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Background Parental mindfulness may be a novel intervention target for child obesity prevention. Objective To examine associations between maternal mindfulness and child body mass index z-score (BMIz). Methods In a secondary data analysis of pre-intervention data from a randomized controlled trial, we assessed survey and anthropometric data from English-speaking mother/child dyads enrolled in Head Start in south central Michigan (n=105). Surveys included demographic information, child dietary intake, family meal frequency, and the Philadelphia Mindfulness Questionnaire. Multivariable linear regression examined associations between maternal mindfulness and child BMIz, child intake of fruits and vegetables, and frequency of family meals. Results Children were M=53.7 (SD 7.5) months old, and mothers were M=31.6 (SD 8.3) years old. The sample of children was 39% white, 26% black, 14% Hispanic, and 35% of children were overweight or obese. Mean maternal BMI was 32.0 (SD 8.3). Greater mindfulness was associated with child BMIz (β=-0.02 (SE 0.01), p=.027) adjusting for child race/ethnicity, household food security, maternal education, maternal age, and maternal BMI. Mindfulness was not associated with child fruit intake, child vegetable intake or frequency of family meals. The results were consistent with alternative outcomes of BMI percentile (p=.016) and BMI at the trend level (p=.0595) at the trend level. Conclusions Greater maternal mindfulness was associated with lower child BMIz. Future work should consider mechanisms of association. Pediatric providers might consider supporting maternal mindfulness as one element of multicomponent strategies for child obesity prevention.

Background With one in eight preschoolers classified as obese in the USA, childhood obesity remains a significant public health issue. This study examined rural–urban differences in low-income preschoolers’ body mass index z-scores (BMIz), eating behaviors, dietary quality, physical activity (PA) and screen time. Methods Pre-intervention data from 572 preschooler-parent dyads participating in a randomized, controlled obesity prevention trial in the Midwest USA were analyzed. We examined the associations among living in rural versus urban areas, child BMIz and child obesity-related behaviors, including eating behaviors, dietary quality, PA and screen time. Results Rural children had higher BMIz, more emotional overeating behaviors and more time spent playing outdoors compared with urban children. We found no associations between children living in rural versus urban areas and dietary quality and screen time. Conclusions The study found that rural–urban differences in BMIz may start as early as 3–4 years of age, if not earlier. To reverse the weight-related health disparities between rural and urban low-income preschoolers, structural changes in rural locations and family supports around coping skills may be needed.

To determine the effect of a bundled intervention (home meal delivery and provision of cooking/serving resources) on preschoolers' body mass index z-score (BMIz), dietary quality, and family meal frequency.Participants (299 families; mean child age 4.4 years, 47% male, 55% White, 18% Black, 27% Hispanic or other race and ethnicity, and 25% were overweight or obese) were randomized to a control group or to provision of cooking/serving resources plus home meal delivery for 12 weeks (meals provided by Meals on Wheels [MOW cohort, n = 83] or a commercial service [COM cohort, n = 216]). Outcomes were child dietary quality, family meal frequency, and child BMIz.The intervention increased dinnertime intake of red and orange vegetables in the full sample (MOW cohort+COM cohort) (0.10 pre- to 0.15 cup equivalents (CE) post-in the intervention group vs 0.10 pre- to 0.09 post- in the control group; P = .01) and the COM cohort (0.11 pre- to 0.17 CE post- vs 0.11 pre- to 0.09 post-; P = .002), and typical daily dietary intake of fruit and fruit juice in the MOW cohort (1.50 CE pre- to 1.66 post- vs 1.48 pre- to 1.19 post-; P = .05). The intervention did not change meal frequency or BMIz.Short-term home meal delivery with provision of cooking/serving resources improved dietary quality among preschool-aged children but did not change meal frequency or BMIz. Expansion of Meals on Wheels programs to preschool-aged children may be a promising intervention to improve dietary quality. Family meals, when already frequent, are not further increased by reducing the burden of meal preparation.

We aimed to test main, additive, interactive effects, and feasibility of all possible combinations of six intervention components implemented for 8 weeks (Cooking/Serving Resources; Meal Delivery; Ingredient Delivery; Community Kitchen; Nutrition Education; Cooking Demonstrations). Primary outcomes were family meal frequency and preschoolers' dietary quality; secondary outcomes included family meal preparation type, meal preparation barriers, family functioning, and kitchen inventory adequacy. All possible intervention combinations were tested using a randomized factorial trial design in the first phase of a Multiphase Optimization Strategy (MOST). Feasibility was assessed via attendance, delivery logs, and satisfaction. Parent-reported data collection included: socio-demographics, frequency and type of family meals; preschooler dietary intake; perceived barriers to meal planning and preparation; assessment of family functioning; and a kitchen inventory of materials generally needed for meal preparation. Participants (n = 499) were recruited at two Head Start agencies in mid-Michigan with data collection and delivery of some intervention components in participants' homes. Promising intervention bundles were identified by evaluating pre-to post-intervention effect sizes. The combination of Cooking/Serving Resources and Meal Delivery increased family meal frequency (Cohen's d = 0.17), cooking dinner from scratch (d = 0.21), prioritization of family meals (d = 0.23), and kitchen inventory (d = 0.46) and decreased use/consumption of ready-made (d = -0.18) and fast foods (d = -0.23). Effects on diet quality were in the expected direction but effect sizes were negligible. Community Kitchen, Nutrition Education, and Cooking Demonstration showed poor feasibility due to low attendance while Ingredient Delivery was infeasible due to staffing challenges related to its labor intensity. Additionally, although not one of our pre-specified outcomes, Cooking/Serving Resources (RR = 0.74) and Meal Delivery (RR = 0.73) each decreased food insecurity. Cooking/Serving Resources combined with Meal Delivery showed promise as a strategy for increasing family meal frequency.

OBJECTIVE Disparities in childhood obesity necessitate identification of risk-protective and risk- augmenting factors for young children experiencing socioeconomic adversity born with perinatal risk. Temperamental reactivity is a biological marker of susceptibility to environmental characteristics. This study tested whether temperamental reactivity moderated the relation between socioeconomic risk and children's body mass index (BMI). METHOD This study examined 100 Head Start preschoolers (Mage = 4.07 years, SD = 0.56) with perinatal risk, defined as preterm birth (PT

Little research has examined teachers' classroom social-emotional practices, including how teachers' warmth and their more explicit emotion socialization practices may be associated with children's social-emotional competencies in different but complementary ways. Likewise, there is scant knowledge on how the effects of the classroom climate may vary by child characteristics. We examined the moderating roles of child gender and temperament in the associations between two aspects of the classroom climate, Head Start teachers' warmth and their explicit emotion socialization practices, and preschoolers' (N = 611) social-emotional competencies, including emotion recognition, self-regulation, and positive social behaviors. While no three-way interactions (teachers' warmth and teachers' emotion socialization practices × child gender × temperament) were significantly associated with outcomes, a two-way interaction between teachers' emotion socialization practices and temperament was significant. Specifically, teachers' emotion socialization practices in the fall were associated with greater self-regulation for all children in the spring, including children with more reactive temperaments although effects were most robust for children with the least reactive temperaments. Implications for teacher practices are discussed.

Objective Assessment of pediatric behavior problems often requires rating scales from multiple reporters in different settings (eg, home and school); however, concordance between reporters may be low. Pediatricians must reconcile differences to inform treatment. We sought to examine characteristics predicting parent–teacher concordance on ratings of preschoolers' behavior problems. Methods Data from 562 preschoolers were used from the Growing Healthy study, an obesity prevention trial in Head Start programs (2011–2015). Parents and teachers completed the Eyberg Child Behavior Inventory (ECBI)/Student Behavior Inventory (SBI) and the Social Competence and Behavior–Evaluation (SCBE). Outcome variables were: parent–teacher concordance (teacher minus parent score on each subscale of ECBI/SBI and SCBE); teacher reports problem behavior, parent does not (children rated in the top quintile of challenging behavior by teacher but not parent); and parent reports problem behavior, teacher does not (children rated in the top quintile of challenging behavior by parent but not teacher). Multiple linear and logistic regression models were created for each subscale outcome, including the following covariates: child sex, child race/ethnicity, parent age, parent education, family structure, parent depressive symptoms, and parenting self-efficacy, and time of school year. Results Lower concordance was associated with child female sex, and child black or Hispanic race/ethnicity; parent older age, lower education, more depressive symptoms, and greater self-efficacy; and beginning of school year. Conclusions Low parent–teacher concordance may reflect different perceptions of child behavior. Pediatricians could consider parent depressive symptoms, culture, and implicit bias when interpreting differences in behavior ratings by parents and teachers.

Objective Excessive screen media exposure in childhood is associated with parent-reported self-regulation difficulties. No studies have used laboratory-based or teacher-reported measures of child self-regulatory behaviors. This study examines cross-sectional associations between preschooler screen media exposure and multiple measures of self-regulatory behaviors. Methods Preintervention data were used from 541 preschoolers in the Growing Healthy study, an obesity prevention trial (2011-2015). Screen media exposure was measured by daily screen media exposure (hr/d), television (TV) in the bedroom, frequency of background TV, and TV with meals (1 = rarely/never, 4 = frequently). Child self-regulatory behaviors were measured by the following: child ability to delay gratification, a standardized waiting paradigm; teacher-reported Social Competence and Behavior Evaluation; and parent-reported difficult temperament on the Child Behavior Questionnaire (CBQ). Multivariate regression analyses modeled screen media exposure predicting each self-regulatory measure, adjusting for child age, sex, parent age, education, marital status, income-to-needs ratio, number of adults in household, parent depressive symptoms, and sensitivity. Results Children were aged 4.1 years (SD = 0.5), parents were aged 29.6 years (SD = 6.8), 48% had high school education or less, and 67% were married. Daily screen media exposure and background TV were associated with weaker observed self-regulation (β: -10.30 seconds for each hr/d media, -12.63 seconds for 1-point increase, respectively). Background TV and TV with meals were associated with greater parent-reported difficult temperament (β: 0.04 and 0.05 CBQ, respectively, for 1-point increase). Conclusion Greater screen media exposure had small but significant associations with weaker observed and parent-reported, but not teacher-reported, self-regulatory behaviors. Longitudinal studies are needed to determine the directionality of associations.

Background Picky eating is common in children. Few studies have examined predictors of picky eating, and the association of picky eating with weight status and dietary quality is inconsistent in the literature. We aimed to identify predictors of picky eating and to test the association of picky eating with child body mass index z-score (BMIz), dietary quality, and micronutrient intake. Methods This was a cross-sectional analysis of baseline data from a randomized controlled trial to prevent obesity among 506 preschoolers attending Head Start. Parents completed questionnaires to assess picky eating and child temperament. Three 24-hour dietary recalls were collected to assess dietary intake. Multivariate regression models assessed child, parent, and family predictors of picky eating; additional models tested adjusted associations of picky eating with child BMIz, dietary quality (measured using the Healthy Eating Index-2010), and micronutrient intake. Results Picky eating was predicted by male sex, older child age, and more difficult temperament but not race/ethnicity, maternal body mass index, maternal depressive symptoms, household food insecurity, or single parent home. Picky eating was not associated with child BMIz or micronutrient deficiencies; it was inversely associated with total Healthy Eating Index-2010 score and servings of whole fruit, total vegetables, greens and beans, and total protein foods. Conclusions Pediatric providers should support parents in expanding the number of healthy foods the child eats to improve dietary quality, but reassure parents that picky eating is not associated with children's weight status or micronutrient deficiencies.

Infant feeding practices are a focus of early obesity prevention. We tested whether infant growth velocity increased after breastfeeding termination and complementary food introduction.Our secondary analysis included a sample of 547 mother-infant dyads from a longitudinal randomized controlled trial conducted in Michigan and Colorado. Infant anthropometrics at birth, baseline, and 6- and 12-month follow-up were standardized to BMI-for-age z-score (ZBMI) according to World Health Organization (WHO) growth charts. We used growth curve models with time-varying predictors to quantify effects of breastfeeding termination and timing of complementary food introduction on growth velocity.Median breastfeeding duration was 2.0 months [confidence interval (CI) = 2.0-2.5]; median introduction of complementary foods occurred at 3.0 months (CI = 2.8-3.2). Breastfed infants not yet introduced to complementary foods had an average ZBMI growth velocity of 0.050 (CI = -0.013 to 0.113) z-score units per month [zpm], not significantly faster than WHO growth trajectory (p = 0.118) defined as 0 zpm. Breastfeeding termination had negligible effect on ZBMI growth velocity (γAverage postcomplementary food introduction growth velocity was significantly higher than WHO growth trajectory, but did not differ from the sample's initial average trajectory. Growth curve models can accurately estimate effects of feeding practices on infant growth to direct obesity prevention efforts.

Children living in households that have recently become food insecure may be particularly vulnerable to adverse weight and dietary changes, but longitudinal studies examining these associations are lacking. Using data from 501 Head Start preschoolers from Michigan (48% male) who were followed during one school year as a part of a randomized obesity prevention trial, we examined changes in children's adiposity indices and dietary quality according to changes in household food insecurity. Household food insecurity change status was categorized as persistently food secure, became food secure, persistently food insecure, or became food insecure. Linear mixed effects models were used to estimate relative changes in BMI-for-age z scores (BAZ), triceps skinfolds-for-age z scores (TAZ), or diet quality (assessed with the 2010 Healthy Eating Index) over the school year according to food insecurity category. We found that girls from households that became food insecure over the year had a 0.21 unit higher gain in BAZ than girls from households that were persistently food secure, after adjustment for potential confounders (95% CI 0.02 to 0.39, P = 0.03). Girls from households that became food secure had improvements in dietary quality over the year compared to girls from persistently food insecure households (adjusted difference in Healthy Eating Index score change = 9.1 points; 95% CI 3.0 to 15.0; p = 0.003). There were no statistically significant associations with changes in TAZ. Among boys, there were no associations between changes in household food insecurity and changes in BAZ, TAZ, or dietary quality. In summary, we found that BMI and diet quality changes of Head Start preschool girls were correlated with short-term changes in household food insecurity. Continued research efforts should focus on identifying the most effective ways to promote the health of children in food insecure households, especially those who may have recently transitioned or are transitioning into food insecurity.

BACKGROUND Behaviour problems and obesity are related but research findings have been inconclusive regarding the direction of effects. OBJECTIVES This study examined the cross-lagged associations between behaviour problems, body mass index (BMI) and obesity in preschoolers, and whether sex modified these associations. METHODS Repeated measures of teacher-reported externalizing (EXT) and internalizing behaviour problems (clinically significant T scores were >90th percentile), BMI z-scores (BMI-Z) and obesity status (BMI ≥95th for age and sex) were assessed in the fall (T1) and spring (T2) of the school year in Head Start preschoolers (N = 423). Associations were examined with cross-lagged modelling. RESULTS Prospective paths from T1 clinically significant EXT to both T2 BMI-Z (β = .05) and obesity (β = .18) were significant. There was no evidence that T1 BMI-Z or obesity preceded T2 behaviour problems. However, sex-specific models indicated that T1 BMI-Z was prospectively associated with higher T2 EXT for boys (β = .13), but not girls. T1 EXT was predictive of subsequent BMI-Z (β = .09) and obesity (β = .33) at T2 for girls only. CONCLUSION Findings suggest that behaviour problems, particularly externalizing behaviours, are prospectively related to childhood obesity, and early prevention methods should reflect sex-specific modifications.

Purpose The purpose of this study was to examine women's evaluation of postpartum care services (postpartum clinical assessments, health education, and midwife kindness) received from midwives prior to discharge in rural health facilities, and to examine husband-and-wife-farmer dyads’ reasons for their decisions to return or not return for 1-week postpartum care visits in rural central Malawi. Design Cross-sectional matched-pairs survey design. Methods Participants included a convenience sample of 70 husband-and-wife-farmer dyads living in rural communities who had a live birth in the past year at one of four health facilities in Ntcheu district, central Malawi. Data were collected using an interviewer-administered postpartum care questionnaire from the World Health Organization (WHO) Safe Motherhood Needs Assessment Questionnaires. Data analysis included univariate and multivariate statistics. Findings Women's evaluation of postpartum care assessments received from midwives in rural health facilities prior to discharge included partial assessments of blood pressure (44%), temperature (41%), abdominal examination (50%), vaginal examination/bleeding (46%), breast examination/soreness (34%), and baby examination (77%). Only 16% of the women received all six of these postpartum clinical assessments prior to discharge, while 11% received none. Women also reported that midwives did not: introduce themselves (50%); ask if patients had questions (44%); explain what they were doing (43%); or explain what to expect after delivery (50%). Despite this, 77% of women felt midwives paid close attention to them and 83% gave an overall positive evaluation (3.5–5 on a scale of 1–5). Numbers of postpartum clinical assessments (p = .09) and overall evaluation (p = .71) did not differ between the four health facilities. The top three reasons for husbands’ and wives’ decisions to return for 1-week postpartum care visits were: being advised to return for care, wanted the mother to be examined, and wanted the baby to be examined. Participants stated prior negative experiences, or not perceiving a need for care (feels fine), may potentially prevent them from returning for postpartum care visits in a health facility. Conclusions Most women reported they received only partial postpartum clinical assessments; thus, it is important for health facilities to address the adequacy of postpartum clinical assessments provided to women by midwives before discharge. Women returned for 1-week postpartum care visits because they were advised to return for care, and also to make sure their babies were examined. However, the principal reason why husbands permitted their wives to return for postpartum care was because they wanted their wives to be examined. Clinical Relevance Midwives need to advise all patients to return for postpartum care visits consistent with WHO or country guidelines, and continue to educate husbands and wives regarding the importance of postpartum care even when the wife feels fine. Refresher in-service trainings on postpartum care are recommended for midwives to encourage them to perform the recommended postpartum clinical assessments.

We examined husbands' knowledge and attendance at their wives' postpartum visit in a sample of rural husband-and-wife farmer dyads in central Malawi. A cross-sectional matched-pairs survey of 70 husband-and-wife farmer dyads, who lived in rural communities in Ntcheu district, and had a live birth in the past year was conducted. Data were collected using an interviewer-administered, structured postpartum questionnaire adapted from WHO Safe Motherhood Needs Assessment Questionnaires. Many husbands did not know about postpartum assessments and education their wives received from health facilities. Percent agreement between dyads' responses was lower on questions referring to assessments than to education. The odds of reporting that the woman received postpartum assessments were greater among husbands than among wives. Fifty-nine percent of husbands did not go with their wives for 1-week postpartum visits. Top three reasons for not attending visits were: at work, out of town, and did not see the need.

Objective While obesity prevention efforts emphasize the importance of healthy family meals, few studies have addressed instrumental barriers to family meals as an obesity prevention strategy. Therefore, our study objectives are to: Phase 1 - test the additive effects of six intervention components reflecting differing levels of supports for family mealtimes; identify components associated with family meals and dietary outcomes in a Screening Phase and Phase 2 - evaluate the identified components as an intervention in a randomized controlled trial in a Confirming Phase. Description Phase 1 (n = 499 children from Head Start/parents) analyses indicated that the provision of healthy meals and cookware/dinnerware sets was most robustly associated with mealtime frequency and dietary quality. In Phase 2, participants in the treatment condition receive two prepared meals delivered weekly by Meals on Wheels for 12 weeks and a comprehensive set of cookware/dinnerware. We have enrolled 58 pilot parent-child dyads (Mage parents = 31.12 years, SD = 7.97; Mage children = 4.21 years, SD = 0.52) who reflect a racially diverse, low-income sample. 75% of parents/27% of children are overweight/obese and 57% of families were food insecure at enrollment. Recruitment for an additional 250 children/parents is underway. Evaluation Given the small pilot, we utilized descriptive analyses of pre-post changes in mean scores, with Cohen's d compared to the control condition noted. The pilot intervention showed pre-post increases in the frequency of eating meals together (d = 0.13), increases in efficacy in mealtime planning (d = 0.27) and decreases in time barriers regarding meal preparation (d = -0.36). Children's body mass index z-score decreased in the treatment and control groups. Conclusion and Implications Preliminary pilot results suggest the provision of healthy, prepared meals may be related to greater frequency of family meals eaten together and improvements in perceived barriers to planning and preparing meals. At the conclusion of Phase 2, study results are expected to inform policy (e.g. where limited resources may be best allocated) and interventions (e.g. supports most effective in promoting family meals).

As part of a curriculum-development project, focus groups were implemented with Early Head Start staff and with parents of infants and toddlers enrolled in Early Head Start. Focus groups were designed to identify staff and parent beliefs about early emotional development. Three major themes were identified that crossed the staff and parent focus groups: (a) Infants' and toddlers' abilities to have emotions and to be aware of others' emotions; (b) roles of parents as advocates, teachers, and disciplinarians; and (c) parental reflectivity about their own experiences as influences on their parenting. The findings suggest that parents participating in Early Head Start have some knowledge about basic emotions and the developmental nature of emotions, but may easily misinterpret emotional displays only as attempts at manipulation rather than as valid expressions of feelings; expectations for gender-appropriate emotional expressiveness begin early; more empowered parents may view themselves as role models and teachers for their children; and more reflective parents are better prepared to engage in the sensitive interactions needed to guide young children's growing awareness of their own and others' emotions. Implications for parenting education and program planning utilizing an infant mental health perspective are discussed.

OBJECTIVES: To determine the effect of an intervention to improve emotional and behavioral self-regulation in combination with an obesity-prevention program on the prevalence of obesity and obesity-related behaviors in preschoolers. METHODS: This was a cluster-randomized intervention trial in Head Start (HS) classrooms conducted in each of 4 academic years from 2011 to 2015. Participants (697 children; 49% boys; mean age: 4.1 ± 0.5 years; 48% white, 30% African American, 12% Hispanic) were randomly assigned by classroom to 1 of 3 intervention arms: (1) HS + Preschool Obesity Prevention Series (POPS) + Incredible Years Series (IYS) (HS enhanced by the POPS [program targeting evidence-based obesity-prevention behaviors] and the IYS [program to improve children’s self-regulation]), (2) HS+POPS, or (3) HS. Primary outcomes were changes in prevalence of obesity, overweight/obesity, BMI z score, and teacher-reported child emotional and behavioral self-regulation; secondary outcomes were dietary intake, outdoor play, screen time, and parent nutrition knowledge and nutrition self-efficacy. RESULTS: HS+POPS+IYS improved teacher-reported self-regulation compared with HS+POPS (P < .001) and HS (P < .001), but there was no effect on the prevalence of obesity (16.4% preintervention to 14.3% postintervention in HS+POPS+IYS versus 17.3% to 14.4% in HS+POPS [P = .54] versus 12.2% to 13.0% in HS [P = .33]). There was no effect of HS+POPS compared with HS alone (P = .16). There was no effect on other outcomes except for sugar-sweetened beverage intake (HS+POPS+IYS resulted in a greater decline than HS; P = .005). CONCLUSIONS: An intervention for parents and children to improve HS preschoolers’ emotional and behavioral self-regulation in combination with an obesity-prevention curriculum did not reduce obesity prevalence or most obesity-related behaviors.

Background High intake of added sugar and sodium is a public health concern for preschool-aged children living in the US. Externalizing behavior may predict higher consumption of added sugar and/or sodium; however, previous studies have mostly been cross-sectional. The aim was to evaluate whether externalizing behavior is prospectively related to added sugar and intake in a sex-specific manner among preschoolers. Methods This was a secondary analysis of 524 preschool children (48% male) from Michigan who participated in an obesity prevention trial that occurred during one school year from 2011 to 2015. Teacher-assessed externalizing behaviors and three 24-h dietary recalls were completed at baseline and follow-up. We used linear mixed effects regression to evaluate the association between externalizing behavior at baseline and added sugar (% of total Calories) and sodium intake (mg/1000 Calories) at follow-up. In adjusted analysis, we included baseline income-to-needs ratio, child race/ethnicity, and baseline overweight status. All models were adjusted for total energy intake and accounted for clustering by classroom. Results Baseline externalizing behavior was positively associated with added sugar intake at follow-up among boys; after adjustment for confounders, every 5 points lower externalizing T-score (corresponding to higher externalizing behavior) was associated with a 0.6 higher percentage of added sugar per total Calories (95% CI 0.2 to 1.1; P value = 0.004). In contrast, girls with higher levels of externalizing behavior had lower consumption of added sugars; after confounder adjustment, every 5 points lower externalizing T-score was related to 0.6 lower percentage intake (95% CI -1.0 to −0.1; P value = 0.01). Baseline externalizing behavior was inversely associated with sodium intake at follow-up among boys. After potential confounder adjustment, for every 5 points lower externalizing behavior T-score, there was a 22 mg/1000 Cal lower sodium intake (95% CI -45 to 1; P value = 0.06). In contrast, after adjustment for confounders, every 5 points lower externalizing T-score among girls was related to 24 mg/1000 Cal higher sodium intake (95% CI 1 to 46; P value = 0.04). Conclusions Externalizing behavior among preschool-aged children was prospectively related to added sugar and sodium intake in a sex-dependent manner. Trial registration NCT01398358 Registered 19 July 2011. Electronic supplementary material The online version of this article (10.1186/s12966-017-0591-y) contains supplementary material, which is available to authorized users.

Background Early child weight gain predicts adolescent and adult obesity, underscoring the need to determine early risk factors affecting weight status and how risk factors might be mitigated. Socioeconomic status, food insecurity, caregiver depressive symptomology, single parenthood, and dysfunctional parenting each have been linked to early childhood weight status. However, the associations between these risk factors and children's weight status may be moderated by caregiver feeding styles (CFS). Examining modifiable factors buffering risk could provide key information to guide early obesity intervention efforts. Methods This analysis used baseline data from the Growing Healthy project that recruited caregivers/child dyads (N = 626) from Michigan Head Start programs. Caregivers were primarily non-Hispanic white (62%) and African American (30%). After using latent class analysis to identify classes of familial psychosocial risk, CFS was tested as a moderator of the association between familial psychosocial risk class and child body mass index (BMI) z-score. Results Latent class analysis identified three familial psychosocial risk classes: (1) poor, food insecure and depressed families; (2) poor, single parent families; and (3) low risk families. Interactive effects for uninvolved feeding styles and risk group indicated that children in poor, food insecure, and depressed families had higher BMI z-scores compared to children in the low risk group. Authoritative feeding styles in low risk and poor, food insecure, and depressed families showed lower child BMI z-scores relative to poor, single parent families with authoritative feeding styles. Conclusions Uninvolved feeding styles intensified the risk and an authoritative feeding style muted the risk conferred by living in a poor, food-insecure, and depressed family. Interventions that promote responsive feeding practices could help decrease the associations of familial psychosocial risks with early child weight outcomes.

Maternal and/or child-feeding behaviors and food choices may be important contributors to childhood obesity. We aimed to compare food patterns and mealtime behaviors and to determine predictors of frequent intake of nutrient-dense and energy-dense foods of low-income African American (AA; n = 199) and non-Hispanic White (NHW; n = 200) mother-toddlers dyads using a cross-sectional study. Energy-dense foods were consumed frequently by AA than NHW mother-toddler dyads. Mealtime TV watching for AA and being single for NHW mothers predicted toddlers' frequency of nutrient-dense food intake. These findings have implications for culturally relevant interventions aimed at obesigenic food behavior in low-income parents of toddlers.

Purpose The purpose of this secondary analysis was to examine racial and ethnic differences in the propensity to engage in breastfeeding, maternal knowledge, and self-efficacy in infant feeding among three groups of low-income mothers: non-Hispanic (NH) White, NH African American, and Hispanic. Background While racial and ethnic differences in infant feeding practices are substantial, these differences have not been broadly examined in relation to breastfeeding, maternal knowledge, and self-efficacy in infant feeding among low-income mothers. Methods This secondary analysis used baseline data from a randomized clinical trial with a sample of 540 low-income, mother-infant dyads from Michigan and Colorado. All data were collected when infants were approximately one month old via self-report questionnaires. Results After adjusting for mothers' age, education, marital and working status, the odds of engaging in any form of breastfeeding among Hispanic mothers remained significantly higher than among NH African-American mothers (OR = 2.5, 95% CI:1.59–3.96) and NH White mothers (OR = 1.7, 95% CI:1.08–2.81). However, Hispanic mothers had significantly lower maternal knowledge and self-efficacy in infant feeding than the other two groups. No significant correlations were found between maternal knowledge, self-efficacy in infant feeding, and the propensity to breastfeed. Conclusions Racial and ethnic variations were evident in the propensity to breastfeed, maternal knowledge, and self-efficacy in infant feeding suggesting the importance of tailoring breastfeeding programs to improve breastfeeding, and associated positive health outcomes. Further investigation is needed to find a better way to address breastfeeding disparity in relation to race and ethnicity, maternal knowledge, and self-efficacy in infant feeding.

This study tested the validity of an emotion-related parenting construct, indicated by six key emotion-related socialization behaviors (ERSBs) occurring in daily, developmentally salient parenting in a low-income sample of mothers ( N = 123) of toddlers, and examined the relationship between the ERSB construct and toddlers’ self-regulation. Structural equation modeling confirmed a latent emotion-related parenting construct, indicated by observed maternal warmth and supportiveness, observed emotional responsivity in the home, maternal report of mealtime socialization practices, observed maternal use of mental state language and emotion talk, and maternal report of positive self-expressivity in the family. Emotion-related parenting significantly related to toddlers’ effective coping and delay of gratification (medium effect sizes). Maternal demographic risk was negatively related to emotion-related parenting (large effect size) but positively related to toddlers’ effective coping (medium effect size); toddler age and gender were not significantly related to ERSBs. Results suggest that maternal ERSBs are cohesive in a low-income population, reflecting emotion-related parenting, and play a role in economically at-risk toddlers’ self-regulation. Implications for parenting and family support programs as well as implications for future research are discussed.

Objective: To ascertain paraprofessionals’ perceptions regarding a self-directed computer-supported nutrition educational intervention to disadvantaged mothers of infants. Design: Qualitative focus group study. Setting: Three county extension programs in a Midwestern state, which serve disadvantaged families. Method: Sixteen paraprofessional nutrition educators, affiliated with Extended Food and Nutrition Programs (EFNEP), took part in three focus groups led by a facilitator following a semi-structured questioning route. Results: Three themes emerged: (1) paraprofessionals’ perceptions of personal connections with learners; (2) paraprofessionals’ perceptions of lesson plans; and (3) paraprofessionals’ perceptions of self-directed lessons. Conclusions: Data provided exemplars of paraprofessional teaching strategies used with the disadvantaged populations they service, a recommendation to develop a blended curriculum, and insight regarding technology. A preventive nutrition education program, focusing on the reduction of childhood obesity though informed infant feeding practices, can be delivered using a combination of direct contact paraprofessional education and self-directed computer-supported lessons.

Objective: To ascertain infant feeding practices and to explore the feasibility of an in-home feeding intervention with Native American Indian (NAI) mothers in six Native American communities in the United States (US). Design: Qualitative focus group study. Setting: Six Native American communities in the Midwest region of the United States. Method: Fourteen NAI health paraprofessionals and 42 NAI mothers took part in 12 focus groups that were conducted by a facilitator, according to a semi-structured topic guide. Focus group data were supplemented with demographic data. Results: For the NAI health paraprofessionals, four major themes emerged: (1) maternal feeding practices for their infants; (2) special considerations when working with the NAI population; (3) sources of advice for NAI mothers; and (4) tailoring a feeding intervention to NAI mothers of infants. For the NAI mothers, four major themes emerged: (1) maternal feeding practices for their infants; (2) expectations about an in-home intervention and how to make it work; (3) useful information regarding infant feeding; and (4) importance of family. Conclusion: Data provided examples of NAI mothers’ feeding practices, suggesting that development of an effective intervention to assist NAI mothers transition their infants to solid foods can help promote healthy infant growth during their first year of life. Health paraprofessionals need to incorporate nutrition messages that are culturally-congruent for NAI mothers. Inclusion of NAI family members may enhance successful changes in infant feeding practices.

Early social-emotional development occurs in the context of parenting, particularly via processes such as maternal emotion socialization and parent–child interactions. Results from structural equation modeling indicated that maternal contingent responsiveness partially mediated the relationship between maternal emotion socialization of toddlers (N = 119, ages 12–36 months) and toddlers' social-emotional competence. Effect size was strongest for the direct path between maternal emotion socialization and toddler social–emotional competence. Toddler age and maternal demographic risk status (covariates) predicted toddler competence. Study results extend the previous literature on early competencies by focusing on toddlers rather than preschool-aged children and by employing a contextual model in which both low-income mothers' emotion socialization and their contingent responsiveness predicted toddlers' competencies.

Objective To ascertain maternal expectations and experiences with mealtimes and feeding of toddlers among low-income African American mothers in two mid- to large-size cities in the United States. Design Qualitative focus group study. Setting Two Early Head Start programme sites in a Midwestern state which serve low income families. Method Twenty-seven low-income African American mothers took part in two focus groups which were conducted by a facilitator, according to a semi-structured topic guide. Focus group data were supplemented with demographic family data. Results Four major themes emerged: (1) maternal perceptions of healthy toddlers, (2) maternal food choices for toddlers, (3) maternal expectations about toddler autonomy and self-regulation of feeding, and (4) mealtime context and interaction. Conclusions and implications Data provided examples of maternal expectations and experiences, suggesting the development of healthy feeding patterns among some toddlers and provided evidence of less healthy feeding patterns in others. Evidence of less healthy feeding patterns included limiting toddler autonomy and food regulation, and misinterpretation of normative toddler behaviours. Because parenting practices and perceptions have been reported to contribute to social and environmental influences of obesity, this research could aid development of culturally sensitive nutrition education interventions.

The purpose of this study was to determine the perspectives of health professionals on assisting low income mothers with infant feeding. Low income mothers interact with a variety of health professionals through medical care and public health programs. Mothers indicate that health professionals are an important source of infant feeding information; however, they also report this information to be conflicting or difficult to follow. Five focus groups were conducted with 36 health professionals (pediatricians, nurses, WIC professionals, and Cooperative Extension nutrition educators). Individual interviews were also conducted with WIC professionals who were unavailable to meet as a group. Focus groups and interviews were audio taped, transcribed, and analyzed for common content categories. Six major content categories emerged from focus groups and individual interviews with health professionals: (1) Mothers’ sources of infant feeding information, (2) Helping mothers deal with multiple sources of infant feeding advice, (3) Use of infant feeding recommendations by health professionals and their clients (4) Reasons mothers introduce cereal early to their infants (5) Mothers feeding infants in poor mealtime environments, and (6) Ways of providing education to mothers on infant feeding. Conclusions: A better understanding of health professionals’ perspectives on working with low income mothers on infant feeding will inform nutrition education for these mothers, and may also inform strategies to improve communication between mothers and health professionals, subsequently improving infant health.

Beverage intake and diet quality of toddlers from families with limited incomes were described and compared to their mother's beverage intake. At both 2 and 3 years of age, the children's average milk intake was adequate, the juice intake was twice that recommended, and the intake of sweetened beverages was high. Mothers who consumed more than 12 fl oz of soft drinks per day were nearly four times more likely to have a child with poor diet quality. Health practitioners should do focused screening of mothers' and children's beverage intakes to quickly assess those at high risk for poor diets.

The prevalence of obesity is increasing at an alarming rate in African-American children. Fathers influence mealtime behaviors but are often overlooked in nutrition education. A sample of six African-American fathers of toddlers participated in a focus group to describe mealtime behaviors with their toddlers. The focus group was audiotaped and transcribed verbatim. Five thematic categories were identified: mealtime rituals and routines, division of responsibility, family constellation, nutritional knowledge, and tension during mealtimes. Fathers expressed frustration with the toddler's “picky-eater” developmental stage. Fathers need to be included in nutrition education that promotes healthy mealtime habits with their toddlers.

Childhood obesity is a major health problem. Effective strategies are necessary to promote healthy eating in toddlers. The Nutrition Education Aimed at Toddlers project examined rural, low-income caregivers' knowledge, attitudes, mealtime practices, and dietary intake before and after a nutrition program. A convenience sample of 38 families participated in the study; 19 attended classes, and 19 did not. Six months after the lessons, no significant differences were found between groups; however, the resultant dietary, feeding knowledge, attitudinal, and behavioral data provide a valuable description regarding a hard to reach, high-risk population. However, caregivers' perceptions about feeding their toddlers differed from their reported dietary intakes of dairy, fruits, and vegetables. It appears that knowledge is insufficient to change eating habits. Identification of the issues that prevent caregivers in providing proper feeding is needed for a lasting change of eating habits.

Background Unhealthy infant feeding practices, such as a combination of formula feeding and early introduction of solids may lead to rapid or excessive weight gain in early infancy. Adolescent mothers’ feeding behaviors are most directly related to infant weight gain in the first year of life. Compared to adult mothers, adolescent mothers are less knowledgeable, less responsive, more controlling, and less skilled in infant feeding, which interferes with infants’ healthy growth. The Tools for Teen Moms trial aims to compare the effect of a social media intervention for low-income adolescent, first-time mothers of infants 2 months of age or younger, versus standard care on infant weight, maternal responsiveness, and feeding style and practices. The intervention is conducted during the infant’s first four months of life to promote healthy transition to solids during their first year. Tools for Teen Moms is an intervention delivered via a social media platform that actively engages and coaches low-income adolescent mothers in infant-centered feeding to reduce rapid/excessive infant weight gain in the first six months of life. Methods/Design We describe our study protocol for a randomized control trial with an anticipated sample of 100 low-income African- American and Caucasian adolescent, first–time mothers of infants. Participants are recruited through Maternal-Infant Health Programs in four counties in Michigan, USA. Participants are randomly assigned to the intervention or the control group. The intervention provides infant feeding information to mothers via a web-based application, and includes daily behavioral challenges, text message reminders, discussion forums, and website information as a comprehensive social media strategy over 6 weeks. Participants continue to receive usual care during the intervention. Main maternal outcomes include: (a) maternal responsiveness, (b) feeding style, and (c) feeding practices. The primary infant outcome is infant weight. Data collection occurs at baseline, and when the baby is 3 and 6 months old. Discussion Expected outcomes will address the effectiveness of the social media intervention in helping teen mothers develop healthy infant feeding practices that contribute to reducing the risk of early onset childhood obesity. Trial registration Clinical Trials.Gov NCT02244424, June 24, 2014

To examine whether and how toddlers' vegetable and fruit consumption is associated with maternal vegetable and fruit consumption, mothers' perceptions of toddlers as "picky eaters," maternal efficacy, and sociodemographic characteristics of the family.A cross-sectional survey. One hundred and ninety-nine African American and 200 Non-Hispanic White low-income, mother-toddler dyads enrolled in 8 Early Head Start programs in a Midwestern state.Mothers completed the Feeding Self-Efficacy Scale, Toddler-Parent Mealtime Behavior Questionnaire, and Mothers' and Toddlers' Food Frequency Questionnaires. Data were analyzed using linear and logistic regression models.Toddlers were less likely to consume vegetables 4 or more times a week if their mothers: viewed them as "picky eaters" (OR: 2.5), did not consume vegetables 4 or more times a week themselves (OR: 10.1), and were African American (OR: 2.2). Toddlers were less likely to consume fruits 4 or more times a week if their mothers: viewed them as "picky eaters" (OR: 1.6) and did not consume fruit 4 or more times a week (OR: 9.9) themselves.Health professionals need to consider mothers' own consumption of fruits and vegetables when developing strategies to increase toddler consumption of fruits and vegetables.

To examine maternal demographic characteristics and depressive symptoms as predictors of TV viewing during mealtimes, and to investigate how mealtime TV viewing predicts mothers' and toddlers' food consumption. A prospective, cross-sectional survey design was employed with 199 African American and 200 Caucasian, low-income, mother-toddler dyads enrolled in eight Early Head Start programs in a Midwestern state. Mothers completed the Toddler-Parent Mealtime Behavior Questionnaire to assess toddler mealtime behavior. Data were analyzed using a three-step multiple regression: (a) step one was to determine what characteristics predicted family TV viewing during mealtime; (b) step two was to determine whether TV viewing during mealtime predicted maternal food consumption, and (c) step three was to determine whether TV viewing during mealtime predicted toddler food consumption. Direct and indirect effects of TV watching were explored via path models. Maternal race, education, and depressive symptoms predicted 8% of the variance in TV viewing during mealtime (Por = 0.001). African American mothers and mothers who had fewer years of schooling and exhibited more depressive symptoms tended to watch more TV during mealtime. More TV viewing during mealtime predicted mothers' intake of 'more' unhealthy foods. Mothers' food consumption was the single best predictor of toddlers' food consumption, while TV viewing during mealtime had an indirect effect through mothers' TV viewing. TV viewing practices affect mothers' food consumption and mealtime behaviors; this, in turn, impacts toddlers' food consumption. Practical interventions are needed to positively influence the nutritional habits of lower-income mothers. Reducing mothers' "unhealthy" food consumption while watching TV may offer one effective strategy.

The early introduction of solids to infants is a risk factor associated with later health problems including allergies, overweight, and diabetes. The Infant Feeding Series (TIFS), a newly designed curriculum that promotes the appropriate transition to solids through parenting education and behavior change among low-income mothers, used the Theory of Planned Behavior and the Transtheoretical Model of Change to develop TIFS curricular foci and activities. Using a pre-post design, pilot study results indicate that after exposure to the TIFS curriculum, mothers had significantly increased knowledge about appropriate infant feeding, could more accurately identify developmental indicators of infants’ readiness for solids, and reported greater feelings of self efficacy about initiating and maintaining healthy feeding practices. Editors’ Strategic Implications: Replication is necessary, but TIFS appears to be a promising prevention program based on short-term knowledge and long-term behavioral outcomes (i.e., healthy feeding practices).

Preventive measures for long-life illnesses such as asthma, obesity, and diabetes can start as early as in infant feeding practices. The American Academy of Pediatrics recommends introducing babies to solid foods, anything other than breast milk or formula, no earlier than 4-6 months of age (Kleinman, 2004). This study's purpose was to assess beliefs and attitudes of mothers enrolled in Medicaid about the introduction of solid foods and other infant feeding behaviors. Six focus groups (N = 23) were conducted with Black and Caucasian mothers with infants under 1 year old. The Theory of Planned Behavior was used as a framework for moderator questions and interpretation of themes. Maternal knowledge about infant feeding, maternal perceptions of applicability of infant feeding guidelines, and manner and type of information useful for infant feeding decisions emerged as themes. Implications of themes for informing an educational program for mothers to delay the introduction of solid foods are discussed.

Objective To examine the effectiveness of three modalities for delivery of nutrition education. Design Between-subjects, repeated-measures design. Setting Data were collected at community agencies or during home visits. Participants Low-income, European American and African American mothers (N = 155). Intervention Participants were exposed to nutrition education material in 1 of 3 modalities (a computer game, The Fantastic Food Challenge; Web site; or pamphlet). Likeability, nutrition knowledge, intention to use, and demographic measures followed the intervention at T1 and T2. Main Outcome Measures 5-point Likert-type scales measured likeability (5 items), and 33 multiple-choice questions measured knowledge. Analysis Data were analyzed using analysis of variance (ANOVA) and analysis of covariance (ANCOVA) procedures using SPSS version 15.0 (SPSS Inc., Chicago, IL) software, P Results Overall, the Web site was liked more than the other conditions with this audience of women. Significant differences in attention, understanding, and intent to use the information existed across modalities. The Web site performed better than other modalities on knowledge outcomes, with no differences in knowledge retention from T1 toT2. Conclusions and Implications The Web site modality performed best with this audience of women, indicating that interactive computer games may not confer greater benefits than traditional modes of information delivery for all audiences, particularly those with low computer skills.

Objective: Evaluate effectiveness of the Healthy Babies (HB) intervention compared to a control group on maternal responsiveness, feeding style, and feeding practices, and compare infant feeding self-regulation and growth pattern of infants. Description: The HB Curriculum is a series of 6 in-home lessons and 3 follow-up telephone contacts, based on the Theory of Planned Behavior. Evaluation: Preliminary results (N 1⁄4 170) showed significant positive results related to pressuring to eat cereal, responding to infant fullness cues, and feeding knowledge. Conclusions and Implications: Preventive feeding interventions are necessary during age-appropriate transition to solid foods. Funding: USDA Grant # 2009-55215-05220. Other Funding/Support: Michigan State University (MSU), College of Nursing, MSU Families and Communities Together, MSUE EFNEP, and CSUE EFNEP.

Weight problems in children are increasing at an alarming rate, especially among low-income populations. This concern requires effective strategies to promote healthy eating. A quasi-experiment was used to assess the effectiveness of an intervention, Nutrition Education Aimed at Toddlers (NEAT), aimed at enhancing parent-toddler feeding practices. The NEAT intervention comprises four nutrition lessons and structured reinforcements over 6 months. A convenience sample of 135 low-income families participated in the study up to the first data collection wave. Complete data were available for 43 parent-toddler dyads in the intervention and 53 dyads in the control group. The results show that, compared to the controls, caregivers exposed to the intervention had significantly higher knowledge scores concerning toddler feedings. No statistically significant differences were found for measures of child and parent mealtime behaviors. Because it is generally easier to change knowledge than actual behaviors, our study results demonstrate the need to focus on other avenues to enhance parents' ability to feed toddlers appropriately.

Quality mother-child interaction is imperative for normal child growth and development. Early intervention programs may support mother-child interaction, particularly at-risk mother-child dyads. The purpose of this study was to describe mother-child dyadic interaction as they entered and exited a rural Early Head Start (EHS) program and compare their interaction with a normed national sample. Thirty mothers and their children participated in the study and agreed to allow trained data collectors to observe an in-home teaching situation using the Nursing Child Assessment Satellite Training (NCAST) Teaching Scale. At exit from the program, although no significant differences in mother-child interactions were found, more than half of the mothers maintained or improved their ability to read cues and respond to their child. However, over 40% of the mothers remained at risk for poor interaction. Differences in program outcomes may be a result of family participation and involvement levels. Poor maternal health may also adversely affect mother-child interaction. Program implications include resource allocation for those mothers with the greatest "worry" scores. Nurses and other professionals working with mothers and children need to be vigilant in their ongoing assessment of the mother's health and possible influence on the quality of the mother-child interaction.

This paper contains a description of the use of the theory of dependent-care in the Nutrition Aimed at Toddlers project, a nursing intervention study with parents of toddlers, and discusses the research and practice utility of the theory of dependent-care, a corollary theory to Orem’s self-care theory. In particular, the concepts of dependent-care, dependent-care agency, therapeutic self-care demand and an educative-supportive nursing system are discussed within the context of the Nutrition Aimed at Toddlers project.