Developing Sustainable Family-Centered Obesity Interventions:

What Can We Learn from Developmental Psychology and Implementation Science

PRINCIPAL INVESTIGATORS:

Kirsten K. Davison, PhD (PI)

Janine M. Jurkowski, PhD, MPH (PI)

CO-INVESTIGATORS

Hal Lawson (co-I),

Sibylle Kranz (co-I)

Lawrence Schell (co-I)

Glenn Deane (co-I)

Funded by NIH R24 MD004865Davison et al. (2013). A childhood obesity intervention developed by families for families: results from a pilot study. International Journal of Behavioral Nutrition and Physical Activity, Jan 5;10:3.

Key challenges of family-based childhood obesity interventions

• Reaching families

• Passive refusals (consent but don’t show up)

• Parents not interested if don’t see immediate need

• Priorities for intervention do not match family priorities

Possible strategies

• Maintain contact with families over time

• Partner with organizations that reach families

• Use electronic means to collect data

• Build intervention into other appointments

• Design programs around the needs and interests of families

• Ask families members what they hope to gain from participating

Goals

1. Utilize community-based participatory research (CBPR) to develop and pilot test a family-centered obesity prevention program for children enrolled in Head Start.

2. Incorporate the resulting intervention into systems of care (e.g., Head Start, WIC, pediatric care).

Family Action-based Model of Intervention Layout and Implementation (FAMILI)

Phase 1: Theory

Utilize theories of family development to frame family-centered research

Phase 2: Research

Use a mixed methods approach to examine factors impacting on parents and families that are relevant for intervention design.

Phase 3: Intervention Design & Implementation

Utilize a CBPR paradigm to develop interventions that empower parents and caregivers to foster healthy family lifestyles and establish systems-level change that reinforces family change.

CBPR = community-based participatory research

Davison, Lawson, & Coatsworth (2011). Health Promotion Practice

PARENTING

Shaping children’s eating and physical activity behaviors by the use of reward and punishment systems

Family Demographics

Family income Single versus two parent household Ethnicity Education

Child Characteristics

Age Gender Weight status Athletic competence

Organizational Characteristics

• School environment• Job characteristics • Work demands

Policies and the Media

School PE and food policies

Advertising to children Nutrition labeling

Community Characteristics

Neighborhood walkability Crime levelsAccess to healthy foods and recreational spaces

Knowledge and Beliefs about behaviors that educe/promote obesity risk behaviors

Modeling of healthy and unhealthy eating and activity behaviors

Accessibility of healthy and unhealthy eating and physical activity options

Family Ecological Model

Davison & Campbell (2005). Public health approaches to the prevention of obesity. Oxford University Press

Setting

• Small city in upstate New York• Five Head Start centers (423 2-5-year olds)

38.5% non-Hispanic White17.8% non-Hispanic Black6.1% Hispanic or Latino13.5% biracial 24% unknown

• Primary household language90% English6% Spanish

Community Advisory Board – Majority were parents/grandparents of children in Head Start

Participated in all aspects of project– Development of the mission, logo, topics to explore

– Recruitment, data collection (IRB trained), workshops and conferences, research team meetings

Phase 1

Community Assessment– Focus groups– Key informant interviews– Photovoice– 24 hour dietary recall (children); Sibylle Kranz– 7-day accelerometery (children); Karin Pfeiffer– Surveys, follow-up interview– Behavioral observation in centers

Phase 2

Findings were presented to the community in two town hall meetings. Solicited ideas on what the program should entail.

What did we learn?

Children• Watched TV extensively; a coping strategy• Excessive consumption of sugar-sweetened beverages • 35% overweight or obese; 14% met PA recommendations

Parents• failed to recognize when their children were overweight• didn’t like how physicians interacted with them• wanted

• to gain advocacy skills• to connect with other parents• the program to be center-based• their children to gain something from the program

What did we learn?

Children

• watched TV extensively; a coping strategy• excessive consumption of sugar-sweetened beverages • 35% overweight or obese; 14% met PA recommendations

Parents• Failed to recognize when their children were overweight• Didn’t like how physicians interacted with them• Wanted

• to gain advocacy skills• to connect with other parents• the program to be center-based• their children to gain something from the program

What did we learn?

Community• No where to send parents concerned about their child’s

weight • Some programs available in community to promote healthy living, but underutilized

Phase 3 The CHL program

Multiple components

1. Health communication campaign

2. BMI letters sent home

3. Family coffee hour with nutrition counseling

4. Parent’s Connect for Family Wellness program

Phase 3 The CHL program

Multiple components

1. Health communication campaign

2. BMI letters sent home

3. Family coffee hour with nutrition counseling

4. Parent’s Connect for Family Wellness program

Parents Connect for Healthy Living

• 6 week parent-led program• 2 hour session each week; meal provided• Center-based• Sessions focused on:

– Resource empowerment

– Nutrition, media literacy, and communication (workshops)

– Conflict resolution, social networking and stress (hands-on)

– Effective communication with health professionals (panel discussions with pediatricians)

Intervention and Evaluation Timelines

Sept Oct Nov Dec Jan Feb Mar Apr May Jun

Baseline Intervention Implemented Follow-up

Survey (N=154)

Survey

(N=88)

Survey

(N=109)

Activity Monitors (N=90)

Activity Monitors (N=57)

Diet recall (N=55)

Diet recall

(N=33)

Evaluation sample and methods

Construct Method Sample size(Pre-test)

Sample size(Pre-test)

Child BMI; obesity Record extraction: measured height and weight

152 136

Parenting, empowerment, demographics, intervention exposure

Parent survey 145 102

Child dietary recall 24 Hour Dietary Recall 55 33

Child physical activity 7-day accelerometry 83 57

Recruited from all five Head Start centersWhite (45%); African American (15%) Some high school (21%); high school graduate (37%); some college (42%)

Parents (N= 13)

Range 3-19 out of 23 meetings Average = 41% of meetings attended Median = 35% of meetings attended

Community members & Agency staff (N= 8)

Range = 4-17 of 23 meetings Average = 42% of meetings attendedMedian = 43% of meetings attended

Community Advisory BoardParticipation Rates

ResultsProgram exposure•Health communication campaign: 90%+ parents reported seeing posters, 85% reported reading posters

•Family coffee hour: 40% parents heard about, 29% spoke with a nutrition counselor

•Parents Connect program: 69% heard about program, 20% attended at least one session.

•Total number of components parents exposed to: 0 (4%), 1 (16%), 2 (50%), 3+ (30%)

Pre-post intervention differences in child and parent outcomes

• Paired t-tests examined pre-post intervention change in measures of:– child BMI, dietary intake, and physical activity– food, physical activity, and screen-related parenting, parent resource

empowerment

• Performed as intent to treat analyses

Results

Pre intervention Mean (std)

Post intervention Mean (std)

t-value

Child weight status  

BMI z-score 0.86 (1.24) 0.72 (1.12) 1.69Obesity (%) 19.7% 15.8% 10.7**

Child physical activity (min/day)  Sedentary 33.3 (4.0) 32.6 (1.82) 1.82Light physical activity 21.2 (2.9) 21.7 (3.2) -2.04*Moderate physical activity 4.7 (1.5) 4.9 (1.5) -1.76

Child TV viewing (min/day) 141.9 (77.0) 94.10 (61.2) 8.62**

Child diet – dietary recall  

Total energy (kcals) 1531.2 (405.3) 1395.7 (423.8) 3.20** Total fat (gm) 50.1 (18.6) 47.3 (20.1) 2.27* Total carbohydrate (gm) 214.6 (57.4) 199.1 (59.4) 2.60*

Total protein (gm) 58.1 (18.7) 52.9 (17.5) 3.15**

* p< .05 ** p< .01 *** p< .001

Child Outcomes

Pre intervention Mean (std)

Post intervention Mean (std)

t-value

Parent resource empowerment

Weight 3.37 (.63) 3.53 (0.82) 3.19**Physical activity 3.21 (.63) 3.40 (.66) 4.24***

Diet 3.33 (.61) 3.48 (.59) 3.96**

Parenting: Diet

Freq. eat fast food 1.19 (.61) 1.15 (.59) .69

Freq. offer fruits and vegetables 4.43 (1.15) 4.56 (1.14) -1.87Self efficacy to offer healthy foods 4.64(.50) 4.78 (.39) -4.08***

Parenting: Physical activity

Support for physical activity 3.37 (.51) 3.50(.50) -3.36***

Parenting: Television viewingMonitor child screen time 3.34 (.53) 3.33 (.60) .57

TV in child’s bedroom 66% 65% 0.69

* p< .05 ** p< .01 *** p< .001

Parent outcomes

Estimate SE t-value P-value

Outcome: Child BMI z-score (post)BMI z-score (pre) 0.71 .058 12.09 <.0001

Dose .0.1 .05 0.137 .89

Outcome: Child moderate PA (post)

Child moderate PA (pre) 0.72 .08 8.68 <.0001

Dose 0.08 .09 0.86 0.39

Outcome: Child TV viewing (post)

Child TV viewing (pre) 0.66 0.05 12.56 <.0001

Dose -16.59 2.73 -6.08 <.0001

Outcome: Child energy intake1 (post)

Child energy intake (pre) 0.83 .10 8.67 <.0001Dose -48.92 28.35 -1.73 0.09

Dose effectsDose = # components of CHL to which parents were exposed

Multiple regression analysisOutcome (post test) = outcome (pre test) + dose

1 To reduce the risk of type II error, dose effects were only assessed for one key indicator for each construct.

Estimate SE t-value P-value

Outcome: Parent empowerment1 (post)Parent weight-related empowerment (pre) .634 .083 7.63 <.0001

Dose .09 .046 1.97 .05

Outcome: Parent support for child PA (post)

Parent support for child PA 0.66 0.06 11.35 <.0001Dose 0.06 0.02 2.74 .006

Outcome: Parent self efficacy-healthy foodsParent self efficacy (pre) 0.51 0.05 10.51 <.0001

Dose 0.05 0.02 2.84 0.005

Dose effects

1 To reduce the risk of type II error, dose effects were only assessed for one key indicator for each construct.

Summary of Results

• Successful parent and community engagement

• Broad exposure to CHL

• Improvements in child and parent outcomes

• Dose effects were observed

Limitations•Absence of a control group•Small sample size

What now? Scaling up a CBPR-based program

•Focus on best processes rather than best practices

Component Practice Process

Health communication campaign

Posters illustrating myths endorsed by parents and research dispelling such myths

Parent awareness and understanding of their child’s weight status

Family nutrition counseling

Nutrition graduate student is available during “pick up” to answer parents’ questions

Nutrition knowledge; parent social networking; knowledge of relevant community resources

Implementation science as a framework for future research

Challenges us to:•Utilize methods to efficiently move research to practice•Focus on ecological validity (applicability, utility, feasibility, implementation effectiveness)•Collect measures relevant to stakeholders and key decision makers•Ensure representative samples