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A collaborative approach to identify opportunities for interactions between multiple systems is an important model for childhood obesity prevention. This paper describes a process aligning multiple partners in primary care, public health, university research, schools, and community organizations. Jointly implemented strategies in a Latino underserved community included: (1) building an effective and sustainable collaborative team; (2) disseminating a healthy weight message across sectors; (3) assessing weight status and healthy weight plans in primary care, school, and early childhood settings; and (4) implementing policy changes to support healthy eating and physical activity. The process and lessons learned were analyzed so other communities can utilize a systems approach to develop culturally appropriate interventions tailored to a specific community.

Data on childhood obesity collected by the Centers for Disease Control and Prevention helped reveal the nation's epidemic of overweight and obese children. But more information is needed. Collecting body mass index (BMI)-the widely accepted measurement of childhood weight status-at the state and local levels can be instrumental in identifying and tracking obesity trends, designing interventions to help overweight children, and guiding broader policy solutions. Approximately thirty states have enacted or proposed BMI surveillance laws and regulations. Arkansas stands out as the state with the highest-quality surveillance data. Innovative strategies being pursued in a number of other states should be explored for broader dissemination.

Background. Developing and evaluating interventions to influence students' opportunities for healthful choices has been a focus of school-based health promotion research; however, few studies have examined the sustainability of these programs and viability of continued organizational implementation. Methods. The purpose of this study was to determine the maintenance of Child and Adolescent Trial for Cardiovascular Health (CATCH) school-level changes in former intervention (n = 56) and former comparison (n = 20) schools 5 years post-intervention. Twelve schools unexposed to CATCH were measured as controls. Macronutrient content of 5 days of school lunch menus, amount and type of physical education (PE) classes, and health instruction practices in the classroom were assessed. An institutionalization score for schools was developed, using program maintenance variables: % kcal from fat and saturated fat in school lunches, % PE class spent in vigorous and moderate-to-vigorous physical activity, and class time devoted to CATCH topics. Results. Menus from 50% of former intervention cafeterias met the Eat Smart guidelines for fat, compared to 10% of former control cafeterias and 17% of unexposed school cafeterias (P < 0.005). There were no significant differences in implementation of CATCH PE goals between conditions. Although the total time spent teaching CATCH was low in former CATCH schools, the former intervention schools spent significantly more time teaching CATCH and taught more lessons as compared to former comparison schools. Former intervention schools had a higher mean institutionalization score than former comparison schools (P < 0.001). Training had the greatest impact on maintenance of CATCH. Conclusions. Results from this study suggest that changes in the school environment to support healthful behaviors can be maintained over time. Staff training is an important factor in achieving institutionalization of these programs.

We examined associations of demographic/biological, psychological, social, and environmental variables with two different measures (self-reported and accelerometer) of physical activity (PA) in Mexican-American (56 boys; 64 girls) and European-American (49 boys; 45 girls) children (mean age = 12.1 years). Among 32 potential correlates, 4 gender and 16 ethnic differences were found. Percent of variance explained from 3% to 24% for self-reported PA and from 7% to 16% for accelerometer-measured PA. Physical self-perception was the only variable with a significant association across all subgroups and both measures. Less favorable levels of psychosocial variables among Mexican-Americans may explain ethnic differences in PA.

Objective. To determine from 2 surveys, in 1991 and 2001, 1) the proportion of pediatricians and which pediatricians report doing school health, 2) which school health activities are most commonly engaged in and whether this has changed, 3) whether training/education during residency influences doing school health later in practice, and 4) whether the amount or nature of residency training in school health (as reported by practicing pediatricians) increased over time, as recommended by various task forces. Methods. Surveys were mailed to a 10% randomly selected group of the voting membership of the American Academy of Pediatrics. Results. An estimated 50% to 70% of pediatricians report doing school health, and a consistent 20% report having had training in school health. The nature of school health work varies in urban, suburban, and rural areas, and pediatricians who practice in rural areas are more likely to be involved in school health. When resident education in school health is offered during residency, it is associated with a higher likelihood of pediatricians’ doing school health later in practice. Recent trainees report having more residency training in school health, yet fewer recent trainees report doing school health compared with their older colleagues. Conclusions. The gap between those who do school health and have received education in school health during residency has continued over at least a 10-year period. Recommendations include specification of school health and community pediatrics competencies for the effective practice of pediatrics in the future.

This was a prospective randomized cohort study to assess the effectiveness of an educational immunization intervention with pregnant Latinas on timely initiation of infant immunization. Study participants were recruited from two community clinics in north San Diego County. A total of three hundred and fifty-two Latinas in the third trimester of pregnancy were recruited and randomly assigned to intervention or control groups. Participants received either a culturally and linguistically appropriate session on infant immunization (intervention) or a session on prevention of Sudden Infant Death Syndrome (control). The main outcome measures were pre-post immunization knowledge change and infant immunization status at 92 days. Immunization knowledge increased significantly in the intervention group [p < .0001, 95%CI (1.76, 2.47)]. No difference was found between groups in immunization series initiation: 95 percent of the children in the intervention group were up-to-date by 92 days from birth, and 93 percent of the control group was up-to-date at 92 days. The lack of significant association between receiving immunization education and infant immunization series initiation suggests that parent education may be necessary but not sufficient for timely immunization, particularly in clinics with effective well-child programs. Given the significant increase in immunization knowledge, the broader and perhaps more important implication is that language- and culturally specific infant health education messages in the prenatal period may have a positive long-term impact on the child's health and promote well-child care overall. Future studies should assess the role of prenatal well-child education in the context of clinics with low immunization levels

Background. The purpose of the study was to compare immunization-relevant knowledge, certainty about knowledge, self-efficacy, vested interest, and reported practices of providers and clinical staff in the same clinics. Methods. A valid and reliable instrument measuring the aforementioned issues was developed and administered to a sample of 50 providers and 60 members of the clinical staff. Results. Providers were significantly more knowledgeable than staff (P < 0.001); however, they were not more certain about their knowledge (P = 0.52) nor were they more confident in their capability to properly immunize all children in their practice (P = 0.10). Providers reported lower vested interest in immunizations than clinical staff (P < 0.05). Both groups were equally likely to immunize a child with a cold. Providers were less likely to defer needed immunizations for a 15-month-old child, and they were more likely to administer multiple injections to an 18-month-old (both P < 0.05). Providers were more likely than staff to immunize during acute and chronic illness visits (both P < 0.001), and both groups were equally likely to immunize during preventive visits. Conclusions. Discrepancies in reported immunization practices between providers and staff may be a barrier to full immunization.

Recent studies in adults suggest that individual dietary fatty acids differ markedly in their effects on serum lipids and lipoprotein levels. However, these associations have rarely been studied in children.To assess, using regression procedures, the associations in children between specific fatty acids and nonfasting serum lipids and cholesterol after controlling for total energy and total fat intake,The sample consisted of 1,182 children who participated in the Child and Adolescent Trial for Cardiovascular Health. The sample was equally distributed across 4 sites (Louisiana, Texas, Minnesota, California). The sample was 48% boys; 71% white, 15% Hispanic-American, 10% African-American, 2% Asian, and 2% from other or unspecified racial/ethnic heritage.In this randomized multicenter trial with 56 intervention and 40 control elementary schools, food record-assisted 24-hour dietary recalls and serum lipid measurements were collected for each child at baseline (3rd grade) and at the 5th grade follow-up.Repeated-measures analysis of variance was used to evaluate the association between nutrient composition of the diet and serum lipids. Independent dietary variables included amount and type of fat, individual fatty acids, protein, carbohydrate, and fiber. The dependent variables were the absolute values of serum total cholesterol (TC) and high-density lipoprotein cholesterol (HDL-C) both at baseline (3rd grade) and at follow-up (5th grade).Increased total fat (b=0.053; P.03) was associated with increased TC in the model when energy was held constant, whereas increased carbohydrate was associated with decreased TC (b=-0.021, P.02) and HDL-C (b=-0.010, P.005) levels. Increased total protein (b=0.017, P.05) was associated with increased HDL-C when energy was held constant. Saturated fat (b=0.004, P.04), unsaturated fat (b=0.004, P.03), and myristic fatty acid (b=0.021, P.01) all increased TC in the model when total fat and total energy were held constant.We conclude that using a modeling approach, the effect of diet on serum lipids in children is similar to that observed in adults. Total fat and saturated fat were positively associated with TC and HDLC levels, saturated fat was positively associated with TC, and carbohydrate was inversely associated with both TC and HDL-C. In the statistical model, substitution of unsaturated fatty acids, monounsaturated fatty acids, or oleic acid for saturated fat, while holding total fat and energy constant, slightly lowered TC. In contrast, substitution of total fat for carbohydrate in the model increased TC and, thus, did not seem to be associated with an apparent health advantage except for HDL-C elevating effects. However, consumption of individual fats tends to be highly correlated, and we were unable to determine if these biological effects were operating independently.

The Child and Adolescent Trial for Cardiovascular Health (CATCH) is a field study conducted in elementary schools that was designed to assess the outcomes of health behavior interventions for the primary prevention of cardiovascular disease. Beginning in 1991, third grade students (N = 5106) from ethnically diverse backgrounds in 96 public schools in California, Louisiana, Minnesota, and Texas were randomized to intervention or control status. Twenty-eight schools participated in a third through fifth grade intervention that included food service modifications, enhanced physical education, and classroom health curricula. An additional 28 schools received these components plus family education. Outcomes were assessed using pre-randomization measures in early third grade and follow-up at the end of fifth grade. At the school level, the two primary endpoints were changes in the fat content of food service lunch offerings and the amount of moderate to vigorous physical activity in the physical education programs. At the individual student level, endpoints included psychosocial factors, measures of eating and physical activity patterns, and physiologic measures. In the intervention school lunches, the percentage of energy intake from fat fell significantly more (fron 38.7% to 31.9%) than in control lunches (from 38.9% to 36.2%) (P < 0.001 ). The intensity of physical activity in CATCH intervention schools was increased significantly compared with the control schools (P < 0.02). Self-reported energy intake from fat among students in the intervention schools was significantly reduced (from 32.7% to 30.3%) compared with the controls (from 32.6% to 32.2%) (P < 0.001 ). Intervention students reported significantly more daily vigorous physical activity than controls (58.6 vs. 46.5 minutes) (P < 0.003). Blood pressure, body size, and cholesterol measures did not differ significantly between treatment groups. No evidence of deleterious effects of the intervention on growth or development was observed. The CATCH intervention was able to modify the fat content of school lunches. increase daily school physical activity, and improve individual eating patterns and physical activity in children during three school years. Follow-up of this cohort continues.

Managed care organizations (MCOs) are being recruited to support school health services delivered in school clinics. Schools without clinics already provide numerous health services and could provide more if they had support from managed care organizations. This article describes the first two years of a San Diego-based collaborative consisting of MCOs, school districts, and other health care agencies. By establishing trust, developing overriding principles, and creating an interagency communication infrastructure, this collaborative has encouraged shared management of many student health issues. Because the agreements apply to all schools, programs can reduce high rates of absenteeism district-wide and avoid unnecessary doctor appointments for common health problems. These collaborative agreements are designed to be financially self-sustaining. However, data collection, the logistics of obtaining parental consent, and getting health professionals to communicate with each other in new ways remain to be significant challenges.

The Child and Adolescent Trial for Cardiovascular Health (CATCH) was the largest school-based field trial ever sponsored by the National Institutes of Health. The trial demonstrated positive changes in the school food service and physical education program, as well as in students' cardiovascular health behaviors. Because the CATCH intervention programs were implemented in 56 schools (in four states) that were typical of schools throughout the United States, their reception by schools and degree of implementation provide evidence about their feasibility for schools nationally. Extensive process evaluation data were collected from students, teachers, school food service personnel, and physical education specialists throughout the three school years of the CATCH intervention. Four of the CATCH programs—school food service, physical education, classroom curricula, and home programs—were assessed over the three school years. The process data provide information on participation, dose, fidelity, and compatibility of the CATCH programs in the intervention schools for these programs. High levels of participation, dose, fidelity, and compatibility were observed for the four programs during the 3 school years. CATCH emerges as a model of a feasible multilevel health promotion program to improve eating and exercise behaviors for elementary schools in the United States.

Background.Cardiovascular risk factors and related behaviors begin during youth.Methods.As part of the Child and Adolescent Trial for Cardiovascular Health, 4,019 children from four states and representing multiple ethnic groups were measured for selected risk factors both at baseline and after 2 1 2 years of intervention. Common protocols were used for both examinations at the four sites.Results.Overall, changes in obesity, blood pressure, and serum lipids in the intervention group, compared with the control group, were not statistically significant. Total cholesterol, the primary physiologic outcome measure, decreased by 1.3 mg/dl over time in the intervention group and by 0.9 mg/dl (P> 0.05) in the control group. Different risk factor patterns for boys and girls and among three ethnic groups were noted.Conclusions.Although the school-based program effected significant institutional changes in food service and physical education class and although the children made significant changes in eating and physical activity behaviors, these did not translate to significant changes in risk factors at these ages. These behavioral changes, however, if sustained into adulthood, have the potential to influence cardiovascular risk reduction.[ep[rsKey words:risk factors; youth; school health promotion; ethnic groups; lipids; blood pressure; obesity.

Background. There are strong theoretical reasons for including a family component with a school-based intervention aimed at eating, activity, and smoking behaviors, but the empirical findings to date are limited and show mixed results. The overall CATCH family intervention added only knowledge and attitudinal effects, but no additional behavioral outcomes. This study provides a dose analysis of the family component of the CATCH study by assessing the effect of the level of adult participation. Method. This secondary analysis included students who attended a CATCH family intervention school during all 3 years of the study. The extent of the adult–child interaction, the key aspect of the CATCH family intervention, was measured by the number of activity packets that an adult household member completed with the child. Multiple regression analysis was used to assess the association of adult participation with the child's knowledge, attitudes, and behaviors related to diet and physical activity. Results. Statistically significant results suggested that dose effects were found for knowledge and attitudes related to diet and physical activity. These effects were more pronounced for minority and male students. Conclusions. These results suggest that dose response of a family intervention has been shown in the acquisition of positive knowledge and attitudes toward health habit changes. The methodology of dose response can be applied to other health promotion projects.

Data on cardiovascular risk factors (body mass index, triceps and subscapular skinfolds, blood pressure, serum total cholesterol, high density lipoprotein (HDL) cholesterol, and apolipoprotein B) were collected as part of the baseline examination (fall 1991) of the Child and Adolescent Trial for Cardiovascular Health, a multicenter school-based intervention study for promoting healthful behaviors. A total of 5,106 third grade children (mean age, 8.76 years) in four states (California, Louisiana, Minnesota, and Texas) were examined. After excluding 194 children of other or unknown origin, the study population consisted of 3,530 Anglo-American children, 674 African-American children, and 708 Latino children. African-American children were the tallest by 1-3 cm (p < 0.0001), while Latino children had the largest body mass index (p < 0.05). Blood pressure levels were similar for boys and girls and among the three races, but systolic levels were 2 mmHg higher in Texas than at the other sites. Serum total cholesterol levels were 5 mg/dl higher in girls than in boys (p < 0.05), while HDL cholesterol levels were 2 mg/dl higher in boys (p < 0.05). HDL cholesterol levels were highest in African-Americans (55.5 mg/dl) compared with Anglo-Americans (50.7 mg/dl) and Latinos (51.3 mg/dl) (p < 0.0001).

The School Nutrition Dietary Assessment Study provides current data on the nutritional quality and adequacy of the National School Lunch Program (NSLP) and the School Breakfast Program (SBP) as well as on the dietary intakes of students participating in these programs. The study demonstrates that the NSLP and SBP meals and children's total diets do not conform to the recommendations of the US Department of Agriculture and the National Research Council and confirms the need to improve the nutritional quality of the nation's school meal program and student's overall dietary intakes. In this regard, the Child and Adolescent Trial for Cardiovascular Health (CATCH) is the first collaborative, school-based field trial that tests the effectiveness of a multi-level intervention designed to reduce the fat, saturated fat, and sodium content of school meals and student's diets. This commentary highlights the findings and questions raised by the School Nutrition Dietary Assessment Study and presents an overview of CATCH, including the implications and significant questions that can be addressed by this intervention study.

There is an urgent need for effective, sustainable child obesity prevention strategies. Progress toward this goal requires strengthening current approaches to add a component that addresses pregnancy onward. Altering early-life systems that promote intergenerational transmission of obesity holds promise for interrupting the continuing cycle of the obesity epidemic. A 2011 Institute of Medicine (IOM) report emphasizes the need for interventions early in life to prevent obesity. A 2010 IOM report called for addressing gaps in existing obesity research evidence by using a systems perspective, simultaneously addressing interacting obesity promoting factors in multiple sectors and at multiple societal levels. A review of evidence from basic science, prevention, and systems research supports an approach that (1) begins at the earliest stages of development, and (2) uses a systems framework to simultaneously implement health behavior and environmental changes in communities.

The Child and Adolescent Trial for Cardiovascular Health (CATCH) is an elementary school cardiovascular health education field trial in progress in San Diego, California, New Orleans, Louisiana, Minneapolis, Minnesota, and Austin, Texas. Because a significant part of a child's health behaviors are shaped within the home, CATCH is evaluating whether the effects of the school-based program are enhanced by the inclusion of a home-based program. A 7 x 7 x 10 randomized design with 7 school-only and 7 school-plus-family intervention schools, along with 10 control schools is implemented at each site. The CATCH family intervention is implemented during Grades 3 through 5 and consists of home-based curricula and Family Fun Nights focusing on healthier eating and increased physical activity during Grades 3 and 4, along with a smoking prevention curriculum in Grade 5. CATCH is examining the effectiveness of family (household) involvement through changes in students' dietary intake of fat and sodium. This paper describes the process evaluation methods used to document the extent of participation in the family program. Data reported for the third-grade Family Fun Nights held in the 28 family schools across all sites reflected an average student participation rate of 67%. The average family member to student ratio was approximately 2:1. Participation by all third-grade teachers and the majority of physical education specialists was observed.

The Project for Attention-Related Disorders (PARD), instituted by the San Diego (Calif.) School District, represents a unique approach to identification, referral, and management of children with Attention-Deficit Hyperactivity Disorder. As a school-based program, PARD coordinates medical, psychosocial, behavioral, and educational interventions for each child, and provides resources for school personnel caring for children with ADHD. Three years after instituting PARD, about 60% to 70% of the children showed improvement after enrollment, evaluation, and treatment. Parental involvement in and acceptance of intervention for their children represented a significant follow-up problem. Both medical and nonmedical interventions such as counseling, special programs, and behavior modification helped improve the educational life of these children.

We evaluated a Preventive Cardiology Academic Award (PCAA) program designed to integrate preventive cardiology concepts into the medical school curriculum. Diet, preventive cardiology knowledge, preventive cardiology attitudes, exercise behavior, and body mass index were compared at entrance to medical school and during the graduation year. Complete data were available on 94 students (65 men and 29 women). Similar data from students who graduated in 1987, prior to the introduction of the PCAA curriculum, served as a control. Women showed a significant enhancement in attitude towards cardiovascular disease (CVD) prevention, while both men and women significantly increased their knowledge about CVD prevention. The frequency of planned physical activity decreased significantly in both sexes and men showed a significant increase in body mass index. Men significantly reduced total calories, percent of calories from fat and saturated fat and dietary cholesterol and increased fiber intake. In women, the only significant reduction was in total calories. In comparison to the control class that did not have the program, men receiving the PCAA curriculum reduced dietary cholesterol, dietary fat, saturated fat and monounsaturated fat. Changes in these dietary parameters were nonsignificant for women in comparison to the control class women. Additional analyses showed no systematic secular trends in dietary or other variables in classes entering from 1986 to 1990. We conclude that the PCAA curriculum changes have favorably affected the preventive cardiology knowledge, attitudes and diet of medical students.

For three consecutive years, beginning in 1986, we evaluated cardiovascular disease (CVD) risk factors of medical students as part of the teaching program in a Preventive Cardiology Academic Award. Entering students in three consecutive classes were screened on the first day of orientation to medical school. The first year, we evaluated 108 students (71 men and 37 women), the second year, 99 students (75 men, 24 women), and the third year 108 students (67 men and 41 women). During the single four-hour period, we obtained data on personal and family history of CVD risk factors, type A behavior, knowledge of CVD, attitudes toward CVD prevention, measures of depression and anger, blood pressure, blood pressure reactivity, physical activity, and diet. Blood was drawn for lipid analysis. Height and weight were measured, and a physical fitness step test was administered. Pulmonary function was measured during the third year. We used a four-tiered approach to preventive cardiology education. During the assessment session, abnormalities, such as elevated blood pressure or abnormal pulse, were discussed with the student. In the second tier, the data were analyzed and returned to all students during teaching sessions, enabling them to compare their levels with the class and the national averages. For the third tier, students with high-risk values, defined as low-density lipoprotein cholesterol level > or = 150 mg/dL, a total cholesterol or triglyceride level > or = 200 mg/dL, or blood pressure > or = 140/90 mmHg, were seen by faculty physicians who suggested remedial interventions in separate sessions.(ABSTRACT TRUNCATED AT 250 WORDS)

As part of a family cardiovascular health promotion project, 111 Mexican-American and 95 Anglo-American families with fifth- or sixth-grade children were assigned to either a primary prevention program involving 18 sessions or to a control condition. This article evaluates predictors of attendance at the year long sequence of sessions in the intervention group. In addition it considers the relationship between attendance and program outcomes. Low baseline scores on physical activity and cardiovascular fitness measures were associated with higher attendance for both children and adults. High initial health knowledge and self-motivation were also associated with attendance. Multiple regression analysis showed that adult attendance was significantly predicted by a model including completion of a three-day food record, low exercise, higher socioeconomic status, family adaptability, and self-motivation. Attendance was correlated with greater knowledge gains and larger reductions in blood pressure. The results indicate that motivated families who are in greater need of conditioning attended more sessions in a health promotion program.

'The family that plays together stays together' is not just a cliché. Family exercise is a good way to spend time together, and the resulting mutual support helps people make a long-term commitment to fitness.

OBJECTIVES. Our aim with this study was to assist clinicians by estimating the predictive value of earlier levels of BMI status on later risk of overweight and obesity during the middle childhood and early adolescent years.METHODS. We present growth data from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development, a longitudinal sample of 1042 healthy US children in 10 locations. Born in 1991, their growth reflects the secular trend of increasing overweight/obesity in the population. Height and weight of participating children in the study were measured at 7 time points. We examined odds ratios for overweight and obesity at age 12 years comparing the frequency with which children did versus did not reach specific BMI percentiles in the preschool- and elementary-age periods. To explore the question of whether and when earlier BMI was predictive of weight status at age 12 years, we used logistic regression to obtain the predicted probabilities of being overweight or obese (BMI ≥85%) at 12 years old on the basis of earlier BMI.RESULTS. Persistence of obesity is apparent for both the preschool and elementary school period. Children who were ever overweight (>85th percentile), that is, ≥1 time at ages 24, 36, or 54 months during the preschool period were >5 times as likely to be overweight at age 12 years than those who were below the 85th percentile for BMI at all 3 of the preschool ages. During the elementary school period, ages 7, 9, and 11 years, the more times a child was overweight, the greater the odds of being overweight at age 12 years relative to a child who was never overweight. Sixty percent of children who were overweight at any time during the preschool period and 80% of children who were overweight at any time during the elementary period were overweight at age 12 years. Follow-up calculations showed that 2 in 5 children whose BMIs were ≥50th percentile by age 3 years were overweight at age 12 years. No children who were 6 times more likely to be overweight at age 12 years than those CONCLUSIONS. The data from this study indicate that children with BMIs >85th percentile, as well as with BMIs in the high reference range are more likely than children whose BMI is

Acculturation is typically defined in terms of individual responses to a dominant culture. In the present study, we examined the effects of different levels of acculturation among family members. Specifically, we looked at the health and risk behavior in Mexican-American children as related to a variety of psychosocial predictors, especially the differences in orientation toward Mexican- and Anglo-American cultures between them and their parents. Mother and child pairs (n = 106) noted their orientation toward both Anglo and Mexican cultures. Children’s dietary and sedentary behaviors, tobacco and alcohol use (and susceptibility to use), and depressive symptoms were also measured. Males were more likely to be sedentary and consume higher levels of total fat and saturated fat, whereas girls reported higher levels of depression. Anglo-oriented youth consumed lower levels of calories from fat but also more alcohol than did their Mexican-oriented counterparts. The latter was particularly the case among those children who were relatively more Anglo oriented than were their parents. Parent–child acculturation differential in terms of the differences in Mexican orientation, in comparison, predicted susceptibility to tobacco use. However, the sum of the absolute values of these two differences predicted only lifetime alcohol use, and in a counter-intuitive direction. This familial measure of acculturation shows some promise, but additional formative research is needed to operationalize this construct.

The current report is a follow-up evaluation of a cohort of Mexican-American and non-Hispanic white children 5.5 years after the previous study (1) to determine whether the increased features of insulin resistance observed in these Mexican Americans at age 11 years were still present at age 17 years. Furthermore, we determined which of these measures in childhood would best predict the risk for the insulin resistance syndrome (IRS) at age 17 years. As inflammation has recently been recognized as potentially playing important roles in the pathogenesis of insulin resistance, diabetes, and cardiovascular disease (2–4), measures of C-reactive protein (CRP) were also assessed in the follow-up study. The study cohort was the San Diego Study of Children’s Activity and Nutrition, an ongoing observational study that began when the subjects were 4 years of age (with follow-up assessments at intervals of ∼5–7 years) and consisted of non-Hispanic white and Mexican-American children recruited through state-funded daycare programs. Detailed methods and health behavior results have been previously reported (1,5–11). The current study sample includes 83 adolescents: 29 non-Hispanic white (17 males and 12 females) and 54 Mexican-American (25 males and 29 females) subjects who had completed study visits at age 11 and again at age 17 years. Based on demographic and laboratory data, there was no evidence of a bias in the drop out of subjects between study visits. All blood samples were obtained in the fasting state. ### Anthropometric and blood pressure measures Height, weight, waist circumference, …

Background: The goal of this pilot study was to correlate missed opportunities to immunize young children with providers’ psychosocial characteristics and self-reported immunization practices. Methods: In a population of children aged 0 to 36 months, missed opportunities to immunize were established for a sample of 28 providers, who also responded to a valid and reliable instrument measuring the aforementioned variables. Results: Missed opportunities were significantly lower among providers with higher vested interest ( r =−0.45, p =0.02) and tended to be lower among providers with more positive attitudes toward having all children properly immunized at every healthcare visit ( r =−0.33, p =0.09). Neither knowledge nor perceived barriers correlated significantly with missed opportunities. Providers missed opportunities to immunize in over half of the visits studied (mean, 0.58), yet all of them reported always immunizing at preventive and follow-up visits, almost all (96.3%) at chronic illness visits, and a majority (78.6%) at acute care visits. As a result, none of the self-reported immunization practices was significantly correlated with missed opportunities. Conclusions: Missed opportunities appear to be best predicted by motivational psychosocial factors and not by knowledge or perceived barriers. Self-reported immunization practices do not correspond to actual immunization behavior.

ContextAlthough evidence suggests that homocysteine is a risk factor for cardiovascular disease in adults, little information exists on homocysteine levels in children.ObjectivesTo describe the distribution of serum homocysteine concentrations among children and to examine the association between homocysteine levels and several characteristics, including serum levels of folic acid and vitamins B12 and B6.DesignCross-sectional analysis.SettingSchool-based cohort from California, Louisiana, Minnesota, and Texas.ParticipantsA total of 3524 US schoolchildren, aged 13 and 14 years, from the Child and Adolescent Trial for Cardiovascular Health (completed in 1994). Measurement was conducted in 1997.Main Outcome MeasureNonfasting serum total homocysteine concentration.ResultsThe distribution of homocysteine values ranged from 0.1 to 25.7 µmol/L (median, 4.9 µmol/L). Geometric mean homocysteine concentration was significantly higher in boys (5.22 µmol/L) than girls (4.84 µmol/L); blacks (5.51 µmol/L) than whites (4.96 µmol/L) or Hispanics (4.93 µmol/L); nonusers of multivitamins (5.09 µmol/L) than users (4.82 µmol/L); and smokers (5.19 µmol/L) than nonsmokers (5.00 µmol/L). Serum homocysteine was significantly inversely correlated with serum levels of folic acid (r=−0.36; P=.001), vitamin B12 (r=−0.21; P=.001), and vitamin B6 (r=−0.18; P=.001). Serum homocysteine was not significantly associated with serum lipid levels or family history of cardiovascular disease and was only weakly related to body mass index and systolic blood pressure. After multivariate adjustment, homocysteine remained independently associated with sex, race, serum folic acid and vitamin B12 levels, and systolic blood pressure.ConclusionsThe distribution of homocysteine levels in children is substantially lower than that observed for adults; however, a small percentage of children are still potentially at elevated risk for future cardiovascular disease. Serum folic acid may be an important determinant of homocysteine levels in children.

Background.Physical inactivity is a risk behavior for cardiovascular and other diseases. Schools can promote public health objectives by increasing physical activity among youth.Methods.The Child and Adolescent Trial for Cardiovascular Health (CATCH) was a multicenter, randomized trial to test the effectiveness of a cardiovascular health promotion program in 96 public schools in four states. A major component of CATCH was an innovative, health-related physical education (PE) program. For 2.5 years, randomly assigned schools received a standardized PE intervention, including curriculum, staff development, and follow-up.Results.Systematic analysis of 2,096 PE lessons indicated students engaged in more moderate-to-vigorous physical activity (MVPA) in intervention than in control schools (P= 0.002). MVPA during lessons in intervention schools increased from 37.4% at baseline to 51.9%, thereby meeting the established Year 2000 objective of 50%. Intervention children reported 12 more min of daily vigorous physical activity (P= 0.003) and ran 18.6 yards more than control children on a 9-min run test of fitness (P= 0.21).Conclusions:The implementation of a standardized curriculum and staff development program increased children's MVPA in existing school PE classes in four geographic and ethnically diverse communities. CATCH PE provides a tested model for improving physical education in American schools.

Self-monitoring is often used in health behaviour change programs; but it is not known to what extent self-monitoring data are valid and useful in predicting changes in cardiovascular disease (CVD) risk. Subjects included 72 Anglo adults, 68 Anglo children, 80 Mexican-American adults and 94 Mexican-American children. Subjects were families with fifth and sixth grade children who participated in an 18-session family-based diet and exercise change program designed to reduce CVD risk. During the intervention, each participant self-monitored diet and aerobic physical activity. Families were measured at baseline, 3, 12, and 24 months. For adults, self-monitored changes in diet correlated with changes in body mass index, systolic blood pressure, total cholesterol and LDL 1 and 2 years later. Correlations between self-monitored diet and diet-related risk factor changes were not observed among children. Correlations between self-monitored exercise and subsequent risk factor changes were not observed among adults. For children, self monitored changes in aerobic physical activity correlated significantly with changes in VO2Max and HDL/LDL ratio 1 and 2 years later. Thus, this study provides some support for the predictive validity of diet self-monitoring in adults and exercise self-monitoring in children.

Because physicians play a crucial role in immunizations,1–3 there is a need for reliable and valid assessments of physician-related determinants of immunizations. As part of a project aimed at improving immunization rates by targeting physicians,4 we developed measures of factors, which, according to theories of planned behavior5 and cognitive social learning,6 influence physicians’ immunization practices. Our measures include knowledge (understanding of the schedule, efficacy, and side effects of vaccines); attitudes (evaluative reactions toward immunizations); vested interest (perceptions of personal professional consequences of immunizations); self-efficacy (beliefs in personal capability to properly immunize); and perceived barriers (factors hindering proper immunizations). With few exceptions,7–9 studies measuring these variables either do not examine or do not report reliability and validity of their measures. Interventions based on potentially unreliable or invalid measures of needs may result in wasted resources or may not detect real improvements in immunization practices. Our measures should be of interest to those who plan interventions to improve physicians’ immunization practices or evaluate the effects of such interventions.

Objectives- To examine reciprocal relations between body mass index (BMI), internalizing problems and externalizing problems from infancy through middle childhood with a focus on sex and history of overweight. Study design- Data from 1254 children in the NICHD Study of Early Child Care and Youth Development were used to conduct longitudinal analyses of relations between BMI and scores on the Child Behavior Checklist from age two through 6th grade. Results- BMI and behavior problems showed stability across the 7 measurement occasions. No consistent relation between BMI and behavior problems was evident prior to school entry; but being heavier was associated with later internalizing problems beginning in 1st grade for boys and girls. Higher BMI was not associated with increased conduct problems. Conclusions- As children move into middle childhood, higher BMI is associated with increased likelihood of developing internalizing problems. Health care providers should monitor BMI as children enter school and to provide guidance to parents regarding emerging symptoms of anxiety and depression.

Decreased physical activity plays a critical role in the increase in childhood obesity. Although at least 60 minutes per day of moderate-to-vigorous physical activity (MVPA) is recommended, few longitudinal studies have determined the recent patterns of physical activity of youth.To determine the patterns and determinants of MVPA of youth followed from ages 9 to 15 years.Longitudinal descriptive analyses of the 1032 participants in the 1991-2007 National Institute of Child Health and Human Development Study of Early Child Care and Youth Development birth cohort from 10 study sites who had accelerometer-determined minutes of MVPA at ages 9 (year 2000), 11 (2002), 12 (2003), and 15 (2006) years. Participants included boys (517 [50.1%]) and girls (515 [49.9%]); 76.6% white (n = 791); and 24.5% (n = 231) lived in low-income families.Mean MVPA minutes per day, determined by 4 to 7 days of monitored activity.At age 9 years, children engaged in MVPA approximately 3 hours per day on both weekends and weekdays. Weekday MVPA decreased by 37 minutes per year [corrected], while weekend MVPA decreased by 39 minutes per year [corrected]. By age 15 years, adolescents were only engaging in MVPA for 50 minutes per weekday [corrected] and 36 minutes per weekend day [corrected]. Boys were more active than girls, spending 18 and 14 more minutes per day [corrected] in MVPA on the weekdays and weekends, respectively. The rate of decrease in MVPA was the same for boys and girls. The estimated age at which girls crossed below the recommended 60 minutes of MVPA per day was approximately 13.2 years for weekday [corrected] activity compared with boys at 14.9 years [corrected], and for weekend activity, girls crossed below the recommended 60 minutes of MVPA at 12.7 years [corrected] compared with boys at 13.6 years [corrected].In this study cohort, measured physical activity decreased significantly between ages 9 and 15 years.

The Child and Adolescent Trial for Cardiovascular Health (CATCH) is a multisite intervention research study that builds on significant progress made in school health education research in the 1980s. The study has three phases: Phase I deals with study design, intervention, and measurement development, Phase II involves the main trial in 96 school'; in four states, and Phase III focuses on analysis. The intervention program targets third-fifth grade students and focuses on multiple cardiovascular health behaviors, including eating habits, physical activity, and cigarette smoking. Classroom curricula, school environmental change, and family involvement programs are developed for each grade level and behavioral focus. This paper describes Phase II of CATCH with a rationale for cardiovascular health promotion with youth. The process of change that appears to be necessary for school-based health promotion and that will be tested in CATCH are presented as a framework to guide these efforts.

• Ten years of graduates (1979 through 1988) from a pediatric residency program with a primary care track were surveyed for their perceived level of comfort gained in training for 28 different content/specialty areas of pediatrics and for their recommendations for increasing emphasis/time during residency for these areas. The response rate was 73%. The highest levels of comfort and fewest recommendations for increasing emphasis were for neonatal problems and health maintenance. The lowest perceived comfort levels and the most recommendations for increasing emphasis were for economics of pediatric practice and sports medicine/orthopedies. Graduates from the primary care track of the pediatric residency program expressed more comfort than did regular track graduates for some, but not all, areas of pediatrics emphasized in the primary care track program. Graduates of the first 5 years of study were not as comfortable with their training overall as were graduates from the most recent 5 years. This survey method and its results can provide useful information to medical educators faced with evaluation and revision of pediatrie residency training programs. (AJDC. 1990;144:1102-1105)

Objective To examine the relationship between experience in child care and communicable illnesses (gastrointestinal tract infection, upper respiratory tract infection, and otitis media) in children aged 37 months to 54 months with particular focus on the effect of entry into child care after age 3 years. Design Health, child care, and family data were obtained from more than 1100 participants in the National Institute of Child Health and Human Development Study of Early Child Care, a 10-site prospective study that began at birth. Longitudinal logistic regression analyses were performed using each type of communicable illness as the outcome variable, with family, child, and child care variables as predictors in the model. Results For children aged 37 to 54 months, rates of upper respiratory tract illness, gastrointestinal tract illness, and ear infections were higher in those enrolled in child care arrangements with more than 6 children. During this period, children with experience in large-group care prior to age 3 years were less likely to be ill than children who entered child care for the first time after age 3 years. Even so, their rates were still higher than for those in small-group care or who were cared for at home between the ages of 37 and 54 months. Reported rates of respiratory tract and gastrointestinal tract illnesses were higher for European American than African American children. Number of hours per week in child care was not a factor. Conclusion Children in child care arrangements with more than 6 other children experience more bouts of upper respiratory tract illness between the ages of 37 and 54 months.

Background: Despite improving trends, immunization rates among U.S. preschool children are still suboptimal. It has been recently recognized that healthcare providers play a critical role in undervaccination. Despite this fact, few reliable and validated instruments to assess immunization knowledge, attitudes, and practices have been developed for use among healthcare providers. In a cross-sectional study involving groups of 38 general pediatricians, 46 subspecialty pediatricians, 11 third-year pediatric residents, and 33 first-year pediatric and family medicine residents an instrument was developed to evaluate provider knowledge, attitudes, and practices.

Analysis of immunization workflow in clinics serving patients at risk for underimmunization † 631

Objective. To evaluate the relationship between insulin levels and cardiovascular risk factors in children and determine whether it varies among ethnic groups. Methods. Cardiovascular risk factors and insulin levels were compared in 144 Mexican-American and Anglo-American mother-child pairs, when the children were 11 years of age. Results. Although mean age did not differ between ethnicities, Mexican-American mothers and children both had a greater body mass index (mothers: 29.2 ± 6.2 vs 27.2 ± 7.9; children: 21.7 ± 4.7 vs 19.7 ± 4.6) and sum of skinfolds than did Anglo-Americans. Triglycerides, very low-density lipoprotein cholesterol, fasting insulin, and cholesterol/high-density lipoprotein ratio were higher, while high-density lipoprotein cholesterol was lower in both Mexican-American adults and children compared with Anglo-Americans. After adjusting for measures of obesity, only high-density lipoprotein cholesterol levels remained significantly lower in Mexican-Americans. For both adults and children, higher quartiles of insulin levels were associated with significantly higher triglycerides, blood pressure and lower high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol/apolipoprotein B levels (estimate of dense low-density lipoprotein size). A summary variable representing cardiovascular risk factors present in adult syndrome X patients was higher in both Mexican-American adults and children than in Anglo-Americans. Conclusion. Mexican-American children and adults have higher levels of many cardiovascular risk factors, and this appears related to higher insulin levels and overweight. Appropriate nutrition, weight control, and exercise at early ages could be important in slowing the development of atherosclerosis.

Objective. To determine parental actions and concerns and physician responses to parental notifi- cation that a child's cholesterol value was 200 mg/dL or greater, a value recommended by the National Choles- terol Education Program to warrant physician follow-up and evaluation. Methodology. A telephone survey of parents (n 5 784) and physicians (n 5 117) was carried out after pa- rental notification of a total blood cholesterol value ob- tained as part of measurement done while participating in the Child and Adolescent Trial for Cardiovascular Health in 96 schools located in California, Louisiana, Minnesota, and Texas. Results. Only 20% of parents contacted physicians. Factors associated with this action included whether the parent was notified once or twice, the level of the cho- lesterol, previous cholesterol testing in the parent, and medical insurance that covered the visit. Family history of cardiovascular disease, when other factors were con- sidered, did not increase the likelihood that a physician contact would be made. After contact with the physician, 59% of physicians reported evaluating children for cho- lesterol; about half reported repeating the cholesterol determination. Conclusion. Parental knowledge of a child's choles- terol value of 200 mg/dL or greater did not result in substantially further seeking of health care. Pediatrics 1997;99(5). URL: http://www.pediatrics.org/cgi/content/ full/99/5/e5; children, elevated cholesterol, parental re- sponse, physician response.

Background: The amount of time children spend in play spaces (ie, physical locations that are appropriate for children's physical activity) near their homes is correlated with their level of physical activity. Objective: To examine factors used in parents' decisions about the selection of play spaces for their children. Subjects: Parents (primarily mothers) of 178 Mexican American and 122 white children who were a mean age of 4.9 years old at the first measurement. Measures: In individual interviews, parents rated 24 factors on their importance in selecting for their children a play space that is away from their home or yard. Decision factors were rated from 1 (ie, not important at all) to 5 (ie, very important). Results: The most important factors, with ratings ranging from 4.8 to 4.2, were safety and availability of toilets, drinking water, lighting, and shade. Mexican American parents rated 8 of 24 items significantly higher than did white parents, including lighted at night, organized activities, play supplies, and drinking water. White parents rated 5 of 24 items significantly higher than did Mexican American parents, including distance from home, cost of admission, and child's friends go there. The rated importance of 7 of 24 items increased during 1 year, including play supplies, drinking water, distance from home, and parents' friends or relatives go there. Conclusions: These results indicate that parents can identify factors they use in selecting places for their young children to play, and selection factors differ somewhat by ethnicity or socioeconomic status. Further studies are needed to determine whether improvements on the most important selection factors might be effective in increasing the use of play spaces by children and their parents. Clinicians may be able to use the most highly rated decision factors to help parents assess the acceptability of play spaces in their areas. Arch Pediatr Adolesc Med. 1997;151:414-417

grade intervention including school food service modifications, enhanced physical education (PE), and classroom health curricula. Twenty-eight additional schools received these components plus family education. Main Outcome Measures.\p=m-\Atthe school level, the two primary end points were changes in the fat content of food service lunch offerings and the amount of moderate-to-vigorous physical activity in the PE programs. At the level of the individual student, serum cholesterol change was the primary end point and was used for power calculations for the study. Individual level secondary end points included psychosocial factors, recall measures of eating and physical activity patterns, and other physiologic measures. Results.\p=m-\Inintervention school lunches, the percentage of energy intake from fat fell significantly more (from 38.7% to 31.9%) than in control lunches (from 38.9% to 36.2%)(P

The associations of physical activity and cardiovascular fitness with cardiovascular disease risk factors were studied in 88 male adults, 180 female adults, 148 male children, and 142 female children. Subjects were families recruited from elementary schools in San Diego, California. Fitness (VO2 max) was measured by a submaximal cycle ergometer test. Physical activity was assessed by seven-day recall interview, yielding caloric expenditure, and by a simple self-rating of activity level. Risk factors included blood pressure, high density lipoprotein (HDL) cholesterol, the ratio of high density lipoproteins to low density lipoproteins (LDL), and body mass index. For all subgroups, fitness was strongly and significantly correlated with virtually all risk factors. After adjustment for body mass index, most fitness-risk factor associations were no longer significant. Seven-day caloric expenditure was significantly correlated with HDL/LDL only in female adults and children. The activity rating was significantly correlated with body mass index in all subgroups and with HDL/LDL in female adults and male adults. The simple activity rating tended to be correlated with fitness. The pattern of association was similar for adults and children.

Two studies are presented which deal with the reliability and validity of self-reports of aerobic activity. The first study compared two forms of self-report data obtained as part of a study of intervention strategy. The two forms were daily self-report and weekly retrospective report. Analyses covering the overlapping time period revealed differences in mean minutes engaged in activity, but modest and statistically significant correlations between the two forms among adults participating in the intervention group. No meaningful results were obtained among adults in the control group, nor among children in either group. The need for the development and testing of self-report forms among children was noted, and was the subject of the second study. In Study II, six different forms on which third to sixth grade children recorded their aerobic activity were compared against two days of continuous observations of their behavior. The six forms varied along two dimensions. The first dimension varied the...

The effects of cardiovascular risk reduction are typically assessed by self-reported behavior change and physiological outcomes. There is a need to enhance evaluation protocols by including direct observation measures of targeted health behaviors. To improve the evaluation of a family-based diet and physical activity change program, families were observed during a planned visit to the San Diego Zoo. This standardized environment afforded many options for dietary intake and physical activity. Thirty families who had participated in a 1-year intervention program and 30 control families were observed. Caucasian and Mexican-American families were equally represented. Observations in this standard environment discriminated between intervention and control families, and the findings indicated that intervention effects generalized to this novel setting. Intervention families consumed fewer calories, ate less sodium, and walked further than did control families. Ethnic differences were noted.