic, school-based setting, without parents present.

Barrera CM, et al. Age at introduction to solid foods and child obesity at 6 years. Childhood Obes . 2016;12(3):188-192.

Prevalence of obesity in our sample was 12.0%. The odds of obesity was higher among infants introduced to solids <4 months compared to those introduced at 4-<6 months (odds ratio [OR] = 1.66; 95% CI, 1.15, 2.40) in unadjusted analysis; however, this relationship was no longer significant after adjustment for covariates (OR = 1.18; 95% CI, 0.79, 1.77). Introduction of solids ≥6 months was not associated with obesity. We found no interaction between breastfeeding duration and early solid food introduction and subsequent obesity.

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Guerrero, Alma D; Chu, Lynna; Franke, Todd; Kuo, Alice A. Father Involvement in Feeding Interactions with Their Young Children. Am J Health Behavior . 2016;40 (2):221-30 .

Approximately 40% of fathers reported having a great deal of influence on their preschool child’s nutrition and about 50% reported daily involvement in preparing food for their child and assisting their child with eating. Children had over 2 times the odds of consuming fast food at least once a week if fathers reported eating out with their child a few times a week compared to fathers who reported rarely or never eating out with their child (OR, 2.89; 95% CI, 1.94–4.29), adjusting for all covariates. Whether fathers reported eating out with their children was also significantly associated with children’s sweetened beverage intake. Potentially modifiable behaviors that support healthy dietary practices in children may be supported by targeting fathers.

Horning, Melissa L; Fulkerson, Jayne A; Friend, Sarah E; Neumark-Sztainer, Dianne. Associations among Nine Family Dinner Frequency Measures and Child Weight, Dietary,   and Psychosocial Outcomes. J Acad Nutr Diet . 2016;116(6):991-9.

All family dinner frequency measures had comparable means and were correlated within and across parent/caregiver and child reporters (r=0.17 to 0.94; P<0.01). In unadjusted analyses, 78% of family dinner frequency measures were significantly associated with BMIz and 100% were significantly associated with fruit and vegetable intake and Healthy Eating Index-2010. In adjusted models, most significant associations with dietary and psychosocial outcomes remained, but associations with child BMIz remained significant only for parent/caregiver- (β±standard error=-.07±.03; P<0.05) and child-reported (β±standard error=-.06±.02; P<0.01) family dinner frequency measures asking about "sitting and eating" dinner. Despite phrasing variations in family dinner frequency measures (eg, which family members were present and how meals were occurring), few differences were found in associations with dietary and psychosocial outcomes, but differences were apparent for child BMIz, which suggests that phrasing of family dinner frequency measures can influence associations found with weight outcomes.

Schwartz, MB et al. Testing variations on family-style feeding to increase whole fruit and vegetable consumption among preschoolers in child care. Child Obes . 2015;11(5):499-505 .

Eighty-five children ages 3-5 participated. The sample was 81% Hispanic with diverse racial backgrounds. Thirty percent of the children were overweight. FV consumption was at CACFP recommended levels at baseline and remained consistent across conditions. The average amount served for each meal component was at or above CACFP recommendations for all foods except milk, which was consistently served in small portions. Meat and grains servings were frequently 2-3 times larger than CACFP recommendations. Milk consumption was significantly higher in the Combined intervention forThe intervention led to significant increases in milk consumption, which was the only underconsumed meal component. These strategies should be tested with children who have lower baseline intake of FVs. two meals. Children ate significantly less meat during the Combined intervention for one meal.

Dinkevich E, et al. Mothers' feeding behaviors in infancy: Do they predict child weight

Higher pressuring was associated with lower weight-for-length z-scores (WLZ) over the period from baseline out to 30 months and higher restriction with higher child WLZ over the same period. Pressuring and concern about infant undereating/weight were independently associated

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trajectories? Obesity (Silver Spring, Md.). 2015;23(12):2470-2476 .

with WLZ, but the relationship between restrictive feeding and WLZ was reduced by accounting for concern about infant overeating/weight. Child weight trajectories were not influenced by feeding behavior. Mothers restricted heavier infants and pressured leaner infants to eat, and the relationship between restriction and higher infant weight was mediated by concern about infant overeating/weight. Correcting misperceptions and discussing feeding with mothers reporting concern may help prevent excessive early weight gain.

Benjamin Neelon, Sara, et al. Correlation between maternal and infant cortisol varies by breastfeeding status. Infant Behav Dev . 2015;40:252-258 .

Thirty-four infants received formula only and 20 were either partially or fully breastfed. Breastfeeding was associated with higher household income, higher maternal education, and white race. Cortisol levels were higher among breastfed infants at all three time points. After adjustment, maternal cortisol levels were related with infant cortisol at bedtime only (regression estimate 0.06; 95% CI: 0.10, 1.1; p=0.02). The adjusted association between bedtime maternal and infant cortisol was stronger among breastfeeding dyads than among formula-feeding dyads (regression estimate 1.0; 95% CI: 0.1, 2.0; p=0.04 vs. 0.6; CI: -0.1, 1.3; p=0.10). In addition, we assessed the influence of maternal education and household income in our adjusted model; income strengthened the observed association, whereas maternal education did not change the estimate.

Robinson, Thomas N; Matheson, Donna M. Environmental strategies for portion control in children. Appetite . 2015;88:33-38.

Five potential environmental strategies appear promising for improving portion control in children: (1) using tall, thin, and small volume glasses and mugs, (2) using smaller diameter and volume plates, bowls and serving utensils, (3) using plates with rims, (4) reducing total television and other screen watching and (5) reducing or eliminating eating while watching television and/or other screens. Further experimental research in real world settings is needed to test these interventions as strategies for portion control and their roles in prevention and treatment of obesity.

Boles RE & Gunnarsdottir T. Family meals protect against obesity: Exploring the mechanisms. J Pediatr. 2015;166(2):220-221.

Understanding the mechanisms that mediate the link between eating meals together as a family and how they impact on health-related behaviors and weight require additional research. This type of research has important clinical implications. Family meals are a potentially modifiable factor that could be tested for the prevention and treatment of obesity. Thus, further research on the theoretical and methodological issues of family meals could be one factor resulting in more effective childhood obesity prevention and intervention as well as, consequently, reduced overweight and obesity prevalence over time.

Dancel, L. et al. The relationship between acculturation and infant feeding styles in a Latino

A post-hoc analysis was performed using data from an ongoing four-site RCT to promote early childhood obesity prevention. Cross-sectional data of parent-child dyads at the 12 month well-child visit who self-reported their Latino ethnicity were analyzed. The Short Acculturation Scale for Hispanics (SASH) and a subset of the Infant Feeding Style Questionnaire (IFSQ) that assessed

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population. Obesity (Silver Spring, Md.). 2015;23 (4):840-846 .

four primary feeding styles were administered. Analyses compared SASH level (low v. high) with each feeding style. Complete SASH data was available for 398 of 431 Latino dyads. Median SASH score was 1.8 (IQR 1.4 – 2.7); 82% of participants had low acculturation (score < 3). Of the nine outcome variables, four were significantly associated with SASH: “Laissez-Faire/attention” (AOR 2.3 [95% CI 1.06 – 5.13], p=0.004), “Laissez-Faire/diet quality” (3.9 [1.7 – 8.75], p=0.005), “Pressuring as soothing” (3.6 [1.63 – 8.05], p=0.007) and “Restrictive/diet quality” (0.4 [0.19 – 0.94], p=0.031). Latino parents with lower acculturation were more likely than those with higher acculturation to endorse feeding styles that are associated with child obesity. Further research is needed to determine why acculturation and feeding style relate.

Friend, S. et al. Comparing childhood meal frequency to current meal frequency, routines, and expectations among parents. Journal of family psychology. J Division Family Psychology . 2015;29 (1):136-40.

Parental report of eating frequent family meals while growing up was positively and significantly associated with age, education and self-identification as white (all p<0.05). Compared to those who ate family meals less than three times/week or four to five times/week, parents who ate six to seven family meals/week while growing up reported significantly more frequent family meals with their current family (4.0, 4.2 vs 5.3 family meals/week, p=.001). Eating frequent family meals while growing up was also significantly and positively associated with having current regular meal routines and meal expectations about family members eating together (both p<.05). Promoting family meals with children may have long-term benefits over generations.

Karp, Sharon M; Barry, Kathleen M; Gesell, Sabina B; Po'e, Eli K; Dietrich, Mary S; Barkin, Shari L. Parental feeding patterns and child weight status for Latino preschoolers. Obesity Research & Clinical Practice . 2014;8 (1):e88-97.

Higher child BMI was related to higher parental CFQ concern scores (r = 0.41, p <.001). A general inverse association between child BMI percentile and parental responsibility was also observed (r = −0.23, p = .040). Over the 3-month period, no statistically significant associations between changes in the CFQ subscale scores and changes in child BMI percentile were identified. Child BMI percentile consistent with overweight/obese is associated with parental concern about child weight and child BMI percentile consistent with normal weight is associated with perceived responsibility for feeding. Emphasizing parental responsibility to help children to develop healthy eating habits could be an important aspect of interventions aimed at both preventing and reducing pediatric obesity for Latino preschoolers.

Perrin, E. at al. Racial and ethnic differences associated with feeding- and activity-related behaviors in infants. Pediatrics . 2014;133(4) :e857- e867.

Eight hundred sixty-three parents (50% Hispanic, 27% black, 18% white; 86% Medicaid) were enrolled. Exclusive formula feeding was more than twice as common (45%) as exclusive breastfeeding (19%); 12% had already introduced solid food; 43% put infants to bed with bottles; 23% propped bottles; 20% always fed when the infant cried; 38% always tried to get children to finish milk; 90% were exposed to television (mean, 346 minutes/day); 50% reported active television watching (mean, 25 minutes/day); and 66% did not meet “tummy time”

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recommendations. Compared with white parents, black parents were more likely to put children to bed with a bottle (adjusted odds ratio [aOR] = 1.97, P < .004; bottle propping, aOR = 3.1, P < .001), and report more television watching (aOR = 1.6, P = .034). Hispanic parents were more likely than white parents to encourage children to finish feeding (aOR = 1.9, P = .007), bottle propping (aOR = 2.5, P= .009), and report less tummy time (aOR = 0.6, P = .037). Behaviors thought to relate to later obesity were highly prevalent in this large, diverse sample and varied by race/ethnicity, suggesting the importance of early and culturally-adapted interventions.

Yin, H.S. et al. Parent health literacy and "obesogenic" feeding and physical activity-related infant care behaviors. J Pediatrics . 2014;164(3):577- 583 .

11.0% of parents were categorized as having low health literacy. Low health literacy significantly increased the odds of a parent reporting that they feed more formula than breast milk (AOR=2.0 [95%CI:1.2–3.5]), immediately feed when their child cries (AOR=1.8[1.1–2.8]), bottle prop (AOR=1.8 [1.002–3.1]), any infant TV watching (AOR=1.8 [1.1–3.0]), and inadequate tummy time (<30 minutes/day) (AOR=3.0[1.5–5.8]). Low parent health literacy is associated with certain obesogenic infant care behaviors. These behaviors may be modifiable targets for low health literacy-focused interventions to help reduce childhood obesity.

Boles RE, et al. Home food and activity assessment. Development and validation of an instrument for diverse families of young children. Appetite . 2014;80:23-27

Results showed Kappa statistics were high (.67-1.00) between independent researchers but varied between researchers and parents resulting in 85 items achieving criterion validity (Kappa >.60). Analyses of reliable items revealed the presence in the home of a high frequency of unhealthy snack foods, high fat milk and low frequency of availability of fruits/vegetables and low fat milk. Fifty-two percent of the homes were arranged with a television in the preschool child's bedroom. Physical Activity devices also were found to have high frequency availability. Families reporting lower education reported higher levels of sugar sweetened beverages and less low-fat dairy (p < .05) compared with higher education families. Low-income families (<$27K per year) reported significantly fewer Physical Activity devices (p < .001) compared with higher income families. Hispanic families reported significantly higher numbers of Sedentary Devices (p < .05) compared with non-Hispanic families. There were no significant differences between demographic comparisons on available fruits/vegetables, meats, whole grains, and regular fat dairy. A modified home food and activity instrument was found to reliably identify foods and activity devices with geographically and economically diverse families.

Colen CG & Ramey DM. Is breast truly best? Estimating the effects of breastfeeding on long-term child health and wellbeing in the United States

Results from standard multiple regression models suggest that children aged 4 to 14 who were breast- as opposed to bottle-fed did significantly better on 10 of the 11 outcomes studied. Once we restrict analyses to siblings and incorporate within-family fixed effects, estimates of the association between breastfeeding and all but one indicator of child health and wellbeing dramatically decrease and fail to maintain statistical significance. Our results suggest that much of

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using sibling comparisons. Soc Sci & Med . 2014;109:55-65.

the beneficial long-term effects typically attributed to breastfeeding, per se, may primarily be due to selection pressures into infant feeding practices along key demographic characteristics such as race and socioeconomic status.

Clayton HB, et al. Prevalence and reasons for introducing infants early to solid foods: Variations by milk feeding type. Pediatrics . 2013;131:e1108-e1114.

Overall, 40.4% of mothers introduced solid foods before age 4 months. Prevalence varied by milk feeding type (24.3%, 52.7%, and 50.2% for breastfed, formula-fed, and mixed-fed infants, respectively). The most commonly cited reasons for early introduction of solid food were as follows: “My baby was old enough,” “My baby seemed hungry,” “I wanted to feed my baby something in addition to breast milk or formula,” “My baby wanted the food I ate,” “A doctor or other health care professional said my baby should begin eating solid food,” and “It would help my baby sleep longer at night.” Four of these reasons varied by milk feeding type. Our findings highlight the high prevalence of early introduction of solids and provide details on why mothers introduced solid foods early.

Reifsnider E. et al. A randomized controlled trial to prevent childhood obesity through early childhood feeding and parenting guidance: Rationale and design of study. BMC Public Health . 2013;24:13.

The goal of this study is to compare the effectiveness of structured Community Health Worker (CHW)--provided home visits, using an intervention created through community-based participatory research, to standard care received through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) office visits in preventing the development of overweight (weight/length ≥ 85th percentile) and obesity (weight/length ≥ 95th percentile) in infants during their first 3 years of life. One hundred forty pregnant women in their third trimester (30-36 weeks) will be recruited and randomly assigned to the intervention or control group. This study will provide prospective data on the effects of an intervention to prevent childhood obesity in children at high risk for obesity due to ethnicity, income, and maternal body mass index (BMI). It will have wide-ranging applicability and the potential for rapid dissemination through the WIC program, and will demonstrate the effectiveness of a community approach though employing CHWs in preventing obesity during the first 3 years of life. This easy-to-implement obesity prevention intervention can be adapted for many locales and diverse communities and can provide evidence for policy change to influence health throughout life.

Scharf RJ, et al. Longitudinal evaluation of milk type consumed and weight status in preschoolers. Arch Dis Child . 2013;98:335-340.

The majority of children drank whole or 2% milk (87% at 2 years, 79.3% at 4 years). Across racial/ethnic and socio-economic status subgroups, 1%/skim milk drinkers had higher BMI z scores than 2%/whole milk drinkers. In multivariable analyses, increasing fat content in the type of milk consumed was inversely associated with BMI z score (p<0.0001). Compared to those drinking 2%/whole milk, 2- and 4-year-old children drinking 1%/skim milk had an increased adjusted odds of being overweight (age 2 OR 1.64, p<0.0001; age 4 OR 1.63, p<0.0001) or obese (age 2 OR 1.57, p<0.01; age 4 OR 1.64, p<0.0001). In longitudinal analysis, children drinking

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1%/skim milk at both 2 and 4 years were more likely to become overweight/obese between these time points (adjusted OR 1.57, p<0.05). Consumption of 1%/skim milk is more common among overweight/obese preschoolers, potentially reflecting the choice of parents to give overweight/obese children low-fat milk to drink. Nevertheless, 1%/skim milk does not appear to restrain body weight gain between 2 and 4 years of age in this age range, emphasising a need for weight-targeted recommendations with a stronger evidence base.

Perrin EM. Respecting cultural values of toddler weight perception while discouraging parental overfeeding. Arch Pediatr Adolesc Med . 2012; 166(5):422-423 .

In short, we should be able to explore parental perception and satisfaction with children's weight and preserve cultural ideals and pride in children's growth but also help parents achieve healthy weight trajectories. We can do this by counseling with sensitive and culturally competent dialogue and providing guidelines for eating and activity tailored for age, culture, and socioeconomic status compatible with lifelong health.

Erinosho TO, et al. Nutrition policies at child-care centers and impact on role modeling of healthy eating behaviors of caregivers. J Acad Nutr Diet . 2012; 112(1):119-124.

Caregivers (n=124) reported about modeling healthy eating behaviors to children, trained research staff observed caregivers' (n=112) eating behaviors in classrooms, and directors reported about the presence/absence of center policies on staff eating practices. About 90% of caregivers reported modeling healthy eating behaviors to children. At 80% of centers, caregivers were observed modeling healthy dietary behaviors (eg, sitting with or eating same foods as children), but at fewer centers they were observed consuming unhealthy foods (eg, fast foods, salty snacks: 25%; and sugar-sweetened beverages: 50%). Although no substantial associations were observed between caregiver behaviors and center policies, effect size estimates suggest differences that may be of clinical significance. For example, caregivers were observed modeling healthy dietary behaviors more frequently at centers that had written policies about staff discouraging unhealthy foods for meals/snacks and having informal nutrition talks with children at meals. However, caregivers were observed consuming unhealthy foods and sugar-sweetened beverages more often at centers with policies that promoted healthier foods for meals/snacks. Future research should build on this study by using larger samples to understand why healthy food policies in child-care centers may not translate to eating practices among caregivers.

Harnack LJ, et al. Results from an experimental trial at a Head Start center to evaluate two meal service approaches to increase fruit and vegetable

Fruit intake was significantly higher (p<0.01) when fruits and vegetables were served in advance of other meal items (0.40 servings/meal) compared to the traditional family style meal service control condition when they were served in tandem with other menu items (0.32 servings/meal). Intakes of some nutrients found in fruits (vitamin A and folate) were concomitantly higher. In contrast, fruit and vegetable intakes were significantly lower and energy intake significantly

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intake of preschool aged children. Int J Behav Nut Phys Act . 2012;9:51.

higher during the provider portioned compared with control condition. Serving fruits in advance of other meal items may be a low cost easy to implement strategy for increasing fruit intake in young children. However, serving vegetables first does not appear to increase vegetable intake. Results provide support for current recommendations for traditional family style meal service in preschool settings.

Stein LJ, et al. The development of salty taste acceptance is related to dietary experience in human infants: A prospective study. Am J Clin Nutr . 2012;94:123-129.

Dietary experience was related to salt acceptance, with only those infants previously exposed to starchy table foods (n = 26) preferring the salty solutions at 6 mo (P = 0.007). Fruit exposure was not associated with sodium chloride acceptance. Infants eating starchy table foods at 6 mo were more likely to lick salt from the surface of foods at preschool age (P = 0.007) and tended to be more likely to eat plain salt (P = 0.08). The findings suggest an influential role of early dietary experience in shaping salty taste responses of infants and young children.

Vernarelli, JA, et al. Dietary energy density is associated with body weight status and vegetable intake in US children. J Nutr . 2011; 141(12):2204-2210.

In this sample, dietary ED was positively associated with body weight status in U.S. children aged 2-8 y. Obese children had a higher dietary ED than lean children (2.08 ± 0.03 vs. 1.93 ± 0.05; P = 0.02). Diets high in ED were also found to be associated with greater intakes of energy and added sugars, more energy from fat; and significantly lower intake of fruits and vegetables. Interventions that lower dietary ED by means of increasing fruit and vegetable intake and decreasing fat consumption may be an effective strategy for reducing childhood obesity.

Stark LJ, et al. A pilot randomized controlled trial of a clinic and home-based behavioral intervention to decrease obesity in preschoolers. Obesity (Silver Spring) . 2011;19(1):134-141.

Assessments were conducted at baseline, 6 months (end of LAUNCH treatment) and 12 months (6 months following LAUNCH treatment). LAUNCH showed a significantly greater decrease on the primary outcomes of child at month 6 (post-treatment) BMI z (-0.59 ± 0.17), BMI percentile (-2.4 ± 1.0), and weight gain (-2.7 kg ± 1.2) than PC and this difference was maintained at follow-up (month 12). LAUNCH parents also had a significantly greater weight loss (-5.5 kg ± 0.9) at month 6 and 12 (-8.0 kg ± 3.5) than PC parents. Based on the data from this small sample, an intensive intervention that includes child behavior management strategies to improve healthy eating and activity appears more promising in reducing preschool obesity than a low intensity intervention that is typical of treatment that could be delivered in primary care.

Spill, MK, et al. Hiding vegetables to reduce energy density: An effective strategy to increase children’s vegetable intake and reduce energy intake. Am J Clin Nutr . 2011; 94(3):735-741.

Across conditions, entrées at breakfast, lunch, dinner, and evening snack were reduced in ED by increasing the proportion of puréed vegetables. The conditions were 100% ED (standard), 85% ED (tripled vegetable content), and 75% ED (quadrupled vegetable content). Entrées were served with unmanipulated side dishes and snacks, and children were instructed to eat as much as they liked. The daily vegetable intake increased significantly by 52 g (50%) in the 85% ED condition and by 73 g (73%) in the 75% ED condition compared with that in the standard condition (both P < 0.0001). The consumption of more vegetables in entrées did not affect the consumption of the

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vegetable side dishes. Children ate similar weights of food across conditions; thus, the daily energy intake decreased by 142 kcal (12%) from the 100% to 75% ED conditions (P < 0.05). Children rated their liking of manipulated foods similarly across ED amounts. The incorporation of substantial amounts of puréed vegetables to reduce the ED of foods is an effective strategy to increase the daily vegetable intake and decrease the energy intake in young children.

Spill, MK, et al. Serving large portions of vegetable soup at the start of the meal affected children’s energy and vegetable intake. Appetite . 2011;57(1):213-219.

This study tested whether varying the portion of low-energy-dense vegetable soup served at the start of a meal affects meal energy and vegetable intakes in children. Subjects were 3- to 5-year-olds (31 boys and 41 girls) in daycare facilities. Using a crossover design, children were served lunch once a week for four weeks. On three occasions, different portions of tomato soup (150, 225, and 300 g) were served at the start of the meal, and on one occasion no soup was served. Children had 10 min to consume the soup before being served the main course. All foods were consumed ad libitum. The primary outcomes were soup intake as well as energy and vegetable intake at the main course. A mixed linear model tested the effect of soup portion size on intake. Serving any portion of soup reduced entrée energy intake compared with serving no soup, but total meal energy intake was only reduced when 150 g of soup was served. Increasing the portion size increased soup and vegetable intake. Serving low-energy-dense, vegetable soup as a first course is an effective strategy to reduce children's intake of a more energy-dense main entrée and increase vegetable consumption at the meal.

Spill, MK, et al. Eating vegetables first: The use of portion size to increase vegetable intake in preschool children. Am J Clin Nutr . 2010;91(5):1237-1243.

Serving larger portions of low-energy-dense vegetables at a meal could have beneficial effects on children's food and energy intakes. We investigated whether increasing the portion size of vegetables served at the start of a meal leads to increased vegetable consumption and decreased meal energy intake in children. In a crossover design, 3- to 5-y-old children in a daycare center were served a test lunch once a week for 4 wk (n = 51). In 3 of the meals, a first course of raw carrots varied in portion size (30, 60, or 90 g), and no first course was served in the control meal. Children consumed the first course ad libitum over 10 min and then were served a main course of pasta, broccoli, applesauce, and milk, which was also consumed ad libitum. Total vegetable consumption at the meal increased as the portion size of carrots increased (P < 0.0001). Doubling the portion size of the first course increased carrot consumption by 47%, or 12 +/- 2 g (P < 0.0001). Tripling the portion size of carrots, however, did not lead to a further increase in intake (P = 0.61). Meal energy intake was not significantly affected by the amount of carrots served in the first course. The effect of portion size on intake was not significantly influenced by the children's age or body weight status. Increasing the portion size of a vegetable served as a first course can be an effective strategy for increasing vegetable consumption in preschool children.

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Childcare Centers

LaRowe TL, et al. Active Early: One-year policy intervention to increase physical activity among early care and education programs in Wisconsin. BMC Public Health . 2016;16:607.

Observed teacher-led physical activity significantly increased from 30.9 ± 22.7 min at baseline to 82.3 ± 41.3 min at 12 months. The change in percent time children spent in sedentary activity decreased significantly after 12 months (-4.4 ± 14.2 % time, -29.2 ± 2.6 min, p < 0.02). Additionally, as teacher led-activity increased, percent time children were sedentary decreased (r = -0.37, p < 0.05) and percent time spent in light physical activity increased (r = 0.35, p < 0.05). Among all ECE programs, the physical activity environment improved significantly as indicated by multiple sub-scales of the EPAO; scores showing the greatest increases were the Training and Education (14.5 ± 6.5 at 12-months vs. 2.4 ± 3.8 at baseline, p < 0.01) and Physical Activity Policy (18.6 ± 4.6 at 12-months vs. 2.0 ± 4.1 at baseline, p < 0.01). Active Early promoted improvements in providing structured (i.e. teacher-led) physical activity beyond the recommended 60 daily minutes using low- to no-cost strategies along with training and environmental changes. Furthermore, it was observed that Active Early positively impacted child physical activity levels by the end of the intervention. However, resources, training, and technical assistance may be necessary for ECE programs to be successful beyond the use of the Active Early guide. Implementing local-level physical activity policies combined with support from local and statewide partners has the potential to influence higher standards for regulated ECE programs.

Ganter, C, et al. Community stakeholders' perceptions of major factors influencing childhood obesity, the feasibility of programs addressing childhood obesity, and persisting gaps. J Comm Health . 2016;41(2):305-314 .

The vast majority of stakeholders had recently participated in obesity prevention strategies, and nearly all of them identified gaps in prevention efforts either within their organizations or in the broader community. In addition to factors previously identified in the literature, several themes emerged including the need to change policies to increase physical activity during school, offer healthier snacks in schools and afterschool programs, and increase communication and collaboration within the community in prevention efforts. Community stakeholders can impact the success of interventions by bridging the gap between science and lived experience. The results of this study can guide future research by highlighting the importance of including stakeholders' frontline experiences with target populations, and using information on identified gaps to augment intervention planning efforts.

Benjamin Neelon SE, et al. Preventing childhood obesity in early child care and education

To date, our experiences suggest that an intervention should have a firm basis in behaviour change theory; an advisory group should help evaluate intervention materials and plan for delivery; and realistic recruitment goals should recognize economic challenges of the business of

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settings: Lessons from two intervention studies. Child Care Health Dev . 2016;42(3):351- 358.

child care. A flexible data collection approach and realistic sample size calculations are needed because of high rates of child (and sometimes facility) turnover. An intervention that is relatively easy to implement is more likely to appeal to a wide variety of early care and education providers.

Benjamin Neelson SE, et al. Comparative evaluation of a South Carolina policy to improve nutrition in child care. J Acad Nut Diet . 2016;116(6):949- 956.

Compared with North Carolina, centers in South Carolina were more likely to be consistent with the standard prohibiting the use of food as a reward or punishment (odds ratio=1.22; 95% CI 1.11 to 1.61; P=0.03). Two centers in South Carolina met all 13 standards at follow-up compared with none in North Carolina. No other differences were observed. New standards modestly improved nutrition practices in South Carolina child-care centers, but additional support is needed to bring all centers into compliance with the current policies.

Breck A, Dixon LB, Kettel Khan L. Comparison of planned menus and centre characteristics with foods and beverages served in New York City child-care centres. Public Health Nutr . 2016;10:1-8.

Overall, 87 % of the foods and beverages listed on the menus or allowed as substitutions were served. Menu items matched with foods and beverages served for all major food groups by >60 %. Sweets and water had lower match percentages (40 and 32 %, respectively), but water was served 68% of the time when it was not listed on the menu. The staff person making the food and purchasing decisions predicted the match between the planned or substituted items on the menus and the foods and beverages served. In the present study, child-care centre menus included most foods and beverages served to children. Menus planned in advance have potential to be used to inform parents about which child-care centre to send their child or what foods and beverages their enrolled children will be offered throughout the day.

Dixon LB, Breck A, Kettel Khan L. Comparison of children’s food and beverage intakes with national recommendations in New York City child-care centres. Public Health Nutr. 2016;10:1-7.

Foods and beverages provided to and consumed by children (n 630) met >50 % of the Dietary Reference Intake (DRI) for most nutrients. Intakes of fibre and vitamins D and E were <30 % of the DRI. Foods and beverages provided >50 % of the recommended average daily intake amounts for total grains, fruits and fruit juices, and dairy, but <50 % of the recommended amounts for whole grains, protein foods and vegetables. Intake of oils was below the allowance for energy levels, but foods and beverages with solid fats and added sugars exceeded the limits by 68 %. Providing more whole grains, vegetables and low-fat dairy and fewer foods with solid fats and added sugars may improve children’s diet quality when at child-care centres. Centre staff may need training, resources and strategies in order to meet the nutrition recommendations.

Erinosho T, et al. Impact of policies on physical activity and screen time practices in 50 child-care centers in North Carolina. J Phys Act Health . 2016;13(1):59-

Physical activity and screen time policies varied across centers. Observational data showed 82.7 min/d of active play opportunities were provided to children. Screen time provided did not exceed 30 min/d/child at 98% of centers. Accelerometer data showed children spent 38 min/d in moderate-to-vigorous physical activity and 206 min/d in sedentary activity. Policies about staff supervision of media use were negatively associated with screen time (P < .05). Contrary to

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66. ID: 63050 expectation, policies about physical activity were associated with less time in physical activity. Clear strategies are needed for translating physical activity policies to practice. Further research is needed to evaluate the quality of physical activity policies, their impact on practice, and ease of operationalization.

Schwartz MB, et al. Comparing current practice to recommendations for the Child and Adult Care Food Program. Child Obes . 2015;11(5):491- 498.

All centers provided access to all required lunch components, but not all components were served (i.e., placed on the child's plate). Vegetables were significantly less likely to be served than meat or grains. Compared with CACFP recommended portion sizes, servings of meat and grain were high, whereas milk was low. Compared with IOM recommendations, average calorie consumption was appropriate, but saturated fat, protein, and sodium intake were high and dietary fiber was low. Meals that offered children both a fruit and a vegetable led to significantly higher produce consumption than meals that offered only one fruit or one vegetable. Child care centers generally comply with current CACFP regulations, but do not provide lunches consistent with the 2011 IOM recommendations for saturated fat, protein, fiber, and sodium. Decreased use of beef and cheese and increased provision of whole grains, fruits, and vegetables are recommended.

Tandon PS, et al. Active play opportunities at child care. Pediatrics . 2015;135(6):e1425- 1431.

Children's activity was 73% sedentary, 13% light, and 14% MVPA. For 88% of time children did not have APOs, including 26% time as naptime. On average, 48 minutes per day were APOs (41% sedentary, 18% light, and 41% MVPA), 33 minutes per day were outdoors. The most frequent APO was outdoor free play (8% of time); outdoor teacher-led time was <1%. Children were more active and less sedentary outdoors versus indoors and during the child-initiated APOs (indoors and outdoors) versus teacher-led APOs.

Ball SC, et al. Physical activity-related and weather-related practices of child care centers from 2 States. J Phys Act Health . 2015;12(2):238-244.

MA did not differ from RI in meeting PA recommendations (β = 0.03; 0.15, 0.21; P = .72), but MA centers scored higher on weather-related practices (β = 0.47; 0.16, 0.79; P = .004). For-profit centers had lower PA scores compared with nonprofits (β = −0.20; 95% CI: −0.38, −0.02; P = .03), but they did not differ for weather (β = 0.12; −0.19, 0.44; P = .44).

Schwartz, MB et al. Testing variations on family-style feeding to increase whole fruit and vegetable consumption among preschoolers in child care. Child Obes . 2015;11(5):499-505 .

Eighty-five children ages 3-5 participated. The sample was 81% Hispanic with diverse racial backgrounds. Thirty percent of the children were overweight. FV consumption was at CACFP recommended levels at baseline and remained consistent across conditions. The average amount served for each meal component was at or above CACFP recommendations for all foods except milk, which was consistently served in small portions. Meat and grains servings were frequently 2-3 times larger than CACFP recommendations. Milk consumption was significantly higher in the Combined intervention forThe intervention led to significant increases in milk consumption, which was the only underconsumed meal component. These strategies should be tested with

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children who have lower baseline intake of FVs. two meals. Children ate significantly less meat during the Combined intervention for one meal.

Kwon S, et al. Environmental factors associated with child physical activity at childcare. Health Behav Policy Rev . 2015;4(8):260-267. ID: 67307

ED users engaged in high-risk health behaviors and significantly lower rates of preventive health screenings. The ED cohort reported significantly poorer perceptions of health and lower prevalence of disease.

Ritchie LD, et al. Policy improves what beverages are served to young children in child care. J Acad Nutr Diet . 2015;115(5):724-730.

Responses were obtained from 429 sites in 2008 and 435 in 2012. After adjustment for child-care category, significant improvements in 2012 compared with 2008 were found; more sites served water with meals/snacks (47% vs 28%; P=0.008) and made water available indoors for children to self-serve (77% vs 69%; P=0.001), and fewer sites served whole milk usually (9% vs 22%; P=0.006) and 100% juice more than once daily (20% vs 27%; P=0.038). During 2012, 60% of sites were aware of beverage policies and 23% were judged fully compliant with the California law. A positive effect occurred on beverages served after enactment of state and federal policies. Efforts should continue to promote beverage policies and support their implementation.

Ritchie LD, et al. Drinking water in California child care sites before and after 2011-2012 beverage policy. Prev Chronic Dis . 2015;12:140548 .

A significantly larger percentage of sites in 2012 than in 2008 always served water at the table with meals or snacks (47.0% vs 28.0%, P = .001). A significantly larger percentage of child care sites in 2012 than in 2008 made water easily and visibly available for children to self-serve both indoors (77.9% vs 69.0%, P = .02) and outside (78.0% vs 69.0%, P = .03). Sites that participated in the federal Child and Adult Care Food Program had greater access to water indoors and outside than sites not in the program. In 2012 most (76.1%) child care providers reported no barriers to serving water to children. Factors most frequently cited to facilitate serving water were information for families (39.0% of sites), beverage policy (37.0%), and lessons for children (37.9%). Water provision in California child care improved significantly between samples of sites studied in 2008 and 2012, but room for improvement remains after policy implementation. Additional training for child care providers and parents should be considered.

Benajamin Neelson S, et al. Regulations to promote healthy sleep practices in child care. Pediatrics . 2014;134(6):1167- 1174 .

The mean number of regulations for states was 0.9 for centers and 0.8 for homes out of a possible 4.0. For centers, no state had regulations for all 4 recommendations; 11 states had regulations for 2 of the 4 recommendations. For homes, 9 states had regulations for 2 of the recommendations. States in the Northeast had the greatest mean number of regulations for centers (1.2) and homes (1.1), and states in the South had the fewest (0.7 and 0.7, respectively); these geographic differences were significant for centers (P = .03) but not homes (P = .14).

Duffey KJ, et al. States lack The average number and range of regulations in centers and homes was 4.1 (standard deviation

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physical activity policies in child care that are consistent with national recommendations. Child Obes . 2014;10(6):491-500.

[SD], 1.4; range, 0-8) and 3.8 (SD, 1.5; range, 0-7), respectively. Nearly all states had regulations consistent with providing an outdoor (centers, 98%; homes, 95%) and indoor (centers, 94%, homes, 92%) environment "with a variety of portable play equipment and adequate space." No state had regulations for staff joining children, avoiding punishment for being physically active, yearly consultation from a PA expert, or providing training/education on PA for providers.

Stephens RL, Xu Y, Lesesne CA, Dunn L, Kakietek J, Jernigan J, et al. Relationship between child care centers’ compliance with physical activity regulations and children’s physical activity, New York City, 2010. Prev Chronic Dis . 2014; 11:130432.

Centers' compliance with the regulation of obtaining at least 60 minutes of total physical activity per day was positively associated with children's levels of moderate to vigorous physical activity (MVPA); compliance with the regulation of obtaining at least 30 minutes of structured activity was not associated with increased levels of MVPA. Children in centers with a dedicated outdoor play space available also spent more time in MVPA. Boys spent more time in MVPA than girls, and non-Hispanic black children spent more time in MVPA than Hispanic children. To increase children's level of MVPA in child care, both time and type of activity should be considered. Further examination of the role of play space availability and its effect on opportunities for engaging in physical activity is needed.

Kakietek J, Osuji TA, O’Dell SA, Breck A, Kettel Khan L. Compliance with New York City’s beverage regulations and beverage consumption among children in early child care centers. Prev Chronic Dis . 2014; 11:130430.

Compliance with the regulations was associated with lower odds of children consuming milk with more than 1% fat content and sugar-sweetened beverages during meals and snacks. There was not a significant relationship between compliance with the regulations and children's consumption of water. The findings suggest a strong, direct relationship between what a center serves and what a child consumes, particularly regarding consumption of higher-fat milk and sugar-sweetened beverages. Therefore, policies governing the types of beverages served in child care centers may increase children's consumption of more healthful beverages and reduce the consumption of less healthful ones.

Lessard L, Lesesne C, Kakietek J, Breck A, Jernigan J, Dunn L, et al. Measurement of compliance with New York City’s regulations on beverages, physical activity, and screen time in early child care centers. Prev Chronic Dis . 2014; 11:130433.

Compliance with certain requirements of the beverage regulations was high and fairly consistent between components, whereas compliance with the physical activity regulation varied according to the data collection component. Compliance with the regulation on amount and content of screen time was high and consistent. Compliance with the physical activity regulation may be a more fluid, day-to-day issue, whereas compliance with the regulations on beverages and television viewing may be easier to control at the center level. Multiple indicators over multiple time points may provide a more complete picture of compliance - especially in the assessment of compliance with physical activity policies.

Kakietek J, Dunn L, O’Dell SA, Jernigan J, Kettel Khan L.

Measures of training related to physical activity the center received: the number of staff members who participated in Sport, Play and Active Recreation for Kids (SPARK) and other training

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Training and technical assistance for compliance with beverage and physical activity components of New York City’s regulations for early child care centers. Prev Chronic Dis . 2014; 11:130434.

programs in which a center participated were associated with better compliance with the physical activity regulations. Neither training nor technical assistance were associated with compliance with the regulations related to beverages. Increased compliance with regulations pertaining to physical activity was not related to compliance with beverage regulations. Future trainings should be targeted to the specific regulation requirements to increase compliance.

Nonas C, Silver LD, Kettel Khan L. Insights and implications for health departments from the evaluation of New York City’s regulations on nutrition, physical activity, and screen time in child care centers. Prev Chronic Dis . 2014; 11:130429.

In 2006, the New York City Department of Health and Mental Hygiene, seeking to address the epidemic of childhood obesity, issued new regulations on beverages, physical activity, and screen time in group child care centers. An evaluation was conducted to identify characteristics of New York City child care centers that have implemented these regulations and to examine how varying degrees of implementation affected children's behaviors. This article discusses results of this evaluation and how findings can be useful for other public health agencies. Knowing the characteristics of centers that are more likely to comply can help other jurisdictions identify centers that may need additional support and training. Results indicated that compliance may improve when rules established by governing agencies, national standards, and local regulatory bodies are complementary or additive. Therefore, the establishment of clear standards for obesity prevention for child care providers can be a significant public health achievement.

Benjamin Neelon SE, Taveras EM, Ø stbye T, Gillman MW. Preventing obesity in infants and toddlers in child care: Results from a pilot randomized controlled trial. Maternal Child Health Jour . 2014;18(5):1246- 57.

Few interventions have focused on very young children for obesity prevention. This study evaluated a pilot intervention to improve the nutrition and physical activity environments of child care centers serving infants and toddlers. This randomized controlled trial took place in 32 centers in Boston, Massachusetts. The intervention aimed to improve policies and practices related to nutrition and physical activity within the center. For the outcome, observers assessed center environments using the Environment and Policy Assessment and Observation (EPAO) instrument (range 0-320 points) at baseline and the 6-month follow-up. We fit linear regression models with change in EPAO score from baseline to follow-up, controlling for potential confounders for total score, nutrition sub-score, and physical activity sub-score. Intervention centers had a mean (SD) of 98.2 (144.8) children enrolled, while control centers had 59.2 (34.5). In intervention centers, 47.5% of children were white, compared to 46.2% in controls. Fewer intervention centers had outdoor play areas on site (75 vs. 100%) but more had indoor play space (67 vs. 25%). At baseline, intervention centers had a mean (SD) EPAO score of 134.5 (7.0) points and controls had 146.8 (4.8) points. Compared with controls, intervention centers improved their EPAO scores at follow-up by 18.5 points (95% CI 0.1, 37.0; p = 0.049), chiefly

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through greater improvement in physical activity (12.2; 95% CI -1.6, 26.0; p = 0.075) and not nutrition (6.4; 95% CI -7.1, 19.8; p = 0.385). The pilot showed promise as an intervention to improve center environments, but future studies should include child-level outcomes.

Nonas C, Silver LD, Kettel Khan L, Leviton L. Rationale for New York City’s regulations on nutrition, physical activity, and screen time in early child care centers. Prev Chronic Dis. 2014; 11:130435.

Childhood obesity is associated with health risks in childhood, and it increases the risk of adult obesity, which is associated with many chronic diseases. Therefore, implementing policies that may prevent obesity at young ages is important. In 2007, the New York City Department of Health and Mental Hygiene implemented new regulations for early childhood centers to increase physical activity, limit screen time, and provide healthful beverage offerings (ie, restrict sugar-sweetened beverages for all children, restrict whole milk for those older than 2 years, restrict juice to beverages that are 100% juice and limit serving of juice to only 6 ounces per day, and make water available and accessible at all times). This article explains why these amendments to the Health Code were created, how information about these changes was disseminated, and what training programs were used to help ensure implementation, particularly in high-need neighborhoods.

Breck A, Goodman K, Dunn L, Stephens RL, Dawkins N, Dixon B, et al. Evaluation design of New York City’s regulations on nutrition, physical activity, and screen time in early child care centers. Prev Chronic Dis . 2014; 11:130431.

This article describes the multi-method cross-sectional design used to evaluate New York City Department of Health and Mental Hygiene's regulations of nutrition, physical activity, and screen time for children aged 3 years or older in licensed group child care centers. The Center Evaluation Component collected data from a stratified random sample of 176 licensed group child care centers in New York City. Compliance with the regulations was measured through a review of center records, a facility inventory, and interviews of center directors, lead teachers, and food service staff. The Classroom Evaluation Component included an observational and biometric study of a sample of approximately 1,400 children aged 3 or 4 years attending 110 child care centers and was designed to complement the center component at the classroom and child level. The study methodology detailed in this paper may aid researchers in designing policy evaluation studies that can inform other jurisdictions considering similar policies.

Williams PA, et al. Nutrition-education program improves preschoolers’ at-home diet: A group randomized trial. J Acad Nutr Diet . 2014;114(7):1001- 1008.

The program had a substantial impact on children's at-home daily consumption of vegetables and use of low-fat/fat-free milk. This study also found a significant increase in the frequency of child-initiated vegetable snacking, which might have contributed to the significant increase in vegetable consumption. The program did not have a significant impact on fruit consumption or parental offerings of fruits and vegetables, child-initiated fruit snacking, or child fruit consumption. This intervention in child-care settings that emphasized children, parents, and teachers significantly increased at-home vegetable and low-fat/fat-free milk consumption among low-income preschoolers.

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Middleton AE, et al. From policy to practice: Implementation of water policies in child care centers in Connecticut. J Nutr Educ Behav . 2013;45(2):119-125.

Many centers were in violation of water-promoting policies. Water was available in most classrooms (84%) but was only adult accessible in over half of those classrooms. Water was available during one third of physical activity periods observed. Verbal prompts for children to drink water were few. Support is needed to help centers meet existing water policies and new water requirements included in the 2010 Child Nutrition Reauthorization Act.

Patel & Ritchie. Striving for meaningful policies to reduce sugar-sweetened beverage intake among young children. Pediatrics . 2013;132(3):566- 568.

The percentage of children consuming an SSB on the prior day declined from 40% in 2003 to 16% in 2009 (P < .001) among children ages 2 to 5 and from 54% in 2003 to 33% in 2009 (P < .001) among children ages 6 to 11. The percentage of children consuming any SSB decreased for all racial/ethnic groups, although there were disparities with higher consumption among Latinos. Among children ages 2 to 5, consumption of 2 or more servings of 100% fruit juice per day decreased among white children and increased among Latinos. For children ages 6 to 11, consumption of 2 or more servings of 100% fruit juice per day remained stable for white children and increased among Latinos and African Americans.

Pratt C, et al. Childhood Obesity Prevention and Treatment Research (COPTR): Interventions addressing multiple influences in childhood and adolescent obesity . Contemp Clin Trials . 2013;36 (2) :406- 413.

This paper is the first of five papers in this issue that describes a new research consortium funded by the National Institutes of Health. It describes the design characteristics of the Childhood Obesity Prevention and Treatment Research (COPTR) trials and common measurements across the trials. The COPTR Consortium is conducting interventions to prevent obesity in pre-schoolers and treat overweight or obese 7-13 year olds. Four randomized controlled trials will enroll a total of 1700 children and adolescents (~50% female, 70% minorities), and will test innovative multi-level and multi-component interventions in multiple settings involving primary care physicians, parks and recreational centers, family advocates, and schools. For all the studies, the primary outcome measure is body mass index; secondary outcomes, moderators and mediators of intervention include diet, physical activity, home and neighborhood influences, and psychosocial factors. COPTR is being conducted collaboratively among four participating field centers, a coordinating center, and NIH project offices. Outcomes from COPTR have the potential to enhance our knowledge of interventions to prevent and treat childhood obesity.

Namenek Brouwer RJ, Benjamin Neelon SE. Watch Me Grow: A garden-based pilot intervention to increase vegetable and fruit intake in preschoolers. BMC Public Health . 2013;13:363.

Americans, including children, consume fewer fruit and vegetable servings than is recommended. Given that young children spend large amounts of time in child care centers, this may be an ideal venue for increasing consumption of and enthusiasm for fruits and vegetables. This pilot study aimed to assess the feasibility of a gardening intervention to promote vegetable and fruit intake among preschoolers. We enrolled two intervention centers and two control centers. The intervention included a fruit and vegetable garden, monthly curriculum, gardening support, and

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technical assistance. We measured mean (SD) servings of fruits and vegetables served to and consumed by three children per center before and after the intervention. Post intervention, intervention and control centers served fewer vegetables (mean (standard deviation) difference of -0.18 (0.63) in intervention, -0.37 (0.36) in control), but intervention children consumed more than control children (+0.25 (1.11) vs. -0.18 (0.52). The number of fruits served decreased in all centers (intervention -0.62 (0.58) vs. control -0.10 (0.52)) but consumption was higher in controls (intervention -0.32 (0.58) vs. control 0.15 (0.26)). The garden-based feasibility study shows promise, but additional testing is needed to assess its ability to increase vegetable and fruit intake in children.

Roes, LS, et al. Serving a variety of vegetables and fruit as a snack increased intake in preschool children. Am J Clin Nutr . 2013;98(3):693-699.

Offering a variety of vegetables or fruit increased the likelihood of selection (P < 0.0001); children chose some pieces in 94% of snacks with variety and in 70% of snacks without variety. Serving a variety also increased consumption of both vegetables and fruit (P < 0.0002); the mean (±SEM) increase was 31 ± 5 g, about one-sixth the recommended daily amount. Independent of the variety effect, children were less likely to select vegetables than fruit (P < 0.0001), and the mean intake was substantially less for vegetables than for fruit (22 ± 1 compared with 84 ± 3 g). Providing a variety of vegetables and fruit as a snack led to increased consumption of both food types in a childcare facility. Serving a variety of vegetables or fruit as a snack could help preschool children meet recommended intakes.

Ward DS, et al. Expert and stakeholder consensus on priorities for obesity prevention in early care and education settings. Child Obes . 2013;9(2):116-124. ID: 71393

A total of 64 research issues were identified, and voting narrowed this list to 24 issues. Highest-rated issues included: Assessment of the quality of children's meals and snacks, use of financial incentives, interventions that include healthcare providers, the role of screen time, and need for multilevel interventions. The presentations within this meeting highlighted the importance of research to address the unique challenges for those working in early care and education settings. Expert and stakeholder consensus of priorities identified significant and innovative areas where future obesity prevention research efforts should be focused.

Bellows LL, et al. The Colorado LEAP study: Rationale and design of a study to assess the short term longitudinal effectiveness of a preschool nutrition and physical activity program. BMC Public Health . 2013;13:1146.

The study is located in 5 rural Colorado preschool centers and elementary schools (2 treatment and 3 control). Treatment sites receive The Food Friends nutrition (12 weeks) and physical activity (18 weeks) interventions during preschool. Observational measures assess 3 layers of the social ecological model including individual, family and organizational inputs. Children's food preferences, food intake, gross motor skills, physical activity (pedometers/accelerometers), cognitive, physical and social self-competence and height/weight are collected. Parents provide information on feeding and activity practices, child's diet, oral sensory characteristics, food neophobia, home food and activity environment, height/weight and physical activity

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(pedometers). School personnel complete a school environment and policy assessment. Measurements are conducted with 3 cohorts at 4 time points - baseline, post-intervention, 1- and 2-year follow-up. The design of this study allows for longitudinal exploration of relationships among eating habits, physical activity patterns, and weight status within and across spheres of the social ecological model. These methods advance traditional study designs by allowing not only for interaction among spheres but predictively across time. Further, the recruitment strategy includes both boys and girls from ethnic minority populations in rural areas and will provide insights into obesity prevention effects on these at risk populations.

Harnack LJ, et al. Results from an experimental trial at a Head Start center to evaluate two meal service approaches to increase fruit and vegetable intake of preschool aged children. Int J Behav Nut Phys Act . 2012; 9:51.

Fruit intake was significantly higher (p<0.01) when fruits and vegetables were served in advance of other meal items (0.40 servings/meal) compared to the traditional family style meal service control condition when they were served in tandem with other menu items (0.32 servings/meal). Intakes of some nutrients found in fruits (vitamin A and folate) were concomitantly higher. In contrast, fruit and vegetable intakes were significantly lower and energy intake significantly higher during the provider portioned compared with control condition. Serving fruits in advance of other meal items may be a low cost easy to implement strategy for increasing fruit intake in young children. However, serving vegetables first does not appear to increase vegetable intake. Results provide support for current recommendations for traditional family style meal service in preschool settings.

Erinosho TO, et al. Nutrition policies at child-care centers and impact on role modeling of healthy eating behaviors of caregivers. J Acad Nutr Diet . 2012;112(1):119-124. I D: 63050

Caregivers (n=124) reported about modeling healthy eating behaviors to children, trained research staff observed caregivers' (n=112) eating behaviors in classrooms, and directors reported about the presence/absence of center policies on staff eating practices. About 90% of caregivers reported modeling healthy eating behaviors to children. At 80% of centers, caregivers were observed modeling healthy dietary behaviors (eg, sitting with or eating same foods as children), but at fewer centers they were observed consuming unhealthy foods (eg, fast foods, salty snacks: 25%; and sugar-sweetened beverages: 50%). Although no substantial associations were observed between caregiver behaviors and center policies, effect size estimates suggest differences that may be of clinical significance. For example, caregivers were observed modeling healthy dietary behaviors more frequently at centers that had written policies about staff discouraging unhealthy foods for meals/snacks and having informal nutrition talks with children at meals. However, caregivers were observed consuming unhealthy foods and sugar-sweetened beverages more often at centers with policies that promoted healthier foods for meals/snacks. Future research should build on this study by using larger samples to understand why healthy food policies in child-care

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centers may not translate to eating practices among caregivers.Gooze RA, et al. Obesity and food insecurity at the same table: How Head Start Programs respond. Prev Chronic Dis . 2012;9:E132.

The response rate was 87% (N = 1,583). Nearly all programs (99.5%) reported obtaining height and weight data, 78% of programs calculated BMI for all children, and 50% of programs discussed height and weight measurements with all families. In 14% of programs, directors reported that staff often or very often saw children who did not seem to be getting enough to eat at home; 55% saw this sometimes, 26% rarely, and 5% never. Fifty-four percent of programs addressed perceived food insecurity by giving extra food to children and families. In 39% of programs, staff primarily decided what portion sizes children received at meals, and in 55% the children primarily decided on their own portions. Head Start programs should consider moving resources from assessing BMI to assessing household food security and providing training and technical assistance to help staff manage children's portion sizes.

Ritchie LD, et al. Participation in the child and adult care food program is associated with more nutritious foods and beverages in child care. Child Obes . 2012;8(3):224-229.

CACFP sites in general, and Head Start centers in particular, served more fruits, vegetables, milk, and meat/meat alternatives, and fewer sweetened beverages and other sweets and snack-type items than non-CACFP sites. Reported barriers to providing nutritious foods included high food costs and lack of training. CACFP participation may be one means by which reimbursement for food can be increased and food offerings improved. Further research should investigate whether promoting CACFP participation can be used to provide healthier nutrition environments in child care and prevent obesity in young children.

Patel AI & Hampton KE. Encouraging consumption of water in school and child care settings: Access, challenges, and strategies for improvement. Am J Public Health . 2011;101(8):1370-1379.

Children and adolescents are not consuming enough water, instead opting for sugar-sweetened beverages (sodas, sports and energy drinks, milks, coffees, and fruit-flavored drinks with added sugars), 100% fruit juice, and other beverages. Drinking sufficient amounts of water can lead to improved weight status, reduced dental caries, and improved cognition among children and adolescents. Because children spend most of their day at school and in child care, ensuring that safe, potable drinking water is available in these settings is a fundamental public health measure. We sought to identify challenges that limit access to drinking water; opportunities, including promising practices, to increase drinking water availability and consumption; and future research, policy efforts, and funding needed in this area.

Henderson KE, et al. Validity of a measure to assess the child-care nutrition and physical activity environment. J Am Diet Assoc . 2011;111(9):1306-1313.

Percent agreement with criterion outcomes ranged from 39% to 97%, with 61% of items achieving agreement ≥80%. Agreement was highest for nutrition and policy domains, and lowest for physical activity and barriers to promoting health. Correlations between food scores across measures were moderate. The self-report survey demonstrated adequate criterion validity. We make recommendations for improving validity of low-agreement items and for the use of more labor-intensive evaluation procedures for domains not adequately assessed through self-report.

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Farfan-Ramirez L, et al. Curriculum intervention in preschool children: Nutrition Matters! J Nutr Educ Behav . 2011;43(4)(Suppl 2):S162-S165.

Garden-based nutrition education programs have the potential to improve willingness to taste fruits and vegetables, encourage fruit and vegetable intake, and increase preferences among youth, whose current preferences for them are low. In the present evaluation, preschool children’s willingness to try 3 of the 4 test fruits and vegetables increased after the nutrition lessons (only) and after the nutrition and gardening lessons of NM! One particular outcome noted in the evaluation is the children’s increased willingness to try vegetables and fruits, such as snap peas, figs, and raspberries, after their involvement with growing plants and preparing snacks with seasonal vegetables and fruits. Further studies are needed to help identify whether the slightly higher increase with the addition of gardening is worth the effort gardens require. Behavior change is more likely to occur when there are multiple levels of intervention, and nutrition education is 1 of the targets, particularly during the early years. Our experience with NM! showed children are more likely to taste vegetables and fruits when they participated in gardening and nutrition activities that allowed them to be active learners. Efforts to build health and wellness in schools might include creating parent-run produce stands to increase access in neighborhoods with no nearby supermarkets. Maintaining communication and support from the school district, center directors, teachers, and assistants, as well as providing on going professional development and technical assistance, was valuable to the evaluation process. Interventions aimed at single behavioral targets are unlikely to have a substantial impact on children’s eating behaviors. Nutrition knowledge is important and should be integrated into schools, but it is not enough to affect behavior change. Using age-appropriate gardening education connected to nutrition can positively influence eating behaviors and has the potential to improve vegetable and fruit intake. However, more research is needed to further study the influence of gardening on the consumption of fruits and vegetables by preschool children.

Gooze RA, et al. Reaching staff, parents, and community partners to prevent childhood obesity in Head Start, 2008. Prev Chronic Dis . 2010;7(3):A54.

Among the 1,583 (87%) responding programs, 60% held workshops to train new staff about children's feeding and 63% held workshops to train new staff about children's gross motor activity. Parent workshops on preparing or shopping for healthy foods were offered by 84% of programs and on encouraging children's gross motor activity by 43% of programs. Ninety-seven percent of programs reported having at least 1 community partnership to encourage children's healthy eating, and 75% reported at least 1 to encourage children's gross motor activity. Head Start programs reported using a multilevel approach to childhood obesity prevention that included staff, parents, and community partners. More information is needed about the content and effectiveness of these efforts.

Hughes CC, et al. Barriers to This article details findings gleaned from a national survey of all directors of Head Start, a

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obesity prevention in Head Start. Health Affairs . 2010;29(3):454- 462.

program that provides early childhood education to nearly one million lower-income children, approximately one third of whom are obese. With respect to implementing policies and practices to address obesity, program directors identified three key barriers: lack of time, money and knowledge. Minimizing these barriers, the authors conclude, will require federal resources.

Kaphingst KM & Story M. Child care as an untapped setting for obesity prevention: State child care licensing regulations related to nutrition, physical activity, and media use for preschool-aged children in the United States. Prev Chronic Dis . 2009;6(1):A11.

We found variability among and within states. CCCs were the most heavily regulated and had the most specific regulations, followed by LFGHs. SFHs had the fewest and most general regulations. Just 2 states, Michigan and West Virginia, specified that CCC menus should be consistent with the Dietary Guidelines for Americans. Only 12 states had regulations that limited foods of low nutritional value in CCCs. Thirty-six states required that children have daily outdoor activity time in CCCs; only 9 states set specific minimum lengths of time that children should be outdoors each day. Eight states set quantified time limits on screen time per day or per week in SFHs. Opportunities exist for strengthening state licensing regulations to prevent childhood obesity. The increasing prevalence of childhood obesity underscores the urgency for state policy efforts to create child care environments that foster healthful eating and participation in physical activity.

Hughes LJ. Creating a farm and food learning box curriculum for preschool-aged children and their families. J Nutr Educ Behav . 2007;39(3):171-172.

Formative evaluation of the library-based curriculum was attempted but proved to be impractical, as library staff was unable to allocate sufficient time to the process. Instead, a follow-up telephone survey was administered to the parents/caregivers of 500 families who used the library-based curriculum. The parents/caregivers were surveyed 6 to 9 months after checking out a fruit or vegetable learning box. A total of 195 parents/caregivers (39%) completed the telephone survey. The evaluation revealed a number of behavior changes.

Relevant Review Articles

Wang, Y, et al. What childhood obesity prevention programmes work? A systematic review and meta-analysis. Obes Rev . 2015; 16(7):547-565.

We identified 147 articles (139 intervention studies) of which 115 studies were primarily school based, although other settings could have been involved. Most were conducted in the United States and within the past decade. SOE was high for physical activity-only interventions delivered in schools with home involvement or combined diet–physical activity interventions delivered in schools with both home and community components. SOE was moderate for school-based interventions targeting either diet or physical activity, combined interventions delivered in schools with home or community components or combined interventions delivered in the community with a school component. SOE was low for combined interventions in childcare or home settings. Evidence was insufficient for other interventions. In conclusion, at least moderately strong

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evidence supports the effectiveness of school-based interventions for preventing childhood obesity. More research is needed to evaluate programmes in other settings or of other design types, especially environmental, policy and consumer health informatics-oriented interventions.

Larson N, et al. What role can child-care settings play in obesity prevention? A review of the evidence and call for research efforts. J Am Diet Assoc . 2011;111(9):1343- 1362.

Research published between January 2000 and July 2010 was identified by searching PubMed and MEDLINE databases, and by examining the bibliographies of relevant studies. Although the review focused on US child-care settings, interventions implemented in international settings were also included. In total, 42 studies were identified for inclusion in this review: four reviews of state regulations, 18 studies of child-care practices and policies that may influence eating or physical activity behaviors, two studies of parental perceptions and practices relevant to obesity prevention, and 18 evaluated interventions. Findings from this review reveal that most states lack strong regulations for child-care settings related to healthy eating and physical activity. Recent assessments of child-care settings suggest opportunities for improving the nutritional quality of food provided to children, the time children are engaged in physical activity, and caregivers' promotion of children's health behaviors and use of health education resources. A limited number of interventions have been designed to address these concerns, and only two interventions have successfully demonstrated an effect on child weight status. Recommendations are provided for future research addressing opportunities to prevent obesity in child-care settings.

Falbe J, et al. The wellness child care assessment tool: A measure to assess the quality of written nutrition and physical activity policies. J Am Diet Assoc . 2011;111(12):1852-1860.

Inter-rater reliability was high for total comprehensiveness and strength scores (intraclass correlation coefficient=0.98 and 0.94, respectively) and subscale scores (intraclass correlation coefficient=0.84 to 0.99). Subscales were adequately internally reliable (Cronbach's α=.53 to .83). Comprehensiveness and strength scores were higher for Head Start centers than non-Head Start centers across most domains and higher for National Association for the Education of Young Children-accredited centers than nonaccredited centers across some but not all domains, providing evidence of construct validity. This instrument provides a standardized method to analyze and compare the comprehensiveness and strength of written nutrition and physical activity policies in child-care centers.

Whitaker RC, et al. A national survey of obesity prevention practices in Head Start. Arch Pediatr Adolesc Med . 2009;163(12):1144-1150.

The 1583 (87%) programs responding to the survey enrolled 828 707 preschool children. Of these programs, 70% reported serving only nonfat or 1% fat milk. Ninety-four percent of programs reported that each day they served children some fruit other than 100% fruit juice; 97% reported serving some vegetable other than fried potatoes; and 91% reported both of these daily practices. Sixty-six percent of programs said they celebrated special events with healthy foods or nonfood treats, and 54% did not allow vending machines for staff. Having an on-site outdoor play area at every center was reported by 89% of programs. Seventy-four percent of programs reported that

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children were given structured (adult-led or -guided) gross motor activity for at least 30 minutes each day; 73% reported that children were given unstructured gross motor activity for at least 30 minutes each day, and 56% reported both of these daily practices. Most Head Start programs report doing more to support healthy eating and gross motor activity than required by federal performance standards in these areas.

Story M, et al. The role of child care settings in obesity prevention. Future Child . 2006;16(1):143-168.

Mary Story, Karen Kaphingst, and Simone French argue that researchers and policymakers focused on childhood obesity have paid insufficient attention to child care. Although child care settings can be a major force in shaping children's dietary intake, physical activity, and energy balance-and thus in combating the childhood obesity epidemic-researchers know relatively little about either the nutrition or the physical activity environment in the nation's child care facilities. What research exists suggests that the nutritional quality of meals and snacks may be poor and activity levels may be inadequate. Few uniform standards apply to nutrition or physical activity offerings in the nation's child care centers. With the exception of the federal Head Start program, child care facilities are regulated by states, and state rules vary widely. The authors argue that weak state standards governing physical activity and nutrition represent a missed opportunity to combat obesity. A relatively simple measure, such as specifying how much time children in day care should spend being physically active, could help promote healthful habits among young children. The authors note that several federal programs provide for the needs of low-income children in child care. The Child and Adult Care Food Program, administered by the Department of Agriculture, provides funds for meals and snacks for almost 3 million children in child care each day. Providers who receive funds must serve meals and snacks that meet certain minimal standards, but the authors argue for toughening those regulations so that meals and snacks meet specific nutrient-based standards. The authors cite Head Start, a federal preschool program serving some 900,000 low-income infants and children up to age five, as a model for other child care programs as it has federal performance standards for nutrition. Although many child care settings fall short in their nutritional and physical activity offerings, they offer untapped opportunities for developing and evaluating effective obesity-prevention strategies to reach both children and their parents.

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Child Care Homes

Tover A, et al. An assessment of nutrition practices and attitudes in family child-care homes: Implications for policy implementation. Prev Chronic Dis . 2015;12:140587 .

Nearly 70% of family childcare homes (FCCHs) reported receiving nutrition training only 0 to 3 times during the past 3 years; however, more than 60% found these trainings to be very helpful. More Hispanic than non-Hispanic providers strongly agreed to sitting with children during meals, encouraging children to finish their plate, and being involved with parents on the topics of healthy eating and weight. These differences persisted in multivariate models. Although some positive practices are in place in Rhode Island FCCHs, there is room for improvement. State licensing requirements provide a foundation for achieving better nutrition environments in FCCHs, but successful implementation is key to translating policies into real changes. FCCH providers need culturally and linguistically appropriate nutrition-related training.

Tovar A, et al. Nutrition and physical activity environments of home-based child care: What Hispanic providers have to say. Child Obes . 2015;11(5):521-529.

Providers understood the importance of providing opportunities for healthy eating and PA for the children they cared for, but there was room for improvement, especially with regard to certain feeding and ST practices. Several barriers were evident, including the lack of physical infrastructure for PA, cultural beliefs and practices related to child feeding, and difficulties working with parents to provide consistent messages across environments. Given that FCCPs are aware of the importance of healthy eating and PA, there is a need to address the specific barriers they face, and operationalize some of their knowledge into practical everyday actions. This formative work will inform the development of a culturally relevant, multicomponent intervention for ethnically diverse FCCPs to improve the food and PA environments of their homes, which should, in turn, improve the dietary, PA, and ST behaviors of the 2- to 5-year-old children they care for.

Ostbye, T, et al. The keys to healthy family child care homes intervention: Study design and rationale. Contemp Clin Trials . 2015;40:81-89.

Keys to Healthy Family Child Care Homes (Keys) is a cluster-randomized controlled trial testing the efficacy of an intervention designed to help providers become healthy role models, provide quality food- and physical activity-supportive FCCH environments, and implement effective business practices. The intervention is delivered through workshops, home visits, tailored coaching calls, and educational toolkits. Primary outcomes are child physical activity measured via accelerometry data and dietary intake data collected using direct observation at the FCCH. Secondary outcomes include child body mass index, provider weight-related behaviors, and observed obesogenic environmental characteristics. Keys is an innovative approach to promoting healthy eating and physical activity in young children. The intervention operates in a novel setting, targets children during a key developmental period, and addresses both provider and child behaviors to synergistically promote health.

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Mann, CM, et al. Application of the intervention Mapping protocol to develop Keys, a family child care home intervention to prevent early childhood obesity. BMC Public Health . 2015;15:1227.

Application of the IM process resulted in the creation of the Keys to Healthy Family Child Care Homes program (Keys), which includes three modules: Healthy You, Healthy Home, and Healthy Business. Delivery of each module includes a workshop, educational binder and tool-kit resources, and four coaching contacts. Social Cognitive Theory and Self-Determination Theory helped guide development of change objective matrices, selection of behavior change strategies, and identification of outcome measures. The Keys program is currently being evaluated through a cluster-randomized controlled trial.

Monsivais P & Johnson DB. Improving nutrition in home child care: Are food costs a barrier? Public Health Nutr . 2012;15(2):370-376. ID: 63046

In bivariate analyses, higher daily food expenditures were associated with higher total food energy and higher nutritional quality of menus. Controlling for energy and other covariates, higher food expenditures were strongly and positively associated with number of portions of whole grains and fresh produce served (P = 0·001 and 0·005, respectively), with lower energy density and with higher mean nutrient adequacy of menus overall (P = 0·003 and 0·032, respectively). The results indicate that improving the nutritional quality of foods in child care may require higher food spending.

Monsivais P, et al. More nutritious food is served in child-care homes receiving higher federal food subsidies. J Am Diet Assoc . 2011;111(5):721-726. ID: 63046

The two groups of providers were socioeconomically and demographically similar with comparable professional backgrounds. However, higher reimbursement providers had significantly greater menu expenditures than the lower reimbursement group ($2.36 vs $1.96/child/day; P=0.031). Reimbursement level was not associated with a difference in calories, but menus of higher reimbursement providers showed a significantly higher mean nutritional adequacy (64.5% vs 56.3%; P=0.033). The finding that reimbursement rates were positively associated with food expenditures and the nutritional quality of foods served suggests that raising CACFP reimbursements can improve child nutrition.

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Childcare Menus

Breck A, Dixon LB, Kettel Khan L. Comparison of planned menus and centre characteristics with foods and beverages served in New York City child-care centres. Public Health Nutr . 2016;10:1-8 .

Overall, 87 % of the foods and beverages listed on the menus or allowed as substitutions were served. Menu items matched with foods and beverages served for all major food groups by >60 %. Sweets and water had lower match percentages (40 and 32 %, respectively), but water was served 68 % of the time when it was not listed on the menu. The staff person making the food and purchasing decisions predicted the match between the planned or substituted items on the menus and the foods and beverages served. In the present study, child-care centre menus included most foods and beverages served to children. Menus planned in advance have potential to be used to inform parents about which child-care centre to send their child or what foods and beverages their enrolled children will be offered throughout the day.

Environmental, Policy and System Approaches

Benjamin Neelson SE, et al. Comparative evaluation of a South Carolina policy to improve nutrition in child care. J Acad Nut Diet . 2016;116(6):949-956.

Compared with North Carolina, centers in South Carolina were more likely to be consistent with the standard prohibiting the use of food as a reward or punishment (odds ratio=1.22; 95% CI 1.11 to 1.61; P=0.03). Two centers in South Carolina met all 13 standards at follow-up compared with none in North Carolina. No other differences were observed. New standards modestly improved nutrition practices in South Carolina child-care centers, but additional support is needed to bring all centers into compliance with the current policies.

Perez-Escamilla R, et al. Impact of the baby-friendly Hospital Initiative on breastfeeding and child health outcomes: A systematic review. Mater Child Nutr . 2016;12:402-417.

Experimental, quasi-experimental and observational studies were considered eligible for this review if they assessed breastfeeding outcomes and/or infant health outcomes for healthy, term infants born in a hospital or birthing center with full or partial implementation of BFHI steps. Of the 58 reports included in the systematic review, nine of them were published based on three randomized controlled trials, 19 followed quasi-experimental designs, 11 were prospective and 19 were cross-sectional or retrospective. Studies were conducted in 19 different countries located in South America, North America, Western Europe, Eastern Europe, South Asia, Eurasia and Sub-Saharan Africa. Adherence to the BFHI Ten Steps has a positive impact on short-term, medium-term and long-term breastfeeding (BF) outcomes. There is a dose-response relationship between the number of BFHI steps women are exposed to and the likelihood of improved BF outcomes (early BF initiation, exclusive breastfeeding (EBF) at hospital discharge, any BF and EBF duration). Community support (step 10) appears to be essential for sustaining breastfeeding

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impacts of BFHI in the longer term.LaRowe TL, et al. Active Early: One-year policy intervention to increase physical activity among early care and education programs in Wisconsin. BMC Public Health . 2016;16:607.

Observed teacher-led physical activity significantly increased from 30.9 ± 22.7 min at baseline to 82.3 ± 41.3 min at 12 months. The change in percent time children spent in sedentary activity decreased significantly after 12 months (-4.4 ± 14.2 % time, -29.2 ± 2.6 min, p < 0.02). Additionally, as teacher led-activity increased, percent time children were sedentary decreased (r = -0.37, p < 0.05) and percent time spent in light physical activity increased (r = 0.35, p < 0.05). Among all ECE programs, the physical activity environment improved significantly as indicated by multiple sub-scales of the EPAO; scores showing the greatest increases were the Training and Education (14.5 ± 6.5 at 12-months vs. 2.4 ± 3.8 at baseline, p < 0.01) and Physical Activity Policy (18.6 ± 4.6 at 12-months vs. 2.0 ± 4.1 at baseline, p < 0.01). Active Early promoted improvements in providing structured (i.e. teacher-led) physical activity beyond the recommended 60 daily minutes using low- to no-cost strategies along with training and environmental changes. Furthermore, it was observed that Active Early positively impacted child physical activity levels by the end of the intervention. However, resources, training, and technical assistance may be necessary for ECE programs to be successful beyond the use of the Active Early guide. Implementing local-level physical activity policies combined with support from local and statewide partners has the potential to influence higher standards for regulated ECE programs.

Ritchie LD, et al. Drinking water in California child care sites before and after 2011-2012 beverage policy. Prev Chronic Dis . 2015;12:140548 .

A significantly larger percentage of sites in 2012 than in 2008 always served water at the table with meals or snacks (47.0% vs 28.0%, P = .001). A significantly larger percentage of child care sites in 2012 than in 2008 made water easily and visibly available for children to self-serve both indoors (77.9% vs 69.0%, P = .02) and outside (78.0% vs 69.0%, P = .03). Sites that participated in the federal Child and Adult Care Food Program had greater access to water indoors and outside than sites not in the program. In 2012 most (76.1%) child care providers reported no barriers to serving water to children. Factors most frequently cited to facilitate serving water were information for families (39.0% of sites), beverage policy (37.0%), and lessons for children (37.9%). Water provision in California child care improved significantly between samples of sites studied in 2008 and 2012, but room for improvement remains after policy implementation. Additional training for child care providers and parents should be considered.

Ritchie LD, et al. Policy improves what beverages are served to young children in child care. J Acad Nutr Diet . 2015;115(5):724-730.

Responses were obtained from 429 sites in 2008 and 435 in 2012. After adjustment for child-care category, significant improvements in 2012 compared with 2008 were found; more sites served water with meals/snacks (47% vs 28%; P=0.008) and made water available indoors for children to self-serve (77% vs 69%; P=0.001), and fewer sites served whole milk usually (9% vs 22%; P=0.006) and 100% juice more than once daily (20% vs 27%; P=0.038). During 2012, 60% of

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sites were aware of beverage policies and 23% were judged fully compliant with the California law. A positive effect occurred on beverages served after enactment of state and federal policies. Efforts should continue to promote beverage policies and support their implementation.

Boles RE, et al. Influencing the home food and activity environment of families of preschool children receiving home-based treatment for obesity. Clin Pediatr . 2015;54(14):1387-1390.

This study showed that despite a small, but significant reduction in preschool zBMI for a subsample, families showed little change in the home food and activity environment. The home food and activity environment has rarely been studied with treatment seeking families from diverse backgrounds. This study adds to the literature by showing the potential challenges in making environmental changes related to healthy weight outcomes. While no significant increase in fruits and vegetables was observed in the home environment for the overall sample, subgroup post hoc analysis surprisingly showed greater fruit availability in the weak responder group, suggesting that increasing the availability of fruits may still require other changes in the home environment to affect weight outcomes. The data also showed, however, that strong treatment responders maintained their availability of fruits and vegetables, which may be important given other similar reported data showed lower baseline levels of fruits and vegetables compared with our sample or even reductions following treatment.

Kwon S, et al. Environmental factors associated with child physical activity at childcare. Health Behav Policy Rev . 2015;4(8):260-267.

ED users engaged in high-risk health behaviors and significantly lower rates of preventive health screenings. The ED cohort reported significantly poorer perceptions of health and lower prevalence of disease.

Breck A, Goodman K, Dunn L, Stephens RL, Dawkins N, Dixon B, et al. Evaluation design of New York City’s regulations on nutrition, physical activity, and screen time in early child care centers. Prev Chronic Dis . 2014; 11:130431.

The Center Evaluation Component collected data from a stratified random sample of 176 licensed group child care centers in New York City. Compliance with the regulations was measured through a review of center records, a facility inventory, and interviews of center directors, lead teachers, and food service staff. The Classroom Evaluation Component included an observational and biometric study of a sample of approximately 1,400 children aged 3 or 4 years attending 110 child care centers and was designed to complement the center component at the classroom and child level. The study methodology detailed in this paper may aid researchers in designing policy evaluation studies that can inform other jurisdictions considering similar policies.

Sekhobo JP, Edmunds LS, Dalenius K, Jernigan J, Davis CF, Giddings M, et al. Neighborhood disparities in

Early childhood obesity prevalence declined in all study neighborhoods from 2004-2006 to 2008-2010. The greatest decline occurred in Manhattan high-risk neighborhoods where obesity prevalence decreased from 18.6% in 2004-2006 to 15.3% in 2008-2010. The results showed a narrowing of the gap in obesity prevalence between high-risk and low-risk neighborhoods in

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prevalence of childhood obesity among low-income children before and after implementation of New York City child care regulations. Prev Chronic Dis . 2014; 11:140152.

Manhattan and the Bronx, but not in Brooklyn. The reductions in early childhood obesity prevalence in some high-risk and low-risk neighborhoods in New York City suggest that progress was made in reducing health disparities during the years just before and after implementation of the 2007 regulations. Future research should consider the built environment and markers of differential exposure to known interventions and policies related to childhood obesity prevention.

Benajamin Neelson S, et al. Regulations to promote healthy sleep practices in child care. Pediatrics . 2014;134(6):1167-1174 .

The mean number of regulations for states was 0.9 for centers and 0.8 for homes out of a possible 4.0. For centers, no state had regulations for all 4 recommendations; 11 states had regulations for 2 of the 4 recommendations. For homes, 9 states had regulations for 2 of the recommendations. States in the Northeast had the greatest mean number of regulations for centers (1.2) and homes (1.1), and states in the South had the fewest (0.7 and 0.7, respectively); these geographic differences were significant for centers (P = .03) but not homes (P = .14).

Middleton AE, et al. From policy to practice: Implementation of water policies in child care centers in Connecticut. J Nutr Educ Behav . 2013;45(2):119-125.

Many centers were in violation of water-promoting policies. Water was available in most classrooms (84%) but was only adult accessible in over half of those classrooms. Water was available during one third of physical activity periods observed. Verbal prompts for children to drink water were few. Support is needed to help centers meet existing water policies and new water requirements included in the 2010 Child Nutrition Reauthorization Act.

Patel & Ritchie. Striving for meaningful policies to reduce sugar-sweetened beverage intake among young children. Pediatrics . 2013;132(3):566- 568.

The percentage of children consuming an SSB on the prior day declined from 40% in 2003 to 16% in 2009 (P < .001) among children ages 2 to 5 and from 54% in 2003 to 33% in 2009 (P < .001) among children ages 6 to 11. The percentage of children consuming any SSB decreased for all racial/ethnic groups, although there were disparities with higher consumption among Latinos. Among children ages 2 to 5, consumption of 2 or more servings of 100% fruit juice per day decreased among white children and increased among Latinos. For children ages 6 to 11, consumption of 2 or more servings of 100% fruit juice per day remained stable for white children and increased among Latinos and African Americans.

Namenek Brouwer RJ, Benjamin Neelon SE. Watch Me Grow: A garden-based pilot intervention to increase vegetable and fruit intake in preschoolers. BMC Public

Americans, including children, consume fewer fruit and vegetable servings than is recommended. Given that young children spend large amounts of time in child care centers, this may be an ideal venue for increasing consumption of and enthusiasm for fruits and vegetables. This pilot study aimed to assess the feasibility of a gardening intervention to promote vegetable and fruit intake among preschoolers. We enrolled two intervention centers and two control centers. The intervention included a fruit and vegetable garden, monthly curriculum, gardening support, and

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Health . 2013;13:363. technical assistance. We measured mean (SD) servings of fruits and vegetables served to and consumed by three children per center before and after the intervention. Post intervention, intervention and control centers served fewer vegetables (mean (standard deviation) difference of -0.18 (0.63) in intervention, -0.37 (0.36) in control), but intervention children consumed more than control children (+0.25 (1.11) vs. -0.18 (0.52). The number of fruits served decreased in all centers (intervention -0.62 (0.58) vs. control -0.10 (0.52)) but consumption was higher in controls (intervention -0.32 (0.58) vs. control 0.15 (0.26)). The garden-based feasibility study shows promise, but additional testing is needed to assess its ability to increase vegetable and fruit intake in children.

Erinosho TO, et al. Nutrition policies at child-care centers and impact on role modeling of healthy eating behaviors of caregivers. J Acad Nutr Diet . 2012; 112(1):119-124.

Caregivers (n=124) reported about modeling healthy eating behaviors to children, trained research staff observed caregivers' (n=112) eating behaviors in classrooms, and directors reported about the presence/absence of center policies on staff eating practices. About 90% of caregivers reported modeling healthy eating behaviors to children. At 80% of centers, caregivers were observed modeling healthy dietary behaviors (eg, sitting with or eating same foods as children), but at fewer centers they were observed consuming unhealthy foods (eg, fast foods, salty snacks: 25%; and sugar-sweetened beverages: 50%). Although no substantial associations were observed between caregiver behaviors and center policies, effect size estimates suggest differences that may be of clinical significance. For example, caregivers were observed modeling healthy dietary behaviors more frequently at centers that had written policies about staff discouraging unhealthy foods for meals/snacks and having informal nutrition talks with children at meals. However, caregivers were observed consuming unhealthy foods and sugar-sweetened beverages more often at centers with policies that promoted healthier foods for meals/snacks. Future research should build on this study by using larger samples to understand why healthy food policies in child-care centers may not translate to eating practices among caregivers.

Monsivais P & Johnson DB. Improving nutrition in home child care: Are food costs a barrier? Public Health Nutr . 2012;15(2):370-376.

In bivariate analyses, higher daily food expenditures were associated with higher total food energy and higher nutritional quality of menus. Controlling for energy and other covariates, higher food expenditures were strongly and positively associated with number of portions of whole grains and fresh produce served (P = 0·001 and 0·005, respectively), with lower energy density and with higher mean nutrient adequacy of menus overall (P = 0·003 and 0·032, respectively). The results indicate that improving the nutritional quality of foods in child care may require higher food spending.

Monsivais P, et al. More nutritious food is served in

The two groups of providers were socioeconomically and demographically similar with comparable professional backgrounds. However, higher reimbursement providers had

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child-care homes receiving higher federal food subsidies. J Am Diet Assoc . 2011;111(5):721-726.

significantly greater menu expenditures than the lower reimbursement group ($2.36 vs $1.96/child/day; P=0.031). Reimbursement level was not associated with a difference in calories, but menus of higher reimbursement providers showed a significantly higher mean nutritional adequacy (64.5% vs 56.3%; P=0.033). The finding that reimbursement rates were positively associated with food expenditures and the nutritional quality of foods served suggests that raising CACFP reimbursements can improve child nutrition.

Falbe J, et al. The wellness child care assessment tool: A measure to assess the quality of written nutrition and physical activity policies. J Am Diet Assoc . 2011;111(12):1852-1860.

Inter-rater reliability was high for total comprehensiveness and strength scores (intraclass correlation coefficient=0.98 and 0.94, respectively) and subscale scores (intraclass correlation coefficient=0.84 to 0.99). Subscales were adequately internally reliable (Cronbach's α=.53 to .83). Comprehensiveness and strength scores were higher for Head Start centers than non-Head Start centers across most domains and higher for National Association for the Education of Young Children-accredited centers than nonaccredited centers across some but not all domains, providing evidence of construct validity. This instrument provides a standardized method to analyze and compare the comprehensiveness and strength of written nutrition and physical activity policies in child-care centers.

Henderson KE, et al. Validity of a measure to assess the child-care nutrition and physical activity environment. J Am Diet Assoc . 2011;111(9):1306-1313.

Percent agreement with criterion outcomes ranged from 39% to 97%, with 61% of items achieving agreement ≥80%. Agreement was highest for nutrition and policy domains, and lowest for physical activity and barriers to promoting health. Correlations between food scores across measures were moderate. The self-report survey demonstrated adequate criterion validity. We make recommendations for improving validity of low-agreement items and for the use of more labor-intensive evaluation procedures for domains not adequately assessed through self-report.

Patel AI & Hampton KE. Encouraging consumption of water in school and child care settings: Access, challenges, and strategies for improvement. Am J Public Health . 2011;101(8):1370- 1379.

We sought to identify challenges that limit access to drinking water; opportunities, including promising practices, to increase drinking water availability and consumption; and future research, policy efforts, and funding needed in this area.

Kaphingst KM & Story M. Child care as an untapped setting for obesity prevention: State child care licensing

We found variability among and within states. CCCs were the most heavily regulated and had the most specific regulations, followed by LFGHs. SFHs had the fewest and most general regulations. Just 2 states, Michigan and West Virginia, specified that CCC menus should be consistent with the Dietary Guidelines for Americans. Only 12 states had regulations that limited foods of low

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regulations related to nutrition, physical activity, and media use for preschool-aged children in the United States. Prev Chronic Dis . 2009;6(1):A11.

nutritional value in CCCs. Thirty-six states required that children have daily outdoor activity time in CCCs; only 9 states set specific minimum lengths of time that children should be outdoors each day. Eight states set quantified time limits on screen time per day or per week in SFHs. Opportunities exist for strengthening state licensing regulations to prevent childhood obesity. The increasing prevalence of childhood obesity underscores the urgency for state policy efforts to create child care environments that foster healthful eating and participation in physical activity.

Farm-to-Preschool

Farm-to-Preschool: The state of the research literature and a snapshot of national practice. J Hunger Environ Nutr . Accepted.

A wide range of activities was represented in the 14 studies reviewed; most employed participatory research collaborations, assessed process outcomes, and used uncontrolled research designs. Survey findings indicated that programs operate in at least 39 states and Puerto Rico, in many types of communities and settings. Respondents identified types of foods and activities, motivations for participation, and parent engagement. There is still much to be learned about farm to preschool programs, and well-controlled research is necessary.

Food Security

Gooze RA, et al. Obesity and food insecurity at the same table: How Head Start Programs respond. Prev Chronic Dis . 2012;9:E132.

The response rate was 87% (N = 1,583). Nearly all programs (99.5%) reported obtaining height and weight data, 78% of programs calculated BMI for all children, and 50% of programs discussed height and weight measurements with all families. In 14% of programs, directors reported that staff often or very often saw children who did not seem to be getting enough to eat at home; 55% saw this sometimes, 26% rarely, and 5% never. Fifty-four percent of programs addressed perceived food insecurity by giving extra food to children and families. In 39% of programs, staff primarily decided what portion sizes children received at meals, and in 55% the children primarily decided on their own portions. Head Start programs should consider moving resources from assessing BMI to assessing household food security and providing training and technical assistance to help staff manage children's portion sizes.

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Head Start

Bellows LL, et al. The Colorado LEAP study: Rationale and design of a study to assess the short term longitudinal effectiveness of a preschool nutrition and physical activity program. BMC Public Health . 2013;13:1146 .

The design of this study allows for longitudinal exploration of relationships among eating habits, physical activity patterns, and weight status within and across spheres of the social ecological model. These methods advance traditional study designs by allowing not only for interaction among spheres but predictively across time. Further, the recruitment strategy includes both boys and girls from ethnic minority populations in rural areas and will provide insights into obesity prevention effects on these at risk populations.

Gooze RA, et al. Obesity and food insecurity at the same table: How Head Start Programs respond. Prev Chronic Dis . 2012;9:E132.

The response rate was 87% (N = 1,583). Nearly all programs (99.5%) reported obtaining height and weight data, 78% of programs calculated BMI for all children, and 50% of programs discussed height and weight measurements with all families. In 14% of programs, directors reported that staff often or very often saw children who did not seem to be getting enough to eat at home; 55% saw this sometimes, 26% rarely, and 5% never. Fifty-four percent of programs addressed perceived food insecurity by giving extra food to children and families. In 39% of programs, staff primarily decided what portion sizes children received at meals, and in 55% the children primarily decided on their own portions. Head Start programs should consider moving resources from assessing BMI to assessing household food security and providing training and technical assistance to help staff manage children's portion sizes.

Harnack LJ, et al. Results from an experimental trial at a Head Start center to evaluate two meal service approaches to increase fruit and vegetable intake of preschool aged children. Int J Behav Nut Phys Act . 2012; 9:51.

Fruit intake was significantly higher (p<0.01) when fruits and vegetables were served in advance of other meal items (0.40 servings/meal) compared to the traditional family style meal service control condition when they were served in tandem with other menu items (0.32 servings/meal). Intakes of some nutrients found in fruits (vitamin A and folate) were concomitantly higher. In contrast, fruit and vegetable intakes were significantly lower and energy intake significantly higher during the provider portioned compared with control condition. Serving fruits in advance of other meal items may be a low cost easy to implement strategy for increasing fruit intake in young children. However, serving vegetables first does not appear to increase vegetable intake. Results provide support for current recommendations for traditional family style meal service in preschool settings.

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Gooze RA, et al. Reaching staff, parents, and community partners to prevent childhood obesity in Head Start, 2008. Prev Chronic Dis . 2010;7(3):A54.

Among the 1,583 (87%) responding programs, 60% held workshops to train new staff about children's feeding and 63% held workshops to train new staff about children's gross motor activity. Parent workshops on preparing or shopping for healthy foods were offered by 84% of programs and on encouraging children's gross motor activity by 43% of programs. Ninety-seven percent of programs reported having at least 1 community partnership to encourage children's healthy eating, and 75% reported at least 1 to encourage children's gross motor activity. Head Start programs reported using a multilevel approach to childhood obesity prevention that included staff, parents, and community partners. More information is needed about the content and effectiveness of these efforts.

Hughes CC, et al. Barriers to obesity prevention in Head Start. Health Affairs . 2010;29(3):454-462.

This article details findings gleaned from a national survey of all directors of Head Start, a program that provides early childhood education to nearly one million lower-income children, approximately one third of whom are obese. With respect to implementing policies and practices to address obesity, program directors identified three key barriers: lack of time, money and knowledge. Minimizing these barriers, the authors conclude, will require federal resources.

Whitaker RC, et al. A national survey of obesity prevention practices in Head Start. Arch Pediatr Adolesc Med . 2009;163(12):1144-1150.

The 1583 (87%) programs responding to the survey enrolled 828 707 preschool children. Of these programs, 70% reported serving only nonfat or 1% fat milk. Ninety-four percent of programs reported that each day they served children some fruit other than 100% fruit juice; 97% reported serving some vegetable other than fried potatoes; and 91% reported both of these daily practices. Sixty-six percent of programs said they celebrated special events with healthy foods or nonfood treats, and 54% did not allow vending machines for staff. Having an on-site outdoor play area at every center was reported by 89% of programs. Seventy-four percent of programs reported that children were given structured (adult-led or -guided) gross motor activity for at least 30 minutes each day; 73% reported that children were given unstructured gross motor activity for at least 30 minutes each day, and 56% reported both of these daily practices. Most Head Start programs report doing more to support healthy eating and gross motor activity than required by federal performance standards in these areas.

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Racial, Ethnic, and Income Disparities

Granberry PJ, et al. Developing research and community literacies to recruit Latino researchers and practitioners to address health disparities. J Racial Ethn Health Disparities . 2016;3(1):138-144.

Engaging community residents and undergraduate Latino students in developing research and community literacies can expose both groups to resources needed to address health disparities. The bidirectional learning process described in this article developed these literacies through an ethnographic mapping fieldwork activity that used a learning-by-doing method in combination with reflection on the research experience. The active efforts of research team members to promote reflection on the research activities were integral for developing research and community literacies. Our findings suggest that, through participating in this field research activity, undergraduate students and community residents developed a better understanding of resources for addressing health disparities. Our research approach assisted community residents and undergraduate students by demystifying research, translating scientific and community knowledge, providing exposure to multiple literacies, and generating increased awareness of research as a tool for change among community residents and their organizations. The commitment of the community and university leadership to this pedagogical method can bring out the full potential of mentoring, both to contribute to the development of the next generation of Latino researchers and to assist community members in their efforts to address health disparities.

Vedovato, G. et al. Food insecurity, overweight and obesity among low-income African-American families in Baltimore City: Associations with food-related perceptions. Public Health Nutr . 2016;19(8):1405-1416.

41.6% of households had some level of food insecurity, and 12.4% experienced some level of hunger. Food insecure participants with hunger were significantly more likely to be unemployed and to have lower incomes. We found high rates of excess body weight (overweight and obese) among adults and children (82.8% and 37.9% food insecure without hunger; 89.2% and 45.9% with hunger, respectively), although there were no significant differences by security status. Food source usage patterns, food acquisition, preparation, knowledge, self-efficacy and intentions did not differ by food security. Food security was associated with perceptions that healthy foods are affordable and convenient. Greater caregiver body satisfaction was associated with food insecurity and excess body weight. In this setting, obesity and food insecurity are major problems. For many food insecure families, perceptions of healthy foods may serve as additional barriers to their purchase and consumption.

Guerrero, Alma D; Chung, Paul J. Racial and ethnic disparities in dietary intake among California children. J

Asians regardless of interview language were more likely than whites to have low vegetable intake consumption (Asians English interview odds ratio [OR] 1.20, 95% CI 1.01 to 1.43; Asians non-English-interview OR 2.09, 95% CI 1.23 to 3.57) and low fruit consumption (Asians English interview OR 1.69, 95% CI 1.41 to 2.03; Asians non-English interview OR 3.04, 95% CI 2.00 to 4.6). Latinos regardless of interview language were also more likely than whites to have high fruit juice

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Acad Nutr Diet . 2016;116(3):439-448 .

(Latinos English interview OR 1.54, 95% CI 1.28 to 1.84 and Latinos non-English interview OR 1.29, 95% CI 1.02 to 1.62) and fast-food consumption (Latinos English interview OR 1.74, 95% CI 1.46 to 2.08 and Latinos non-English interview OR 1.48, 95% CI 1.16 to 1.91); but Latinos were less likely than whites to consume sweets (Latinos English interview OR 0.81, 95% CI 0.66 to 0.99 and Latinos non-English interview OR 0.56, 95% CI 1.16 to 1.91). Significant racial and ethnic differences exist in the dietary practices of California children. Increased fruit and vegetable consumption appears to be associated with parent education but not income. Our findings suggest that anticipatory guidance and dietary counseling might benefit from tailoring to specific ethnic groups to potentially address disparities in overweight and obesity.

Guerrero, A. et al. Racial and ethnic disparities in early childhood obesity: Growth trajectories in Body Mass Index. J Racial Ethn Health Disparities . 2016;3 (1):129-137 .

Approximately one-third of 4-year-old females and males were overweight and/or obese. African-American and Latino children displayed higher predicted mean BMI scores and differing mean BMI trajectories, compared with White children, adjusting for time-independent and time-dependent predictors. Several factors were significantly associated with lower mean BMI trajectories, including very low birth weight, higher maternal education level, residing in a two-parent household, and breastfeeding during infancy. Greater consumption of soda and fast food was associated with higher mean BMI growth. Soda consumption was a particularly strong predictor of mean BMI growth trajectory for young Black children. Neither the child's inactivity linked to television viewing nor fruit nor vegetable consumption was predictive of BMI growth for any racial/ethnic group. Significant racial and ethnic differences are discernible in BMI trajectories among young children. Raising parents' and health practitioners' awareness of how fast food and sweetened-beverage consumption contributes to early obesity and growth in BMI-especially for Blacks and Latinos-could improve the health status of young children.

Malika, Nipher M; Hayman Jr, Lenwood W; Miller, Alison L; Lee, Hannah J; Lumeng, Julie C. Low-income women's conceptualizations of food craving and food addiction. Eating Behaviors . 2015;18:25- 29.

Low-income women with preschool-aged children (2-5years old) participated in either a semi-structured individual interview or focus group in which they were asked about their conceptualization of eating behaviors among adults and children. All responses were audio-recorded and transcribed. Themes were identified using the constant comparative method of qualitative analysis. Identified themes revealed that the women perceived food craving to be common, less severe and to a degree more humorous than food addiction. It was not felt that food cravings were something to be guarded against or resisted. Food addiction was described in a very "matter of fact" manner and was believed to be identifiable through its behavioral features including a compulsive need to have certain foods all the time. A more detailed understanding of how the general population perceives food craving and food addiction may enable more refined measurement of these constructs with questionnaire measures in the future. In addition, interventions may be designed to use the language most consistent

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with participants' conceptualizations of these constructs.Cui Z, et al. Recruitment and retention in obesity prevention and treatment trials targeting minority or low-income children: A review of the clinical trials registration database. Trials . 2015;16:564.

Our final analytic sample included 43 studies. Of these, 25 studies reported recruitment or retention strategies, with the amount of information varying from a single comment to several pages; 4 published no specific information on recruitment or retention; and 14 had no publications listed in PubMed. The vast majority (92 %) of the 25 studies reported retention rates of, on average, 86 %. Retention rates were lower in studies that: targeted solely Hispanics or African Americans (vs. mixed races of African Americans, whites, and others); involved children and parents (vs. children only); focused on overweight or obese children (vs. general children), lasted ≥1 year (vs. <1 year), were home or community-based (vs. school-based), included nutrition and physical activity intervention (vs. either intervention alone), had body mass index or other anthropometrics as primary outcome measures (vs. obesity-related behavior, insulin sensitivity, etc.). Retention rates did not vary based on child age, number of intervention sessions, or sample size. Variable amounts of information were provided on recruitment and retention strategies in obesity-related trials involving minority or low-income children. Although reported retention rates were fairly high, a lack of reporting limited the available information. More and consistent reporting and systematic cataloging of recruitment and retention methods are needed. In addition, qualitative and quantitative studies to inform evidence-based decisions in the selection of effective recruitment and retention strategies for trials including minority or low-income children are warranted.

Perrin, E. at al. Racial and ethnic differences associated with feeding- and activity-related behaviors in infants. Pediatrics . 2014;133(4) :e857-e867.

Eight hundred sixty-three parents (50% Hispanic, 27% black, 18% white; 86% Medicaid) were enrolled. Exclusive formula feeding was more than twice as common (45%) as exclusive breastfeeding (19%); 12% had already introduced solid food; 43% put infants to bed with bottles; 23% propped bottles; 20% always fed when the infant cried; 38% always tried to get children to finish milk; 90% were exposed to television (mean, 346 minutes/day); 50% reported active television watching (mean, 25 minutes/day); and 66% did not meet “tummy time” recommendations. Compared with white parents, black parents were more likely to put children to bed with a bottle (adjusted odds ratio [aOR] = 1.97, P < .004; bottle propping, aOR = 3.1, P < .001), and report more television watching (aOR = 1.6, P = .034). Hispanic parents were more likely than white parents to encourage children to finish feeding (aOR = 1.9, P = .007), bottle propping (aOR = 2.5, P= .009), and report less tummy time (aOR = 0.6, P = .037). Behaviors thought to relate to later obesity were highly prevalent in this large, diverse sample and varied by race/ethnicity, suggesting the importance of early and culturally-adapted interventions.

Sekhobo JP, Edmunds Early childhood obesity prevalence declined in all study neighborhoods from 2004-2006 to 2008-

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LS, Dalenius K, Jernigan J, Davis CF, Giddings M, et al. Neighborhood disparities in prevalence of childhood obesity among low-income children before and after implementation of New York City child care regulations. Prev Chronic Dis . 2014; 11:140152.

2010. The greatest decline occurred in Manhattan high-risk neighborhoods where obesity prevalence decreased from 18.6% in 2004-2006 to 15.3% in 2008-2010. The results showed a narrowing of the gap in obesity prevalence between high-risk and low-risk neighborhoods in Manhattan and the Bronx, but not in Brooklyn. The reductions in early childhood obesity prevalence in some high-risk and low-risk neighborhoods in New York City suggest that progress was made in reducing health disparities during the years just before and after implementation of the 2007 regulations. Future research should consider the built environment and markers of differential exposure to known interventions and policies related to childhood obesity prevention.

Reifsinder E, et al. A randomized controlled trial to prevent childhood obesity through early childhood feeding and parenting guidance: Rationale and design of study. BMC Public Health . 2013;13:880.

This study will provide prospective data on the effects of an intervention to prevent childhood obesity in children at high risk for obesity due to ethnicity, income, and maternal body mass index (BMI). It will have wide-ranging applicability and the potential for rapid dissemination through the WIC program, and will demonstrate the effectiveness of a community approach though employing CHWs in preventing obesity during the first 3 years of life. This easy-to-implement obesity prevention intervention can be adapted for many locales and diverse communities and can provide evidence for policy change to influence health throughout life.

Guerrero, A. et al. Racial and ethnic disparities in pediatric experiences of family-centered care. Medical Care . 2010;48 (4):388-393 .

Black children have similar experiences as white children on overall family-centered care and on each of the 4 components of family-centered care in models that adjust for child characteristics and socioeconomic factors. In contrast, differences in dimensions of and overall family-centered care between white children and Latino children, irrespective of interview language, persist after multivariate adjustment. Future research should examine the extent to which Latino-white differences in the receipt of family-centered care can be narrowed with programs and policies geared at improving parental education, health literacy, the quality of provider communication, and quality improvement strategies for health care systems.

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Health Literacy

Bathory E, et al. Infant sleep and parent health literacy. Acad Pediatric s. 2016;16(6):550-557.

We enrolled 557 caregivers of 9-month-old children (49.7% Hispanic, 26.9% black, 56.2% <$20,000 annual income); 49.6% reported having a TV in the room where their child sleeps; 26.6% did not have regular naptimes nor bedtimes. Median sleep duration was 2.3 (interquartile range, 1.5-3.0) hours (daytime), and 9.0 (interquartile range, 8.0-10.0) hours (night) (30.2% low daytime; 20.3% low nighttime sleep duration). Children of parents with low HL were more likely to have a bedroom TV (66.7% vs 47.7%, P = .01; adjusted odds ratio, 2.2; 95% confidence interval, 1.1-4.3) and low night-time sleep (37.0% vs 18.5%; P = .002; adjusted odds ratio, 2.4; 95% confidence interval, 1.2-4.8).Low parent health literacy is associated with TV in the bedroom and low night sleep duration. Additional study is needed to further explore these associations and intervention strategies to address child sleep problems.

Heerman W. et al. Health literacy and injury prevention behaviors among caregivers of infants. Am J Prev Med . 2014; 46(5):449-456 .

Data were analyzed from 844 English and Spanish-speaking caregivers of 2-month-old children. Many caregivers were non-adherent with injury prevention guidelines, regardless of health literacy. Notably, 42.6% inappropriately placed their children in the prone position to sleep, and 88.6% did not have their hot water heater set <120°F. Eleven percent of caregivers were categorized as having low health literacy. Low caregiver health literacy, compared to adequate health literacy, was significantly associated with increased odds of caregiver non-adherence with recommended behaviors for car seat position (AOR=3.4, 95% CI=1.6, 7.1), and fire safety (AOR=2.0, 95% CI=1.02, 4.1) recommendations. Caregivers with low health literacy were less likely to be non-adherent to fall prevention recommendations (AOR=0.5, 95% CI=0.2, 0.9). Non-adherence to injury prevention guidelines was common. Low caregiver health literacy was significantly associated with some injury prevention behaviors. Future interventions should consider the role of health literacy in promoting injury prevention.

Yin, H.S. et al. Parent health literacy and "obesogenic" feeding and physical activity-related infant care behaviors. J Pediatrics . 2014;164(3):577- 583 .

11.0% of parents were categorized as having low health literacy. Low health literacy significantly increased the odds of a parent reporting that they feed more formula than breast milk (AOR=2.0 [95%CI:1.2–3.5]), immediately feed when their child cries (AOR=1.8[1.1–2.8]), bottle prop (AOR=1.8 [1.002–3.1]), any infant TV watching (AOR=1.8 [1.1–3.0]), and inadequate tummy time (<30 minutes/day) (AOR=3.0[1.5–5.8]). Low parent health literacy is associated with certain obesogenic infant care behaviors. These behaviors may be modifiable targets for low health literacy-focused interventions to help reduce childhood obesity.

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Ciampa, P. et al. The association of acculturation and health literacy, numeracy and health-related skills in Spanish-speaking caregivers of young children. J Immigr Minor Health. 2013;15(3) :492-498 .

Little is known about the relationship among acculturation, literacy, and health skills in Latino caregivers of young children. Latino caregivers of children <30 months seeking primary care at four medical centers were administered measures of acculturation (SASH), functional health literacy (STOFHLA), numeracy (WRAT-3) and health-related skills (PHLAT Spanish). Child anthropomorphics and immunization status were ascertained by chart review. Caregivers (N = 184) with a median age of 27 years (IQR: 23–32) participated; 89.1 % were mothers, and 97.1 % had low acculturation. Lower SASH scores were significantly correlated (P < 0.01) with lower STOFHLA (ρ = 0.21), WRAT-3 (ρ = 0.25), and PHLAT Spanish scores (ρ = 0.34). SASH scores predicted PHLAT Spanish scores in a multivariable linear regression model that adjusted for the age of child, the age and gender of the caregiver, number of children in the family, the type of health insurance of the caregiver, and study site (adjusted β: 0.84, 95 % CI 0.26–1.42, P = 0.005). This association was attenuated by the addition of literacy (adjusted β: 0.66, 95 % CI 0.11–1.21, P = 0.02) or numeracy (adjusted β: 0.50, 95 % CI −0.04–1.04, P = 0.07) into the model. There was no significant association between acculturation and up-to-date child immunizations or a weight status of overweight/obese. Lower acculturation was associated with worse health literacy and diminished ability to perform child health-related skills. Literacy and numeracy skills attenuated the association between acculturation and child health skills. These associations may help to explain some child health disparities in Latino communities.

White, R. et al. A health literate approach to the prevention of childhood overweight and obesity. Patient Educ Couns . 2013;93(3):612-618.

12 core modules were developed and assessed in an iterative process. Average readability was at the 6th grade reading level (SMOG Index 5.63 ± 0.76, and Fry graph 6.0 ± 0.85). SAM evaluation resulted in adjustments to literacy demand, layout & typography, and learning stimulation & motivation. Cognitive interviews with target population revealed additional changes incorporated to enhance participant's perception of acceptability and feasibility for behavior change. The GROW modules are a collection of evidence-based materials appropriate for parents with low health literacy and their preschool aged children, that target the prevention of childhood overweight/obesity.

Yin, H.S. et al. Assessment of health literacy and numeracy among Spanish-Speaking parents of young children: validation of the Spanish Parental Health Literacy Activities Test (PHLAT

Of 176 caregivers, 77% had adequate health literacy (S-TOFHLA), while only 0.6% had 9th grade or higher numeracy skills. Mean PHLAT-10 score was 41.6% (SD 21.1). Fewer than half (45.5%) were able to read a liquid antibiotic prescription label and demonstrate how much medication to administer within an oral syringe. Less than a third (31.8%) were able to interpret a food label to determine whether it met WIC guidelines. Higher PHLAT-10 score was associated with higher years of education (r=0.49), S-TOFHLA (r=0.53) and WRAT-3 (r=0.55) scores (p<0.001). Internal reliability was good (KR-20=0.61). An 8-item scale was highly correlated with the full

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Spanish). Acad Pediatrics . 2012;12(1):68-74 .

10-item scale (r=0.97, p<0.001), with comparable internal reliability (KR-20= 0.64). Many Spanish-speaking parents have difficulty carrying out health-related literacy and numeracy tasks. The Spanish PHLAT demonstrates good psychometric characteristics and may be useful for identifying parents who would benefit from receiving low-literacy child health information.

Kumar, D. et al. Parental understanding of infant health information: health literacy, numeracy, and the Parental Health Literacy Activities Test (PHLAT). Acad Pediatrics . 2010;10(5):309-316 .

182 caregivers were recruited. While 99% had adequate literacy skills, only 17% had >9th-grade numeracy skills. Mean score on the PHLAT was 68% (SD 18); for example, only 47% of caregivers could correctly describe how to mix infant formula from concentrate, and only 69% could interpret a digital thermometer to determine if an infant had a fever. Higher performance on the PHLAT was significantly correlated (p<0.001) with education, literacy skill, and numeracy level (r=0.29, 0.38, and 0.55 respectively). Caregivers with higher PHLAT scores were also more likely to interpret age recommendations for cold medications correctly (OR 1.6, 95% CI 1.02, 2.6). Internal reliability on the PHLAT was good (KR-20=0.76). The PHLAT-10 also demonstrated good validity and reliability. Many parents do not understand common health information required to care for their infants. The PHLAT, and PHLAT-10 have good reliability and validity and may be useful tools for identifying parents who need better communication of health-related instructions.

Infancy

Gross RS, et al. Randomized controlled trial of a primary care-based child obesity prevention intervention on infant feeding practices. J Pediatr . 2016;174:171-177 .

A total of 456 families completed 3-month assessments. The intervention group had higher prevalence of exclusive breastfeeding on the 24-hour diet recall (42.7% vs 33.0%, P = .04) compared with controls. The intervention group reported a higher percentage of breastfeeding vs formula feeding per day (mean [SD] 67.7 [39.3] vs 59.7 [39.7], P = .03) and was less likely to introduce complementary foods and liquids compared with controls (6.3% vs 16.7%, P = .001). The intervention group had higher maternal infant feeding knowledge scores (Cohen d, 0.29, 95% CI .10-.48). The effect of Starting Early on breastfeeding was mediated by maternal infant feeding knowledge (Sobel test 2.86, P = .004). Starting Early led to increased exclusive breastfeeding and reduced complementary foods and liquids in 3-month-old infants. Findings document a feasible and effective infrastructure for promoting breastfeeding in families at high risk for obesity in the context of a comprehensive obesity prevention intervention.

Daly JM, et al. Factors associated with parents’

A total of 1323 parent/infant pairs were enrolled in the study at Duke University, Indiana University, and the University of Iowa. Through a survey, 283 (21%) of the parents perceived they did an

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perception of their infants’ oral health care. J Prim Community Health . 2016;7(3):180-187.

excellent job of both taking care of both the infant's oral and medical health, while 861 (65%) perceived the care of their infant's medical health was better than their care of the teeth and/or gums. In the multivariable model, parents who perceived they provided excellent/very good/good care for the infants' teeth and/or gums were more likely to brush the infant's teeth daily, use toothpaste daily, clean inside the infant's mouth and/or gums daily, and not let the infant have something other than water after brushing and prior to bedtime. Also, those with infants having Medicaid or State Insurance, parents not eating sugary snacks frequently, and parents getting dental checkups at least annually were likely Parents who provide good infant oral health care are more likely to perceive they provide good care and more likely to have better personal dental health behaviors. This agrees with previous studies concerning older children.to perceive that they provided excellent/very good/good care for their infant's teeth and/or gums.

Daly JM, et al. Recruitment strategies at the Iowa state for parent/infant pairs in a longitudinal dental caries study. Clin Trials . 2016;13(3):311-318.

From these recruitment efforts, 515 potential participants expressed interest and were screened for this study and 348 (68%) were enrolled during an 11-month time period. The face-to-face strategy had the highest recruitment rate of 25%, followed by direct individual mailings at 9% and follow-up telephone calls at 7%. For the face-to-face strategy, the contact at the children's museum was most successful compared to the other office settings. The lowest rate of recruitment of 0.09% was attained with the mass e-mail. However, in terms of actual numbers recruited, the mass e-mail remained an important modality since it yielded 21 recruits and was much less time-intensive. An intensive, multi-pronged recruitment strategy proved successful in meeting enrollment goals and resulted in finishing the enrollment prior to the projected study deadline. Effective recruitment approaches are imperative for a study's success and each recruitment strategy needs to be budgeted and planned for in a study. Investigators may need to adapt their approach to attain the needed number of subjects. Planning needs to include the numbers needed to be approached to attain your recruitment goal, how you will recruit, who will be responsible, and the costs and time commitment for various strategies.

Warren JJ, et al. Timing of primary tooth emergence among U.S. racial and ethnic groups. J Public Health Dent. 2016;Mar 18 [Epub ahead of print].

AI children had significantly more teeth present (Mean: 7.8, Median: 8.0) than did Whites (4.4, 4.0, P < 0.001) or Blacks (4.5, 4.0, P < 0.001). No significant differences were detected between Black and White children (P = 0.58). There was no significant sex difference overall or within any of the racial groups.

Bathory E, et al. Infant sleep and parent health literacy. Acad Pediatr .

We enrolled 557 caregivers of 9-month-old children (49.7% Hispanic, 26.9% black, 56.2% <$20,000 annual income); 49.6% reported having a TV in the room where their child sleeps; 26.6% did not have regular naptimes nor bedtimes. Median sleep duration was 2.3 (interquartile range, 1.5-3.0) hours

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2016;16(6):550-557. (daytime), and 9.0 (interquartile range, 8.0-10.0) hours (night) (30.2% low daytime; 20.3% low nighttime sleep duration). Children of parents with low HL were more likely to have a bedroom TV (66.7% vs 47.7%, P = .01; adjusted odds ratio, 2.2; 95% confidence interval, 1.1-4.3) and low night-time sleep (37.0% vs 18.5%; P = .002; adjusted odds ratio, 2.4; 95% confidence interval, 1.2-4.8).Low parent health literacy is associated with TV in the bedroom and low night sleep duration. Additional study is needed to further explore these associations and intervention strategies to address child sleep problems.

Brown CL, et al. Parental perceptions of weight during the first year of life. Acad Pediatr . 2016;16(6):558-564.

Approximately 85% to 90% of infants (n = 853 at 2 months, n = 563 at 12 months) were at a healthy WFL at all measurement times, and parents of these infants were more likely to have an accurate perception of their child's weight (accuracy 89%-95%) than overweight children (accuracy 7%-26%; P < .001 across time points). Approximately 10% of healthy weight infants were perceived as underweight by their parents at all time points. At 12 months, mothers who were overweight were significantly more likely to underestimate their child's weight status (P = .008). In our diverse and low-income sample, parents of overweight infants infrequently know that their infants are overweight. Future studies should examine how perception is related to feeding habits and weight status over time.

Hager ER, et al. Nighttime sleep duration and sleep behaviors among toddlers from low-income families: Associations with obesgenic behaviors and obesity and the role of parenting. Childhood Obes . 2016;x:1-9.

Sample included 240 toddlers (mean age = 20.2 months), 55% male, 69% black, 59% urban. Toddlers spent 55.4 minutes/day in MVPA, mean HEI-2005 score was 55.4, 13% were obese. Mean sleep duration was 9.1 hours, with 35% endorsing 5-6 recommended sleep behaviors (TSBS-BISQ). In multivariable models, MVPA was positively related to sleep duration; obese toddlers had a shorter nighttime sleep duration than healthy weight toddlers [odds ratio = 0.69, p = 0.014]. Nighttime sleep duration was associated with high TSBS-BISQ scores, F = 6.1, p = 0.003. Toddlers with a shorter nighttime sleep duration are at higher risk for obesity and inactivity. Interventions to promote healthy sleep behaviors among toddlers from low-income families may improve nighttime sleep duration and reduce obesogenic behaviors/obesity.

Anstey EH, et al. Five-year progress update on the Surgeon General’s Call to Action to Support Breastfeeding, 2011. J Women Health . 2016;25(8):768-776.

In 2011, Surgeon General Regina Benjamin issued a Call to Action to Support Breastfeeding (Call to Action) in an effort to mobilize families, communities, clinicians, healthcare systems, and employers to take action to improve support for breastfeeding. The Call to Action identified 20 key action steps to address society-wide breastfeeding barriers in six areas: mothers and families, communities, healthcare, employment, research, and public health infrastructure. This report highlights major federal activities that show progress toward answering the Call to Action in the first 5 years since its launch.

Perez-Escamilla R, et al. Impact of the baby-friendly

Experimental, quasi-experimental and observational studies were considered eligible for this review if they assessed breastfeeding outcomes and/or infant health outcomes for healthy, term infants born in a

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Hospital Initiative on breastfeeding and child health outcomes: A systematic review. Mater Child Nutr . 2016;12:402- 417.

hospital or birthing center with full or partial implementation of BFHI steps. Of the 58 reports included in the systematic review, nine of them were published based on three randomized controlled trials, 19 followed quasi-experimental designs, 11 were prospective and 19 were cross-sectional or retrospective. Studies were conducted in 19 different countries located in South America, North America, Western Europe, Eastern Europe, South Asia, Eurasia and Sub-Saharan Africa. Adherence to the BFHI Ten Steps has a positive impact on short-term, medium-term and long-term breastfeeding (BF) outcomes. There is a dose-response relationship between the number of BFHI steps women are exposed to and the likelihood of improved BF outcomes (early BF initiation, exclusive breastfeeding (EBF) at hospital discharge, any BF and EBF duration). Community support (step 10) appears to be essential for sustaining breastfeeding impacts of BFHI in the longer term.

Taveras EM. Childhood obesity risk and prevention: Shining a lens on the first 1000 days. Childhood Obes . 2016;12(3):159-161.

Editorial discusses the theme of the Childhood Obesity issue was to have investigators from a range of disciplines submit articles that advanced the science of early life obesity risk factors and prevention.

Barrera CM, et al. Age at introduction to solid foods and child obesity at 6 years. Childhood Obes . 2016;12(3):188-192.

Prevalence of obesity in our sample was 12.0%. The odds of obesity was higher among infants introduced to solids <4 months compared to those introduced at 4-<6 months (odds ratio [OR] = 1.66; 95% CI, 1.15, 2.40) in unadjusted analysis; however, this relationship was no longer significant after adjustment for covariates (OR = 1.18; 95% CI, 0.79, 1.77). Introduction of solids ≥6 months was not associated with obesity. We found no interaction between breastfeeding duration and early solid food introduction and subsequent obesity.

Wood CT, et al. Association between bottle size and formulate intake in 2-month-old infants. Acad Pediatr . 2016;16(3):254-259.

Of 865 participants in the Greenlight study, 44% (n = 378; 21.8% white, 40.6% black, 35.3% Hispanic, 2.4% other) of infants were exclusively formula fed at 2 months. Median volume per day was 30 oz (interquartile range 12), and 46.0% of infants were fed with large bottles. Adjusted for covariates, parents using larger bottles reported feeding 4 oz more formula per day (34.2 oz, 95% confidence interval 33.5-34.9 vs 29.7 oz, 95% confidence interval 29.2-30.3, P = .03). Among exclusively formula-fed infants, use of a larger bottle is associated with parental report of more formula intake compared to infants fed with smaller bottles. If infants fed with larger bottles receive more formula, these infants may be overfed and consequently at risk for obesity.

Wood, CT, et al. Confirmatory factor analysis of the Infant Feeding Styles Questionnaire in Latino

Of 303 parents completing the IFSQ, 84% were born outside the US, and 74% completed the IFSQ in Spanish. Reliability coefficients ranged from 0.28 to 0.61 for the laissez-faire sub-constructs and from 0.58 to 0.83 for the pressuring, restrictive, and responsive sub-constructs. Results for all coefficients were similar between participants responding to an English and Spanish version of the IFSQ.

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families. Appetite . 2016; 100:118-125 .

Goodness of fit indices ranged from CFI 0.82-1 and RMSEA 0.00-0.31, and the model performed best in pressuring-soothing (CFI 1.0, RMSEA 0.00) and restrictive-amount (CFI 0.98, RMSEA 0.1) sub-constructs. In a sample of Latino families, pressuring, restrictive, and responsive constructs performed well. The modified IFSQ in both English and Spanish-speaking Latino families may be used to assess parenting behaviors related to early obesity risk in this at-risk population.

Dinkevich E, et al. Mothers' feeding behaviors in infancy: Do they predict child weight trajectories? Obesity (Silver Spring, Md.). 2015;23(12):2470-2476 .

Higher pressuring was associated with lower weight-for-length z-scores (WLZ) over the period from baseline out to 30 months and higher restriction with higher child WLZ over the same period. Pressuring and concern about infant undereating/weight were independently associated with WLZ, but the relationship between restrictive feeding and WLZ was reduced by accounting for concern about infant overeating/weight. Child weight trajectories were not influenced by feeding behavior. Mothers restricted heavier infants and pressured leaner infants to eat, and the relationship between restriction and higher infant weight was mediated by concern about infant overeating/weight. Correcting misperceptions and discussing feeding with mothers reporting concern may help prevent excessive early weight gain.

Gunderson EP, et al. The study of women, infant feeding and type 2 diabetes after GDM pregnancy and growth of their offspring (SWIFT Offspring study): Prospective design, methodology and baseline characteristics. BMC Pregnancy Childbirth . 2015;15:150.

The study enrolled 466 mother-infant pairs among GDM deliveries in northern California from 2009-2011. Participants attended three in-person study exams at 6-9 weeks, 6 months and 12 months after delivery for infant anthropometry (head circumference, body weight, length, abdominal circumference and skinfold thicknesses), as well as maternal anthropometry (body weight, waist circumference and percent body fat). Mothers also completed questionnaires on health and lifestyle behaviors, including infant diet, sleep and temperament. Breastfeeding intensity and duration were assessed via several sources (diaries, telephone interviews, monthly mailings and in-person exams) from birth through the first year of life. Pregnancy course, clinical perinatal and newborn outcomes were obtained from health plan electronic medical records. Infant saliva samples were collected and stored for genetics studies. This large, racially and ethnically diverse cohort of GDM offspring will enable evaluation of the relationship of infant feeding to growth during infancy independent of perinatal characteristics, sociodemographics and other risk factors. The longitudinal design provides the first quantitative measures of breastfeeding intensity and duration among GDM offspring during early life.

Toro-Ramos T, et al. Body composition during fetal development and infancy through the age of 5 years. Eur J Clin Nutr . 2015;69(12);1279-1289.

Fetal body composition is an important determinant of body composition at birth, and it is likely to be an important determinant at later stages in life. The purpose of this work is to provide a comprehensive overview by presenting data from previously published studies that report on body composition during fetal development in newborns and the infant/child through 5 years of age. Understanding the changes in body composition that occur both in utero and during infancy and childhood, and how they may be related, may help inform evidence-based practice during pregnancy

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and childhood. We describe body composition measurement techniques from the in utero period to 5 years of age, and identify gaps in knowledge to direct future research efforts. Available literature on chemical and cadaver analyses of fetal studies during gestation is presented to show the timing and accretion rates of adipose and lean tissues. Quantitative and qualitative aspects of fetal lean and fat mass accretion could be especially useful in the clinical setting for diagnostic purposes. The practicality of different pediatric body composition measurement methods in the clinical setting is discussed by presenting the assumptions and limitations associated with each method that may assist the clinician in characterizing the health and nutritional status of the fetus, infant and child. It is our hope that this review will help guide future research efforts directed at increasing the understanding of how body composition in early development may be associated with chronic diseases in later life.

Dancel, L. et al. The relationship between acculturation and infant feeding styles in a Latino population. Obesity (Silver Spring, Md.). 2015;23 (4):840-846 .

A post-hoc analysis was performed using data from an ongoing four-site RCT to promote early childhood obesity prevention. Cross-sectional data of parent-child dyads at the 12 month well-child visit who self-reported their Latino ethnicity were analyzed. The Short Acculturation Scale for Hispanics (SASH) and a subset of the Infant Feeding Style Questionnaire (IFSQ) that assessed four primary feeding styles were administered. Analyses compared SASH level (low v. high) with each feeding style. Complete SASH data was available for 398 of 431 Latino dyads. Median SASH score was 1.8 (IQR 1.4 – 2.7); 82% of participants had low acculturation (score < 3). Of the nine outcome variables, four were significantly associated with SASH: “Laissez-Faire/attention” (AOR 2.3 [95% CI 1.06 – 5.13], p=0.004), “Laissez-Faire/diet quality” (3.9 [1.7 – 8.75], p=0.005), “Pressuring as soothing” (3.6 [1.63 – 8.05], p=0.007) and “Restrictive/diet quality” (0.4 [0.19 – 0.94], p=0.031). Latino parents with lower acculturation were more likely than those with higher acculturation to endorse feeding styles that are associated with child obesity. Further research is needed to determine why acculturation and feeding style relate.

Toro-Ramos T. Body composition during fetal development and infancy through the age of 5 years. Eur J Clin Nutr . 2015; 69 (12):1279-1289.

Available literature on chemical and cadaver analyses of fetal studies during gestation is presented to show the timing and accretion rates of adipose and lean tissues. Quantitative and qualitative aspects of fetal lean and fat mass accretion could be especially useful in the clinical setting for diagnostic purposes. The practicality of different pediatric body composition measurement methods in the clinical setting is discussed by presenting the assumptions and limitations associated with each method that may assist the clinician in characterizing the health and nutritional status of the fetus, infant and child. It is our hope that this review will help guide future research efforts directed at increasing the understanding of how body composition in early development may be associated with chronic diseases in later life.

Lumeng JC, et al. Prevention Addressing the childhood obesity epidemic continues to be a challenge. Given that once obesity

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of obesity in infancy and early childhood: A National Institutes of Health Workshop. JAMA Pediatrics . 2015;169(5):484-490.

develops it is likely to persist, there has been an increasing focus on prevention at earlier stages of the life course. Research to develop and implement effective prevention and intervention strategies in the first 2 years after birth has been limited. In fall 2013, the National Institute of Diabetes and Digestive and Kidney Diseases convened a multidisciplinary workshop to summarize the current state of knowledge regarding the prevention of infant and early childhood obesity and to identify research gaps and opportunities. The questions addressed included (1) "What is known regarding risk for excess weight gain in infancy and early childhood?" (2) "What is known regarding interventions that are promising or have been shown to be efficacious?" and (3) "What are the challenges and opportunities in implementing and evaluating behavioral interventions for parents and other caregivers and their young children?"

Benjamin Neelon, Sara, et al. Correlation between maternal and infant cortisol varies by breastfeeding status. Infant Behav Dev . 2015;40:252- 258.

Thirty-four infants received formula only and 20 were either partially or fully breastfed. Breastfeeding was associated with higher household income, higher maternal education, and white race. Cortisol levels were higher among breastfed infants at all three time points. After adjustment, maternal cortisol levels were related with infant cortisol at bedtime only (regression estimate 0.06; 95% CI: 0.10, 1.1; p=0.02). The adjusted association between bedtime maternal and infant cortisol was stronger among breastfeeding dyads than among formula-feeding dyads (regression estimate 1.0; 95% CI: 0.1, 2.0; p=0.04 vs. 0.6; CI: -0.1, 1.3; p=0.10). In addition, we assessed the influence of maternal education and household income in our adjusted model; income strengthened the observed association, whereas maternal education did not change the estimate.

Gunderson, E, et al. The study of women, infant feeding and type 2 diabetes after GDM pregnancy and growth of their offspring (SWIFT Offspring study): prospective design, methodology and baseline characteristics. BMC pregnancy and childbirth . 2015;15:150.

The study enrolled 466 mother-infant pairs among GDM deliveries in northern California from 2009–2011. Participants attended three in-person study exams at 6–9 weeks, 6 months and 12 months after delivery for infant anthropometry (head circumference, body weight, length, abdominal circumference and skinfold thicknesses), as well as maternal anthropometry (body weight, waist circumference and percent body fat). Mothers also completed questionnaires on health and lifestyle behaviors, including infant diet, sleep and temperament. Breastfeeding intensity and duration were assessed via several sources (diaries, telephone interviews, monthly mailings and in-person exams) from birth through the first year of life. Pregnancy course, clinical perinatal and newborn outcomes were obtained from health plan electronic medical records. Infant saliva samples were collected and stored for genetics studies. This large, racially and ethnically diverse cohort of GDM offspring will enable evaluation of the relationship of infant feeding to growth during infancy independent of perinatal characteristics, sociodemographics and other risk factors. The longitudinal design provides the first quantitative measures of breastfeeding intensity and duration among GDM offspring during early life.

Perrin, E. at al. Racial and Eight hundred sixty-three parents (50% Hispanic, 27% black, 18% white; 86% Medicaid) were

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ethnic differences associated with feeding- and activity-related behaviors in infants. Pediatrics . 2014;133(4) :e857-e867.

enrolled. Exclusive formula feeding was more than twice as common (45%) as exclusive breastfeeding (19%); 12% had already introduced solid food; 43% put infants to bed with bottles; 23% propped bottles; 20% always fed when the infant cried; 38% always tried to get children to finish milk; 90% were exposed to television (mean, 346 minutes/day); 50% reported active television watching (mean, 25 minutes/day); and 66% did not meet “tummy time” recommendations. Compared with white parents, black parents were more likely to put children to bed with a bottle (adjusted odds ratio [aOR] = 1.97, P < .004; bottle propping, aOR = 3.1, P < .001), and report more television watching (aOR = 1.6, P = .034). Hispanic parents were more likely than white parents to encourage children to finish feeding (aOR = 1.9, P = .007), bottle propping (aOR = 2.5, P= .009), and report less tummy time (aOR = 0.6, P = .037). Behaviors thought to relate to later obesity were highly prevalent in this large, diverse sample and varied by race/ethnicity, suggesting the importance of early and culturally-adapted interventions.

Paul, IM, et al. The Intervention Nurses Start Infants Growth on Healthy Trajectories (INSIGHT) study. BMC Pediatr . 2014;14:184.

316 first-time mothers and their full-term newborns were enrolled from one maternity ward. Two weeks following delivery, dyads were randomly assigned to the "parenting" or "safety" groups. Subsequently, research nurses conduct study visits for both groups consisting of home visits at infant age 3-4, 16, 28, and 40 weeks, followed by annual clinic-based visits at 1, 2, and 3 years. Both groups receive intervention components framed around four behavior states: Sleeping, Fussy, Alert and Calm, and Drowsy. The main study outcome is BMI z-score at age 3 years; additional outcomes include those related to patterns of infant weight gain, infant sleep hygiene and duration, maternal responsiveness and soothing strategies for infant/toddler distress and fussiness, maternal feeding style and infant dietary content and physical activity. Maternal outcomes related to weight status, diet, mental health, and parenting sense of competence are being collected. Infant temperament will be explored as a moderator of parenting effects, and blood is collected to obtain genetic predictors of weight status. Finally, second-born siblings of INSIGHT participants will be enrolled in an observation-only study to explore parenting differences between siblings, their effect on weight outcomes, and carryover effects of INSIGHT interventions to subsequent siblings.

Yin, H.S. et al. Parent health literacy and "obesogenic" feeding and physical activity-related infant care behaviors. J Pediatrics . 2014;164(3):577-583 .

11.0% of parents were categorized as having low health literacy. Low health literacy significantly increased the odds of a parent reporting that they feed more formula than breast milk (AOR=2.0 [95%CI:1.2–3.5]), immediately feed when their child cries (AOR=1.8[1.1–2.8]), bottle prop (AOR=1.8 [1.002–3.1]), any infant TV watching (AOR=1.8 [1.1–3.0]), and inadequate tummy time (<30 minutes/day) (AOR=3.0[1.5–5.8]). Low parent health literacy is associated with certain obesogenic infant care behaviors. These behaviors may be modifiable targets for low health literacy-focused interventions to help reduce childhood obesity.

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Ahluwalia N, et al. Data needs for B-24 and beyond: NHANES data relevant for nutrition surveillance of infants and young children. Am J Clin Nutr . 2014;99(suppl):747S-754S.

A few large-scale national studies (eg, the Feeding Infants and Toddlers Study and Infant Feeding Practices Study) offer important insights into infant feeding practices and food consumption patterns in young children in the United States. The NHANES collects comprehensive cross-sectional data on the nutrition and health of Americans including infants and toddlers. This article describes the NHANES program and data from NHANES 1999-2010 on young children that are relevant for the B-24 Project. NHANES is a nationally representative survey of the noninstitutionalized US population that combines personal interviews with standardized physical examination and measurements via mobile examination centers. Data on infant feeding practices (breastfeeding and timing of introduction and nature of complementary foods), dietary intake (two 24-h recalls), and nutrient supplements are collected. Data on demographic characteristics, anthropometric measurements, biomarkers of nutrient status, food security, and participation in federal nutrition programs are also available. Data can be accessed online, downloaded, and pooled over several survey cycles, allowing examination of infant feeding practices, food and nutrient intakes, and nutritional status of Americans <2 y old. Subgroup analyses by race-ethnicity and income status are also possible. NHANES responds to evolving data needs, as feasible, in the context of the survey design, research priorities, and funding. It offers a vehicle for potentially gathering additional data on children <2 y to address the objectives of the B-24 Project in the future.

Birch LL & Doub AE. Learning to eat: Birth to age 2 y. Am J Clin Nutr . 2014;99(suppl):723S-728S.

During the first 2 y of life, development is rapid and includes dramatic changes in eating behavior. Individual patterns of food preferences and eating behaviors emerge and differ depending on the foods offered and on the contexts of feeding during this early period of dietary transition. In this review, we discuss evidence on ways in which early learning influences food preferences and eating behavior, which, in turn, shape differences in dietary patterns, growth, and health. Although the evidence reviewed indicates that this early period of transition provides opportunities to influence children's developing intake patterns, there is no consistent, evidence-based guidance for caregivers who are feeding infants and toddlers; the current Dietary Guidelines are intended to apply to Americans over the age of 2 y. At present, the evidence base with regard to how and what children learn about food and eating behavior during these first years is limited. Before developing guidance for parents and caregivers, more scholarship and research is necessary to understand how infants and toddlers develop the food preferences and self-regulatory processes necessary to promote healthy growth, particularly in today's environment. By the time they reach 2 y of age, children have essentially completed the transition to "table foods" and are consuming diets similar to those of other family members. This article discusses parenting and feeding approaches that may facilitate or impede the development of self-regulation of intake and the acceptance of a variety of foods and flavors necessary for a healthy

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diet. We review the limited evidence on how traditional feeding practices, familiarization, associative learning, and observational learning affect the development of eating behavior in the context of the current food environment. Areas for future research that could inform the development of anticipatory guidance for parents and caregivers responsible for the care and feeding of young children are identified.

Heerman W. et al. Health literacy and injury prevention behaviors among caregivers of infants. Am J Prev Med . 2014; 46(5):449-456 .

Data were analyzed from 844 English and Spanish-speaking caregivers of 2-month-old children. Many caregivers were non-adherent with injury prevention guidelines, regardless of health literacy. Notably, 42.6% inappropriately placed their children in the prone position to sleep, and 88.6% did not have their hot water heater set <120°F. Eleven percent of caregivers were categorized as having low health literacy. Low caregiver health literacy, compared to adequate health literacy, was significantly associated with increased odds of caregiver non-adherence with recommended behaviors for car seat position (AOR=3.4, 95% CI=1.6, 7.1), and fire safety (AOR=2.0, 95% CI=1.02, 4.1) recommendations. Caregivers with low health literacy were less likely to be non-adherent to fall prevention recommendations (AOR=0.5, 95% CI=0.2, 0.9). Non-adherence to injury prevention guidelines was common. Low caregiver health literacy was significantly associated with some injury prevention behaviors. Future interventions should consider the role of health literacy in promoting injury prevention.

Harrison GG, et al. WIC Infant and Toddler Feeding Practice Study: Protocol design and implementation. Am J Clin Nutr . 2014;99(suppl):742S-746S.

The federal Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which began in the 1970s, has undergone revisions in the past several years, including revision to contents of the supplemental food "packages" in 2009 based on recommendations provided by an Institute of Medicine (IOM) committee of The National Academies. In 2010, the IOM held a workshop to examine and recommend research priorities for the program. The overall purpose of the current (ie, second) WIC Infant and Toddler Feeding Practices Study (ITFPS-2) is to conduct a nationally representative, longitudinal study of contemporary WIC infant and toddler feeding practices. This study will update earlier studies and collect information on variations in WIC program components. The study will also assess ways in which WIC may address obesity in early childhood and examine changes in feeding practices that may stem from the 2009 food package revisions. The sample is drawn from the universe of WIC sites nationally, excluding only those with an insufficient volume of eligible participants. Eligibility for the study includes the ability to be interviewed in English or Spanish. Approximately 8000 women and infants are being sampled, and ∼ 4000 are expected to participate. Eligible women are invited to participate during their WIC enrollment visit, and informed consent is sought. The design includes a core sample to be followed until the infant reaches age 2 y and a supplemental sample to be used in some cross-sectional analyses to ensure adequate

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representation of groups that might be underrepresented in the core sample. Participants will complete up to 11 interviews (core sample) or 4 interviews (supplemental sample) each except for the prenatal interview, which includes a quantitative 24-h recall of food intake for the infant. Eighty sites have been sampled across 26 states and 1 territory. Instruments have been developed and pretested in both English and Spanish, and interviewers have been rigorously trained. Recruitment and interviewing began in July 2013. This study will provide the only current large-sample longitudinal feeding data available on a nationally representative sample of infants in low-income families, and results will be available to inform the 2020 Dietary Guidelines for Americans for the 0- to 24-mo age group.

Innis SM. Impact of maternal diet on human milk composition and neurological development of infants. Am J Clin Nutr . 2014;99(suppl):734S-741S.

Maternal nutrition has little or no effect on many nutrients in human milk; for others, human milk may not be designed as a primary nutritional source for the infant; and for a few, maternal nutrition can lead to substantial variations in human milk quality. Human milk fatty acids are among the nutrients that show extreme sensitivity to maternal nutrition and are implicated in neurological development. Extensive development occurs in the infant brain, with growth from ∼350 g at birth to 925 g at 1 y, with this growth including extensive dendritic and axonal arborization. Transfer of n–6 (omega-6) and n–3 (omega-3) fatty acids from the maternal diet into human milk occurs with little interconversion of 18:2n–6 to 20:4n–6 or 18:3n–3 to docosahexaenoic acid (DHA) and little evidence of mammary gland regulation to maintain individual fatty acids constant with varying maternal fatty acid nutrition. DHA has gained attention because of its high concentrations and roles in the brain and retina. Studies addressing DHA intakes by lactating women or human milk amounts of DHA at levels above those typical in the United States and Canada on infant outcomes are inconsistent. However, separating effects of the fatty acid supply in gestation or in the weaning diet from effects on neurodevelopment solely due to human milk fatty acids is complex, particularly when neurodevelopment is assessed after the period of exclusive human milk feeding. Information on infant fatty acid intakes, including milk volume consumed and energy density, will aid in understanding of the human milk fatty acids that best support neurological development.

Obbagy JE, et al. USDA Nutrition Evidence Library: Methodology used to identify topics and develop systematic review questions for the birth-to-24-mo population. Am J Clin Nutr . 2014;99(suppl):692S-696S.

The USDA's Nutrition Evidence Library (NEL) specializes in conducting food- and nutrition-related systematic reviews that are used to inform federal government decision making. To ensure the utility of NEL systematic reviews, the most relevant topics must be addressed, questions must be clearly focused and appropriate in scope, and review frameworks must reflect the state of the science. Identifying the optimal topics and questions requires input from a variety of stakeholders, including scientists with technical expertise, as well as government policy and program leaders. The objective of this article is to describe the rationale and NEL methodology for identifying topics and developing systematic review questions implemented as part of the “Evaluating the evidence base to support the

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inclusion of infants and children from birth to 24 months of age in the Dietary Guidelines for Americans—the B-24 Project.” This is the first phase of a larger project designed to develop dietary guidance for the birth to 24-mo population in the United States.

Sela DA & Mills DA. The marriage of nutrigenomics with the microbiome: The case of infant-associated bifidobacteria and milk. Am J Clin Nutr. 2014;99(3):697S- 703S.

Broadly, nutrigenomics examines the association of exogenous nutrients and molecular responses to maintain homeostasis in an individual. Phenotypic expression profiling, often transcriptomics, has been applied to identify markers and metabolic consequences of suboptimal diet, lifestyle, or both. The decade after the Human Genome Project has been marked with advances in high-throughput analysis of biological polymers and metabolites, prompting a rapid increase in characterization of the profound nature by which our symbiotic microbiota influences human physiology. Although the technology is widely accessible to assess microbiome composition, genetic potential, and global function, nutrigenomics studies often exclude the microbial contribution to host responses to ingested nutritive molecules. Perhaps a hallmark of coevolution, milk provides a dramatic example of a diet that promotes a particular microbial community structure, because the lower infant gastrointestinal tract is often dominated by bifidobacteria that flourish on milk glycans. Systems-level approaches should continue to be applied to examine the microbial communities in the context of their host's dietary habits and metabolic status. In addition, studies of isolated microbiota species should be encouraged to inform clinical studies and interventions as well as community studies. Whereas nutrigenomics research is beginning to account for resident microbiota, the need remains to consistently consider our microscopic partners in the human holobiont.

Raiten DJ, et al. Executive summary: Evaluating the evidence base to support the inclusion of infants and children from birth to 24 mo of age in the Dietary Guidelines for Americans – “the B-24 Project.” Am J Clin Nutr. 2014;99(suppl):663S-691S.

The Dietary Guidelines for Americans (DGA) are the cornerstone of US government efforts to promote health and prevent disease through diet and nutrition. The DGA currently provides guidelines for ages ≥2 y. In an effort to determine the strength of the evidence to support the inclusion of infants and children from birth to age 24 mo, the partner agencies led by the Department of Health and Human Services Office of Disease Prevention and Health Promotion and the USDA Center for Nutrition Program and Policy initiated the project entitled “Evaluating the evidence base to support the inclusion of infants and children from birth to 24 months of age in the Dietary Guidelines for Americans—the B-24 Project.” This project represents the first step in the process of applying systematic reviews to the process of deciding whether the evidence is sufficient to include this age group in future editions of the DGA. This supplement includes the B-24 Executive Summary, which describes the B-24 Project and the deliberations of the 4 working groups during the process of developing priority topics for the systematic review, and a research agenda to address the critical gaps. Also included in this supplement issue is an article on the Nutrition Evidence Library methodology for developing systematic review questions and articles from the invited content presenters at the B-24

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Prime meeting.Mennella JA. Ontogeny of taste preferences: Basic biology and implications of health. Am J Clin Nutr . 2014;99(suppl):704S-711S.

Health initiatives address childhood obesity in part by encouraging good nutrition early in life. This review highlights the science that shows that children naturally prefer higher levels of sweet and salty tastes and reject lower levels of bitter tastes than do adults. Thus, their basic biology does not predispose them to favor the recommended low-sugar, low-sodium, vegetable-rich diets and makes them especially vulnerable to our current food environment of foods high in salt and refined sugars. The good news is that sensory experiences, beginning early in life, can shape preferences. Mothers who consume diets rich in healthy foods can get children off to a good start because flavors are transmitted from the maternal diet to amniotic fluid and mother's milk, and breastfed infants are more accepting of these flavors. In contrast, infants fed formula learn to prefer its unique flavor profile and may have more difficulty initially accepting flavors not found in formula, such as those of fruit and vegetables. Regardless of early feeding mode, infants can learn through repeated exposure and dietary variety if caregivers focus on the child's willingness to consume a food and not just the facial expressions made during feeding. In addition, providing complementary foods low in salt and sugars may help protect the developing child from excess intake later in life. Early-life experiences with healthy tastes and flavors may go a long way toward promoting healthy eating, which could have a significant impact in addressing the many chronic illnesses associated with poor food choice.

Lonnerdal B. Infant formula and infant nutrition: Bioactive proteins of human milk and implications for composition of infant formulas. Am J Clin Nutr . 2014;99(suppl):712S-717S.

Human milk contains an abundance of biologically active components that are highly likely to contribute to the short- and long-term benefits of breastfeeding. Many of these components are proteins; this article describes some of these proteins, such as α-lactalbumin, lactoferrin, osteopontin, and milk fat globule membrane proteins. The possibility of adding their bovine counterparts to infant formula is discussed as well as the implications for infant health and development. An important consideration when adding bioactive proteins to infant formula is that the total protein content of formula needs to be reduced, because formula-fed infants have significantly higher concentrations of serum amino acids, insulin, and blood urea nitrogen than do breastfed infants. When reducing the protein content of formula, the amino acid composition of the formula protein becomes important because serum concentrations of the essential amino acids should not be lower than those in breastfed infants. Both the supply of essential amino acids and the bioactivities of milk proteins are dependent on their digestibility: some proteins act only in intact form, others act in the form of larger or small peptides formed during digestion, and some are completely digested and serve as a source of amino acids. The purity of the proteins or protein fractions, potential contaminants of the proteins (such as lipopolysaccharide), as well as the degree of heat processing used during their isolation also need to be considered. It is likely that there will be more bioactive components added to infant formulas in the

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near future, but guidelines on how to assess their bioactivities in vitro, in animal models, and in clinical studies need to be established. The extent of testing needed is likely going to depend on the degree of complexity of the components and their bioequivalence with the human compounds whose effects they are intended to mimic.

Michaelsen KF & Greer FR. Protein needs early in life and long-term health. Am J Clin Nutr . 2014;99(suppl):718S-722S.

The objective of this review was to summarize selected health aspects of protein intake during the first 2 y of life. During this period there is a marked increase in protein intake from an intake of ∼ 5% of energy from protein (PE%) in an exclusively breastfed infant to ∼ 15 PE% when complementary foods have been introduced. At this age, mean protein intake is ∼ 3 times as high as the physiologic requirement, but some children receive 4-5 times their physiologic requirement. Protein from cow milk constitutes a main part of protein intake in toddlers and seems to have a specific effect on insulin-like growth factor I concentrations and growth. Meat has a high protein content, but the small amounts of meat needed to ensure good iron status have less impact on total protein intake. The difference in protein intake between breastfed and formula-fed infants is likely to play a role in the difference between breastfed and formula-fed infants. There is emerging evidence that high protein intake during the first 2 y of life is a risk factor for later development of overweight and obesity. It therefore seems prudent to avoid a high protein intake during the first 2 y of life. This could be accomplished by decreasing the upper allowable limit of the protein content of infant formulas for the first year of life and limiting the intake of cow milk in the second year of life.

Worobey J. Physical activity in infancy: Developmental aspects, measurement, and importance. Am J Clin Nutr . 2014;99(suppl):729S-733S.

Relative to work on nutrient intake and growth in infancy and toddlerhood, research on physical activity (PA) from birth to age 24 mo is limited. In this review, the developmental course of PA in infancy and toddlerhood is described, and the issues that surround its measurement are addressed. Of the variety of techniques that allow for gauging PA in infancy and toddlerhood, caregiver questionnaires, direct observations, and motion sensors have been used most frequently. Although each method has shown utility, the limitations of each are also acknowledged. In addition, the relation of early PA to nutrition and overweight in infants is considered. Despite the challenges to accurately monitoring early PA, its possible contribution to early excess weight gain should be recognized.

Colen CG & Ramey DM. Is breast truly best? Estimating the effects of breastfeeding on long-term child health and wellbeing in the United States using sibling comparisons. Soc Sci & Med .

Results from standard multiple regression models suggest that children aged 4 to 14 who were breast- as opposed to bottle-fed did significantly better on 10 of the 11 outcomes studied. Once we restrict analyses to siblings and incorporate within-family fixed effects, estimates of the association between breastfeeding and all but one indicator of child health and wellbeing dramatically decrease and fail to maintain statistical significance. Our results suggest that much of the beneficial long-term effects typically attributed to breastfeeding, per se, may primarily be due to selection pressures into infant feeding practices along key demographic characteristics such as race and socioeconomic status.

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2014;109:55-65.Clayton HB, et al. Prevalence and reasons for introducing infants early to solid foods: Variations by milk feeding type. Pediatrics . 2013;131:e1108-e1114.

Overall, 40.4% of mothers introduced solid foods before age 4 months. Prevalence varied by milk feeding type (24.3%, 52.7%, and 50.2% for breastfed, formula-fed, and mixed-fed infants, respectively). The most commonly cited reasons for early introduction of solid food were as follows: “My baby was old enough,” “My baby seemed hungry,” “I wanted to feed my baby something in addition to breast milk or formula,” “My baby wanted the food I ate,” “A doctor or other health care professional said my baby should begin eating solid food,” and “It would help my baby sleep longer at night.” Four of these reasons varied by milk feeding type. Our findings highlight the high prevalence of early introduction of solids and provide details on why mothers introduced solid foods early.

Brownell EA, et al. The effect of immediate postpartum depot medroxyprogesterone on early breastfeeding cessation. Contraception . 2013;87(6):836-843.

Consistent with the biologic model, the Kaplan-Meier results raised the possibility of a detrimental effect of DMPA on duration of any breastfeeding, but differences in these distributions did not achieve statistical significance (p=.24); after adjustment for potential confounders, this nonstatistically significant association remained (HR: 1.22; confidence interval: 0.75-1.98). Given the state of the evidence, it is unclear whether a causal effect does or does not exist. However, if there is a causal effect of DMPA on breastfeeding duration, it is minimal. Additional well-designed research is warranted.

Dozier AM, et al. Labor epidural anesthesia, obstetric factors and breastfeeding cessation. Matern Child Health J . 2013;17(4):689- 698.

Breastfeeding benefits both infant and maternal health. Use of epidural anesthesia during labor is increasingly common and may interfere with breastfeeding. Studies analyzing epidural anesthesia's association with breastfeeding outcomes show mixed results; many have methodological flaws. We analyzed potential associations between epidural anesthesia and overall breast-feeding cessation within 30 days postpartum while adjusting for standard and novel covariates and uniquely accounting for labor induction. A pooled analysis using Kaplan-Meier curves and modified Cox Proportional Hazard models included 772 breastfeeding mothers from upstate New York who had vaginal term births of healthy singleton infants. Subjects were drawn from two cohort studies (recruited postpartum between 2005 and 2008) and included maternal self-report and maternal and infant medical record data. Analyses of potential associations between epidural anesthesia and overall breastfeeding cessation within 1 month included additional covariates and uniquely accounted for labor induction. After adjusting for standard demographics and intrapartum factors, epidural anesthesia significantly predicted breastfeeding cessation (hazard ratio 1.26 [95% confidence interval 1.10, 1.44], p < 0.01) as did hospital type, maternal age, income, education, planned breastfeeding goal, and breastfeeding confidence. In post hoc analyses stratified by Baby Friendly Hospital (BFH) status, epidural anesthesia significantly predicted breastfeeding cessation (BFH: 1.19 [1.01, 1.41], p < 0.04; non-BFH:

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1.65 [1.31, 2.08], p < 0.01). A relationship between epidural anesthesia and breastfeeding was found but is complex and involves institutional, clinical, maternal and infant factors. These findings have implications for clinical care and hospital policies and point to the need for prospective studies.

Chin NP, et al. Deaf mothers and breastfeeding: Do unique features of deaf culture and language support breastfeeding success? J Hum Lact . 2013;29(4):564- 571.

Fifteen mothers participated. All had initiated breastfeeding with their most recent child. Breastfeeding duration for 8 of the mothers was 3 weeks to 12 months. Seven of the mothers were still breastfeeding, the longest for 19 months. Those mothers who breastfed longer described a supportive social environment and the ability to surmount challenges. Participants described characteristics of Deaf culture such as direct communication, sharing information, use of technology, language access through interpreters and ASL-using providers, and strong self-advocacy skills. Finally, mothers used the sign for "struggle" to describe their breastfeeding experience. The sign implies a sustained effort over time that leads to success. In a setting with a large population of Deaf women and ASL-using providers, we identified several aspects of Deaf culture and language that support breastfeeding mothers across institutional, community, and interpersonal levels of the SEM.

Stein LJ, et al. The development of salty taste acceptance is related to dietary experience in human infants: A prospective study. Am J Clin Nutr . 2012;94:123-129.

Dietary experience was related to salt acceptance, with only those infants previously exposed to starchy table foods (n = 26) preferring the salty solutions at 6 mo (P = 0.007). Fruit exposure was not associated with sodium chloride acceptance. Infants eating starchy table foods at 6 mo were more likely to lick salt from the surface of foods at preschool age (P = 0.007) and tended to be more likely to eat plain salt (P = 0.08). The findings suggest an influential role of early dietary experience in shaping salty taste responses of infants and young children.

Brownell E, et al. Does delayed onset lactogensis II predict the cessation of any or exclusive breastfeeding. J Pediatr . 2012;16(4):608-614 .

DLII was associated with cessation of any and exclusive breastfeeding at 4-weeks postpartum (OR: 1.62; CI: 1.14–2.31; OR: 1.62; CI 1.18–2.22 respectively); numerous independent risk factors qualified for inclusion in the multivariable model(s) and were associated with the outcome(s) of interest (e.g. WIC enrollment, onset of prenatal care, feeding on-demand, time initiated first breastfeed, hospital rooming-in, obstetric provider preference for exclusive breastfeeding and maternal tobacco use). Women experiencing DLII may be less able to sustain any and/or exclusive breastfeeding in the early postpartum period. These findings have significant clinical and programmatic implications. Routine assessment of DLII in postpartum breastfeeding follow-up is warranted, and women with DLII may benefit from additional early postpartum interventions to support favorable breastfeeding outcomes.

Dozier AM. Quick reference breastfeeding guide available for medical students and

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residents. Breastfeed Med . 2012;Aug 7:320.

Brownell EA, et al. A systematic review of early postpartum medroxyprogesterone receipt and early breastfeeding cessation: Evaluating the methodological rigor of the evidence. Breastfeed Med . 2012;7(1):10-18.

Of the 20 articles identified, only three studies satisfied the inclusion criteria. However, all three studies were of low-quality methodological rigor, and none accounted for potential confounders. Current evidence is methodologically weak and provides an inadequate basis for inference about a possible causal relationship between early postpartum medroxyprogesterone use and poor breastfeeding outcomes. However, given the presence of a strong biological model describing the potential deleterious effect of postpartum medroxyprogesterone use on lactation, further research that improves on current literature is warranted. Meanwhile, we recommend that potential breastfeeding risks associated with early (<6 weeks) postpartum medroxyprogesterone use be disclosed to allow for a fully informed consent and decision-making process.

Dozier AM, et al. The relationship between life stress and breastfeeding outcomes among low-income mothers. Adv Prev Med . 2012;902487.

Stressful life events during pregnancy negatively affect maternal and infant outcomes including breastfeeding initiation. Their impact on breastfeeding duration is uncertain. Given breastfeeding's important health benefits we analyzed stressful life event types and cessation of any and exclusive breastfeeding by 4 and 13 weeks. Methods. We collected self-administered survey data at 5-7 months postpartum from over 700 primarily urban low-income US mothers. Data covered prepregnancy, prenatal, and postpartum periods including 14 stressful life events (categorized into financial, emotional, partner-associated, traumatic). Analyses included only mothers initiating breastfeeding (n = 341). Logistic regressions controlled for maternal characteristics including a breastfeeding plan. Results. All four stress categories were associated with shorter duration of any and exclusive breastfeeding. In the adjusted models, statistically significant relationships remained for financial stress (4 weeks cessation of any breastfeeding duration) and traumatic stress (13 weeks exclusive breastfeeding cessation). Controlling for stress, a longer breastfeeding plan was significantly associated with a shorter breastfeeding duration (all models) as was depression during pregnancy and current smoking (several models). Conclusions. Among low-income women, impact of stressful life events on cessation of breastfeeding may differ by stress type and interfere with achievement of breastfeeding goal. Among these stressed mothers, breastfeeding may serve as a coping mechanism.

Yin, H.S. et al. Assessment of health literacy and numeracy among Spanish-Speaking parents of young

Of 176 caregivers, 77% had adequate health literacy (S-TOFHLA), while only 0.6% had 9th grade or higher numeracy skills. Mean PHLAT-10 score was 41.6% (SD 21.1). Fewer than half (45.5%) were able to read a liquid antibiotic prescription label and demonstrate how much medication to administer within an oral syringe. Less than a third (31.8%) were able to interpret a food label to determine

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children: validation of the Spanish Parental Health Literacy Activities Test (PHLAT Spanish). Acad Pediatrics . 2012;12(1):68-74 .

whether it met WIC guidelines. Higher PHLAT-10 score was associated with higher years of education (r=0.49), S-TOFHLA (r=0.53) and WRAT-3 (r=0.55) scores (p<0.001). Internal reliability was good (KR-20=0.61). An 8-item scale was highly correlated with the full 10-item scale (r=0.97, p<0.001), with comparable internal reliability (KR-20= 0.64). Many Spanish-speaking parents have difficulty carrying out health-related literacy and numeracy tasks. The Spanish PHLAT demonstrates good psychometric characteristics and may be useful for identifying parents who would benefit from receiving low-literacy child health information.

Perrin EM. Respecting cultural values of toddler weight perception while discouraging parental overfeeding. Arch Pediatr Adolesc Med . 2012; 166(5):422-423 .

In short, we should be able to explore parental perception and satisfaction with children's weight and preserve cultural ideals and pride in children's growth but also help parents achieve healthy weight trajectories. We can do this by counseling with sensitive and culturally competent dialogue and providing guidelines for eating and activity tailored for age, culture, and socioeconomic status compatible with lifelong health.

Dozier AM & McKee KS. State breastfeeding worksite statutes…breastfeeding rates…and… Breastfeed Med . 2011;6:319-324 .

Although requiring a site and/or break time for breastfeeding increased the likelihood of breastfeeding at 6 months (odds ratio, 1.20; 95% confidence interval, 1.07-1.35; p=0.002), after accounting for other factors this relationship remained positive but was not significant (adjusted odd ratio, 1.07; 95% confidence interval, 0.92-1.24). Because all mothers, not just those in or returning to the workforce, were included in the analysis this relationship could be underestimated. Breastfeeding at 6 months was associated with being from a state that had had a breastfeeding coalition for a longer period of time (adjusted odds ratio, 1.25; 95% confidence interval, 1.04-1.49; p<0001). State worksite breastfeeding statutes alone may not directly affect breastfeeding duration. Analysis of breastfeeding duration using the multiple levels of the social-ecological model is a potentially useful approach to understanding the impact of state breastfeeding statutes. The impact of state breastfeeding coalitions warrants further study.

Kumar, D. et al. Parental understanding of infant health information: health literacy, numeracy, and the Parental Health Literacy Activities Test (PHLAT). Acad Pediatrics . 2010;10(5):309-316 .

182 caregivers were recruited. While 99% had adequate literacy skills, only 17% had >9th-grade numeracy skills. Mean score on the PHLAT was 68% (SD 18); for example, only 47% of caregivers could correctly describe how to mix infant formula from concentrate, and only 69% could interpret a digital thermometer to determine if an infant had a fever. Higher performance on the PHLAT was significantly correlated (p<0.001) with education, literacy skill, and numeracy level (r=0.29, 0.38, and 0.55 respectively). Caregivers with higher PHLAT scores were also more likely to interpret age recommendations for cold medications correctly (OR 1.6, 95% CI 1.02, 2.6). Internal reliability on the PHLAT was good (KR-20=0.76). The PHLAT-10 also demonstrated good validity and reliability.

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Many parents do not understand common health information required to care for their infants. The PHLAT, and PHLAT-10 have good reliability and validity and may be useful tools for identifying parents who need better communication of health-related instructions.

Dozier AM. Community engagement and dissemination of effective breastfeeding programs. Breastfeed Med . 2010;5(5);215-216.Chin NP. Environmental toxins: Physical, social, and emotional. Breastfeed Med . 2010;5(5):223-224.

Relevant Review Articles

Blake-Lamb, Tiffany L; Locks, Lindsey M; Perkins, Meghan E; Woo Baidal, Jennifer A; Cheng, Erika R; Taveras, Elsie M. Interventions for Childhood Obesity in the First 1,000 Days A Systematic Review. Am J Prev Med . 2016;50(6):780- 789.

Of 34 completed studies from 26 unique identified interventions, nine were effective. Effective interventions focused on individual- or family-level behavior changes through home visits, individual counseling or group sessions in clinical settings, a combination of home and group visits in a community setting, and using hydrolyzed protein formula. Protein-enriched formula increased childhood obesity risk. Forty-seven ongoing interventions were identified. Across completed and ongoing interventions, the majority target individual- or family-level changes, many are conducted in clinical settings, and few target early-life systems and policies that may impact childhood obesity. Obesity interventions may have the greatest preventive effect if begun early in life. Yet, few effective interventions in the first 1,000 days exist, and many target individual-level behaviors of parents and infants. Interventions that operate at systems levels and are grounded in salient conceptual frameworks hold promise for improving future models of early-life obesity prevention.

Bever B, et al. Reduced breastfeeding rates among obese mothers; A review of contributing factors, clinical

The key findings concerned factors impacting initiation and early breastfeeding, factors impacting later breastfeeding and exclusivity, interventions to increase breastfeeding in obese women, and clinical considerations. The factors impacting early breastfeeding include mechanical factors and delayed onset of lactogenesis II and we have critically analyzed the potential contributors to these

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considerations and future directions. Int Brestfeed J . 2015;10:21

factors. The factors impacting later breastfeeding and exclusivity include hormonal imbalances, psychosocial factors, and mammary hypoplasia. Several recent interventions have sought to increase breastfeeding duration in obese women with varying levels of success and we have presented the strengths and weaknesses of these clinical trials. Clinical considerations include specific techniques that have been found to improve breastfeeding incidence and duration in obese women. Many obese women do not obtain the health benefits of exclusive breastfeeding and their children are more likely to also be overweight or obese if they are not breastfed. Further research is needed into the physiological basis for decreased breastfeeding among obese women along with effective interventions supported by rigorous clinical research to advance the care of obese reproductive age women and their children.

Ciampa, P. et al. The association of acculturation and health literacy, numeracy and health-related skills in Spanish-speaking caregivers of young children. J Immigr Minor Health. 2013;15(3) :492-498 .

Little is known about the relationship among acculturation, literacy, and health skills in Latino caregivers of young children. Latino caregivers of children <30 months seeking primary care at four medical centers were administered measures of acculturation (SASH), functional health literacy (STOFHLA), numeracy (WRAT-3) and health-related skills (PHLAT Spanish). Child anthropomorphics and immunization status were ascertained by chart review. Caregivers (N = 184) with a median age of 27 years (IQR: 23–32) participated; 89.1 % were mothers, and 97.1 % had low acculturation. Lower SASH scores were significantly correlated (P < 0.01) with lower STOFHLA (ρ = 0.21), WRAT-3 (ρ = 0.25), and PHLAT Spanish scores (ρ = 0.34). SASH scores predicted PHLAT Spanish scores in a multivariable linear regression model that adjusted for the age of child, the age and gender of the caregiver, number of children in the family, the type of health insurance of the caregiver, and study site (adjusted β: 0.84, 95 % CI 0.26–1.42, P = 0.005). This association was attenuated by the addition of literacy (adjusted β: 0.66, 95 % CI 0.11–1.21, P = 0.02) or numeracy (adjusted β: 0.50, 95 % CI −0.04–1.04, P = 0.07) into the model. There was no significant association between acculturation and up-to-date child immunizations or a weight status of overweight/obese. Lower acculturation was associated with worse health literacy and diminished ability to perform child health-related skills. Literacy and numeracy skills attenuated the association between acculturation and child health skills. These associations may help to explain some child health disparities in Latino communities.

Dolinsky DH, et al. Recognizing and preventing childhood obesity. Contemp Pediatr . 2011;28(1):32-42.

Childhood obesity remains a challenge for primary care providers. Preventing the problem or identifying it early and intervening is clearly the best solution. Physicians should counsel mothers early in pregnancy about weight gain, smoking, and nutrition. Pediatricians should use WHO growth curves to track infant growth from 0 to 24 months and closely watch young children who cross growth percentiles upward. In addition, pediatricians should encourage breastfeeding,

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recommend minimal juice and other sweet-drink consumption, discuss feeding practices that are guided by the infant’s cues, and encourage proper sleep duration and avoidance of screen time as part of anticipatory guidance. Delayed introduction of solids may also be beneficial to encourage. Pediatricians can advocate for making child care settings healthy places for young children and assist parents with choosing healthy child care options. In their offices, pediatricians also can set good examples by providing private rooms for nursing mothers, eliminating televisions in waiting rooms, and offering only healthy vending options for patients and families. In addition, there are resources for pediatricians and for patients that can be used directly. Working with parents to prevent obesity in the early years can place young children on a lifelong trajectory toward good health.

Hesketh KD & Campbell KJ. Interventions to prevent obesity in 0-5 year olds: An updated systematic review of the literature. Obes . 2010;18(1):S27-S35.

The current review was conducted to provide an update of the rapidly emerging evidence in this area and to assess the quality of studies reported. Ten electronic databases were searched to identify literature published from January 1995 to August 2008. Inclusion criteria: interventions reporting child anthropometric, diet, physical activity, or sedentary behavior outcomes and focusing on children aged 0–5 years of age. Exclusion criteria: focusing on breastfeeding, eating disorders, obesity treatment, malnutrition, or school-based interventions. Two reviewers independently extracted data and assessed study quality. Twenty-three studies met all criteria. Most were conducted in preschool/childcare (n = 9) or home settings (n = 8). Approximately half targeted socioeconomically disadvantaged children (n = 12) and three quarters were published from 2003 onward (n = 17). The interventions varied widely although most were multifaceted in their approach. While study design and quality varied most studies reported their interventions were feasible and acceptable, although impact on behaviors that contribute to obesity were not achieved by all. Early childhood obesity-prevention interventions represent a rapidly growing research area. Current evidence suggests that behaviors that contribute to obesity can be positively impacted in a range of settings and provides important insights into the most effective strategies for promoting healthy weight from early childhood.

Ciampa PJ, et al. Interventions aimed at decreasing obesity in children younger than 2 years: a systematic review. Archives of pediatrics & adolescent medicine. 2010;164(12):1098-1104 .

We retrieved 1557 citations; 38 articles were reviewed, and 12 articles representing 10 studies met study inclusion criteria. Eight studies used educational interventions to promote dietary behaviors, and 2 studies used a combination of nutrition education and physical activity. Study settings included home (n=2), clinic (n=3), classroom (n=4), or a combination (n=1). Intervention durations were generally less than 6months and had modest success in affecting measures, such as dietary intake and parental attitudes and knowledge about nutrition. No intervention improved child weight status. Studies were of poor or fair quality (median quality score, 0.86; range, 0.28–

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1.43). Few published studies attempted to intervene among children younger than 2 years to prevent or reduce obesity. Limited evidence suggests that interventions may improve dietary intake and parental attitudes and knowledge about nutrition for children in this age group. For clinically important and sustainable effect, future research should focus on designing rigorous interventions that target young children and their families.

Parental Perceptions of Weight

Brown CL, et al. Parental perceptions of weight during the first year of life. Acad Pediatr . 2016;16(6):558-564.

Infants' length and weight were measured at well-child checks, and parents completed questionnaires including demographic characteristics and perception of their children's weight. Weight-for-length (WFL) percentile at the fifth to ≤95 was considered healthy weight and WFL percentile >95th was considered overweight. We used chi-squared tests to compare accuracy according to weight category and performed logistic regression analysis to assess accuracy at each time point. Approximately 85% to 90% of infants (n = 853 at 2 months, n = 563 at 12 months) were at a healthy WFL at all measurement times, and parents of these infants were more likely to have an accurate perception of their child's weight (accuracy 89%-95%) than overweight children (accuracy 7%-26%; P < .001 across time points). Approximately 10% of healthy weight infants were perceived as underweight by their parents at all time points. At 12 months, mothers who were overweight were significantly more likely to underestimate their child's weight status (P = .008). In our diverse and low-income sample, parents of overweight infants infrequently know that their infants are overweight. Future studies should examine how perception is related to feeding habits and weight status over time.

Perrin EM. Respecting cultural values of toddler weight perception while discouraging parental overfeeding. Arch Pediatr Adolesc Med . 2012; 166(5):422-423 .

In short, we should be able to explore parental perception and satisfaction with children's weight and preserve cultural ideals and pride in children's growth but also help parents achieve healthy weight trajectories. We can do this by counseling with sensitive and culturally competent dialogue and providing guidelines for eating and activity tailored for age, culture, and socioeconomic status compatible with lifelong health.

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Parental Stress

Parks EP, et al. Perspectives on stress, parenting, and children's obesity-related behaviors in black families. Health Educ Behav . 2016;Jan 5 [Epub ahead of print].

Parents/grandparents described a pathway between how stress affected them personally and their child's eating, structured (sports/dance) and unstructured (free-play) physical activity, and screen-time usage, as well as strategies to prevent this association. Five themes emerged: stress affects parent behaviors related to food and physical activity variably; try to be healthy even with stress; parent/grandparent stress eating and parenting; stress influences family cooking, food choices, and child free-play; and screen-time use to decrease parent stress. Negative parent/grandparent response to their personal stress adversely influenced food purchases and parenting related to child eating, free-play, and screen-time. Children of parents/grandparents who ate high-fat/high-sugar foods when stressed requested these foods. In addition to structured physical activity, cooking ahead and keeping food in the house were perceived to guard against the effects of stress except during parent cravings. Parent/child screen-time helped decrease parent stress. Parents/grandparents responded variably to stress which affected the child eating environment, free-play, and screen-time. Family-based interventions to decrease obesity in Black children should consider how stress influences parents. Targeting parent cravings and coping strategies that utilize structure in eating and physical activity may be useful intervention strategies.

Hayman LW, et al. Low-income women's conceptualizations of emotional- and stress-eating. Appetite . 2014;83:269-76.

Sixty-one low-income women from South-central Michigan with young children (ages 2–5 years) participated in either a focus group or individual semi-structured interview during which they were asked about their conceptualizations of eating behaviors among adults and children. Responses were transcribed and the constant comparative method was used to identify themes. Identified themes included that emotional- and stress-eating are viewed as uncommon, severe, pitiable behaviors that reflect a lack of self-control and are highly stigmatized; that when these behaviors occurred among children, the behaviors resulted from neglect or even abuse; and that bored-eating is viewed as distinct from emotional- or stress-eating and is a common and humorous behavior with which participants readily self-identified. Future research and interventions should seek to develop more detailed conceptualizations of these behaviors to improve measurement, destigmatize emotional- and stress-eating and potentially capitalize on the strong identification with bored-eating by targeting this behavior for interventions.

Parks EP, et al. Influence of stress in parents on child obesity and related behaviors.

The number of parent stressors was related to child obesity in unadjusted (1.12, 1.03–1.22, P = .007) and adjusted models (1.12, 1.03–1.23, P = .010). Parent-perceived stress was related to fast-food consumption in unadjusted (1.07, 1.03–1.10, P < .001) and adjusted (1.06, 1.02–1.10, P

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Pediatrics . 2012;130(5):e1096-e1104 .

< .001) models. The number of parent stressors was directly related to child obesity. Parent-perceived stress was directly related to child fast-food consumption, an important behavioral indicator of obesity risk. Clinical care models and future research that address child obesity should explore the potential benefits of addressing parent stressors and parent-perceived stress.

Physical Activity

Tandon, P et al. The relationship of physical activity and nutrition with young children’s cognitive development: A systematic review. Preventive Medicine Reports . 2016;3:379-90 .

Systematic review examined the relationship between physical activity and dietary patterns and cognitive development in the early childhood. Twelve studies were included for physical activity including 5 cross sectional studies, 3 longitudinal studies, and 4 experimental studies. Eleven of the twelve (11/12) studies reported evidence suggesting that physical activity or gross motor skills are related to learning or cognition. Eight studies were included for diet and all used data from longitudinal cohort studies done in the UK or Australia. Researchers found that a healthier diet pattern was associated with better cognitive outcomes in all studies, although some of the associations were weak and there was variability of measurement across the studies. Both physical activity and a healthy diet in the early childhood period was associated with better cognitive outcomes in young children. The small amount of literature and the variability in the type and quality of the measures highlight the need for improved research and can help inform future interventions.

LaRowe TL, et al. Active Early: One-year policy intervention to increase physical activity among early care and education programs in Wisconsin. BMC Public Health . 2016;16:607.

Observed teacher-led physical activity significantly increased from 30.9 ± 22.7 min at baseline to 82.3 ± 41.3 min at 12 months. The change in percent time children spent in sedentary activity decreased significantly after 12 months (-4.4 ± 14.2 % time, -29.2 ± 2.6 min, p < 0.02). Additionally, as teacher led-activity increased, percent time children were sedentary decreased (r = -0.37, p < 0.05) and percent time spent in light physical activity increased (r = 0.35, p < 0.05). Among all ECE programs, the physical activity environment improved significantly as indicated by multiple sub-scales of the EPAO; scores showing the greatest increases were the Training and Education (14.5 ± 6.5 at 12-months vs. 2.4 ± 3.8 at baseline, p < 0.01) and Physical Activity Policy (18.6 ± 4.6 at 12-months vs. 2.0 ± 4.1 at baseline, p < 0.01). Active Early promoted improvements in providing structured (i.e. teacher-led) physical activity beyond the recommended 60 daily minutes using low- to no-cost strategies along with training and environmental changes. Furthermore, it was observed that Active Early positively impacted child physical activity levels by the end of the intervention. However, resources, training, and technical assistance may be

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necessary for ECE programs to be successful beyond the use of the Active Early guide. Implementing local-level physical activity policies combined with support from local and statewide partners has the potential to influence higher standards for regulated ECE programs.

Erinosho T, et al. Impact of policies on physical activity and screen time practices in 50 child-care centers in North Carolina. J Phys Act Health . 2016;13(1):59-66. ID: 63050

Physical activity and screen time policies varied across centers. Observational data showed 82.7 min/d of active play opportunities were provided to children. Screen time provided did not exceed 30 min/d/child at 98% of centers. Accelerometer data showed children spent 38 min/d in moderate-to-vigorous physical activity and 206 min/d in sedentary activity. Policies about staff supervision of media use were negatively associated with screen time (P < .05). Contrary to expectation, policies about physical activity were associated with less time in physical activity. Clear strategies are needed for translating physical activity policies to practice. Further research is needed to evaluate the quality of physical activity policies, their impact on practice, and ease of operationalization.

Kwon S, et al. Environmental factors associated with child physical activity at childcare. Health Behav Policy Rev . 2015;4(8):260-267. ID: 67307

ED users engaged in high-risk health behaviors and significantly lower rates of preventive health screenings. The ED cohort reported significantly poorer perceptions of health and lower prevalence of disease.

Ball SC, et al. Physical activity-related and weather-related practices of child care centers from 2 States. J Phys Act Health . 2015;12(2):238- 244.

MA did not differ from RI in meeting PA recommendations (β = 0.03; 0.15, 0.21; P = .72), but MA centers scored higher on weather-related practices (β = 0.47; 0.16, 0.79; P = .004). For-profit centers had lower PA scores compared with nonprofits (β = −0.20; 95% CI: −0.38, −0.02; P = .03), but they did not differ for weather (β = 0.12; −0.19, 0.44; P = .44).

Ashish, N. et al. The clinical translation gap in child health exercise research: a call for disruptive innovation. Clinical and translational science . 2015 Feb; 8 (1):67-76.

In children, levels of play, physical activity, and fitness are key indicators of health and disease and closely tied to optimal growth and development. Cardiopulmonary exercise testing (CPET) provides clinicians with biomarkers of disease and effectiveness of therapy, and researchers with novel insights into fundamental biological mechanisms reflecting an integrated physiological response that is hidden when the child is at rest. Yet the growth of clinical trials utilizing CPET in pediatrics remains stunted despite the current emphasis on preventative medicine and the growing recognition that therapies used in children should be clinically tested in children. There exists a translational gap between basic discovery and clinical application in this essential component of child health. To address this gap, the NIH provided funding through the Clinical and Translational Science Award (CTSA) program to convene a panel of experts. This report summarizes our major

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findings and outlines next steps necessary to enhance child health exercise medicine translational research. We present specific plans to bolster data interoperability, improve child health CPET reference values, stimulate formal training in exercise medicine for child health care professionals, and outline innovative approaches through which exercise medicine can become more accessible and advance therapeutics across the broad spectrum of child health.

Tandon PS, et al. Active play opportunities at child care. Pediatrics . 2015;135(6):e1425-1431.

Children's activity was 73% sedentary, 13% light, and 14% MVPA. For 88% of time children did not have APOs, including 26% time as naptime. On average, 48 minutes per day were APOs (41% sedentary, 18% light, and 41% MVPA), 33 minutes per day were outdoors. The most frequent APO was outdoor free play (8% of time); outdoor teacher-led time was <1%. Children were more active and less sedentary outdoors versus indoors and during the child-initiated APOs (indoors and outdoors) versus teacher-led APOs.

Stephens RL, Xu Y, Lesesne CA, Dunn L, Kakietek J, Jernigan J, et al. Relationship between child care centers’ compliance with physical activity regulations and children’s physical activity, New York City, 2010. Prev Chronic Dis . 2014; 11:130432.

Centers' compliance with the regulation of obtaining at least 60 minutes of total physical activity per day was positively associated with children's levels of moderate to vigorous physical activity (MVPA); compliance with the regulation of obtaining at least 30 minutes of structured activity was not associated with increased levels of MVPA. Children in centers with a dedicated outdoor play space available also spent more time in MVPA. Boys spent more time in MVPA than girls, and non-Hispanic black children spent more time in MVPA than Hispanic children. To increase children's level of MVPA in child care, both time and type of activity should be considered. Further examination of the role of play space availability and its effect on opportunities for engaging in physical activity is needed.

Duffey KJ, et al. States lack physical activity policies in child care that are consistent with national recommendations. Child Obes . 2014;10(6):491-500.

The average number and range of regulations in centers and homes was 4.1 (standard deviation [SD], 1.4; range, 0-8) and 3.8 (SD, 1.5; range, 0-7), respectively. Nearly all states had regulations consistent with providing an outdoor (centers, 98%; homes, 95%) and indoor (centers, 94%, homes, 92%) environment "with a variety of portable play equipment and adequate space." No state had regulations for staff joining children, avoiding punishment for being physically active, yearly consultation from a PA expert, or providing training/education on PA for providers.

Baranowski, T. et al. School year versus summer differences in child weight gain: a narrative review. Childhood obesity (Print). 2014 Feb; 10 (1):18-24.

Four physical activity (PA) intervention studies demonstrated that school year fitness improvements were lost during the summer. One study showed that PA declined across the summer. Another study provided conflicting results of lower total energy expenditure in the summer, but no seasonal difference in total energy expenditure after adjusting for fat-free mass. This pattern of fairly rapid seasonal differences suggests that PA is the primary factor contributing to seasonal differences in weight or BMI, but the documented seasonal pattern in PA (i.e., higher in summer) does not support this relationship. Sleep duration has also been inversely related to

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child adiposity. Seasonal patterns in adiposity, PA, and sleep need to be clearly established separately for overweight and healthy weight children in further longitudinal research to provide a clear focus for national policy.

Bellows LL, et al. The Colorado LEAP study: Rationale and design of a study to assess the short term longitudinal effectiveness of a preschool nutrition and physical activity program. BMC Public Health . 2013;13:1146 .

The design of this study allows for longitudinal exploration of relationships among eating habits, physical activity patterns, and weight status within and across spheres of the social ecological model. These methods advance traditional study designs by allowing not only for interaction among spheres but predictively across time. Further, the recruitment strategy includes both boys and girls from ethnic minority populations in rural areas and will provide insights into obesity prevention effects on these at risk populations.

Falbe, J., Kenney, E. L., Henderson, K. E., & Schwartz, M. B. (2011). The Wellness Child Care Assessment Tool: A Measure to Assess the Quality of Written Nutrition and Physical Activity Policies.   Journal of the American Dietetic Association, 2011(12), 1852-1860.

There is a growing interest in studying the influence of child-care center policies on the health of preschool-aged children. OBJECTIVE: To develop a reliable and valid instrument to quantitatively evaluate the quality of written nutrition and physical activity policies at child-care centers. DESIGN: Reliability and validation study. A 65-item measure was created to evaluate five areas of child-care center policies: nutrition education, nutrition standards for foods and beverages, promoting healthy eating in the child-care setting, physical activity, and communication and evaluation. The total scale and each subscale were scored on comprehensiveness and strength. SETTING: Analyses were conducted on 94 independent policies from Connecticut child-care centers participating in the Child and Adult Care Food Program. STATISTICAL ANALYSES PERFORMED: Intraclass correlation coefficient was calculated to measure inter-rater reliability, and Cronbach's α was used to estimate internal consistency. To test construct validity, t tests were used to assess differences in scores between Head Start and non-Head Start centers and between National Association for the Education of Young Children-accredited and nonaccredited centers. RESULTS: Inter-rater reliability was high for total comprehensiveness and strength scores (intraclass correlation coefficient=0.98 and 0.94, respectively) and subscale scores (intraclass correlation coefficient=0.84 to 0.99). Subscales were adequately internally reliable (Cronbach's α=.53 to .83). Comprehensiveness and strength scores were higher for Head Start centers than non-Head Start centers across most domains and higher for National Association for the Education of Young Children-accredited centers than nonaccredited centers across some but not all domains, providing evidence of construct validity. CONCLUSIONS: This instrument provides a standardized method to analyze and compare the

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comprehensiveness and strength of written nutrition and physical activity policies in child-care centers.

Henderson, K. E., Grode, G. M., Middleton, A. E., Kenney, E. L., Falbe, J., & Schwartz, M. B. (2011). Validity of a Measure to Assess the Child-Care Nutrition and Physical Activity Environment.   Journal of the American Dietetic Association, 2011(9), 1306-1313.

Percent agreement with criterion outcomes ranged from 39% to 97%, with 61% of items achieving agreement ≥80%. Agreement was highest for nutrition and policy domains, and lowest for physical activity and barriers to promoting health. Correlations between food scores across measures were moderate. The self-report survey demonstrated adequate criterion validity. We make recommendations for improving validity of low-agreement items and for the use of more labor-intensive evaluation procedures for domains not adequately assessed through self-report.

Hennessy, E., Hughes, S. O., Goldberg, J. P., Hyatt, R. R., & Economos, C. D. (2010). Parent-Child Interactions and Objectively Measured Child Physical Activity: A Cross-Sectional Study.   International Journal of Behavioral Nutrition and Physical Activity, 7(71), 14.

Seventy-six children had valid accelerometer data. Children engaged in 113.4 ± 37.0 min. of moderatevigorous physical activity (MVPA) per day. Children of permissive parents accumulated more minutes of MVPA than those of uninvolved parents (127.5 vs. 97.1, p < 0.05), while parents who provided above average levels of support had children who participated in more minutes of MVPA (114.2 vs. 98.3, p = 0.03). While controlling for known covariates, an uninvolved parenting style was the only parenting behavior associated with child physical activity. Parenting style moderated the association between two parenting practices - reinforcement and monitoring - and child physical activity. Specifically, post-hoc analyses revealed that for the permissive parenting style group, higher levels of parental reinforcement or monitoring were associated with higher levels of child physical activity. This work extends the current literature by demonstrating the potential moderating role of parenting style on the relationship between activity-related parenting practices and children’s objectively measured physical activity, while controlling for known covariates. Future studies in this area are warranted and, if confirmed, may help to identify the mechanism by which parents influence their child’s physical activity behavior.

Cosco, N., Moore, R., & Islam, Z. (2010). Behavior Mapping: A Method for Linking Preschool Physical Activity and Outdoor Design.   Medicine and Science in Sports and Exercise, 42(3), 513-519.

Physical activity levels at the two centers varied across different types of behavior settings, including pathways, play structures, and open areas. The same type of setting with different attributes, such as circular versus straight pathways, and open areas with different ground surfaces, such as asphalt, compacted soil, woodchips, and sand, attracted different levels of physical activity.

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Prenatal

Barcelona de Mendoza V, et al. Acculturation and adverse birth outcomes in a predominantly Puerto Rican population. Matern Child Health J . 2016;20(6):1151- 1160.

Introduction Latinas in the United States on average have poorer birth outcomes than Whites, yet considerable heterogeneity exists within Latinas. Puerto Ricans have some of the highest rates of adverse outcomes and are understudied. The goal of this study was to determine if acculturation was associated with adverse birth outcomes in a predominantly Puerto Rican population. Methods We conducted a secondary analysis of Proyecto Buena Salud, a prospective cohort study conducted from 2006 to 2011. A convenience sample of pregnant Latina women were recruited from a tertiary care hospital in Massachusetts. Acculturation was measured in early pregnancy; directly via the Psychological Acculturation Scale, and via proxies of language preference and generation in the United States. Birth outcomes (gestational age and birthweight) were abstracted from medical records (n = 1362). Results After adjustment, psychological acculturation, language preference, and generation was not associated with odds of preterm birth. However, every unit increase in psychological acculturation score was associated with an increase in gestational age of 0.22 weeks (SE = 0.1, p = 0.04) among all births. Women who preferred to speak Spanish (β = -0.39, SE = 0.2, p = 0.02) and who were first generation in the US (β = -0.33, SE = 0.1, p = 0.02) had significantly lower gestational ages than women who preferred English or who were later generation, respectively. Similarly, women who were first generation had babies who weighed 76.11 g less (SE = 35.2, p = 0.03) than women who were later generation. Discussion We observed a small, but statistically significant adverse impact of low acculturation on gestational age and birthweight in this predominantly Puerto Rican population.

Barcelona de Mendoza V, et al. Acculturation and intention to breastfeed among a population of predominantly Puerto Rican women. Birth . 2016;43(1):78-85.

Increasing acculturation as measured by English language preference (aOR 0.61 [95% CI 0.42-0.88]) and second or third generation in the United States (aOR 0.70 [95% CI 0.52-0.95)] was inversely associated with odds of intending to exclusively breastfeed. Similarly, women with higher levels of acculturation as measured by the PAS (aOR 0.67 [95% CI 0.45-0.99]), English language preference (aOR 0.48 [95% CI 0.33-0.70]) and second or third generation in the United States (aOR 0.42 [95% CI 0.31-0.58]) were less likely to report intent to combination feed as compared with women with lower acculturation. Acculturation was inversely associated with intent to exclusively breastfeed and intent to combination feed in this predominantly Puerto Rican sample.

Chasan-Taber L. It is time to view pregnancy as a stress test. J Womens He alth (Larchmt).

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2016;25(1):2-3.Chasan-Taber L, et al. Gestational weight gain, body mass index, and risk of hypertensive disorders of pregnancy in a predominantly Puerto Rican population. Matern Child Health J . 2016;Mar 22 [Epub ahead of print].

Four percent (n = 54) of women were diagnosed with hypertension in pregnancy, including 2.6 % (n = 36) with preeclampsia. As compared to women who gained within IOM GWG guidelines (22.8 %), those who gained above guidelines (52.5 %) had an odds ratio of 3.82 for hypertensive disorders (95 % CI 1.46-10.00; ptrend = 0.003) and an odds ratio of 2.94 for preeclampsia (95 % CI 1.00-8.71, ptrend = 0.03) after adjusting for important risk factors. Each one standard deviation (0.45 lbs/week) increase in rate of GWG was associated with a 1.74 odds of total hypertensive disorders (95 % CI 1.34-2.27) and 1.86 odds of preeclampsia (95 % CI 1.37-2.52). Conclusions for Practice Findings from this prospective study suggest that excessive GWG is associated with hypertension in pregnancy and could be a potentially modifiable risk factor in this high-risk ethnic group.

Barcelona de Mendoza V, et al. Effects of acculturation of prenatal anxiety among Latina women. Arch Womens Ment Health . 2016;19(4):635-644.

Anxiety in pregnancy has been associated with adverse birth outcomes. Relatively few studies have investigated how acculturation affects mental health in pregnancy among Latinas. The goal of this study was to determine if acculturation was associated with anxiety over the course of pregnancy in a sample of predominantly Puerto Rican women. Women were recruited in pregnancy for participation in Proyecto Buena Salud, a prospective cohort study of Latina women (n = 1412). Acculturation was measured via the Psychological Acculturation Scale (PAS), language preference and generation in the USA. Anxiety was measured using the State-Trait Anxiety Instrument. Linear and logistic multivariable regressions were used to investigate associations. After adjustment, women with bicultural identification had significantly lower trait anxiety scores in early pregnancy (β = -3.62, SE = 1.1, p < 0.001) than low acculturated women. Women with higher levels of acculturation as indicated by English-language preference (β = 1.41, SE = 0.7, p = 0.04) and second or third generation in the USA had significantly higher trait anxiety scores in early pregnancy (β = 1.83, SE = 0.6, p < 0.01). Bicultural psychological acculturation was associated with lower trait anxiety in early pregnancy, while English-language preference and higher generation in the USA were associated with higher trait anxiety in early pregnancy.

Silveria ML, et al. Anxiety, depression, and oral health among US pregnant women: 2010 Behavioral Risk Factor Surveillance System. J Public Health Dent . 2016;76(1):56- 64.

One-fifth (21.2 percent) of respondents reported a tooth loss and 32.5 percent reported nonuse of oral health services. The prevalence of lifetime diagnosed anxiety and depression was 13.6 percent and 11.3 percent, respectively, whereas 10.6 percent reported current depression. After adjusting for risk factors, pregnant women with diagnosed anxiety had increased odds of one or more tooth loss [odds ratio (OR) = 3.30; 95 percent confidence interval (CI): 1.01-10.77] compared with those without the disorder. Similarly, after adjusting for socioeconomic factors, women with anxiety had increased odds of nonuse of oral health services (OR = 2.67; 95 percent CI: 1.03-6.90); however,

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this was no longer significant after adjusting for health behaviors and body mass index. We observed no significant association with depression. In this population-based sample, we found a two- to threefold increased odds of tooth loss and nonuse of oral health services among pregnant women with a lifetime diagnosis of anxiety. To our knowledge, this is the first study to examine these associations among pregnant women.

Gross RS, et al. Maternal hardship and internal local of control over the prevention of child obesity in low-income Hispanic pregnant women. Acad Pediatr . 2016;16(5):468- 474.

The sample included 559 low-income Hispanic pregnant women, with 60% having experienced at least 1 hardship. Food insecurity was independently associated with a low internal locus of control over the prevention of child obesity (adjusted odds ratio, 2.38; 95% confidence interval, 1.50-3.77), controlling for other hardships and confounders. Experiencing a greater number of material hardships was associated in a dose-dependent relationship with an increased odds of having a low internal locus of control. Prenatal material hardships, in particular food insecurity, were associated with having a lower prenatal internal locus of control over the prevention of child obesity. Longitudinal follow-up of this cohort is needed to determine how relations between material hardships and having a low internal locus of control will ultimately affect infant feeding practices and child weight trajectories.

Wang G, et al. Association between maternal prepregnancy body mass index and plasma folate concentrations with child metabolic health. JAMA Pediatr . 2016.0845[Epub ahead of print]

The mean (SD) age was 28.6 (6.5) years for mothers and 6.2 (2.4) years for the children. An L-shaped association between maternalfolate concentrations and child OWO was observed: the risk for OWO was higher among those in the lowest quartile (Q1) as compared with those in Q2 through Q4, with an odds ratio of 1.45 (95% CI, 1.13-1.87). The highest risk for child OWO was found among children of obese mothers with low folate concentrations (odds ratio, 3.05; 95% CI, 1.91-4.86) compared with children of normal-weight mothers with folate concentrations in Q2 through Q4 after accounting for multiple covariables. Among children of obese mothers, their risk for OWO was associated with a 43% reduction (odds ratio, 0.57; 95% CI, 0.34-0.95) if their mothers had folate concentrations in Q2 through Q4 compared with Q1. Similar patterns were observed for child metabolic biomarkers. In this urban low-income prospective birth cohort, we demonstrated an L-shaped association betweenmaternal plasma folate concentrations and child OWO and the benefit of sufficient folate concentrations, especially among obese mothers. The threshold concentration identified in this study exceeded the clinical definition of folate deficiency, which was primarily based on the hematological effect of folate. Our findings underscore the need to establish optimal rather than minimal folate concentrations for preventing adverse metabolic outcomes in the offspring.

Fuemmeler BF, et al. Several prenatal and maternal characteristics were linked with infant growth parameters. The

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Association between prepregnancy body mass index and gestational weight gain with size, tempo, and velocity of infant growth: Analysis of the newborn epigenetic study cohort. Childhood Obes . 2016;12(3):210-218.

primary findings show that compared to women with a prepregnancy BMI between 18 and 24.9, women with a prepregnancy BMI ≥40 had infants that were 8% larger during the first 24 months, a delayed tempo of around 9 days, and a slower velocity. Mothers who had greater than adequate gestational weight gain had infants that were 5% larger even after controlling for prepregnancy BMI and several other covariates.

G Clifton, R, et al. LIFE-Moms Research Group. Design of lifestyle intervention trials to prevent excessive gestational weight gain in women with overweight or obesity. Obesity (Silver Spring, Md.). 2016;24 (2) :305-313.

The Lifestyle Interventions for Expectant Moms (LIFE-Moms) Consortium is designed to determine, in pregnant women with overweight or obesity, whether various behavioral and lifestyle interventions reduce excessive gestational weight gain (GWG) and subsequent adverse maternal and neonatal outcomes and obesity in offspring. Numerous committees and working groups were created to define common measures and outcomes during pregnancy and through 1 year postpartum, develop Consortium policies, and oversee progress of the trials. The primary outcome for the Consortium is excessive GWG. Secondary outcomes include maternal, neonatal, and infant anthropometric measures, physical activity, sleep, and complications of pregnancy and delivery. A multi-center consortium of independent, lifestyle interventions with common measures and outcomes may enhance the ability to identify promising interventions for improving outcomes in pregnant women and their offspring.

Arinze NV, et al. Evaluating provider advice and women's beliefs on total weight gain during pregnancy. J Immigr Minor Health . 2016;18(1):282- 286.

To inform future interventions, we examined the prevalence and accuracy of provider advice and its association with personal beliefs about necessary maternal weight gain among predominantly Latina pregnant women. Secondary analysis examining baseline data (N = 123) from a healthy lifestyle randomized controlled trial conducted in and urban area of the South East. Only 23.6 % of women reported being told how much weight to gain during pregnancy; although 58.6 % received advice that met Institute of Medicine recommendations. Concordance of mothers’ personal weight gain target with clinical recommendations varied by mothers’ pre-pregnancy weight status [χ(4)

2 = 9.781, p = 0.044]. Findings suggest the need for prenatal providers of low-income, minority women to engage patients in shaping healthy weight gain targets as a precursor to preventing excessive GWG and its complications.

Gesell SB, et al. Feasibility and initial efficacy evaluation of a community-based cognitive-behavioral lifestyle

Compared to usual care, fewer normal-weight women in the intervention exceeded IOM recommendations (47.1 % usual care vs. 6.7 % intervention; absolute difference 40.4 %; p = .036). Recommendations for recruitment, retention, and delivery are discussed. A community-based cognitive-behavioral lifestyle intervention during pregnancy was feasible in a hard-to-reach, high-

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intervention to prevent excessive weight gain during pregnancy in Latina women. Matern Child Health J . 2015;19(8):1842-1852.

risk population of low-income Latina women, and showed efficacy in preventing excessive gestational weight gain. Due to frequently changing work schedules, strategies are needed to either increase attendance at group sessions (e.g., within a group prenatal care format) or to build core skills necessary for behavior change through other modalities.

Silveira ML, et al. The role of body image in prenatal and postpartum depression: A critical review of the literature. Arch Womens Ment Health . 2015;18(3):409-421.

Maternal depression increases risk of adverse perinatal outcomes, and recent evidence suggests that body image may play an important role in depression. This systematic review identifies studies of body image and perinatal depression with the goal of elucidating the complex role that body image plays in prenatal and postpartum depression, improving measurement, and informing next steps in research. We conducted a literature search of the PubMed database (1996-2014) for English language studies of (1) depression, (2) body image, and (3) pregnancy or postpartum. In total, 19 studies matched these criteria. Cross-sectional studies consistently found a positive association between body image dissatisfaction and perinatal depression. Prospective cohort studies found that body image dissatisfaction predicted incident prenatal and postpartum depression; findings were consistent across different aspects of body image and various pregnancy and postpartum time periods. Prospective studies that examined the reverse association found that depression influenced the onset of some aspects of body image dissatisfaction during pregnancy, but few evaluated the postpartum onset of body image dissatisfaction. The majority of studies found that body image dissatisfaction is consistently but weakly associated with the onset of prenatal and postpartum depression. Findings were less consistent for the association between perinatal depression and subsequent body image dissatisfaction. While published studies provide a foundation for understanding these issues, methodologically rigorous studies that capture the perinatal variation in depression and body image via instruments validated in pregnant women, consistently adjust for important confounders, and include ethnically diverse populations will further elucidate this association.

Ertel KA, et al. Prepregnancy body mass index, gestational weight gain, and elevated depressive symptoms in a Hispanic cohort. Health Psychol . 2015;34(3):274-278.

In multivariable, longitudinal modeling, overweight (25.0 to <30 kg/m2) women had an odds ratio of 0.53 (95% CI [0.31, 0.90]) for EPDS scores ≥13 and 0.51 (95% CI [0.28, 0.91]) for EPDS scores ≥15 compared to normal weight women. We did not observe an association between GWG or an interaction between BMI and GWG, in predicting elevated depressive symptoms. Our findings provide preliminary support for an association of prepregnancy overweight status and lower depressive symptoms across pregnancy in Hispanic women. Future research should focus on potential social and cultural differences in perceptions of weight and weight gain in the perinatal period and how these influence psychological health.

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Chasan-Taber L, et al. Physical activity, sedentary behavior and risk of hypertensive disorders of pregnancy in Hispanic women. Hypertens Pregnancy . 2015;34(1):1-16.

A total of 49 women (4.0%) were diagnosed with a hypertensive disorder of pregnancy, including 32 women (2.6%) with pre-eclampsia. In age-adjusted analyses, high levels of early pregnancy household/caregiving activity were associated with reduced risk of total hypertensive disorders (OR = 0.4, 95% CI 0.1-0.9) and pre-eclampsia (OR = 0.3, 95% CI 0.1-0.9) relative to low levels; however, these findings were no longer statistically significant in multivariable models. Pre-pregnancy activity and pattern of activity from pre- to early-pregnancy were not significantly associated with risk. Finally, sedentary behavior was not significantly associated with hypertensive disorders. Findings from this prospective study of Hispanic women were consistent with those of prior prospective cohorts indicating that physical activity prior to and during early pregnancy does not significantly reduce risk of hypertensive disorders of pregnancy.

Chasan-Taber L. Lifestyle interventions to reduce risk of diabetes among women with prior gestational diabetes mellitus. Best Pract Res Clin Obstet Gynaecol . 2015;29(1):110-122.

While lifestyle interventions involving exercise and a healthy diet in high-risk adults have been found to reduce progression to type 2 diabetes by >50%, little attention has been given to the potential benefits of such strategies in women with a history of gestational diabetes mellitus (GDM). We conducted a literature search of PubMed for English language studies of randomized controlled trials of lifestyle interventions among women with a history of GDM. In total, nine studies were identified which fulfilled the eligibility criteria. The majority of randomized trials of lifestyle interventions in women with GDM have been limited to pilot or feasibility studies. However, preliminary findings suggest that such interventions can improve diabetes risk factors in women with a history of GDM. Larger, well-designed controlled randomized trials are needed to assess the effects of lifestyle interventions on preventing subsequent progression to type 2 diabetes among women with GDM.

Moore Simas TA, et al. Understanding multifactorial influences on the continuum of maternal weight trajectories in pregnancy and early postpartum: Study protocol,, and participation baseline characteristics. BMC Pregnancy Childbirth . 2015;15:71.

We sought to recruit a sample of 100 healthy women age 18-45 years, between 28-34 weeks gestation, with singleton pregnancies, enrolled in care prior to 17 weeks gestation. Women provide written consent for face-to-face (medical history, anthropometrics, biologic specimens), and paper-and-pencil assessments, at five time points: baseline (third trimester), delivery-associated, and 6-weeks, 3-months and 6-months postpartum. Additional telephone-based assessments (diet, physical activity and breastfeeding) administered baseline and three-months postpartum. Infant weights are collected until 1-year of life. We seek to retain 80% of participants at six-months postpartum and 80% of offspring at 12-months. 110 women were recruited. Sample characteristics include: mean age 28.3 years, BMI 25.7 kg/m(2), and gestational age at baseline visit of 32.5 weeks. One-third of cohort was non-white, over a quarter were Latina, and almost a quarter were non-US born. The cohort majority was multigravida, had graduated high school and/or had higher levels of education, and worked outside the home. Documentation of study

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feasibility and preliminary data for theory-driven hypothesis of maternal and child factors associated with weight trajectories will support future large scale longitudinal studies of risk and protective factors for maternal and child health. This research will also inform intervention targets facilitating healthy maternal and child weight.

Liew Z, et al. Bias from conditioning on live birth in pregnancy cohorts: An illustration based on neurodevelopment in children after prenatal exposure to organic pollutants. Int J Epide m. 2015;44(1):345-354.

Only 60-70% of fertilized eggs may result in a live birth, and very early fetal loss mainly goes unnoticed. Outcomes that can only be ascertained in live-born children will be missing for those who do not survive till birth. In this article, we illustrate a common bias structure (leading to 'live-birthbias') that arises from studying the effects of prenatal exposure to environmental factors on long-term health outcomes among live births only inpregnancy cohorts. To illustrate this we used prenatal exposure to perfluoroalkyl substances (PFAS) and attention-deficit/hyperactivity disorder (ADHD) in school-aged children as an example. PFAS are persistent organic pollutants that may impact human fecundity and be toxic forneurodevelopment. We simulated several hypothetical scenarios based on characteristics from the Danish National Birth Cohort and found that a weak inverse association may appear even if PFAS do not cause ADHD but have a considerable effect on fetal survival. The magnitude of the negative bias was generally small, and adjusting for common causes of the outcome and fetal loss can reduce the bias. Our example highlights the need to identify the determinants of pregnancy loss and the importance of quantifying bias arising from conditioning on live birth in observational studies.

Toro-Ramos T, et al. Body composition during fetal development and infancy through the age of 5 years. Eur J Clin Nutr . 2015;69(12);1279- 1289.

Fetal body composition is an important determinant of body composition at birth, and it is likely to be an important determinant at later stages in life. The purpose of this work is to provide a comprehensive overview by presenting data from previously published studies that report on body composition during fetal development in newborns and the infant/child through 5 years of age. Understanding the changes in body composition that occur both in utero and during infancy and childhood, and how they may be related, may help inform evidence-based practice during pregnancy and childhood. We describe body composition measurement techniques from the in utero period to 5 years of age, and identify gaps in knowledge to direct future research efforts. Available literature on chemical and cadaver analyses of fetal studies during gestation is presented to show the timing and accretion rates of adipose and lean tissues. Quantitative and qualitative aspects of fetal lean and fat mass accretion could be especially useful in the clinical setting for diagnostic purposes. The practicality of different pediatric body composition measurement methods in the clinical setting is discussed by presenting the assumptions and limitations associated with each method that may assist the clinician in characterizing the health and

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nutritional status of the fetus, infant and child. It is our hope that this review will help guide future research efforts directed at increasing the understanding of how body composition in early development may be associated with chronic diseases in later life.

Tanner-Smith, Emily E; Steinka-Fry, Katarzyna T; Gesell, Sabina B. Comparative effectiveness of group and individual prenatal care on gestational weight gain. Matern Child Health J . 2014; 18(7):1711-1720.

Compared to the matched group of women receiving standard individual prenatal care, CP participants were less likely to have excessive gestational weight gain, regardless of their pre-pregnancy weight (b = −.99, 95% CI [−1.92, −.06], RRR = .37). CP reduced the risk of excessive weight gain during pregnancy to 54% of what it would have been in the standard model of prenatal care (NNT = 5). The beneficial effect of CP was largest for women who were overweight or obese prior to their pregnancy. Effects did not vary by gestational age at delivery. Post-hoc analyses provided no evidence of adverse effects on newborn birth weight outcomes. Group prenatal care had statistically and clinically significant beneficial effects on reducing excessive gestational weight gain relative to traditional individual prenatal care.

Korfmacher KS, et al. Environmental risks and children’s health: what can PRAMS tell us? Matern Child Health J. 2014;18(5):1155-1168.

Environmental exposures during pregnancy have a lasting impact on children's health. We combined environmental and maternal risk factor survey data to inform efforts to protect children's health. We made recommendations for future use of such data. A modified version of the Pregnancy Risk Assessment Monitoring System (PRAMS) mail survey was conducted based on weighted sampling design with low-income and non-low income women in Monroe County, NY (1,022 respondents). A series of environmental questions were included in the questionnaire. Data were analyzed using Chi square tests and Poisson loglinear regression model to identify patterns in environmental health risk and sociodemographic characteristics. We identified women who rented their homes, had lower incomes, and lived in inner city zip codes as "high environmental health risk" (HEHR). HEHR respondents were more likely to report that a health care provider talked with them about lead and on average reported more behaviors to protect their children from lead poisoning. Combining environmental and perinatal risk factor data could yield important recommendations for medical practice, health education, and policy development. However, at present PRAMS gathers only limited and inconsistent environmental data. We found that existing PRAMS environmental questions are insufficient. Further work is needed to develop updated and more comprehensive environmental health survey questions and implement them consistently across the country.

Silveira ML, et al. Perceived psychosocial stress and glucose intolerance among pregnant Hispanic women.

The prevalence of gestational diabetes mellitus, impaired glucose tolerance, and abnormal glucose tolerance was 4.1%, 7.2%, and 14.5%, respectively. Absolute levels of early or mid-pregnancy stress were not significantly associated with glucose intolerance. However, participants with an increase in stress from early to mid-pregnancy had a 2.6-fold increased odds of gestational

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Diabetes Metab . 2014;40(6):466-475.

diabetes mellitus (95% confidence intervals: 1.0-6.9) as compared to those with no change or a decrease in stress after adjusting for age and pre-pregnancy body mass index. In addition, every one-point increase in stress scores was associated with a 5.5mg/dL increase in screening glucose level (β=5.5; standard deviation=2.8; P=0.05), after adjusting for the same variables. In this population of predominantly Puerto Rican women, stress patterns during pregnancy may influence the risk of glucose intolerance.

Moore Simas TA, et al. Cigarette smoking and gestational diabetes mellitus in Hispanic woman. Diabetes Res Clin Pract . 2014;105(1):126- 134.

One-fifth of participants (20.4%) reported smoking prior to pregnancy, and 11.0% reported smoking in pregnancy. A total of 143 women (4.7%) were diagnosed with GDM. We did not observe an association between pre-pregnancy cigarette smoking and odds of GDM (multivariable OR=0.77, 95% CI 0.47, 1.25). In contrast, smoking during pregnancy was associated with a 54% reduction in odds of GDM (OR=0.46, 95% CI 0.22, 0.95). However, this association was no longer statistically significant after adjustment for age, parity, and study site (OR=0.47, 95% CI 0.23, 1.00). In this population of Hispanic pregnant women, we did not observe statistically significant associations between pre-pregnancy smoking and odds of GDM. A reduction in odds of GDM among those who smoked during pregnancy was no longer apparent after adjustment for important diabetes risk factors.

Szegda K, et al. Depression during pregnancy: A risk factor for adverse neonatal outcomes? A critical review of the literature. J Matern Fetal Neonatal Med . 2014;27(9):960-967.

Elevated depression levels, particularly in early- to mid-pregnancy, appear to increase risk of PTB and SGA. Findings suggest an increased risk for LBW, but were less consistent. Methodological differences and limitations likely contributed to conflicting findings. A wide range of depression measures were used with the majority of studies utilizing measures not designed, or validated, for pregnant women. Studies failed to assess depression at multiple pregnancy time points, thus constraining the ability to assess the impact of duration and pattern of exposure to depression. Antidepressant use and co-morbid psychosocial factors were rarely considered as potential confounders or effect modifiers. Studies suggest that depression during pregnancy may be an important risk factor for PTB and SGA, and possibly LBW. Improved study methodology is needed to elucidate the consequence of maternal depression on adverse birth outcomes.

Chasen-Taber L, et al. Physical activity and gestational weight gain in Hispanic women. Obesity (Silver Spring) . 2014;22(3):909-918.

A total of 26.9% of women gained within IOM guidelines, 21.2% had inadequate GWG, and 51.9% experienced excessive GWG. Overall, we did not observe statistically significant associations between type or intensity of physical activity during pre, early, mid, and late pregnancy and inadequate or excessive GWG, total GWG, or rate of GWG. In this prospective cohort study of Hispanic women, after controlling for important risk factors, pregnancy physical activity did not appear to be associated with GWG.

Ertel KA, et al. Prenatal The aim of this study is to prospectively examine the association between maternal depressive

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depressive symptoms and abnormalities of glucose tolerance during pregnancy among Hispanic women. Arch Womens Ment Health . 2014;17(1):65-72.

symptoms in early pregnancy and risk of abnormal glucose tolerance (AGT) and impaired glucose tolerance (IGT) in mid-pregnancy. We evaluated this association among 934 participants in Proyecto Buena Salud, a prospective cohort study of Hispanic (predominantly Puerto Rican) women in Western Massachusetts. Depressive symptoms were assessed in early pregnancy using the 10-item Edinburgh Postnatal Depression Scale. Scores ≥13 indicated at least probable minor depression and scores ≥15 indicated probable major depression. AGT and IGT were diagnosed using American Diabetes Association criteria. In early pregnancy, 247 (26.5 %) participants experienced at least minor depression and 163 (17.4 %) experienced major depression. A total of 123 (13.2 %) were classified with AGT and 56 (6.0 %) were classified with IGT. In fully-adjusted models, the odds ratio for AGT associated with minor depression was 1.20 (95 % CI 0.77-1.89) and for major depression was 1.34 (95 % CI 0.81-2.23). The odds ratio for IGT associated with minor depression was 1.22 (95 % CI 0.62-2.40) and for major depression was 1.53 (95 % CI 0.73-3.22). We did not observe an association with continuous screening glucose measures. Findings in this prospective cohort of Hispanic women did not indicate a statistically significant association between minor or major depression in early pregnancy and AGT or screening glucose values in mid-pregnancy. Due to the small number of cases of IGT, our ability to evaluate the association between depression and IGT risk was constrained.

Chasan-Taber L, et al. Physical activity before and during pregnancy and risk of abnormal glucose tolerance among Hispanic women. Diabetes Metab . 2014;40(1):67-75.

A total of 175 women (14.1%) were diagnosed with abnormal glucose tolerance and 57 women (4.6%) were diagnosed with gestational diabetes. Increasing age and body mass index were strongly and positively associated with risk of gestational diabetes. We did not observe statistically significant associations between total physical activity or meeting exercise guidelines and risk. However, after adjusting for age, BMI, gestational weight gain, and other important risk factors, women in the top quartile of moderate-intensity activity in early pregnancy had a decreased risk of abnormal glucose tolerance (odds ratio = 0.48, 95% Confidence Interval 0.27–0.88, Ptrend = 0.03) as compared to those in the lowest quartile. Similarly, women with the highest levels of occupational activity in early pregnancy had a decreased risk of abnormal glucose tolerance (odds ratio = 0.48, 95% Confidence Interval 0.28–0.85, Ptrend = 0.02) as compared to women who were unemployed. In this Hispanic population, total physical activity and meeting exercise guidelines were not associated with risk. However, high levels of moderate-intensity and occupational activity were associated with risk reduction.

Chasan-Taber L, et al. Estudio Parto: Postpartum diabetes prevention program for

Hispanic pregnant women who screen positive for GDM will be recruited and randomly assigned to a Lifestyle Intervention (n = 150) or a Health & Wellness (control) Intervention (n = 150). Multimodal contacts (i.e., in-person, telephone, and mailed materials) will be used to deliver the

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Hispanic women with abnormal glucose tolerance in pregnancy: A randomized controlled trial – study protocol. BMC Pregnancy Childbirt h. 2014;14:100.

intervention from late pregnancy (29 weeks gestation) to 12 months postpartum. Targets of the intervention are to achieve Institute of Medicine Guidelines for postpartum weight loss; American Congress of Obstetrician and Gynecologist guidelines for physical activity; and American Diabetes Association guidelines for diet. The intervention draws from Social Cognitive Theory and the Transtheoretical Model and addresses the specific cultural and environmental challenges faced by low-income Hispanic women. Assessments will be conducted at enrollment, and at 6-weeks, 6-months, and 12-months postpartum by trained bicultural and bilingual personnel blinded to the intervention arm. Efficacy will be assessed via postpartum weight loss and biomarkers of insulin resistance and cardiovascular risk. Changes in physical activity and diet will be measured via 7-day actigraph data and three unannounced 24-hour dietary recalls at each assessment time period. Hispanic women are the fastest growing minority group in the U.S. and have the highest rates of sedentary behavior and postpartum diabetes after a diagnosis of GDM. This randomised trial uses a high-reach, low-cost strategy that can readily be translated into clinical practice in underserved and minority populations.

Widen EM & Gallaher D. Body composition changes in pregnancy: Measurement, predictors and outcomes. Eur J Clin Nutr . 2014;68(6):643- 652.

Prevalence of overweight and obesity has risen in the United States over the past few decades. Concurrent with this rise in obesity has been an increase in pregravid body mass index and gestational weight gain affecting maternal body composition changes in pregnancy. During pregnancy, many of the assumptions inherent in body composition estimation are violated, particularly the hydration of fat-free mass, and available methods are unable to disentangle maternal composition from fetus and supporting tissues; therefore, estimates of maternal body composition during pregnancy are prone to error. Here we review commonly used and available methods for assessing body composition changes in pregnancy, including: (1) anthropometry, (2) total body water, (3) densitometry, (4) imaging, (5) dual-energy X-ray absorptiometry, (6) bioelectrical impedance and (7) ultrasound. Several of these methods can measure regional changes in adipose tissue; however, most of these methods provide only whole-body estimates of fat and fat-free mass. Consideration is given to factors that may influence changes in maternal body composition, as well as long-term maternal and offspring outcomes. Finally, we provide recommendations for future research in this area.

Dozier AM, et al. Adapting the pregnancy risk assessment monitoring survey to enhance locally available data: Methods. Matern Child Health

Despite the increasing emphasis on pre- and interconception planning, perinatal data available to local municipalities and organizations is often limited to that on the birth certificate. A partnership between a local health department and an academic medical center sought to overcome this gap. Using the core questions from the Pregnancy Risk Assessment Monitoring System (PRAMS) and a stratified random sample methodology (by income) in a county with ~8,000 annual births we

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J . 2014;18(5):1196-1204 . mailed 2,462 surveys to mothers who gave birth between May 2009 and April 2010. Mailings occurred at 4-5 months postpartum. Low income mothers (those with a Medicaid-funded delivery and/or prenatal WIC enrollment) were oversampled based on a projected response rate of 35% (rate for non-low income was 55%). Over 1,000 usable surveys were returned and linked with birth certificate data. Target response rates were achieved. 9.4% of addresses for low income mothers were undeliverable (vs. 4.2% of non-low income). Both low and non-low income respondents were more likely to be over age 18 and White. After statistical adjustments the survey dataset was demographically similar to the original birth data. Personnel and non-personnel costs per usable survey exceeded $20. Collecting local data using a modified PRAMS methodology is feasible but requires expertise in survey, data management and birth certificate data and local knowledge about survey response patterns. These types of data can serve to inform policy and program planning and provide data to support relevant funding requests.

Heerman, William J; Bian, Aihua; Shintani, Ayumi; Barkin, Shari L. Interaction between maternal prepregnancy body mass index and gestational weight gain shapes infant growth. Acad Pediatrics . 2014;14(5):463- 470.

We included 499 maternal-infant dyads. The average maternal age was 28.2 years; 55% of mothers were overweight or obese prior to pregnancy and 42% of mothers had excess GWG, as defined by the Institute of Medicine. Maternal pre-pregnancy BMI (p<0.001), and the interaction between pre-pregnancy BMI and maternal GWG (p=0.02) showed significant association with infant growth trajectory through the first year of life after controlling for breastfeeding and other covariates, while GWG alone did not reach statistical significance (p=0.38). Among infants of mothers with excess GWG, a pre-pregnancy BMI of 40 kg/m2versus 25 kg/m2 resulted in a 13.6% (95% CI 5.8%, 21.5%; p<0.001) increase in 3-month infant weight/length percentile that persisted at 12 months (8.4%, 95% CI 0.2%, 16.5%; p=0.04). The combined effect of excess maternal GWG and pre-pregnancy obesity resulted in higher infant birth weight, rapid weight gain in the first 3 months of life, with a sustained elevation throughout the first year of life. These findings highlight the importance of the preconception and prenatal periods for pediatric obesity prevention.

Widen EM and Gallagher D. Body composition changes in pregnancy: measurement, predictors and outcomes. Eur J Clin Nutr . 2014;68(6):643- 652.

Here we review commonly used and available methods for assessing body composition changes in pregnancy, including: (1) anthropometry, (2) total body water, (3) densitometry, (4) imaging, (5) dual-energy X-ray absorptiometry, (6) bioelectrical impedance and (7) ultrasound. Several of these methods can measure regional changes in adipose tissue; however, most of these methods provide only whole-body estimates of fat and fat-free mass. Consideration is given to factors that may influence changes in maternal body composition, as well as long-term maternal and offspring outcomes. Finally, we provide recommendations for future research in this area.

Silveria ML, et al. Correlates Young maternal age (odds ratio (OR) =0.6; 95% confidence interval (CI) 0.4-0.9 for <19 vs. 19-

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of stress among pregnant Hispanic women. Matern Child Health . 2013;17(6):1138-1150.

23yrs), pre-pregnancy consumption of alcohol (OR=2.2; 95% CI 1.4-3.5 for >12 drinks/mo. vs. none) and smoking (OR=2.2; 95% CI 1.3-3.7 for >10 cigarettes/day vs. none) were associated with high perceived stress during early pregnancy. Furthermore, higher annual household income (OR=0.4; 95% CI 0.1-0.9 for >$30,000 vs. <$15,000), greater number of adults in the household (OR=1.8; 95% CI 1.1-3.0 for ≥3 vs. 1) and language preference (OR=0.6; 95% CI 0.4-0.9 for Spanish vs. English) were associated with high stress during mid-pregnancy. Likewise, annual household income was inversely associated with high stress during late pregnancy. Our results have important implications for incorporation of routine screening for psychosocial stress during prenatal visits and implementation of psychosocial counseling services for women at high risk.

Tovar A, et al. Acculturation and gestational weight gain in a predominantly Puerto Rican population. BMC Pregnancy Childbirth . 2012;12:133.

Adjusting for age, parity, perceived stress, gestational age, and prepregnancy weight, women who had at least one parent born in Puerto Rico/Dominican Republic (PR/DR) and both grandparents born in PR/DR had a significantly higher mean total gestational weight gain (0.9 kg for at least one parent born in PR/DR and 2.2 kg for grandparents born in PR/DR) and rate of weight gain (0.03 kg/wk for at least one parent born in PR/DR and 0.06 kg/wk for grandparents born in PR/DR) vs. women who were of PR/DR born. Similarly, women born in the US had significantly higher mean total gestational weight gain (1.0 kg) and rate of weight gain (0.03 kg/wk) vs. women who were PR/ DR born. Spoken language preference and psyWe found that psychological acculturation was not associated with gestational weight gain while place of birth and higher generation in the US were significantly associated with higher gestational weight gain. We interpret these findings to suggest the potential importance of the US "obesogenic" environment in influencing unhealthy pregnancy weight gains over specific aspects of psychological acculturation.chological acculturation were not significantly associated with total or rate of pregnancy weight gain.

Downs DS, et al. Physical activity and pregnancy: Past and present evidence and future recommendations. Res Q Exerc Sport . 2012;83(4):485-502.

We discuss: (a) historical overview of prenatal physical activity relative to the physical activity guidelines, how they have changed over time, and how evidence of the effect of prenatal activity on maternal/fetal health outcomes has affected clinical recommendations; (b) existing tools and challenges associated with measuring prenatal physical activity; (c) empirical evidence on multilevel determinants of prenatal activity to guide future intervention work; (d) empirical evidence of prenatal activity on adverse maternal outcomes (gestational diabetes mellitus, preeclampsia, excessive gestational weight gain) from observational and intervention studies; and (e) summary/recommendations for future research and practice. The physical activity and pregnancy literature has evolved over the past 50 years, and there is sufficient empirical evidence to support the promotion of moderate-to-vigorous prenatal physical activity for maternal health

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benefits. Future studies and interventions should be carefully designed, theoretically driven, and include validated and reliable activity measures. Researchers and practitioners should also consider the multifaceted determinants and outcomes of prenatal physical activity and intervene to promote physical activity before, during, and after pregnancy.

Lynch KE, et al. Physical activity of pregnant Hispanic women. Am J Prev Med . 2012;43(4):434-439.

Household/caregiving activity was the primary mode of pregnancy activity ranging from 56% to 60% of total activity while sports/exercise contributed the least (<10%). Compared to nulliparous women, women with two or more children were 85% less likely to become inactive at any time during pregnancy (OR=0.15 [95% CI=0.04, 0.56], p-trend <0.01). Women with one or more children increased their total physical activity on average 9.73±2.04 MET hours/week and 12.04±2.39 MET-hours/week, respectively, with the onset of pregnancy (p<0.01). Those with the highest levels of total physical activity prior to pregnancy were 87% less likely to become inactive with the onseFindings can inform culturally appropriate interventions designed to reduce pregnancy complications through the promotion of physical activity during pregnancy.t of pregnancy than those who were inactive prior to pregnancy (OR=0.13 [95% CI= 0.05, 0.29]).

Evenson KR, et al. Review of Self-report physical activity assessments for pregnancy: Summary of the evidence for validity and reliability. Pediatr Perinat Epidemiol . 2012;26(5):479-494.

We identified 15 studies, including 12 studies that assessed questionnaires and 4 studies that assessed diaries, conducted in Australia, Finland, Norway, United Kingdom, United States, and Vietnam. For questionnaires, 92% (11/12) assessed mode, all assessed frequency and/or duration, and 58% (7/12) collected information on perceived intensity. All but one study (92%) assessed validity of the questionnaires. Questionnaires compared to objective measures (accelerometers, pedometers) ranged from slight to fair agreement, while comparison to other self-reported measures ranged from substantial to almost perfect agreement. Five studies (42%) assessed test-retest reliability of the questionnaires, ranging from substantial to almost perfect agreement. The four studies on diaries were all asSelection of valid and reliable physical activity measures that collect information on dose (type, frequency, duration, intensity) is recommended to increase precision and accuracy in detecting associations of physical activity with maternal and fetal outcome assessed for validity against objective measures, ranging from slight to substantial agreement.

Chasan-Taber L. Physical activity and dietary behaviors associated with weight gain and impaired glucose tolerance among pregnant Latinas. Adv Nutr . 2012;3(1):101-118.

Pregnancy has been proposed as a critical period for the development of subsequent maternal overweight and/or obesity. Excessive gestational weight gain is, in turn, associated with maternal complications such as cesarean delivery, hypertension, preeclampsia, impaired glucose tolerance, and gestational diabetes mellitus. Although there is substantial evidence that targeting at-risk groups for type 2 diabetes prevention is effective if lifestyle changes are made, relatively little attention has been paid to the prevention of excessive gestational weight gain and impaired

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glucose tolerance during pregnancy. Latinos are the largest minority group in the United States, with the highest birth and immigration rates of any minority group and are disproportionately affected by overweight and obesity. However, due to cultural factors, socioeconomic factors, and language barriers, Latinos have had limited access to public health interventions that promote healthy lifestyles. Therefore, the objective of this article is to review the scientific evidence regarding the association between physical activity, dietary behaviors, and gestational weight gain and impaired glucose tolerance among Latinas. A second objective is to discuss how lifestyle interventions including weight management through diet and exercise could be successful in reducing the risk of excessive gestational weight gain and gestational diabetes mellitus. Finally, recommendations are provided for future lifestyle intervention programs in this population with a focus on translation and dissemination of research findings.

Fortner RT, et al. Risk factors for prenatal depressive symptoms among Hispanic women. Matern Child Health J. 2011;15(8):1287-1295.

A total of 30% of participants were classified as having depressive symptoms (EPDS scores >12) with mean+SD scores of 9.28+5.99. Higher levels of education (college/graduate school vs. < high school: RR=0.60, 95% CI 0.41–0.86), household income (>$30,000 vs. <$15,000 per year: RR=0.72, 95% CI 0.55–0.92), and living with a spouse/partner (0.80; 95% CI 0.63–1.00) were independently associated with lower risk of depressive symptoms. There was the suggestion that failure to discontinue cigarette smoking with the onset of pregnancy (RR=1.32; 95% CI 0.97–1.71) and English language preference (RR=1.33; 95% CI 0.96–1.70) were associated with higher risk. Single marital status, second generation in the U.S., and higher levels of alcohol consumption were associated with higher risk of depressive symptoms in univariate analyses, but were attenuated after adjustment for other risk factors. Findings in the largest, fastest-growing ethnic minority group can inform intervention studies targeting Hispanic women at risk of depression in pregnancy.

Gollenberg AL, et al. Physical activity and risk of small-for-gestational-age birth among predominantly Puerto Rican women. Matern Child Health J . 2011;15(1):49-59 .

To estimate the association between multiple domains of physical activity and risk of small-for-gestational-age (SGA) birth. We utilized data from 1,040 participants in the Latina Gestational Diabetes Mellitus Study, a prospective cohort of predominantly Puerto Rican prenatal care patients in Massachusetts. Physical activity was assessed by bilingual interviewers using a modified version of the Kaiser physical activity survey in early (mean = 15 weeks) and mid pregnancy (mean = 28 weeks). Physical activity (i.e., sports/exercise, household, occupational, and active living) in pre, early and mid pregnancy was categorized in quartiles. SGA was classified as <10th percentile of birth weight for gestational age. Pre- and early-pregnancy physical activity were not associated with SGA. In multivariable analyses, women with high total activity in mid-pregnancy had a decreased risk of SGA [risk ratio (RR) = 0.42; 95% confidence

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interval (CI) 0.21-0.82; p(trend) = 0.003] as compared to those with low total activity. Findings were similar for high household activity (RR = 0.69; 95% CI = 0.34-1.40; p(trend) = 0.26), active living (RR = 0.63; 95% CI = 0.35-1.13; p(trend) = 0.04), and occupational activity (RR = 0.79, 95% CI = 0.47-1.34; p(trend) = 0.26). High levels of sports/exercise were associated with an increased SGA risk without a significant dose-response association (RR = 2.14, 95% CI 1.04-4.39; p(trend) = 0.33). Results extend prior studies of physical activity and SGA to the Hispanic population.

Chin NP & Solomonik A. Inadequate: A metaphor for the lives of low-income women? Breastfeed Med . 2009;4(Suppl 1):S41-S43.

Exclusive breastfeeding of infants for the first 6 months of life with continued breastfeeding for at least 6 more months occurs only 11.9% of the time in the United States. Efforts of the past 30 years to promote optimal breastfeeding practices have had little impact. In order to create significant change in the way we feed infants in this country, we need to change the way we look at this public health issue and examine the cultural logic that makes bottle feeding the preferred choice of most U.S. women. This article analyzes the term "inadequate" not just as self-description of a woman's milk supply, but also as a metaphor for the lives of low-income women in the United States, the group least likely to breastfeed. Low-income women in the United States not only have inadequate incomes as compared to the general population, but inadequate child care, education, preventive health services, inadequate lifespans, and lives saturated with violence, leaving them inadequately safe even in their own homes. Here we outline a research agenda to explore the relationship between socially determined inadequacies and the cultural logic that makes bottle feeding a preferred form of infant feeding.

Postpartum

Phelan S, et al. ‘Fit Moms/Mama Activas’ internet-based weight control program with group support to reduce postpartum weight retention in low-income women: Study protocol for a randomized controlled trial. Trials. 2015;16:59.

Fit Moms/Mamás Activas targets recruitment of 12 Women, Infants and Children (WIC) Supplemental Nutrition Program clinics with a total of 408 adult (>18 years), postpartum (<1 year) women with 14.5 kg or more weight retention or a body mass index of 25.0 kg/m2 or higher. Clinics are matched on size and randomly assigned within county to either a 12-month standard WIC intervention or to a 12-month WIC enhanced plus internet-based weight loss intervention. The intervention includes: monthly face-to-face group sessions; access to a website with weekly lessons, a web diary, instructional videos, and computer-tailored feedback; four weekly text messages; and brief reinforcement from WIC counselors. Participants are assessed at baseline, six months, and 12 months. The primary outcome is weight loss over six and 12 months; secondary outcomes include diet and physical activity behaviors, and psychosocial measures. Fit

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Moms/Mamás Activas is the first study to empirically examine the effects of an internet-based treatment program, coupled with monthly group contact at the WIC program, designed to prevent sustained postpartum weight retention in low-income women at high risk for weight gain, obesity, and related comorbidities.

Dozier AM, et al. Patterns of postpartum depot medroxyprogesterone administration among low-income mothers. J Womens Hea lth. 2014;23(3):224-230 .

Unintended pregnancy was reported by 48.8% of the subjects. Their deliveries occurred across four local hospitals. Among the 31.3% of subjects who received postpartum DMPA, 62.6% received it prior to hospital discharge. Those receiving in-hospital DMPA (n=127) were significantly more likely than other mothers to be black, older, urban dwelling, non–high school graduates, multiparous, and planning to formula feed. Administration patterns differed by hospital. This study of postpartum DMPA administration among a convenience sample of low-income mothers demonstrated rates of 26% overall, but there was between-hospital variability. Additional study may identify approaches to ensure timely administration to appropriate candidates.

Preschool-Aged

Tandon, P et al. The relationship of physical activity and nutrition with young children’s cognitive development: A systematic review. Preventive Medicine Reports . 2016;3:379-90 .

Systematic review examined the relationship between physical activity and dietary patterns and cognitive development in the early childhood. Twelve studies were included for physical activity including 5 cross sectional studies, 3 longitudinal studies, and 4 experimental studies. Eleven of the twelve (11/12) studies reported evidence suggesting that physical activity or gross motor skills are related to learning or cognition. Eight studies were included for diet and all used data from longitudinal cohort studies done in the UK or Australia. Researchers found that a healthier diet pattern was associated with better cognitive outcomes in all studies, although some of the associations were weak and there was variability of measurement across the studies. Both physical activity and a healthy diet in the early childhood period was associated with better cognitive outcomes in young children. The small amount of literature and the variability in the type and quality of the measures highlight the need for improved research and can help inform future interventions.

Cespedes EM, et al. Chronic insufficient sleep and diet quality: Contributors to childhood obesity. Obesity (Silver Spring, Md.). 2016;24 (1):184-190.

Mean (SD) sleep and YHEI scores were 10.21 (2.71) and 58.76 (10.37). Longer sleep duration was associated with higher YHEI in mid-childhood (0.59 points/unit sleep score; 95%CI: 0.32, 0.86). Though higher YHEI was associated with lower BMI z-score (−0.07 units/10-point increase; 95%CI: −0.13, −0.01), adjustment for YHEI did not attenuate sleep-BMI associations. Children with sleep and YHEI scores below the median (<11 and <60) had BMI z-scores 0.34 units higher (95%CI: 0.16, 0.51) than children with sleep and YHEI scores above the median.

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While parent-reported diet did not explain inverse associations of sleep with adiposity, both sufficient sleep and high-quality diets are important to obesity prevention.

Guerrero, Alma D; Chu, Lynna; Franke, Todd; Kuo, Alice A. Father Involvement in Feeding Interactions with Their Young Children. Am J Health Behavior . 2016;40 (2):221-30 .

Approximately 40% of fathers reported having a great deal of influence on their preschool child’s nutrition and about 50% reported daily involvement in preparing food for their child and assisting their child with eating. Children had over 2 times the odds of consuming fast food at least once a week if fathers reported eating out with their child a few times a week compared to fathers who reported rarely or never eating out with their child (OR, 2.89; 95% CI, 1.94–4.29), adjusting for all covariates. Whether fathers reported eating out with their children was also significantly associated with children’s sweetened beverage intake. Potentially modifiable behaviors that support healthy dietary practices in children may be supported by targeting fathers.

Guerrero AD, et al. Racial and ethnic disparities in early childhood obesity: Growth trajectories in Body Mass Index. J Racial Ethn Health Disparities . 2016;3(1):129- 137.

Approximately one-third of 4-year-old females and males were overweight and/or obese. African-American and Latino children displayed higher predicted mean BMI scores and differing mean BMI trajectories, compared with White children, adjusting for time-independent and time-dependent predictors. Several factors were significantly associated with lower mean BMI trajectories, including very low birth weight, higher maternal education level, residing in a two-parent household, and breastfeeding during infancy. Greater consumption of soda and fast food was associated with higher mean BMI growth. Soda consumption was a particularly strong predictor of mean BMI growth trajectory for young Black children. Neither the child's inactivity linked to television viewing nor fruit nor vegetable consumption was predictive of BMI growth for any racial/ethnic group. Significant racial and ethnic differences are discernible in BMI trajectories among young children. Raising parents' and health practitioners' awareness of how fast food and sweetened-beverage consumption contributes to early obesity and growth in BMI-especially for Blacks and Latinos-could improve the health status of young children.

Guerrero AD & Chung PJ. Racial and ethnic disparities in dietary intake among California children. J Acad Nut Diet . 2016;116(3):439- 448.

The sample included 15,902 children aged 2 to 11 years. In multivariate regressions, substantial differences in fruit juice, fruit, vegetable, sugar-sweetened beverages, sweets, and fast-food consumption were found among the major racial and ethnic groups of children. Asians regardless of interview language were more likely than whites to have low vegetable intake consumption (Asians English interview odds ratio [OR] 1.20, 95% CI 1.01 to 1.43; Asians non-English-interview OR 2.09, 95% CI 1.23 to 3.57) and low fruit consumption (Asians English interview OR 1.69, 95% CI 1.41 to 2.03; Asians non-English interview OR 3.04, 95% CI 2.00 to 4.6). Latinos regardless of interview language were also more likely than whites to have high fruit juice (Latinos English interview OR 1.54, 95% CI 1.28 to 1.84 and

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Latinos non-English interview OR 1.29, 95% CI 1.02 to 1.62) and fast-food consumption (Latinos English interview OR 1.74, 95% CI 1.46 to 2.08 and Latinos non-English interview OR 1.48, 95% CI 1.16 to 1.91); but Latinos were less likely than whites to consume sweets (Latinos English interview OR 0.81, 95% CI 0.66 to 0.99 and Latinos non-English interview OR 0.56, 95% CI 1.16 to 1.91). Significant racial and ethnic differences exist in the dietary practices of California children. Increased fruit and vegetable consumption appears to be associated with parent education but not income. Our findings suggest that anticipatory guidance and dietarycounseling might benefit from tailoring to specific ethnic groups to potentially address disparities in overweight and obesity.

Schwartz BS, et al. Antibiotic use and childhood body mass trajectory. Int J Obe s. 2016;40(4):615-621.

Among 142,824 children under care in the prior year, a reversible association was observed and this short-term BMI gain was modified by age (p < 0.001); effect size peaked in mid-teen years. A persistent association was observed and this association was stronger with increasing age (p < 0.001). The addition of the progressive association among children with at least three BMIs (n = 79,752) revealed that higher cumulative orders were associated with progressive weight gain; this did not vary by age. Among children with an antibiotic order in the prior year and at least seven lifetime orders, antibiotics (all classes combined) were associated with an average weight gain of approximately 1.4 kg at age 15 years. When antibiotic classes were evaluated separately, the largest weight gain at 15 years was associated with macrolide use.

Gesell SB, et al. Increases in network ties are associated with increased cohesion among intervention participants. Health Educ Behav . 2016 Apr; 43 (2):208- 16.

Cohesion increased from 6.51 to 6.71 (t=4.4, p<0.01). Network nominations tended to increase over the 3-week period in each network. In the combined discussion and advice network, the number of nominations increased from 1.76 to 1.95 (z=2.59, p<0.01). Cohesion at week 3 was the strongest predictor of cohesion at week 6 (b=0.55, p<0.01). Number of new network nominations at week 6 was positively related to cohesion at week 6 (b=0.06, p<.01). In sum, being able to name new network contacts was associated with feelings of cohesion. This is the first study to demonstrate how network changes affect perceived group cohesion within a behavioral intervention. Given that many behavioral interventions occur in group settings, intentionally building new social networks could be promising to augment desired outcomes.

LaRowe TL, et al. Active Early: One-year policy intervention to increase physical activity among early care and education programs in Wisconsin. BMC Public

Observed teacher-led physical activity significantly increased from 30.9 ± 22.7 min at baseline to 82.3 ± 41.3 min at 12 months. The change in percent time children spent in sedentary activity decreased significantly after 12 months (-4.4 ± 14.2 % time, -29.2 ± 2.6 min, p < 0.02). Additionally, as teacher led-activity increased, percent time children were sedentary decreased (r = -0.37, p < 0.05) and percent time spent in light physical activity increased (r = 0.35, p < 0.05). Among all ECE programs, the physical activity environment improved significantly as

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Health . 2016;16:607. indicated by multiple sub-scales of the EPAO; scores showing the greatest increases were the Training and Education (14.5 ± 6.5 at 12-months vs. 2.4 ± 3.8 at baseline, p < 0.01) and Physical Activity Policy (18.6 ± 4.6 at 12-months vs. 2.0 ± 4.1 at baseline, p < 0.01). Active Early promoted improvements in providing structured (i.e. teacher-led) physical activity beyond the recommended 60 daily minutes using low- to no-cost strategies along with training and environmental changes. Furthermore, it was observed that Active Early positively impacted child physical activity levels by the end of the intervention. However, resources, training, and technical assistance may be necessary for ECE programs to be successful beyond the use of the Active Early guide. Implementing local-level physical activity policies combined with support from local and statewide partners has the potential to influence higher standards for regulated ECE programs.

Taveras EM, et al. Connect for Health: Design of a clinical-community childhood obesity intervention testing best practices of positive outliers. Contemp Clin Trials . 2015;45(Pt B):287-295.

Children randomized to the intervention arm receive a contextually-tailored intervention delivered by trained health coaches who use advanced geographic information system tools to characterize children's environments and neighborhood resources. Health coaches link families to community-level resources and use multiple support modalities including text messages and virtual visits to support families over a one-year intervention period. The control group receives enhanced pediatric care plus non-tailored health coaching. The Connect for Health study seeks to support families in leveraging clinical and community resources to improve obesity-related outcomes that are most important to parents and children.

Malika NM, et al. Low-income women’s conceptualizations of food cravings and food addiction. Eat Behav . 2015;18:25-29.

Food craving and food addiction have been proposed as targets for obesity focused interventions. However, individuals' conceptualizations of these constructs are not well understood and no studies have employed a qualitative approach. Therefore, we sought to understand how women conceptualize food craving and food addiction. Low-income women with preschool-aged children (2-5years old) participated in either a semi-structured individual interview or focus group in which they were asked about their conceptualization of eating behaviors among adults and children. All responses were audio-recorded and transcribed. Themes were identified using the constant comparative method of qualitative analysis. Identified themes revealed that the women perceived food craving to be common, less severe and to a degree more humorous than food addiction. It was not felt that food cravings were something to be guarded against or resisted. Food addiction was described in a very "matter of fact" manner and was believed to be identifiable through its behavioral features including a compulsive need to have certain foods all the time. A more detailed understanding of how the general population perceives food craving and food addiction may enable more refined measurement of these

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constructs with questionnaire measures in the future. In addition, interventions may be designed to use the language most consistent with participants' conceptualizations of these constructs.

Carnell S, et al. Lunch-time food choices in preschoolers: Relationships between absolute and relative intakes of different food categories, and appetitive characteristics and weight. Physiology & Behavior . 2015;162:151-160.

As part of a larger preloading study, we served 4-5year olds from primary school classes five school lunches at which they were presented with the same standardized multi-item meal. Parents completed Child Eating Behavior Questionnaire (CEBQ) sub-scales assessing satiety responsiveness (CEBQ-SR), food responsiveness (CEBQ-FR) and enjoyment of food (CEBQ-EF), and children were weighed and measured. Despite differing preload conditions, children showed remarkable consistency of intake patterns across all five meals with day-to-day intra-class correlations in absolute and percentage intake of each food category ranging from 0.78 to 0.91. Higher CEBQ-SR was associated with lower mean intake of all food categories across all five meals, with the weakest association apparent for snack foods. Higher CEBQ-FR was associated with higher intake of white bread and fruits and vegetables, and higher CEBQ-EF was associated with greater intake of all categories, with the strongest association apparent for white bread. Analyses of intake of each food group as a percentage of total intake, treated here as an index of the child's choice to consume relatively more or relatively less of each different food category when composing their total lunch-time meal, further suggested that children who were higher in CEBQ-SR ate relatively more snack foods and relatively less fruits and vegetables, while children with higher CEBQ-EF ate relatively less snack foods and relatively more white bread. Higher absolute intakes of white bread and snack foods were associated with higher BMI z score. CEBQ sub-scale associations with food intake variables were largely unchanged by controlling for daily metabolic needs. However, descriptive comparisons of lunch intakes with expected amounts based on metabolic needs suggested that overweight/obese boys were at particularly high risk of overeating. Parents' reports of children's appetitive characteristics on the CEBQ are associated with differential patterns of food choice as indexed by absolute and relative intake of various food categories assessed on multiple occasions in a naturalistic, school-based setting, without parents present.

Boles RE, et al. Influencing the home food and activity environment of families of preschool children receiving home-based treatment for obesity. Clin Pediatr (Phila) . 2015;54(14):1387-1390.

There were no significant associations between home environment subscales and child zBMI for the entire sample (P > .05). Two groups of responders were created in which “Strong Responders” (n = 30) were defined as having a reduction in zBMI greater than or equal to 0.1 zBMI units, while “Weak Responders” showed less than 0.1 reduction in zBMI from baseline to postintervention (n = 25). Among Weak Responders, a significant increase in fruit availability was observed, t(24) = −2.2, P < .05. There were no other significant changes in measured home food and activity environment subscales for either group. This study showed

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that despite a small, but significant reduction in preschool zBMI for a subsample, families showed little change in the home food and activity environment. The home food and activity environment has rarely been studied with treatment seeking families from diverse backgrounds. This study adds to the literature by showing the potential challenges in making environmental changes related to healthy weight outcomes. While no significant increase in fruits and vegetables was observed in the home environment for the overall sample, subgroup post hoc analysis surprisingly showed greater fruit availability in the weak responder group, suggesting that increasing the availability of fruits may still require other changes in the home environment to affect weight outcomes. The data also showed, however, that strong treatment responders maintained their availability of fruits and vegetables, which may be important given other similar reported data showed lower baseline levels of fruits and vegetables compared with our sample or even reductions following treatment.

Tandon PS, et al. Active play opportunities at child care. Pediatrics . 2015;135(6):e1425-1431.

Children's activity was 73% sedentary, 13% light, and 14% MVPA. For 88% of time children did not have APOs, including 26% time as naptime. On average, 48 minutes per day were APOs (41% sedentary, 18% light, and 41% MVPA), 33 minutes per day were outdoors. The most frequent APO was outdoor free play (8% of time); outdoor teacher-led time was <1%. Children were more active and less sedentary outdoors versus indoors and during the child-initiated APOs (indoors and outdoors) versus teacher-led APOs.

Ball SC, et al. Physical activity-related and weather-related practices of child care centers from 2 States. J Phys Act Health . 2015;12(2):238- 244.

MA did not differ from RI in meeting PA recommendations (β = 0.03; 0.15, 0.21; P = .72), but MA centers scored higher on weather-related practices (β = 0.47; 0.16, 0.79; P = .004). For-profit centers had lower PA scores compared with nonprofits (β = −0.20; 95% CI: −0.38, −0.02; P = .03), but they did not differ for weather (β = 0.12; −0.19, 0.44; P = .44).

Taveras, E. et all. Connect for Health: Design of a clinical-community childhood obesity intervention testing best practices of positive outliers. Contem Clin Trials. 2015;45(Pt B):287-295.

Children randomized to the intervention arm receive a contextually-tailored intervention delivered by trained health coaches who use advanced geographic information system tools to characterize children's environments and neighborhood resources. Health coaches link families to community-level resources and use multiple support modalities including text messages and virtual visits to support families over a one-year intervention period. The control group receives enhanced pediatric care plus non-tailored health coaching. Lower age-associated increase in BMI over a 1-year period. The main parent- and child-reported outcome is improved health-related quality of life. The Connect for Health study seeks to support families in leveraging clinical and community resources to improve obesity-related outcomes that are most important

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to parents and children.England JI, et al. Reach out and eat: Food and beverages depicted in books for preschoolers. Clin Pediatr . 2015;54(13):1257-1264.

66% of books depicted at least 1 food or beverage. More books depicted nutritive items than empty-calorie items (87.5% vs 54.7%, P < .001). There was a trend toward fewer empty-calorie depictions in ROR books than in other booklists. Yet nearly half of ROR books depicted at least 1 empty-calorie item. ROR books also accounted for 5 of 10 books with the most empty-calorie item depictions and 3 of 4 books with branding. With regard to messaging, approximately a third of books with the most empty-calorie depictions promoted unhealthy foods.

Cui Z, et al. Recruitment and retention in obesity prevention and treatment trials targeting minority or low-income children: a review of the clinical trials registration database. Trials . 2015;16 564.

Variable amounts of information were provided on recruitment and retention strategies in obesity-related trials involving minority or low-income children. Although reported retention rates were fairly high, a lack of reporting limited the available information. More and consistent reporting and systematic cataloging of recruitment and retention methods are needed. In addition, qualitative and quantitative studies to inform evidence-based decisions in the selection of effective recruitment and retention strategies for trials including minority or low-income children are warranted.

Karp, Sharon M; Barry, Kathleen M; Gesell, Sabina B; Po'e, Eli K; Dietrich, Mary S; Barkin, Shari L. Parental feeding patterns and child weight status for Latino preschoolers. Obesity Research & Clinical Practice . 2014;8 (1):e88-97.

Higher child BMI was related to higher parental CFQ concern scores (r = 0.41, p <.001). A general inverse association between child BMI percentile and parental responsibility was also observed (r = −0.23, p = .040). Over the 3-month period, no statistically significant associations between changes in the CFQ subscale scores and changes in child BMI percentile were identified. Child BMI percentile consistent with overweight/obese is associated with parental concern about child weight and child BMI percentile consistent with normal weight is associated with perceived responsibility for feeding. Emphasizing parental responsibility to help children to develop healthy eating habits could be an important aspect of interventions aimed at both preventing and reducing pediatric obesity for Latino preschoolers.

Boles RE, et al. Home food and activity assessment. Development and validation of an instrument for diverse families of young children. Appetite . 2014;80:23-27

Results showed Kappa statistics were high (.67-1.00) between independent researchers but varied between researchers and parents resulting in 85 items achieving criterion validity (Kappa >.60). Analyses of reliable items revealed the presence in the home of a high frequency of unhealthy snack foods, high fat milk and low frequency of availability of fruits/vegetables and low fat milk. Fifty-two percent of the homes were arranged with a television in the preschool child's bedroom. Physical Activity devices also were found to have high frequency availability. Families reporting lower education reported higher levels of sugar sweetened beverages and less low-fat dairy (p < .05) compared with higher education families. Low-income families (<$27K per year) reported significantly fewer Physical Activity devices (p < .001) compared with higher

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income families. Hispanic families reported significantly higher numbers of Sedentary Devices (p < .05) compared with non-Hispanic families. There were no significant differences between demographic comparisons on available fruits/vegetables, meats, whole grains, and regular fat dairy. A modified home food and activity instrument was found to reliably identify foods and activity devices with geographically and economically diverse families.

Hayman LW Jr., et al. Low-income women’s conceptualizations of emotional- and stress-eating. Appetit e. 2014;83:269-276.

Emotional- and stress-eating have been proposed as risk factors for obesity. However, the way that individuals conceptualize these behaviors is not well understood and no studies have employed a qualitative approach. We sought to understand how women conceptualize emotional- and stress-eating. Sixty-one low-income women from South-central Michigan with young children (ages 2-5 years) participated in either a focus group or individual semi-structured interview during which they were asked about their conceptualizations of eating behaviors among adults and children. Responses were transcribed and the constant comparative method was used to identify themes. Identified themes included that emotional- and stress-eating are viewed as uncommon, severe, pitiable behaviors that reflect a lack of self-control and are highly stigmatized; that when these behaviors occurred among children, the behaviors resulted from neglect or even abuse; and that bored-eating is viewed as distinct fromemotional- or stress-eating and is a common and humorous behavior with which participants readily self-identified. Future research and interventions should seek to develop more detailed conceptualizations of these behaviors to improve measurement, destigmatize emotional- and stress-eating and potentially capitalize on the strong identification with bored-eating by targeting this behavior for interventions.

Duffey KJ, et al. States lack physical activity policies in child care that are consistent with national recommendations. Child Obes . 2014;10(6):491-500.

The average number and range of regulations in centers and homes was 4.1 (standard deviation [SD], 1.4; range, 0-8) and 3.8 (SD, 1.5; range, 0-7), respectively. Nearly all states had regulations consistent with providing an outdoor (centers, 98%; homes, 95%) and indoor (centers, 94%, homes, 92%) environment "with a variety of portable play equipment and adequate space." No state had regulations for staff joining children, avoiding punishment for being physically active, yearly consultation from a PA expert, or providing training/education on PA for providers.

Benajamin Neelson S, et al. Regulations to promote healthy sleep practices in child care. Pediatrics . 2014;134(6):1167-1174 .

The mean number of regulations for states was 0.9 for centers and 0.8 for homes out of a possible 4.0. For centers, no state had regulations for all 4 recommendations; 11 states had regulations for 2 of the 4 recommendations. For homes, 9 states had regulations for 2 of the recommendations. States in the Northeast had the greatest mean number of regulations for centers (1.2) and homes (1.1), and states in the South had the fewest (0.7 and 0.7, respectively);

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these geographic differences were significant for centers (P = .03) but not homes (P = .14).Pratt CA, et al. Childhood Obesity and Treatment Research (COPTR): Interventions addressing multiple influences in childhood and adolescent obesity. Contemp Clin Trials . 2013;36(2):406-413.

This paper is the first of five papers in this issue that describes a new research consortium funded by the National Institutes of Health. It describes the design characteristics of the Childhood Obesity Prevention and Treatment Research (COPTR) trials and common measurements across the trials. The COPTR Consortium is conducting interventions to prevent obesity in pre-schoolers and treat overweight or obese 7-13 year olds. Four randomized controlled trials will enroll a total of 1700 children and adolescents (~50% female, 70% minorities), and will test innovative multi-level and multi-component interventions in multiple settings involving primary care physicians, parks and recreational centers, family advocates, and schools. For all the studies, the primary outcome measure is body mass index; secondary outcomes, moderators and mediators of intervention include diet, physical activity, home and neighborhood influences, and psychosocial factors. COPTR is being conducted collaboratively among four participating field centers, a coordinating center, and NIH project offices. Outcomes from COPTR have the potential to enhance our knowledge of interventions to prevent and treat childhood obesity.

Sherwood NE, et al. NET-Works: Linking families, communities and primary care to prevent obesity in preschool-age children. Contemp Clin Trials . 2013;36(2):544-554.

Obesity prevention in children offers a unique window of opportunity to establish healthful eating and physical activity behaviors to maintain a healthful body weight and avoid the adverse proximal and distal long-term health consequences of obesity. Given that obesity is the result of a complex interaction between biological, behavioral, family-based, and community environmental factors, intervention at multiple levels and across multiple settings is critical for both short- and long-term effectiveness. The Minnesota NET-Works (Now Everybody Together for Amazing and Healthful Kids) study is one of four obesity prevention and/or treatment trials that are part of the Childhood Obesity Prevention and Treatment (COPTR) Consortium. The goal of the NET-Works study is to evaluate an intervention that integrates home, community, primary care and neighborhood strategies to promote healthful eating, activity patterns, and body weight among low income, racially/ethnically diverse preschool-age children. Critical to the success of this intervention is the creation of linkages among the settings to support parents in making home environment and parenting behavior changes to foster healthful child growth. Five hundred racially/ethnically diverse, two–four year old children and their parent or primary caregiver will be randomized to the multi-component intervention or to a usual care comparison group for a three-year period. This paper describes the study design, measurement and intervention protocols, and statistical analysis plan for the NET-Works trial.

Reifsnider E. et al. A The goal of this study is to compare the effectiveness of structured Community Health Worker

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randomized controlled trial to prevent childhood obesity through early childhood feeding and parenting guidance: Rationale and design of study. BMC Public Health . 2013;24:13.

(CHW)--provided home visits, using an intervention created through community-based participatory research, to standard care received through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) office visits in preventing the development of overweight (weight/length ≥ 85th percentile) and obesity (weight/length ≥ 95th percentile) in infants during their first 3 years of life. One hundred forty pregnant women in their third trimester (30-36 weeks) will be recruited and randomly assigned to the intervention or control group. This study will provide prospective data on the effects of an intervention to prevent childhood obesity in children at high risk for obesity due to ethnicity, income, and maternal body mass index (BMI). It will have wide-ranging applicability and the potential for rapid dissemination through the WIC program, and will demonstrate the effectiveness of a community approach though employing CHWs in preventing obesity during the first 3 years of life. This easy-to-implement obesity prevention intervention can be adapted for many locales and diverse communities and can provide evidence for policy change to influence health throughout life.

Po'e, E. et al. Growing Right Onto Wellness (GROW): a family-centered, community-based obesity prevention randomized controlled trial for preschool child-parent pairs. Contemp Clin Trials . 2013 Nov; 36 (2) :436-449 .

GROW is a staged intensity intervention, consisting of intensive, maintenance, and sustainability phases. Throughout the study, parents build skills in nutrition, physical activity, and parenting, concurrently forming new social networks. Participants are taught goal-setting, self-monitoring, and problem solving techniques to facilitate sustainable behavior change. The GROW curriculum uses low health literacy communication and social media to communicate key health messages. The control arm is administered to both control and intervention participants. By conducting this trial in public community centers, and by implementing a family-centered approach to sustainable healthy childhood growth, we aim to develop an exportable community-based intervention to address the expanding public health crisis of pediatric obesity.

Beck AL, et al. Trends in sugar-sweetened beverage and 100% fruit juice consumption among California children. Acad Pediatr . 2013;13(4):364-370.

The percentage of children consuming an SSB on the prior day declined from 40% in 2003 to 16% in 2009 (P < .001) among children ages 2 to 5 and from 54% in 2003 to 33% in 2009 (P < .001) among children ages 6 to 11. The percentage of children consuming any SSB decreased for all racial/ethnic groups, although there were disparities with higher consumption among Latinos. Among children ages 2 to 5, consumption of 2 or more servings of 100% fruit juice per day decreased among white children and increased among Latinos. For children ages 6 to 11, consumption of 2 or more servings of 100% fruit juice per day remained stable for white children and increased among Latinos and African Americans. The decrease in SSB consumption by California children from 2003 to 2009 is a promising trend. The increase in 100% fruit juice consumption among minority children during this period may be an unintended consequence of efforts to reduce SSB consumption.

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Roes, LS, et al. Serving a variety of vegetables and fruit as a snack increased intake in preschool children. Am J Clin Nutr . 2013;98(3):693-699.

Although serving a greater variety of food increases intake, this effect has not been well studied as a strategy to encourage consumption of vegetables and fruit in preschool children. This study examined whether providing a variety of familiar vegetables or fruit to preschool children as a snack would lead to increased selection and intake. In a crossover design, 61 children (aged 3-5 y) ate a snack in their childcare facility on 8 afternoons. At 4 snack times, the children were offered vegetables: either a single type (cucumber, sweet pepper, or tomato) or a variety of all 3 types. At 4 other snack times, the children were offered fruit (apple, peach, pineapple, or all 3 types). Uniform-sized pieces were served family style, and children selected and ate as much as they desired. Offering a variety of vegetables or fruit increased the likelihood of selection (P < 0.0001); children chose some pieces in 94% of snacks with variety and in 70% of snacks without variety. Serving a variety also increased consumption of both vegetables and fruit (P < 0.0002); the mean (±SEM) increase was 31 ± 5 g, about one-sixth the recommended daily amount. Independent of the variety effect, children were less likely to select vegetables than fruit (P < 0.0001), and the mean intake was substantially less for vegetables than for fruit (22 ± 1 compared with 84 ± 3 g). Providing a variety of vegetables and fruit as a snack led to increased consumption of both food types in a childcare facility. Serving a variety of vegetables or fruit as a snack could help preschool children meet recommended intakes.

Patel & Ritchie. Striving for meaningful policies to reduce sugar-sweetened beverage intake among young children. Pediatrics . 2013;132(3):566-568.

The percentage of children consuming an SSB on the prior day declined from 40% in 2003 to 16% in 2009 (P < .001) among children ages 2 to 5 and from 54% in 2003 to 33% in 2009 (P < .001) among children ages 6 to 11. The percentage of children consuming any SSB decreased for all racial/ethnic groups, although there were disparities with higher consumption among Latinos. Among children ages 2 to 5, consumption of 2 or more servings of 100% fruit juice per day decreased among white children and increased among Latinos. For children ages 6 to 11, consumption of 2 or more servings of 100% fruit juice per day remained stable for white children and increased among Latinos and African Americans.

Patel, et al. Sociodemographic characteristics and beverage intake of children who drink tap water. Am J Prev Med . 2013;45(1):75-82.

Tap water consumption was more prevalent among school-aged children (OR=1.85, 95% CI=1.47, 2.33, for those aged 6-11 years; OR=1.85, 95% CI=1.32, 2.59, for those aged 12-19 years) as compared to those aged 1-2 years. Tap water intake was less prevalent among girls/women (OR=0.76, 95% CI=0.64, 0.89); Mexican Americans (OR=0.32, 95% CI=0.23, 0.45); non-Hispanic blacks (OR=0.48, 95% CI=0.34, 0.67); and others (OR=0.50, 95% CI=0.36, 0.68) as compared to whites; Spanish speakers (OR=0.72, 95% CI=0.55, 0.95); and among referents with a lower than Grade-9 education (OR=0.52, 95% CI=0.31, 0.88); Grade 9-11

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education (OR=0.50, 95% CI=0.32, 0.77); and high school/General Educational Development test completion (OR=0.50, 95% CI=0.33, 0.76), as compared to college graduates. Tap water consumers drank more fluid (52.5 vs 48.0 ounces, p<0.01); more plain water (20.1 vs 15.2 ounces, p<0.01); and less juice (3.6 vs 5.2 ounces, p<0.01) than nonconsumers. One in six children/adolescents does not drink tap water, and this finding is more pronounced among minorities. Sociodemographic disparities in tap water consumption may contribute to disparities in health outcomes. Improvements in drinking water infrastructure and culturally relevant promotion may help to address these issues.

Scharf RJ, et al. Longitudinal evaluation of milk type consumed and weight status in preschoolers. Arch Dis Child . 2013;98:335-340.

The majority of children drank whole or 2% milk (87% at 2 years, 79.3% at 4 years). Across racial/ethnic and socio-economic status subgroups, 1%/skim milk drinkers had higher BMI z scores than 2%/whole milk drinkers. In multivariable analyses, increasing fat content in the type of milk consumed was inversely associated with BMI z score (p<0.0001). Compared to those drinking 2%/whole milk, 2- and 4-year-old children drinking 1%/skim milk had an increased adjusted odds of being overweight (age 2 OR 1.64, p<0.0001; age 4 OR 1.63, p<0.0001) or obese (age 2 OR 1.57, p<0.01; age 4 OR 1.64, p<0.0001). In longitudinal analysis, children drinking 1%/skim milk at both 2 and 4 years were more likely to become overweight/obese between these time points (adjusted OR 1.57, p<0.05). Consumption of 1%/skim milk is more common among overweight/obese preschoolers, potentially reflecting the choice of parents to give overweight/obese children low-fat milk to drink. Nevertheless, 1%/skim milk does not appear to restrain body weight gain between 2 and 4 years of age in this age range, emphasizing a need for weight-targeted recommendations with a stronger evidence base.

Reinert, KRS, et al. The relationship between executive function and obesity in children and adolescents: a systematic literature review. J Obes. 2013; 2013:820956.

We reviewed 1,065 unique abstracts: 31 from PubMed, 87 from Google Scholar, 16 from Science Direct, and 931 from PsycINFO. Of those abstracts, 28 met inclusion criteria and were reviewed. From the articles reviewed, an additional 3 articles were added from article references (N = 31). Twenty-three studies pertained to EF (2 also studied the prefrontal and orbitofrontal cortices (OFCs); 6 also studied cognitive function), five studied the relationship between obesity and prefrontal and orbitofrontal cortices, and three evaluated cognitive function and obesity. Inhibitory control was most often studied in both childhood (76.9%) and adolescent (72.7%) studies, and obese children performed significantly worse (P < 0.05) than healthy weight controls on various tasks measuring this EF domain. Although 27.3% of adolescent studies measured mental flexibility, no childhood studies examined this EF domain. Adolescents with higher BMI had a strong association with neurostructural deficits evident in the OFC. Future research should be longitudinal and use a uniform method of EF measurement to better establish

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causality between EF and obesity and consequently direct future intervention strategies.Bellows LL, et al. The Colorado LEAP study: Rationale and design of a study to assess the short term longitudinal effectiveness of a preschool nutrition and physical activity program. BMC Public Health . 2013;13:1146 .

The design of this study allows for longitudinal exploration of relationships among eating habits, physical activity patterns, and weight status within and across spheres of the social ecological model. These methods advance traditional study designs by allowing not only for interaction among spheres but predictively across time. Further, the recruitment strategy includes both boys and girls from ethnic minority populations in rural areas and will provide insights into obesity prevention effects on these at risk populations.

Gesell, Sabina B; Barkin, Shari L; Valente, Thomas W. Social network diagnostics: a tool for monitoring group interventions. Implementation Science : IS. 2013; 8:116.

The number of reported advice partners and discussion partners increased during program implementation. Density, the number of ties among people in the network expressed as a percentage of all possible ties, increased from 0.082 to 0.182 (p < 0.05) in the advice network, and from 0.027 to 0.055 (p > 0.05) in the discussion network. The observed two-fold increase in network density represents a significant shift in advice partners over the intervention period. Using the Social Network Tool to empirically guide program activities of an obesity intervention was feasible.

Namenek Brouwer RJ, Benjamin Neelon SE. Watch Me Grow: A garden-based pilot intervention to increase vegetable and fruit intake in preschoolers. BMC Public Health . 2013;13:363.

Americans, including children, consume fewer fruit and vegetable servings than is recommended. Given that young children spend large amounts of time in child care centers, this may be an ideal venue for increasing consumption of and enthusiasm for fruits and vegetables. This pilot study aimed to assess the feasibility of a gardening intervention to promote vegetable and fruit intake among preschoolers. We enrolled two intervention centers and two control centers. The intervention included a fruit and vegetable garden, monthly curriculum, gardening support, and technical assistance. We measured mean (SD) servings of fruits and vegetables served to and consumed by three children per center before and after the intervention. Post intervention, intervention and control centers served fewer vegetables (mean (standard deviation) difference of -0.18 (0.63) in intervention, -0.37 (0.36) in control), but intervention children consumed more than control children (+0.25 (1.11) vs. -0.18 (0.52). The number of fruits served decreased in all centers (intervention -0.62 (0.58) vs. control -0.10 (0.52)) but consumption was higher in controls (intervention -0.32 (0.58) vs. control 0.15 (0.26)). The garden-based feasibility study shows promise, but additional testing is needed to assess its ability to increase vegetable and fruit intake in children.

Stark LJ, et al. A pilot Assessments were conducted at baseline, 6 months (end of LAUNCH treatment) and 12 months

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randomized controlled trial of a clinic and home-based behavioral intervention to decrease obesity in preschoolers. Obesity (Silver Spring) . 2011;19(1):134-141.

(6 months following LAUNCH treatment). LAUNCH showed a significantly greater decrease on the primary outcomes of child at month 6 (post-treatment) BMI z (-0.59 ± 0.17), BMI percentile (-2.4 ± 1.0), and weight gain (-2.7 kg ± 1.2) than PC and this difference was maintained at follow-up (month 12). LAUNCH parents also had a significantly greater weight loss (-5.5 kg ± 0.9) at month 6 and 12 (-8.0 kg ± 3.5) than PC parents. Based on the data from this small sample, an intensive intervention that includes child behavior management strategies to improve healthy eating and activity appears more promising in reducing preschool obesity than a low intensity intervention that is typical of treatment that could be delivered in primary care.

Spill, MK, et al. Hiding vegetables to reduce energy density: An effective strategy to increase children’s vegetable intake and reduce energy intake. Am J Clin Nutr . 2011; 94(3):735-741.

Across conditions, entrées at breakfast, lunch, dinner, and evening snack were reduced in ED by increasing the proportion of puréed vegetables. The conditions were 100% ED (standard), 85% ED (tripled vegetable content), and 75% ED (quadrupled vegetable content). Entrées were served with unmanipulated side dishes and snacks, and children were instructed to eat as much as they liked. The daily vegetable intake increased significantly by 52 g (50%) in the 85% ED condition and by 73 g (73%) in the 75% ED condition compared with that in the standard condition (both P < 0.0001). The consumption of more vegetables in entrées did not affect the consumption of the vegetable side dishes. Children ate similar weights of food across conditions; thus, the daily energy intake decreased by 142 kcal (12%) from the 100% to 75% ED conditions (P < 0.05). Children rated their liking of manipulated foods similarly across ED amounts. The incorporation of substantial amounts of puréed vegetables to reduce the ED of foods is an effective strategy to increase the daily vegetable intake and decrease the energy intake in young children.

Spill, MK, et al. Serving large portions of vegetable soup at the start of the meal affected children’s energy and vegetable intake. Appetite . 2011;57(1):213- 219.

This study tested whether varying the portion of low-energy-dense vegetable soup served at the start of a meal affects meal energy and vegetable intakes in children. Subjects were 3- to 5-year-olds (31 boys and 41 girls) in daycare facilities. Using a crossover design, children were served lunch once a week for four weeks. On three occasions, different portions of tomato soup (150, 225, and 300 g) were served at the start of the meal, and on one occasion no soup was served. Children had 10 min to consume the soup before being served the main course. All foods were consumed ad libitum. The primary outcomes were soup intake as well as energy and vegetable intake at the main course. A mixed linear model tested the effect of soup portion size on intake. Serving any portion of soup reduced entrée energy intake compared with serving no soup, but total meal energy intake was only reduced when 150 g of soup was served. Increasing the portion size increased soup and vegetable intake. Serving low-energy-dense, vegetable soup as a first course is an effective strategy to reduce children's intake of a more energy-dense main

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entrée and increase vegetable consumption at the meal.Dolinsky, Diana H; Siega-Riz, Anna Maria; Perrin, Eliana; Armstrong, Sarah C. Recognizing and preventing childhood obesity: Challenging pediatricians with averting this epidemic even in their littlest patients. Contemporary pediatrics. 2011 Jan 1; 28 (1):32-42 .

Childhood obesity is one of the most challenging problems facing pediatricians today. Approximately 10% of children younger than 2 years old and 21% of children between 2 and 5 years of age are overweight. However, there are disparities in the prevalence of childhood obesity. For example, non-Hispanic black and Hispanic preschool-aged children have a higher prevalence of obesity than non-Hispanic white children; in older children, socioeconomic disparities also exist. Young children with excess weight have an increased risk for obesity in the future. Unfortunately, few effective treatments exist for children who already are overweight. Therefore, prevention of obesity is paramount. How early should prevention begin? Experts have suggested that gestation to early infancy is a critical period in which physiologic changes occur that greatly influence a child’s later risk for obesity. Will recognizing the early signs and red flags associated with the development of obesity lead to a change in the growth trajectory and long-term health of the next generation?

Spill, MK, et al. Eating vegetables first: The use of portion size to increase vegetable intake in preschool children. Am J Clin Nutr . 2010;91(5):1237-1243.

Serving larger portions of low-energy-dense vegetables at a meal could have beneficial effects on children's food and energy intakes. We investigated whether increasing the portion size of vegetables served at the start of a meal leads to increased vegetable consumption and decreased meal energy intake in children. In a crossover design, 3- to 5-y-old children in a daycare center were served a test lunch once a week for 4 wk (n = 51). In 3 of the meals, a first course of raw carrots varied in portion size (30, 60, or 90 g), and no first course was served in the control meal. Children consumed the first course ad libitum over 10 min and then were served a main course of pasta, broccoli, applesauce, and milk, which was also consumed ad libitum. Total vegetable consumption at the meal increased as the portion size of carrots increased (P < 0.0001). Doubling the portion size of the first course increased carrot consumption by 47%, or 12 +/- 2 g (P < 0.0001). Tripling the portion size of carrots, however, did not lead to a further increase in intake (P = 0.61). Meal energy intake was not significantly affected by the amount of carrots served in the first course. The effect of portion size on intake was not significantly influenced by the children's age or body weight status. Increasing the portion size of a vegetable served as a first course can be an effective strategy for increasing vegetable consumption in preschool children.

Cosco, N., Moore, R., & Islam, Z. (2010). Behavior Mapping: A Method for Linking Preschool Physical

Physical activity levels at the two centers varied across different types of behavior settings, including pathways, play structures, and open areas. The same type of setting with different attributes, such as circular versus straight pathways, and open areas with different ground surfaces, such as asphalt, compacted soil, woodchips, and sand, attracted different levels of

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Activity and Outdoor Design.   Medicine and Science in Sports and Exercise, 42(3), 513-519.

physical activity. Behavior mapping provides a promising method for objectively measuring relationships between physical behavior settings and directly associated activity levels.

Hennessy, E., Hughes, S. O., Goldberg, J. P., Hyatt, R. R., & Economos, C. D. (2010). Parent-Child Interactions and Objectively Measured Child Physical Activity: A Cross-Sectional Study.   International Journal of Behavioral Nutrition and Physical Activity, 7(71), 14.

Seventy-six children had valid accelerometer data. Children engaged in 113.4 ± 37.0 min. of moderatevigorous physical activity (MVPA) per day. Children of permissive parents accumulated more minutes of MVPA than those of uninvolved parents (127.5 vs. 97.1, p < 0.05), while parents who provided above average levels of support had children who participated in more minutes of MVPA (114.2 vs. 98.3, p = 0.03). While controlling for known covariates, an uninvolved parenting style was the only parenting behavior associated with child physical activity. Parenting style moderated the association between two parenting practices - reinforcement and monitoring - and child physical activity. Specifically, post-hoc analyses revealed that for the permissive parenting style group, higher levels of parental reinforcement or monitoring were associated with higher levels of child physical activity. This work extends the current literature by demonstrating the potential moderating role of parenting style on the relationship between activity-related parenting practices and children’s objectively measured physical activity, while controlling for known covariates. Future studies in this area are warranted and, if confirmed, may help to identify the mechanism by which parents influence their child’s physical activity behavior.

Screen Time

Erinosho T, et al. Impact of policies on physical activity and screen time practices in 50 child-care centers in North Carolina. J Phys Act Health . 2016;13(1):59-66. ID: 63050

Physical activity and screen time policies varied across centers. Observational data showed 82.7 min/d of active play opportunities were provided to children. Screen time provided did not exceed 30 min/d/child at 98% of centers. Accelerometer data showed children spent 38 min/d in moderate-to-vigorous physical activity and 206 min/d in sedentary activity. Policies about staff supervision of media use were negatively associated with screen time (P < .05). Contrary to expectation, policies about physical activity were associated with less time in physical activity. Clear strategies are needed for translating physical activity policies to practice. Further research is needed to evaluate the quality of physical activity policies, their impact on practice, and ease of operationalization.

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Sleep

Hager ER, et al. Nighttime sleep duration and sleep behaviors among toddlers from low-income families: Associations with obesgenic behaviors and obesity and the role of parenting. Childhood Obes . 2016;x:1-9.

Sample included 240 toddlers (mean age = 20.2 months), 55% male, 69% black, 59% urban. Toddlers spent 55.4 minutes/day in MVPA, mean HEI-2005 score was 55.4, 13% were obese. Mean sleep duration was 9.1 hours, with 35% endorsing 5-6 recommended sleep behaviors (TSBS-BISQ). In multivariable models, MVPA was positively related to sleep duration; obese toddlers had a shorter nighttime sleep duration than healthy weight toddlers [odds ratio = 0.69, p = 0.014]. Nighttime sleep duration was associated with high TSBS-BISQ scores, F = 6.1, p = 0.003. Toddlers with a shorter nighttime sleep duration are at higher risk for obesity and inactivity. Interventions to promote healthy sleep behaviors among toddlers from low-income families may improve nighttime sleep duration and reduce obesogenic behaviors/obesity.

Boles RE, et al. Family chaos and child functioning in relation to sleep problems among children at risk for obesity. Behav Sleep Med . 2016;8:1-15.

Chaos associated with bedtime resistance significantly mediated the relationship between Behavioral and Emotional Screening System (BESS) and Bedtime Resistance. Families at high risk for obesity showed children with poorer emotional and behavioral functioning were at higher risk for problematic sleep behaviors, although we found no link between obesity and child sleep. Family chaos appears to play a significant role in understanding part of these relationships. Future longitudinal studies are necessary to establish causal relationships between child and family functioning and sleep problems to further guide obesity interventions aimed at improving child sleep routines and increasing sleep duration.

Bathory E, et al. Infant sleep and parent health literacy. Acad Pediatr . 2016;16(6):550- 557.

We enrolled 557 caregivers of 9-month-old children (49.7% Hispanic, 26.9% black, 56.2% <$20,000 annual income); 49.6% reported having a TV in the room where their child sleeps; 26.6% did not have regular naptimes nor bedtimes. Median sleep duration was 2.3 (interquartile range, 1.5-3.0) hours (daytime), and 9.0 (interquartile range, 8.0-10.0) hours (night) (30.2% low daytime; 20.3% low nighttime sleep duration). Children of parents with low HL were more likely to have a bedroom TV (66.7% vs 47.7%, P = .01; adjusted odds ratio, 2.2; 95% confidence interval, 1.1-4.3) and low night-time sleep (37.0% vs 18.5%; P = .002; adjusted odds ratio, 2.4; 95% confidence interval, 1.2-4.8).Low parent health literacy is associated with TV in the bedroom and low night sleep duration. Additional study is needed to further explore these associations and intervention strategies to address child sleep problems.

Cespedes EM, et al. Chronic insufficient sleep and diet quality: Contributors to childhood obesity. Obesity

Mean (SD) sleep and YHEI scores were 10.21 (2.71) and 58.76 (10.37). Longer sleep duration was associated with higher YHEI in mid-childhood (0.59 points/unit sleep score; 95%CI: 0.32, 0.86). Though higher YHEI was associated with lower BMI z-score (−0.07 units/10-point increase; 95%CI: −0.13, −0.01), adjustment for YHEI did not attenuate sleep-BMI associations.

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(Silver Spring, Md.). 2016;24 (1):184-190.

Children with sleep and YHEI scores below the median (<11 and <60) had BMI z-scores 0.34 units higher (95%CI: 0.16, 0.51) than children with sleep and YHEI scores above the median. While parent-reported diet did not explain inverse associations of sleep with adiposity, both sufficient sleep and high-quality diets are important to obesity prevention.

Miller AL, et al. Sleep patterns and obesity in childhood. C urr Opin Endocrinol Diabetes Obes . 2015;22 (1):41-47.

Beyond sleep duration, sleep timing patterns may contribute to obesity risk. Biological and behavioral processes have been proposed as mechanisms that may explain the association. Understanding the pathways through which poor sleep patterns could increase obesity risk in children may provide novel avenues for intervention.

Benajamin Neelson S, et al. Regulations to promote healthy sleep practices in child care. Pediatrics . 2014;134(6):1167-1174 .

The mean number of regulations for states was 0.9 for centers and 0.8 for homes out of a possible 4.0. For centers, no state had regulations for all 4 recommendations; 11 states had regulations for 2 of the 4 recommendations. For homes, 9 states had regulations for 2 of the recommendations. States in the Northeast had the greatest mean number of regulations for centers (1.2) and homes (1.1), and states in the South had the fewest (0.7 and 0.7, respectively); these geographic differences were significant for centers (P = .03) but not homes (P = .14).

Water and Beverages

Ritchie LD, et al. Drinking water in California child care sites before and after 2011-2012 beverage policy. Prev Chronic Dis . 2015;12:140548 .

A significantly larger percentage of sites in 2012 than in 2008 always served water at the table with meals or snacks (47.0% vs 28.0%, P = .001). A significantly larger percentage of child care sites in 2012 than in 2008 made water easily and visibly available for children to self-serve both indoors (77.9% vs 69.0%, P = .02) and outside (78.0% vs 69.0%, P = .03). Sites that participated in the federal Child and Adult Care Food Program had greater access to water indoors and outside than sites not in the program. In 2012 most (76.1%) child care providers reported no barriers to serving water to children. Factors most frequently cited to facilitate serving water were information for families (39.0% of sites), beverage policy (37.0%), and lessons for children (37.9%). Water provision in California child care improved significantly between samples of sites studied in 2008 and 2012, but room for improvement remains after policy implementation. Additional training for child care providers and parents should be considered.

Ritchie LD, et al. Policy improves what beverages are served to young children in child care. J Acad Nutr Diet .

Responses were obtained from 429 sites in 2008 and 435 in 2012. After adjustment for child-care category, significant improvements in 2012 compared with 2008 were found; more sites served water with meals/snacks (47% vs 28%; P=0.008) and made water available indoors for children to self-serve (77% vs 69%; P=0.001), and fewer sites served whole milk usually (9% vs 22%;

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2015;115(5):724-730. P=0.006) and 100% juice more than once daily (20% vs 27%; P=0.038). During 2012, 60% of sites were aware of beverage policies and 23% were judged fully compliant with the California law. A positive effect occurred on beverages served after enactment of state and federal policies. Efforts should continue to promote beverage policies and support their implementation.

Middleton AE, et al. From policy to practice: Implementation of water policies in child care centers in Connecticut. J Nutr Educ Behav . 2013;45(2):119-125.

Many centers were in violation of water-promoting policies. Water was available in most classrooms (84%) but was only adult accessible in over half of those classrooms. Water was available during one third of physical activity periods observed. Verbal prompts for children to drink water were few. Support is needed to help centers meet existing water policies and new water requirements included in the 2010 Child Nutrition Reauthorization Act.

Patel & Ritchie. Striving for meaningful policies to reduce sugar-sweetened beverage intake among young children. Pediatrics . 2013;132(3):566- 568.

The percentage of children consuming an SSB on the prior day declined from 40% in 2003 to 16% in 2009 (P < .001) among children ages 2 to 5 and from 54% in 2003 to 33% in 2009 (P < .001) among children ages 6 to 11. The percentage of children consuming any SSB decreased for all racial/ethnic groups, although there were disparities with higher consumption among Latinos. Among children ages 2 to 5, consumption of 2 or more servings of 100% fruit juice per day decreased among white children and increased among Latinos. For children ages 6 to 11, consumption of 2 or more servings of 100% fruit juice per day remained stable for white children and increased among Latinos and African Americans.

Patel, et al. Sociodemographic characteristics and beverage intake of children who drink tap water. Am J Prev Med . 2013;45(1):75-82.

Tap water consumption was more prevalent among school-aged children (OR=1.85, 95% CI=1.47, 2.33, for those aged 6-11 years; OR=1.85, 95% CI=1.32, 2.59, for those aged 12-19 years) as compared to those aged 1-2 years. Tap water intake was less prevalent among girls/women (OR=0.76, 95% CI=0.64, 0.89); Mexican Americans (OR=0.32, 95% CI=0.23, 0.45); non-Hispanic blacks (OR=0.48, 95% CI=0.34, 0.67); and others (OR=0.50, 95% CI=0.36, 0.68) as compared to whites; Spanish speakers (OR=0.72, 95% CI=0.55, 0.95); and among referents with a lower than Grade-9 education (OR=0.52, 95% CI=0.31, 0.88); Grade 9-11 education (OR=0.50, 95% CI=0.32, 0.77); and high school/General Educational Development test completion (OR=0.50, 95% CI=0.33, 0.76), as compared to college graduates. Tap water consumers drank more fluid (52.5 vs 48.0 ounces, p<0.01); more plain water (20.1 vs 15.2 ounces, p<0.01); and less juice (3.6 vs 5.2 ounces, p<0.01) than nonconsumers. One in six children/adolescents does not drink tap water, and this finding is more pronounced among minorities. Sociodemographic disparities in tap water consumption may contribute to disparities in health outcomes. Improvements in drinking water infrastructure and culturally relevant promotion may help to address these issues.

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Beck, Amy L; Patel, Anisha; Madsen, Kristine. Trends in sugar-sweetened beverage and 100% fruit juice consumption among California children. Academic pediatrics . 2013 Jul- Aug; 13 (4):364-70.

The percent of children consuming a sugar sweetened beverage (SSB) on the prior day declined from 41% in 2003 to 16% in 2009 (p<0.001) among children ages 2–5 and from 56% in 2003 to 33% in 2009 (p<0.001) among children ages 6–11. The percent of children consuming any SSB decreased for all racial/ethnic groups, although there were disparities with higher consumption among Latinos. Among children ages 2–5, consumption of 2 or more servings of 100% fruit juice per day decreased among white children and increased among Latinos. For children ages 6–11, consumption of 2 or more servings of 100% fruit juice per day remained stable for white children and increased among Latinos and African-Americans. The decrease in SSB consumption by California children from 2003 to 2009 is a promising trend. The increase in 100% fruit juice consumption among minority children during this period may be an unintended consequence of efforts to reduce SSB consumption.

Patel AI & Hampton KE. Encouraging consumption of water in school and child care settings: Access, challenges, and strategies for improvement. Am J Public Health . 2011;101(8):1370- 1379.

Children and adolescents are not consuming enough water, instead opting for sugar-sweetened beverages (sodas, sports and energy drinks, milks, coffees, and fruit-flavored drinks with added sugars), 100% fruit juice, and other beverages. Drinking sufficient amounts of water can lead to improved weight status, reduced dental caries, and improved cognition among children and adolescents. Because children spend most of their day at school and in child care, ensuring that safe, potable drinking water is available in these settings is a fundamental public health measure. We sought to identify challenges that limit access to drinking water; opportunities, including promising practices, to increase drinking water availability and consumption; and future research, policy efforts, and funding needed in this area.

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