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Abstract Background Incorporating principles of family-centered care into pediatric weight management interventions can improve the effectiveness and quality of treatment and reduce attrition rates. To assess the family-centeredness of interventions, reliable, valid, and easy-to-administer scales are needed. The purpose of the study was to develop a shortened version of the modified Family Centered Care Assessment (mFCCA) and assess its psychometric properties. Methods The mFCCA, a scale to assess the family-centeredness of interventions for childhood obesity, was administered to families following the Connect for Health randomized control trial evaluating the effectiveness of a primary care-based pediatric weight management intervention. We iteratively removed items from the mFCCA and used Rasch modeling to examine the reliability and validity of the shortened scale. Results We included data from 318 parents and the exploratory factor analysis showed the presence of a single factor. The results of the Rasch modeling demonstrated acceptable internal consistency of the scale (0.7) and strong validity as evidenced by the overall model fit and range of item difficulty. Following the psychometric analyses, we reduced the number of items from 24 to 8 items. Conclusion The mFCCA short version demonstrates good psychometrics and can be used to evaluate the family-centeredness of childhood obesity interventions with reduced participant burden, thereby improving outcomes for children with obesity. Trial registration Clinicaltrials.gov NCT02124460 registered on April 24, 2014.

Abstract Background To address the evolving needs and context changes due to the COVID-19 pandemic, we adapted Connect for Health, an evidence-based, primary care, pediatric weight management intervention. The objective of this study is to describe the planned adaptation process to ensure continued and equitable program uptake during the pandemic. Methods Guided by adaptation frameworks, we identified the core functions and forms of Connect for Health and then adapted the intervention in response to a changing healthcare context. We engaged stakeholders and surveyed parents of children with a BMI ≥ 85th percentile and pediatric clinicians and examined their experiences using telehealth for pediatric weight management and needs and preferences. Using multivariable logistic regression, we examined the preferences of parents with limited English proficiency regarding key aspects of pediatric weight management. Results We surveyed 200 parents and 43% had a primary language of Spanish. Parents wanted care to be a combination of in-person and virtual visits (80%). We found that parents with limited English proficiency had a higher odds ratio of affirming in-person visits are better than virtual visits for ensuring their child’s health concern can be taken care of (OR: 2.91; 95% CI: 1.36, 6.21), feeling comfortable when discussing personal information (OR: 3.91; 95% CI: 1.82, 8.43), talking about healthy behaviors and setting goals (OR: 3.09; 95% CI: 1.39, 6.90), and talking about mental health and overall well-being (OR: 4.02; 95% CI: 1.83, 8.87) than parents without limited English proficiency. We surveyed 75 clinicians and 60% felt telehealth was a useful tool to provide care for pediatric weight management. Clinicians felt virtual visits did not pose barriers to all aspects of care. Informed by the surveys and stakeholder input, we made clinician- and family-level adaptations while retaining the program’s function. Conclusions By engaging stakeholders and adapting the program for telehealth, we optimized the reach and fit of Connect for Health to ensure its continued uptake. We have provided a real-world example of how clinical innovations can evolve and how to systematically plan adaptations in response to changing healthcare contexts. Trial registration Clinicaltrials.gov (NCT04042493), Registered on August 2, 2019.

Abstract Objective: To examine associations of household food insecurity with health and obesogenic behaviours among pregnant women enrolled in an obesity prevention programme in the greater Boston area. Design: Cross-sectional evaluation. Data were collected from structured questionnaires that included a validated two-item screener to assess household food insecurity. We used separate multivariable linear and logistic regression models to quantify the association between household food insecurity and maternal health behaviours (daily consumption of fruits and vegetables, sugar-sweetened beverages and fast food, physical activity, screen time, and sleep), mental health outcomes (depression and stress), hyperglycaemia status and gestational weight gain. Setting: Three community health centres that primarily serve low-income and racial/ethnic minority patients in Revere, Chelsea and Dorchester, Massachusetts. Participants: Totally, 858 pregnant women participating in the First 1,000 Days program, a quasi-experimental trial. Results: Approximately 21 % of women reported household food insecurity. In adjusted analysis, household food insecurity was associated with low fruit and vegetable intake (β = −0·31 daily servings; 95 % CI −0·52, −0·10), more screen time (β = 0·32 daily hours; 95 % CI 0·04, 0·61), less sleep (β = −0·32 daily hours; 95 % CI −0·63, −0·01), and greater odds of current (adjusted odds ratio (AOR) 4·42; 95 % CI 2·33, 8·35) or past depression (AOR 3·01; 95 % CI 2·08, 4·35), and high stress (AOR 2·91; 95 % CI 1·98, 4·28). Conclusions: In our sample of mostly low-income, racial/ethnic minority pregnant women, household food insecurity was associated with mental health and behaviours known to increase the likelihood of obesity.

While parental behaviors during the ‘first thousand days’ are critical for child health, little is known about fathers during this time. We examined prenatal patterns of health behaviors, social-emotional wellbeing, and infant care intentions among expectant fathers, both overall and compared to expectant mothers. Among 227 mother-father dyads enrolling in a randomized controlled trial of a perinatal obesity prevention program in Boston, Massachusetts (July 2020–July 2022), participants independently completed baseline surveys addressing (1) health behaviors, (2) social emotional wellbeing, and (3) infant care intentions. We compared paternal and maternal responses to survey items within each of these domains. Further, we conducted a latent class analysis of paternal responses and examined their associations with sociodemographic characteristics. Compared to expectant mothers, fathers were more likely to report increased body mass index, less fruit intake, decreased sleep, increased physical activity, and no recent primary care visit. Latent class analysis revealed four distinct groups of paternal health behaviors and infant care intentions: (1) more health behaviors with less infant care; (2) less health behaviors with less infant care; (3) less health behaviors with more infant care; and (4) more health behaviors with more infant care. Fathers with increased health behaviors were more likely to have higher education and income. Fathers with decreased health behaviors were more likely to endorse food insecurity, housing insecurity, and social isolation. Our findings identify potential areas for targeting expectant fathers in health promotion initiatives and suggest that social needs may impact the capacity to adopt healthy lifestyle behaviors.

BackgroundChildhood obesity is highly prevalent in the United States and disproportionately impacts communities of color and low-income populations; these disparities have worsened during the COVID-19 pandemic. Adoption of effective pediatric weight management interventions (PWMIs) that have been evaluated among low-income diverse populations is needed. The Healthy Weight Clinic PWMI, a package co-developed by the American Academy of Pediatrics and Massachusetts General Hospital, helps health centers establish multidisciplinary Healthy Weight Clinics based on previous randomized controlled trials which demonstrated effectiveness. We sought to identify the factors influencing successful adoption of this PWMI and understand adaptations needed prior to implementation in new sites.MethodsWe interviewed 20 stakeholders, 10 from two health centers in Mississippi where the Healthy Weight Clinic PWMI will be piloted (pre-implementation sites) and 10 from health centers that have previously implemented it (sites in maintenance stages). Separate interview guides informed by the Consolidated Framework for Implementation Research (CFIR) were developed for the pre-implementation sites and those in maintenance stages, including questions related to adaptations of the PWMI in response to the COVID-19 pandemic. Qualitative data analysis was conducted using directed content analysis based on CFIR constructs. Adaptations in response to the pandemic were categorized using Framework for Reporting Adaptations and Modifications-Expanded (FRAME).ResultsIn pre-implementation sites, an inner setting facilitator mentioned was a positive learning climate. Characteristics of individuals that can facilitate adoption include staff willingness to learn, valuing evidence-based care for childhood obesity, and culturally and weight-sensitive staff. In terms of patient needs and resources (outer setting), social drivers of health are barriers to adoption, but creative solutions were suggested to mitigate these. Other facilitators related to the intervention included its multidisciplinary model and adaptability. Similar themes were elicited from sites in maintenance stages; adaptations brought on by the pandemic, such as telehealth visits and content modification to align with distancing guidelines and the effects of social isolation were also described.ConclusionUnderstanding the factors influencing adoption of an evidence-based PWMI informs necessary adaptations and implementation strategies required to facilitate nationwide dissemination of PWMIs, with the goal of reaching the populations most at-risk.

Objective: How we communicate about obesity is critical as treatment paradigms shift upstream. We previously identified parental perceptions, concerns, beliefs, and communication preferences about early life obesity risk. We engaged parents of children 0 to 24 months of age and pediatricians from Indianapolis, Indiana, USA in the co-design of messages and tools that can be used to facilitate parent/provider conversations about early life obesity prevention. Methods: From April to June 2021, we conducted a series of co-design workshops with parents of children ages 0 to 24 months and pediatricians to identify their preferences for communicating obesity prevention in the setting of a pediatric well visit. Human-centered design techniques, including affinity diagraming and model building, were used to inform key elements of a communication model and communication strategy messages. These elements were combined and refined to create prototype tools that were subsequently refined using stakeholder feedback. Results: Parent participants included 11 mothers and 2 fathers: 8 white, 4 black, and 1 Asian; median age 33 years with 38% reporting annual household incomes less than $50,000. Pediatricians included 7 female and 6 male providers; 69% white. Through an iterative process of co-design, we created an exam room poster that addresses common misconceptions about infant feeding, sleep and exercise, and a behavior change plan to foster parent/provider collaboration focused on achieving children’s healthy weight. Conclusions: Our hands-on, collaborative approach may ultimately improve uptake, acceptability and usability of early life obesity interventions by ensuring that parents remain at the center of prevention efforts.

Abstract Background Although paternal involvement in the perinatal period is associated with benefits for maternal-child health and reduced obesity risk, fathers are seldom included in perinatal or obesity prevention efforts. Engaging community leaders and fathers as stakeholders in intervention development is a critical step in designing a father-inclusive intervention that is efficacious and responsive to their needs. Methods We conducted a structured engagement study, including community stakeholder engagement and qualitative interviews with new fathers, to inform the development of a prospective randomized controlled trial that includes mothers and fathers as equal partners in infant obesity prevention. We interpreted stakeholder feedback through the Consolidated Framework for Implementation Research (CFIR) framework. Results Between September 2019 and April 2020, we held a Community Engagement meeting, formed a Community Advisory Board, and conducted 16 qualitative interviews with new fathers. Stakeholder engagement revealed insights across CFIR domains including intervention characteristics (relative advantage, complexity, design quality & packaging), outer setting factors (cosmopolitanism and culture), individual characteristics (including self-efficacy, state of change, identification with the organization) and process (engagement and adaptation). Stakeholders discussed the diverse challenges and rewards of fatherhood, as well as the intrinsic paternal motivation to be a loving, supportive father and partner. Both community leaders and fathers emphasized the importance of tailoring program delivery and content to meet specific parental needs, including a focus on the social-emotional needs of new parents. Conclusions A structured process of multidimensional stakeholder engagement was successful in improving the design of a father-inclusive perinatal obesity prevention interventions. Father engagement was instrumental in both reinforcing community ties and increasing our understanding of fathers’ needs, resulting in improvements to program values, delivery strategies, personnel, and content. This study provides a practical approach for investigators looking to involve key stakeholders in the pre-implementation phase of intervention development. Trial registration ClinicalTrials.gov, NCT04477577 . Registered 20 July 2020.

With overdose deaths increasing, improving access to harm reduction and low barrier substance use disorder treatment is more important than ever. The Community Care in Reach R model uses a mobile unit to bring both harm reduction and clinical care for addiction to people experiencing barriers to officebased care. These mobile units provide many resources and services to people who use drugs, including safer consumption supplies, naloxone,medication for substance use disorder treatment, and a wide range of primary and preventative care. This protocol outlines the evaluation plan for the Community in Care R model in MA, USA. Using the RE-AIM framework, this evaluation will assess how mobile services engage new and underserved communities in addiction services and primary and preventative care.

ObjectiveTo examine cross-sectional associations of food and housing security risks and healthy lifestyle parenting behaviors related to nutrition and physical activity among families with children with overweight/obesity.MethodsWe surveyed 407 parents of children ages 6–12 years with overweight/obesity. Exposures were measures of food and housing insecurity risk. Outcomes were healthy lifestyle parenting behaviors related to nutrition and physical activity. Logistic regression models for each exposure-outcome relationship were adjusted for parental educational attainment, parental cohabitation status, household size, and household income.ResultsIn multivariable-adjusted models, food insecurity was associated with significantly lower odds of parent modeling exercise {aOR 0.60 [95% confidence interval (CI): 0.37, 0.96]} and parent modeling eating healthy foods [aOR 0.42 (95% CI: 0.24, 0.73)]. Housing insecurity was associated with significantly lower odds of parent modeling exercise [aOR 0.57 (95% CI: 0.35, 0.95)].ConclusionsFood insecurity and housing insecurity may be barriers to parents adopting and modeling healthy lifestyle parenting behaviors related to physical activity and nutrition.

Abstract Background First 1000 Days is a systems-oriented program starting in early pregnancy lasting through the first 24 months of infancy focused on preventing obesity and related risk factors among low income, mother-infant pairs. The program was developed in partnership with stakeholders to create an infrastructure for system-wide change. It includes screening for adverse health behaviors and socio-contextual factors, patient navigation and educational materials to support behavior change and social needs, and individualized health coaching for women at highest risk of obesity and has been shown to reduce excess gestational weight gain for women who were overweight at the start of their pregnancy. The purpose of this study was to examine changes from the first to third trimester for women participating in the First 1000 Days Program. Methods We collected information through self-administered questionnaires during the first and third trimester of gestation and from electronic health records relating to obesity risk factors. Measures collected included behavior (i.e., diet, physical activity and screen time) and psychosocial (i.e., anxiety) outcomes, as well as enrollment in Women, Infant, and Children (WIC) program. We examined the extent to which participation in the program was associated with changes in behaviors and psychosocial outcomes among women during pregnancy. Results Women completed surveys at their initial and third trimester prenatal visits (n = 264). Mean age (SD) was 30.2 (5.51) years and 75% had an annual household income of

BackgroundMulti-sector stakeholder engagement is essential in the successful implementation, dissemination, and sustainability of pediatric weight management interventions (PWMI), particularly in low-income settings where sustainability relies on external policies and reimbursement. The objective of this study was to engage stakeholders (1) to inform the creation of the intervention with adaptations needed for a successful PWMI in a primary care and community setting and (2) to identify barriers and facilitators to implementation and dissemination.MethodsWe sought to examine the perspectives of local, state, and national clinic and community stakeholders during the pre-implementation period of a two-arm, randomized trial of a Health Weight Clinic PWMI conducted in two health centers and a modified—Healthy Weight and Your Child PWMI at two local YMCAs that serve a predominantly lower income, Hispanic community. The Consolidated Framework for Implementation Research interview guide served as a template for the study but was modified to fit the PWMIs and the various professional roles. Interviews were transcribed and analyzed using the framework analysis approach and themes were linked to the CFIR domains and constructs.ResultsTwenty-six stakeholders perceived the following as needed components of a PWMI: a formal curriculum with illustrative examples, a patient- and family-centered program, group visits, and high-quality multidisciplinary personnel. These findings led to the creation of a group visit curriculum, implementation trainings and cross-site collaborative technical assistance. Additionally, creating partnerships between community and clinical organizations, and addressing patient barriers and unmet social needs (i.e., transportation, food) were identified as facilitators to successful implementation. These results led to the creation of community resource guides, connections to community organizations, and screening and referring for unmet social needs. Perceived facilitators of dissemination included proving cost-effectiveness of the PWMI to inform insurance reimbursement for long-term sustainability. Therefore, we collected cost data and engaged with Medicaid officials to discuss reimbursement.ConclusionFindings highlight the importance of engaging multi-sector stakeholders pre-implementation to ensure the components valued are included, ensuring the program minimizes barriers to participation, considering how staff training can improve implementation and how collected outcomes can inform sustainability and dissemination of PWMIs in clinic and community settings.

ObjectivePediatricians are well positioned to discuss early life obesity risk, but optimal methods of communication should account for parent preferences. To help inform communication strategies focused on early life obesity prevention, we employed human-centered design methodologies to identify parental perceptions, concerns, beliefs, and communication preferences about early life obesity risk.MethodsWe conducted a series of virtual human-centered design research sessions with 31 parents of infants

Early life adversity can significantly impact child development and health outcomes throughout the life course. With the COVID-19 pandemic exacerbating preexisting and introducing new sources of toxic stress, social programs that foster resilience are more necessary now than ever. The Helping Us Grow Stronger (HUGS/Abrazos) program fills a crucial need for protective buffers during the COVID-19 pandemic, which has escalated toxic stressors affecting pregnant women and families with young children. HUGS/Abrazos combines patient navigation, behavioral health support, and innovative tools to ameliorate these heightened toxic stressors. We used a mixed-methods approach, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, to evaluate the implementation of the HUGS/Abrazos program at Massachusetts General Hospital from 6/30/2020–8/31/2021. Results of the quality improvement evaluation revealed that the program was widely adopted across the hospital and 392 unique families were referred to the program. The referred patients were representative of the communities in Massachusetts disproportionately affected by the COVID-19 pandemic. Furthermore, 79% of referred patients followed up with the initial referral, with sustained high participation rates throughout the program course; and they were provided with an average of four community resource referrals. Adoption and implementation of the key components in HUGS/Abrazos were found to be appropriate and acceptable. Furthermore, the implemented program remained consistent to the original design. Overall, HUGS/Abrazos was well adopted as an emergency relief program with strong post-COVID-19 applicability to ameliorate continuing toxic stressors while decreasing burden on the health system.

Fathers’ engagement in infant caregiving is linked with positive social, emotional, and developmental outcomes in children; however, its relationship with fathers’ own health is largely unknown. This longitudinal study examined associations between fathers’ caregiving engagement with their 6-month-old infants and their physical activity, sugar-sweetened beverage (SSB) consumption, nighttime sleep duration, and depressive symptoms 6 months later when infants were 12 months old. Participants were 143 fathers of infants (62.7% non-Hispanic White, 82.3% with a bachelor’s degree). Fathers reported their frequency of engagement in seven caregiving activities when infants were 6 months old. Fathers’ physical activity, SSB consumption, nighttime sleep duration, and depressive symptoms were assessed when infants were 6 and 12 months old. Multivariate logistic regression analysis was used to assess if fathers who reported higher infant caregiving at 6 months had more positive health outcomes at 12 months, controlling for fathers’ age, race/ethnicity, education, employment, household income, and the outcome at 6 months. Fathers who reported higher caregiving engagement when infants were 6 months old had increased odds of being sufficiently physically active 6 months later (unadjusted odds ratio [OR] = 1.19, 95% confidence interval [CI] = [1.00, 1.41]; adjusted OR = 1.47, 95% CI = [1.11, 1.96]). No links were identified between fathers’ caregiving engagement and their SSB consumption, nighttime sleep duration, or depressive symptoms. In summary, fathers’ engagement in infant caregiving may be beneficial to their physical activity in the first year after birth. There was insufficient evidence in this study that the benefits of caregiving engagement were experienced broadly across multiple health outcomes.

Abstract Background Nearly half of all pregnancies in the United States are reported as unintended and rates are highest among women of low socioeconomic status. The purpose of this study was to examine the associations between unintended pregnancies and maternal mental health and timing of prenatal care among low-income women. Methods In this cross-sectional study, 870 women, whom were participating in the First 1000 Days program in three community health centers in the Boston area, were enrolled at their first prenatal visit from August 2016 – September 2017. We assessed pregnancy intention by self-report using the Pregnancy Risk Assessment Monitoring System. We used self-reported survey information and electronic health record data to assess the following outcomes: current stress, current depression, and timing of initial prenatal visit. We used multivariable logistic regression models to examine associations and adjusted for sociodemographic factors. Results Women were a mean (SD) age of 29.3 (6.1), and 39.2% reported that their pregnancy was unintended. 50.6% of women were Hispanic, 28.4% were White, 10.1% were Black, and 10.9% were other races. 78.9% of women reported an annual household income

Abstract Background Parent-child dietary concordance is associated with child diet, but the clinical implications of mother-father dietary concordance during pregnancy are unknown. This study evaluates antenatal mother-father dietary concordance and associations with gestational weight gain (GWG). Methods Mother-father (n = 111) dyads with low income reported their fruit/vegetable (FV), fast food (FF), and sugar-sweetened beverage (SSB) consumption frequency during the first trimester of pregnancy. From electronic health records, we collected height and self-reported pre-pregnancy weight and calculated pre-pregnancy body mass index (BMI). The primary outcome was excessive GWG for pre-pregnancy BMI. Dyads were categorized as healthy or unhealthy concordant (consuming similarly high or low amounts of FV, FF, or SSB), or mother-healthy or father-healthy discordant (consuming different amounts of FV, FF, or SSB). Multivariable and logistic regressions analyzed associations between dietary concordance and GWG. Results Mothers were Hispanic (25%), 43% White, 6% Black, and 23% Asian or Other. Most mothers were employed (62%) making

Abstract Background Connect for Health is an evidence-based weight management program with clinical- and family-facing components for delivery in pediatric primary care for families of children ages 2 to 12 years. We used the Consolidated Framework for Implementation Research (CFIR) to guide formative work prior to national implementation. The purpose of this study was to describe the process and results of stakeholder engagement and program adaptation. Methods We used mixed qualitative and quantitative methods to iteratively adapt and optimize the program by assessing needs and perspectives of clinicians and parents, as well as contextual barriers, facilitators, and organizational readiness for the uptake of the proposed program tools and implementation strategies. We conducted interviews with primary care clinicians from four health care organizations in Boston, MA; Denver, CO; and Greenville, SC, and used principles of immersion-crystallization for qualitative analyses. We also conducted surveys of parents of children with a body mass index ≥ 85th percentile. Results We reached thematic saturation after 52 clinician interviews. Emergent themes representing the CFIR domains of intervention characteristics, outer and inner setting, and process included (1) importance of evidence-based clinical decision support tools that integrate into the workflow and do not extend visit time, (2) developing resources that respond to family’s needs, (3) using multimodal delivery options for family resources, (4) addressing childhood obesity while balancing competing demands, (5) emphasizing patient care rather than documentation and establishing sustainability plans, and (6) offering multiple training methods that incorporate performance feedback. Of the parents surveyed (n = 400), approximately 50% were Spanish-speaking and over 75% reported an annual income < $50,000. Parents affirmed the importance of addressing weight management during well-child visits, being provided with referrals and resources, and offering multiple methods for resource delivery. Decisions about program modifications were made at the program and healthcare-system level and based on stakeholder engagement findings. Modifications included cultural, geographic, and target audience adaptations, as well as varied resource delivery options. Conclusions To ensure the fit between the Connect for Health program and national implementation settings, adaptations were systematically made through engagement of clinician and parent stakeholders to support adoption, sustainability, and health outcomes. Trial registration NCT04042493

Abstract Background Incorporating family-centered care principles into childhood obesity interventions is integral for improved clinical decision making, better follow-through, and more effective communication that leads to better outcomes and greater satisfaction with services. The purpose of this study is to evaluate the psychometric properties of a modified version of the Family Centered-Care Assessment (mFCCA) tool and to assess the family-centeredness of two clinical-community childhood obesity interventions. Methods Connect for Health was a randomized trial testing the comparative effectiveness of two interventions that enrolled 721 children, ages 2–12 years, with a body mass index (BMI) ≥ 85th percentile. The two arms were (1) enhanced primary care; and (2) enhanced primary care plus contextually-tailored, health coaching. At the end of the one-year intervention, the mFCCA was administered. We used Rasch analyses to assess the tool’s psychometrics and examined differences between the groups using multiple linear regression. Results 629 parents completed the mFCCA resulting in an 87% response rate. The mean (SD) age of children was 8.0 (3.0) years. The exploratory factor analysis with 24 items all loaded onto a single factor. The Rasch modeling demonstrated good reliability as evidenced by the person separation reliability coefficient (0.99), and strong validity as evidenced by the range of item difficulty and overall model fit. The mean (SD, range) mFCCA score was 4.14 (0.85, 1–5). Compared to parents of children in the enhanced primary care arm, those whose children were in the enhanced primary care plus health coaching arm had higher mFCCA scores indicating greater perception of family-centeredness (β = 0.61 units [95% CI: 0.49, 0.73]). Conclusions Using the mFCCA which demonstrated good psychometric properties for the assessment of family-centered care among parents of children with obesity, we found that individualized health coaching is a family-centered approach to pediatric weight management. Trial registration Clinicaltrials.gov NCT02124460 .

Summary Background The Food and Drug Administration has approved several pharmacotherapies for the treatment of obesity. This study assesses the cost‐effectiveness of six pharmacotherapies and lifestyle intervention for people with mild obesity (body mass indices [BMIs] 30 to 35). Methods A microsimulation model was constructed to compare seven weight loss strategies plus no treatment: intensive lifestyle intervention, orlistat, phentermine, phentermine/topiramate, lorcaserin, liraglutide, and semaglutide. Weight loss, quality‐of‐life scores, and costs were estimated using clinical trials and other published literature. Endpoints included costs, quality‐adjusted life years (QALYs), and incremental cost‐effectiveness ratios (ICERs) with a willingness‐to‐pay (WTP) threshold of $100 000/QALY. Results were analysed at 1‐, 3‐, and 5‐year time horizons. Results At each of the three follow‐up periods, phentermine was the cost‐effective strategy, with ICERs of $46 258/QALY, $20 157/QALY, and $17 880/QALY after 1, 3, and 5 years, respectively. Semaglutide was the most effective strategy in the 3‐ and 5‐year time horizons, with total QALYs of 2.224 and 3.711, respectively. However, the ICERs were prohibitively high at $1 437 340/QALY after 3 years and $576 931/QALY after 5 years. Deterministic and probabilistic sensitivity analyses indicated these results were robust. Conclusions Phentermine is the cost‐effective pharmacologic weight‐loss strategy. Although semaglutide is the most effective, it is not cost‐effective because of its high price.

Objective: The multi-sector, multi-level Massachusetts Childhood Obesity Research Demonstration (MA-CORD) study resulted in improvements in obesity risk factors among children age 2–4 years enrolled in the Special Supplemental Nutrition program for Women, Infants, and Children (WIC). The goal of this study was to examine whether the MA-CORD intervention increased WIC provider confidence in their ability to identify childhood obesity and obesity-related behaviors. Methods: As part of the MA-CORD intervention conducted from 2012 to 2015, we implemented WIC practice changes focused on childhood obesity prevention within two Massachusetts communities. We examined changes in provider confidence to assess childhood obesity risk factors and practice frequency among WIC practices located in MA-CORD intervention communities over a 3-year period, compared to non-intervention sites. We measured provider confidence on a continuous scale using questions previously developed to assess provider and parent confidence to make weight-related behavior change (range 0 to 24). Results: There were 205 providers at baseline and 165 at follow-up. WIC providers at intervention sites reported greater confidence in their ability to identify childhood obesity and obesity-related behaviors compared to the usual care sites (β = 1.01, standard error = 0.13). These findings persisted after adjusting for provider gender, years in practice, highest education level, and WIC position. Conclusions: The MA-CORD intervention was associated with increased WIC provider confidence to assess children's obesity risk. Interventions that increase confidence in assessing obesity-related behaviors may have salutary effects within WIC programs that serve low-income families. Keywords: Obesity prevention, Child health disparities, WIC

Abstract Background Despite the growing prevalence of excess weight and prediabetes in children, the contributing role of dietary behaviors throughout childhood remains poorly understood. We examined longitudinal associations of dietary behaviors throughout childhood with adiposity and estimated insulin resistance (HOMA-IR) in adolescence. Methods Among 995 children from Project Viva, a pre-birth cohort, we examined associations of child dietary behaviors (frequency of eating breakfast, fast food, family dinner, and eating meals while watching television) reported annually throughout childhood (from ages 4 to 11 years) with body mass index z-score (BMI-z; n = 991), waist circumference (WC; n = 995), DXA overall and central adiposity measurements (n = 721), and HOMA-IR (n = 579) in early adolescence (13.2 ± 0.9 years old). We used mixed effects models adjusted for potential confounders. Results Eating breakfast daily throughout childhood was associated with lower BMI-z and DXA-measured overall and central adiposity in boys and girls (e.g. for whole-body fat %: β − 1.43% [95% CI: -2.42, − 0.45] and − 1.47% [− 2.25, − 0.68]), and with lower HOMA-IR in boys (% difference − 15.6% [− 22.7, − 7.9]). Daily family dinner and eating fast food less than once per week throughout childhood were both associated with lower BMI-z and adiposity in girls (for BMI-z: β − 0.17 units [− 0.24, − 0.11] and β − 0.09 units [− 0.17, − 0.02]) and lower insulin resistance in boys (% difference − 7.3% [− 12.4,− 1.8] and − 7.6% [− 13.2, − 1.7]). Finally, eating meals while watching television

Pregnancy and early childhood pose unique sensitivity to stressors such as economic instability, poor mental health, and social inequities all of which have been magnified by the COVID-19 pandemic. In absence of protective buffers, prolonged exposure to excessive, early adversity can lead to poor health outcomes with significant impact lasting beyond the childhood years. Helping Us Grow Stronger (HUGS/Abrazos) is a community-based program, designed and launched at the time of the COVID-19 surge in the Spring of 2020, that combines emergency relief, patient navigation, and direct behavioral health support to foster family resilience and mitigate the negative impacts of COVID-related toxic stress on pregnant women and families with children under age 6. Through a targeted referral process, community health workers provide resource navigation for social needs, and a social worker provides behavioral health support. The use of innovative tools such as a centralized resource repository, community health workers with specialized knowledge in this age range, and a direct referral system seeks to assist in streamlining communication and ensuring delivery of quality care. We aim to serve over 300 families within the 1st year. The HUGS/Abrazos program aims to fill an important void by providing the necessary tools and interventions to support pregnant women and young families impacted by adversity exacerbated by the COVID-19 pandemic.

This cross-sectional, descriptive study examined unmet social and economic needs and health information requests of low-income, expecting fathers who participated in the First 1000 Days program. The First 1000 Days is a systems-level intervention aiming to prevent obesity among low-income mothers and infants across 3 community health centers in Greater Boston, MA, USA. Fathers who attended their partner’s first prenatal care visit were invited to complete a program survey during early pregnancy. Among 131 fathers surveyed, 45% were white, 21% were Hispanic/Latino, 55% were foreign-born, and 69% reported an annual income under $50 000. Fathers reported elevated levels of food insecurity (18%) and 33% were unaware of someone that could provide a $50 loan; however, over 85% of fathers knew someone that could provide non-financial social support. Fathers requested information about pregnancy, birth preparation, and fatherhood. Findings support addressing fathers’ unmet needs during pregnancy and providing father-specific perinatal information.

Objective: Healthy Habits, Happy Homes (4H) is a home-based, pre-school childhood obesity prevention intervention which demonstrated efficacy in North America which we translated to Scotland (4HS) by considering contextual factors and adapting study design. RE-AIM Framework was used to assess 1) extent to which development of 4HS intervention (including recruitment) was participatory and inclusive; 2) feasibility of translating a complex public health intervention from one setting to another; 3) extent to which translation was pragmatic and 4) fidelity of intervention to the principles of Motivational Interviewing (MI). Study design: Feasibility testing, process evaluation and measurements of intervention fidelity were undertaken to evaluate the translation of 4H to an economically deprived area of Scotland (4HS). Methods: 4HS study processes; participatory approach, recruitment methods, level of pragmatism were evaluated using the RE-AIM framework. Qualitative and quantitative measures identified key implementation features and functioning of 4HS intervention. Fidelity MI principles was determined through coding of audiotapes using Motivation Interviewing Treatment Integrity (MITI) code. Results: Key facilitators for positive impact with families, included: inclusive recruitment methods, appropriate channels of communication and correspondence (Reach) with n ​= ​126 enquiries and n ​= ​26 (21%) families recruited. Positive links with local parents and community workers integral to the research process at n ​= ​9 meetings (Effectiveness). 61.5% of families lived in the most deprived data zone in Scotland, 23% were one parent families, thus awareness and consideration of local contextual factors (Adoption) and locally relevant materials were important. 4HS was feasible to deliver, pragmatic in nature and intervention demonstrated good fidelity to MI (Implementation). Conclusion: Translation of 4H from North America to Scotland was successful. Future studies should consider implementation of 4HS approach within routine practice within the UK (practice based evidence) or through thoughtful evaluation in a future trial (evidence based practice).

Opioid overdoses killed 47,600 people in the United States in 2017. Despite increasing availability of office-based addiction treatment programs, the prevalence of opioid overdose is historically high and disproportionately affects vulnerable populations, including people experiencing homelessness. Despite availability of effective treatment, many at greatest risk of death from overdose experience myriad barriers to care. Launched in 2018, the Community Care in Reach mobile health initiative uses a data-driven approach to bring harm reduction and medication for opioid use disorder directly to those at highest risk of near-term death. Proof-of-concept results suggest that mobile addiction services may serve as a model for expanding access to addiction care for the most vulnerable.

Sugar-sweetened beverage (SSB) consumption is a risk factor for childhood obesity. Including this measure in electronic health records (EHR) could enhance clinical care and facilitate research on this topic. We implemented a single-item, EHR screening question for SSB and 100% fruit juice at 8 pediatric practices affiliated with a North Carolina academic medical center. From March–December 2017, we evaluated SSB screening of children 6 months–17 years of age. In a sub-sample of screened patients, we also conducted a telephone-based validation survey, comparing EHR-based responses to a lengthier beverage questionnaire, using Spearman rank coefficients and Kappa statistic. 22,626 children (91% of all seen) were screened for SSB intake. The screened population was diverse – 35% non-Hispanic White, 26% African-American, and 30% Hispanic. Consistent with national estimates, reported intake was typically higher than recommended: 41% (n = 9220) reported consuming SSB or fruit juice >1×/day in the past month, and consumption was higher among race/ethnic minorities. Of 201 validation survey respondents, direct correlation between their beverage survey and EHR screener responses was moderate, with a Spearman's rank correlation coefficient of 0.41 (p

Objective: Examine the emergence of differences in sleep duration between infants from different racial/ethnic backgrounds and extent to which differences are explained by socioeconomic status (SES) and sleep continuity. Methods: Sleep duration and continuity (number of night wakings and longest nighttime stretch of sleep) were assessed for 394 infants in the Rise & Sleep Health in Infancy & Early Childhood (SHINE) birth cohort at one- and six-months using the Brief Infant Sleep Questionnaire (BISQ). Multivariable regression was used to estimate associations of race/ethnicity with sleep duration adjusting for individual-level covariates, SES, and sleep continuity. Results: The sample was 40% non-Hispanic white, 33% Hispanic, 11% Black, and 15% Asian. Mean (SD) durations for daytime, nighttime, and total sleep at one-month were 6.3 (2.0), 8.9 (1.5), and 15.2 (2.7) hours, respectively. Corresponding durations at six-months were 3.0 (1.4), 9.9 (1.3), and 13.0 (1.9) hours. At one-month, Hispanic infants had shorter nighttime sleep than white infants [β: −0.44 h (95% CI: −0.80, −0.08)]. At six-months, Hispanic [β: −0.96 h (−1.28, −0.63)] and Black [β: −0.60 h (−1.07, −0.12)] infants had shorter nighttime sleep than white infants. The near 1-h differential in night sleep among Hispanics resulted in shorter total sleep [β: −0.66 h (−1.16, −0.15)]. Associations across all racial/ethnic groups were attenuated after adjustment for SES at one- and six months. Sleep continuity attenuated associations with nighttime and total sleep duration by 20–60% for Hispanic infants at six-months. Conclusions: Differences in sleep duration emerge early in life among racial/ethnic groups and are in part explained by SES and sleep continuity.

Background: BMI z-scores (BMIz) based on the Centers for Disease Control and Prevention (CDC) growth charts among children do not accurately characterise BMI levels among children with very high BMIs. These limitations may be particularly relevant in longitudinal and intervention studies, as the large changes in the L (normality) and S (dispersion) parameters with age can influence BMIz. Aim: To compare longitudinal changes in BMIz with BMI expressed as a percentage of the 95th percentile (%BMIp95) and a modified z-score calculated as log(BMI/M)/S. Subjects and methods: A total of 45 414 2–4-year-olds with severe obesity (%BMIp95 ≥ 120). Results: Changes in very high BMIz levels differed from the other metrics. Among severely obese 2-year-old girls, for example, the mean BMIz decreased by 0.6 SD between examinations, but there were only small changes in BMIp95 and modified BMIz. Some 2-year-old girls had BMIz decreases of >1 SD, even though they had large increases in BMI, %BMIp95 and modified BMIz. Conclusions: Among children with severe obesity, BMIz changes may be due to differences in the transformations used to estimate levels of BMIz rather than to changes in body size. The BMIs of these children could be expressed relative to the 95th percentile or as modified z-scores.

Many children are not sufficiently physically active. This study uses a quasi-experimental design to evaluate whether participation in a before-school physical activity program called Build Our Kids' Success (BOKS) increases physical activity. Participants (n = 426) were students in Fall, 2016 enrolled in BOKS programming and matched non-BOKS control students from the same grades (Kindergarten-6) and schools in Massachusetts and Rhode Island. Analyses conducted in 2017 examined differences between children in BOKS versus controls in total daily steps, minutes of moderate-to-vigorous (MVPA), vigorous (VPA), and total physical activity (TPA) assessed via Fitbit Charge HR™ monitors. Additional analyses compared physical activity on program days and non-program days. Students (mean age = 8.6 y; 47% female, 58% White, Non-Hispanic) wore monitors an average of 21.7 h/day on 3.2 days during the school week. Compared with controls, on BOKS days, BOKS participants accumulated more steps (1147, 95% confidence interval (CI): 583–1712, P

Abstract Background The role of fathers in the development of obesity in their offspring remains poorly understood. We evaluated associations of missing paternal demographic information on birth certificates with perinatal risk factors for childhood obesity. Methods Data were from the Linked CENTURY Study, a database linking birth certificate and well-child visit data for 200,258 Massachusetts children from 1980–2008. We categorized participants based on the availability of paternal age, education, or race/ethnicity and maternal marital status on the birth certificate: (1) pregnancies missing paternal data; (2) pregnancies involving unmarried women with paternal data; and (3) pregnancies involving married women with paternal data. Using linear and logistic regression, we compared differences in smoking during pregnancy, gestational diabetes, birthweight, breastfeeding initiation, and ever recording a weight for length (WFL) ≥ the 95th percentile or crossing upwards ≥2 WFL percentiles between 0–24 months among the study groups. Results 11,989 (6.0 %) birth certificates were missing paternal data; 31,323 (15.6 %) mothers were unmarried. In adjusted analyses, missing paternal data was associated with lower birthweight (β -0.07 kg; 95 % CI: −0.08, −0.05), smoking during pregnancy (AOR 4.40; 95 % CI: 3.97, 4.87), non-initiation of breastfeeding (AOR 0.39; 95 % CI: 0.36, 0.42), and with ever having a WFL ≥ 95th percentile (AOR 1.10; 95 % CI: 1.01, 1.20). Similar associations were noted for pregnancies involving unmarried women with paternal data, but differences were less pronounced. Conclusions Missing paternal data on the birth certificate is associated with perinatal risk factors for childhood obesity. Efforts to understand and reduce obesity risk factors in early life may need to consider paternal factors.

Although American children snack more than ever before, the parental role in promoting snacking is not well understood. In 2012–2013 at baseline in an intervention study to prevent childhood obesity in low-income Massachusetts communities, n = 271 parents of children aged 2–12 years completed surveys regarding nutritive and non-nutritive reasons they offered children snacks, demographics, and dietary factors. An analysis of variance demonstrated that parents reported offering snacks (mean/week; standard deviation (SD)) for nutritive reasons like promoting growth (x̄ = 2.5; SD 2.2) or satisfying hunger (x̄ = 2.4; SD 2.1) almost twice as often as non-nutritive reasons like keeping a child quiet (x̄ = 0.7; SD 1.5) or celebrating events/holidays (x̄ = 0.8; SD 1.1). Parents reported giving young children (2–5 years) more snacks to reward behavior (1.9 vs. 1.1, p < 0.001), keep quiet (1.0 vs. 0.5, p < 0.001), and celebrate achievements (1.7 vs. 1.0, p < 0.001) than parents of older children (6–12 years). Multivariable logistic regression models were used to obtain adjusted odds ratios, which indicated reduced child adherence to dietary recommendations when parents offered snacks to reward behavior (Odds Ratio (OR) = 0.83; 95% Confidence Interval (CI) 0.70–0.99), celebrate events/holidays (OR = 0.72; 95% CI 0.52–0.99), or achievements (OR = 0.82; 95% CI 0.68–0.98). Parental intentions around child snacking are likely important targets for obesity prevention efforts.

Objectives. Modifiable behaviors during the first 1000 days (conception age 24 months) mediate Hispanic children’s obesity disparities. We aimed to examine underlying reasons for early life obesity risk factors and identify potential early life intervention strategies. Methods. We conducted 7 focus groups with 49 Hispanic women who were pregnant or had children < age 24 months. Domains included influences on childhood obesity risk factors and future intervention ideas. We analyzed data with immersion-crystallization methods until no new themes emerged. Results. Themes included coping with pregnancy may trump healthy eating and physical activity; early life weight gain is unrelated to later life obesity; fear of infant hunger drives bottle and early solids introduction; beliefs about infant taste promote early solids and sugary beverage introduction; and belief that screen time promotes infant development. Mothers identified physicians, nutritionists, and relatives as important health information sources and expressed interest in mobile technology and group or home visits for interventions. Conclusion. Opportunities exist in the first 1000 days to improve Hispanic mothers’ understanding of the role of early life weight gain in childhood obesity and other obesity risk factors. Interventions that link health care and public health systems and include extended family may prevent obesity among Hispanic children.

Objective. To examine body mass index (BMI) changes among pediatric multidisciplinary weight management participants and nonparticipants. Design. In this retrospective database analysis, we used multivariable mixed effect models to compare 2-year BMI z-score trajectories among 583 eligible overweight or obese children referred to the One Step Ahead program at the Boston Children’s Primary Care Center between 2003 and 2009. Results. Of the referred children, 338 (58%) attended the program; 245 (42%) did not participate and were instead followed by their primary care providers within the group practice. The mean BMI z-score of program participants decreased modestly over a 2-year period and was lower than that of nonparticipants. The group-level difference in the rate of change in BMI z-score between participants and nonparticipants was statistically significant for 0–6 months (P=0.001) and 19–24 months (P=0.008); it was marginally significant for 13–18 months (P=0.051) after referral. Younger participants (

Childhood obesity is currently one of the most prevailing and challenging public health issues among industrialized countries and of international priority. The global prevalence of obesity poses such a serious concern that the World Health Organization (WHO) has described it as a “global epidemic.” Recent literature suggests that the genesis of the problem occurs in the first years of life as feeding patterns, dietary habits, and parental feeding practices are established. Obesity prevention evidence points to specific dietary factors, such as the promotion of breastfeeding and appropriate introduction of nutritious complementary foods, but also calls for attention to parental feeding practices, awareness of appropriate responses to infant hunger and satiety cues, physical activity/inactivity behaviors, infant sleep duration, and family meals. Interventions that begin at birth, targeting multiple factors related to healthy growth, have not been adequately studied. Due to the overwhelming importance and global significance of excess weight within pediatric populations, this narrative review was undertaken to summarize factors associated with overweight and obesity among infants and toddlers, with focus on potentially modifiable risk factors beginning at birth, and to address the need for early intervention prevention.