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Background This study estimates job-related risks among common low wage occupations (cleaning, construction, food service, cashier/baggers, and factory workers) held by predominantly Haitian, El Salvadorian, and Brazilian immigrants living or working in Somerville, Massachusetts. Methods A community-based cross-sectional survey on immigrant occupational health was conducted between 2006 and 2009 and logistic regression was used to assess the job-related risks among the most common low wage occupations. Results Construction workers reported significantly higher health risks, and lower access to occupational health services than the other occupations. Compared to cashier/baggers, the reference population in this study, cleaners reported significantly lower access to health and safety and work training and no knowledge of workers' compensation. Factory workers reported significantly lower work training compared to cashier/baggers. Food service workers reported the least access to doctors compared to the other occupations. Conclusion We found significant variability in risks among different low wage immigrant occupations. The type of occupation independently contributed to varying levels of risks among these jobs. We believe our findings to be conservative and recommend additional inquiry aimed at assuring the representativeness of our findings. Am. J. Ind. Med. 57:516–526, 2014. © 2013 Wiley Periodicals, Inc.

The goal of this paper is to describe the baseline characteristics of Live Well (intervention to prevent weight gain in recent immigrant mother-child dyads from Brazil, Haiti, and Latin America) participants, and to explore self-reported changes in diet and physical activity post-immigration. Baseline data from 383 mothers were used for this study. Dyads attended a measurement day where they completed self-administered surveys collecting information about socio-demographics, diet, physical activity, other psychosocial variables, and height and weight. Haitian mothers' socio-demographic profile differed significantly from that of Brazilians' and Latinas': they have been in the US for a shorter period of time, have higher rates of unemployment, are less likely to be married, more likely to have ≥3 children, more likely to be obese, and have immigrated for family or other reasons. In multivariate models, self-reported changes in diet and physical activity since migrating to the US were significantly associated with BMI with non-linear relationships identified. Future research is needed to understand how diet and physical activity change while acculturating to the US and explore the adoption of both healthy and unhealthy dietary changes.

The emergence of complex global challenges at the convergence of human, animal, and environmental health has catalyzed a movement supporting "One Health" approaches. Despite recognition of the importance of One Health approaches to address these complex challenges, little effort has been directed at identifying the seminal knowledge, skills, and attitudes necessary for individuals to successfully contribute to One Health efforts. Between 2008 and 2011, three groups independently embarked on separate initiatives to identify core competencies for professionals involved with One Health approaches. Core competencies were considered critically important for guiding curriculum development and continuing professional education, as they describe the knowledge, skills, and attitudes required to be effective. A workshop was convened in 2012 to synthesize the various strands of work on One Health competencies. Despite having different mandates, participants, and approaches, all of these initiatives identified similar core competency domains: management; communication and informatics; values and ethics; leadership; teams and collaboration; roles and responsibilities; and systems thinking. These core competency domains have been used to develop new continuing professional education programs for One Health professionals and help university curricula prepare new graduates to be able to contribute more effectively to One Health approaches.

This study examines the burden of occupational health risks among a convenience sample of three immigrant worker populations (Brazilian, Haitian, and El Salvadoran) in Somerville, Massachusetts. In this community based research initiative (n = 346), logistic regression is used to analyze immigrant occupational health survey data collected from 2006 to 2009. In this study, injuries at work were significantly associated with lower English proficiency (OR = 1.8, 95 % CI 1.1-3.0), workers between the ages of 46 and 65 (OR = 2.7, 95 % CI 1.0-7.0), service workers (OR = 13.8, 95 % CI 1.8-105.2), production workers (OR = 10.8, 95 % CI 1.3-90.1), construction workers (OR: 21.7, 95 % CI 2.8-170.9) and immigrants with no health insurance (OR = 1.8, 95 % CI 1.0-3.1). Injuries were negatively associated with years in the US with more established immigrants in the US >15 years reporting more injuries at work. Older immigrants who have been in the US longer but are less proficient in English, and are still employed in low-wage occupations with no health insurance suffered more injuries than recent immigrants. Further validation of this result is required.

ObjectiveTo examine the relationship between intake of whole grains and BMI Z-score in rural children.DesignGeneral linear models and logistic regression were used to examine the cross-sectional associations between whole grain intake and BMI Z-score, prevalence and odds ratios of overweight and obesity. Dietary intake was assessed using the Block Food Screener for ages 2–17 years. Children were classified into three categories according to servings of whole grain intake: 1·5 servings/d.SettingThe CHANGE (Creating Healthy, Active and Nurturing Growing-up Environments) study, an obesity prevention intervention in elementary schools in eight rural US communities in California, Mississippi, Kentucky and South Carolina.SubjectsSeven hundred and ninety-two children attending 3rd–6th grade.ResultsAfter adjusting for age, sex, race/ethnicity, physical activity and state of residence, whole grain intake was inversely associated with BMI Z-score (0·90 v. 0·61 in the lowest v. the highest whole grain intake category; P trend = 0·01). Children who consumed >1·5 servings of whole grains/d had a 40 % lower risk of being obese (OR = 0·60; 95 % CI 0·38, 0·95, P = 0·02) compared with children who consumed ConclusionsIncreasing the intake of whole grains as part of an overall healthy lifestyle may be beneficial for children to achieve and maintain a healthy weight.

Background: Active living integrates physical activity into one’s daily routine. Current understanding of active living among children and their families living in rural communities is limited. A community perspective is critical to understand the contextual factors that influence children’s physical activity in rural areas. Purpose: The purpose of this study was to identify the perceived environmental factors that support or hinder physical activity among rural children to develop testable hypotheses to inform future interventions for reducing unhealthy weight gain and preventing chronic diseases associated with physical inactivity. Methods: PhotoVOICEwasusedtoexploreactivelivingopportunitiesandbarriersforchildrenlivinginfour low-income, rural U.S. communities. In 2007, parents (n99) and elementary school staff (n17) received disposable cameras to document their perspective. Using their photographs and narratives, participants developed emergent themes during a facilitated group discussion. In 2008, study authors used the Analysis Grid for Environments Linked to Obesity (ANGELO) framework to categorize the themes. Results: Microenvironment themes include physical (e.g., natural features, topography); sociocultural (e.g., isolation); policy (e.g., time for school recess); and economic (e.g., funding for physical activity programs). Macroenvironmental themes related to the built and natural environments and transportation infrastructure.

Objective Develop rural-specific assessment tools to be used by researchers and practitioners to measure the activity-friendliness of rural communities. Method The tools were created through a mixed-methods investigation into the determinants of physical activity among rural populations. This informed the development of a conceptual framework defining activity-friendly rural environments. Questions were generated to reflect applicable existing urban-based variables and rural conceptual model elements. Pilot testing was conducted in seven rural US communities during the fall of 2008. Inter-rater reliability was assessed. Results The Rural Active Living Assessment (RALA) Tools include three components: Town-Wide (18 town characteristic questions, and inventory of 15 recreational amenities), Program and Policy (20 questions), and Street Segment (28 questions). We found that the Town-wide and Program and Policy tools were feasible for community members to implement. The observed agreement and κ statistic across all items for the Street Segment Assessment were substantial (91.9% and 0.78, respectively). Conclusions The RALA Tools were shown to be feasible and reliability was supported. They assess features believed to be supportive of active living in rural environments, offer users a resource to assess rural environments for activity-friendliness, and may also inform the design of interventions to help rural communities become more active and healthy.

Among the first tasks in a collaboration between Tufts University and community organizations in Somerville, MA, was designing an interview instrument to assess occupational health needs among immigrant workers. Human subjects protections was a critical issue, but community partners were not well informed about the need for such protections or the role of the institutional review board (IRB). During research meetings, members of the team from Tufts trained community collaborators to work with research participants and organized a presentation by a key university IRB administrator. We present findings from the process evaluation of this project and suggest ways to (1) assess community partners' understanding about working with research volunteers, (2) train collaborators, and (3) involve IRBs.

A renewed interest in promoting health and wellness has prompted both public- and private-sector organizations to adopt systems for rating the nutritional quality of individual food products. Compared here are three food quality scores for ranking foods. The absolute score varies by the food quality score algorithm used, but the relative ranking of foods within a food group is stable. Fruits and vegetables are substantially more nutrient-dense than items from other food groups. There is an imperative need for a simple, consistent method to guide consumers in making healthier food choices.

This study explores the organization of work and occupational health risk as elicited from recently immigrated women (n = 8) who have been in the US for less than three years and employed in informal work sectors such as cleaning and factory work in the greater Boston area in Massachusetts. Additional interviews (n = 8) with Community Key Informants with knowledge of this sector and representatives of temporary employment agencies in the area provides further context to the interviews conducted with recent immigrant women. These results were also compared with our immigrant occupational health survey, a large project that spawned this study. Responses from the study participants suggest health outcomes consistent with being a day-laborer scholarship, new immigrant women are especially at higher risk within these low wage informal work sectors. A difference in health experiences based on ethnicity and occupation was also observed. Low skilled temporary jobs are fashioned around meeting the job performance expectations of the employer; the worker's needs are hardly addressed, resulting in low work standards, little worker protection and poor health outcomes. The rising prevalence of non-standard employment or informal labor sector requires that policies or labor market legislation be revised to meet the needs presented by these marginalized workers.

Given the current childhood obesity epidemic, it is especially important to find effective ways to promote healthful foods to children. School public address (PA) systems represent an inexpensive and a replicable way of reaching children with health messages. To test the effectiveness of this channel, messages were created to promote 2 dried bean (legume) dishes that had been added to the school lunch menu. Six elementary schools were pair matched, and 1 school from each pair was randomly chosen to play the messages. The impact of the intervention on choice of the 2 new entrees was assessed. Results indicate that for all schools combined, choice was not significantly affected. However, compared to their matched control schools, choice was significantly higher in the school that received the highest dose of the intervention and was significantly lower in the school that received the lowest dose. Choice was not changed in the school that received an intermediate dose. These results suggest that PA systems show promise as an effective and appropriate communications channel but only in schools that are able to play messages frequently.

Background: There is a substantial body of research focusing on the health and healthcare utilization of individuals with a disability but less has been done to examine the impact of disability on nondisabled family members. Objective: We sought to investigate the influence of parental disability on children's healthcare as measured by the timely receipt of childhood immunizations. Research Design: Observations on 11,997 children between the ages 2 and 5 years were obtained from the 1994 and 1995 United States National Health Interview Surveys representing 27,534,841 children when weighted. Children are determined to be in compliance with the Centers for Disease Control immunization protocol at age 24 months if they have received 4 DTP, 3 polio, and 1 MMR vaccine dose. Disability is characterized using the activity and personal care scales from the National Health Interview Surveys. The data were analyzed using logistic regression controlling for factors identified in prior research to be related to timely receipt of immunization. Results: Children living with a parent who is unable to provide his or her own personal care are 65% less likely (odds ratio = 0.35; 95% confidence interval = 0.17–0.70) to be immunized on time than children who live with parent(s) who do not have a disability. Children of parents who are limited in their personal care, and children of parents who have work limitations, are not less likely than children of nondisabled parents to receive immunizations on time. Conclusions: The impact of a parent's severe disability extends to the health care of dependent children. These findings argue for research to investigate the full scope of the effects of parental disability on children's health and for policies that address this impact.

Haselwandter is a Nestle doctoral fellow, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA. Corcoran is an assistant professor of health sciences at Merrimack College, North Andover, MA. Folta is an assistant professor, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA. Hyatt is president of Freeport Development Strategies, LLC, Burlington, MA. Fenton is an adjunct professor, Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Medford, MA. Nelson is a professor at the Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy and associate dean at the Tisch College of Citizenship and Public Service, both at Tufts University, Medford, MA. Address author correspondence to Elizabeth M. Haselwandter at bizhaselwandter@gmail.com. The Built Environment, Physical Activity, and Aging in the United States: A State of the Science Review

Whole grains (WGs) consist of intact, ground, cracked, or flaked kernels that include the germ, bran, and endosperm in the same proportions found naturally in unprocessed grains.1,2 Whole grains have several health benefits because of their dietary fiber, phytochemicals, vitamins, and minerals.3-10 Research suggests that replacement of refined grains with WGs is inversely associated with cardiovascular disease, type 2 diabetes, body mass index (BMI), and possibly cancer.3-10 The Dietary Guidelines for Americans, 2010, recommend that children aged 4 to 13 years consume 5 to 6 ounces of WG daily.11 However, children usually consume significantly fewer servings of WG than is recommended, on an average only 0.3 to 0.5 ounces of WG daily.12-15 Children who come from low-income families and/or live in rural populations often have the least access to healthier foods, including WG.16,17 One study in rural South Carolina estimated there were 0.07 food stores per square mile and 74% were convenience stores, which tended to have fewer healthier options than supermarkets.17,18 There is considerably less availability of food stores (and more availability of convenience stores) than what was found by another study examining urban environments; urban sites ranged in food stores per square mile from 1 (North Carolina) to 67 (New York) and the percentage of food outlets that were convenience stores ranged from 8% to 41%.17,18 This limited availability of WG may particularly impact children from low-income families, especially those who rely on school meals for as much as half of their daily energy intake.19,20 Therefore, interventions in rural school districts may be particularly important because students in these areas may depend on school meals for access to WG. However, until recently, there were no WG requirements for school meals, and schools typically serve refined grains, further limiting children's opportunities to consume WG food (beginning during the 2012-2013 school years, United States Department of Agriculture [USDA] standards for school meals will require half of grains to be WG).21,22 Additionally, a recent publication found that WG intake was associated with healthier BMIs and weight status in the rural children.23 Therefore, schools are an important venue to provide rural, low-income students with WG foods. There have been a few previous studies that have focused on WG in schools. STOPP (STockholm Obesity Prevention Program) randomly assigned Swedish elementary schools to healthier foods, which included the substitution of refined bread products with WG in the cafeteria during lunch.24 After 4 years, they found no differences in self-reported WG bread intake between intervention and control students.24 No information regarding successful implementation of WG in the cafeteria was reported.24 A recent intervention among middle school students, the HEALTHY study, attempted to increase WG offerings in the cafeteria as part of a larger nutrition component to reduce the risk of developing type 2 diabetes.25 However, they found that many of the WG products were too costly for the schools to introduce, and they did not find significant changes in grain consumption among students at intervention schools compared with students at control schools.25,26 A pilot study by Burgess-Champoux et al27 that focused exclusively on WG in a suburban elementary school was successful in both improving the availability of WG in school cafeterias and increasing the consumption of WG among the students at lunch compared with a control school. Last, Shape Up Somerville (SUS) was a community-based initiative in Massachusetts that focused on early elementary school-age children and included a cafeteria component to improve the foods served.28 Whole grains were emphasized at both breakfast and lunch.28 Shape Up Somerville was successful in implementing the healthier foods in school cafeterias to improve the nutrient profiles of foods provided, expanding WG consumption, and contributing to a reduction in the BMI z-scores of the students participating in the intervention compared with students at control schools.28,29 As a result of the SUS success, the Creating Healthy, Active, and Nurturing Growing-up Environments (CHANGE) study, a collaboration between Tufts University and Save the Children, adapted and tested the SUS model in a rural setting. The CHANGE study included multiple intervention components, including initiatives that focused on the school during the school day and after-school programs, the students' homes, and the communities in which the students lived. This study focuses on the school cafeteria component of the CHANGE study. The aim of this analysis was to examine the change in availability and quantity of WG and refined grain foods offered to students during breakfast and lunch as part of the school meal programs comparing preintervention (fall 2008) with postintervention (spring 2009). It was hypothesized that school cafeterias participating in the CHANGE study would experience greater increases in the availability and quantity of WG at breakfast and lunch compared with control school cafeterias over 1 school year.

High eating behavior self-efficacy may contribute to successful weight loss. Diet interventions that maximize eating behavior self-efficacy may therefore improve weight loss outcomes. However, data on the effect of diet composition on eating behavior self-efficacy are sparse. To determine the effects of dietary glycemic load (GL) on eating behavior self-efficacy during weight loss, body weight and eating behavior self-efficacy were measured every six months in overweight adults participating in a 12-mo randomized trial testing energy-restricted diets differing in GL. All food was provided during the first six months and self-selected thereafter. Total mean weight loss did not differ between groups, and GL-level had no significant effect on eating behavior self-efficacy. In the combined cohort, individuals losing the most weight reported improvements in eating behavior self-efficacy, whereas those achieving less weight loss reported decrements in eating behavior self-efficacy. Decrements in eating behavior self-efficacy were associated with subsequent weight regain when diets were self-selected. While GL does not appear to influence eating behavior self-efficacy, lesser amounts of weight loss on provided-food energy restricted diets may deter successful maintenance of weight loss by attenuating improvements in eating behavior self-efficacy.

Our goal was to explore the perceived determinants of obesity in Brazilian, Latin American and Haitian women. This is part of an ongoing community-based participatory intervention. Focus groups by immigrant group were conducted and themes extracted. Women expressed differences in beliefs, attitudes, and barriers regarding diet and physical activity in the US versus their home country. Participants thought food in the US is “less natural,” there is less time for preparation, and there is more variety. The weather is a barrier to physical activity in the US and work is more physically demanding. Job-related efforts were not considered physical activity. They reported higher levels of stress, less control of their time and less social support in the US. Providing immigrants with appropriate support and education early in the acculturation process has the potential to help prevent obesity.

In this community based research initiative, we employed a survey instrument predominately developed and administered by Teen Educators to assess occupational health risks for Haitian, Salvadoran, and Brazilian immigrants (n = 405) in Somerville, MA, USA. We demonstrate that a combined analysis of ethnicity, years in the US, and English proficiency better characterized the occupational experience of immigrant workers than considering these variables individually. While years in the US (negatively) and English proficiency (positively) explained the occurrence of health risks, the country of origin identified the most vulnerable populations in the community. Brazilians, Salvadorans, and other Hispanic, all of whom who have been in the US varying length of time, with varying proficiency in English language had twice the odds of reporting injuries due to work compared to other immigrants. Although this observation was not significant it indicates that years in the US and English proficiency alone do not predict health risks among this population. We recommend the initiation of larger studies employing c community based participatory research methods to confirm these differences and to further explore work and health issues of immigrant populations. This study is one of the small number of research efforts to utilize a contemporaneous assessment of occupational health problems in three distinct immigrant populations at the community level within a specific Environmental Justice context and social milieu.

Objective The objective of this study was to test the hypothesis that community-based environmental change intervention prevents undesirable weight gain in children. Method The method used in this study was a two-year, non-randomized, controlled trial (2003–2005) using community-based participatory methodology in three diverse cities in Massachusetts: one intervention and two socio-demographically-matched control communities (pooled for analysis). Children (n = 1028), with a mean age = 7.61 + 1.04 years participated. Interventions were made to improve energy balance by increasing physical activity options and availability of healthful foods (Year 1). To firmly secure sustainability, the study team supported policies and shifted intervention work to community members (Year 2). Results Change in body mass index z-score (BMIz) was assessed by multiple regression, accounting for clustering within communities and adjusting for baseline covariates. Sex-specific overweight/obesity prevalence, incidence and remission were assessed. Over the two-year period, BMIz of children in the intervention community decreased by − 0.06 [p = 0.005, 95% confidence interval: − 0.08 to − 0.04] compared to controls. Prevalence of overweight/obesity decreased in males (OR = 0.61, p = 0.01) and females (OR = 0.78, p = 0.01) and remission increased in males (OR 3.18, p = 0.03) and females (OR 1.93, p = 0.03) in intervention compared to controls. Conclusion Results demonstrate promise for preventing childhood obesity using a sustainable multi-level community-based model and reinforce the need for wide-reaching environmental and policy interventions.

Background Identifying risk factors that affect excess weight gain during pregnancy is critical, especially among women who are at a higher risk for obesity. The goal of this study was to determine if acculturation, a possible risk factor, was associated with gestational weight gain in a predominantly Puerto Rican population. Methods We utilized data from Proyecto Buena Salud, a prospective cohort study of Hispanic women in Western Massachusetts, United States. Height, weight and gestational age were abstracted from medical records among participants with full-term pregnancies (n=952). Gestational weight gain was calculated as the difference between delivery and prepregnancy weight. Acculturation (measured via a psychological acculturation scale, generation in the US, place of birth and spoken language preference) was assessed in early pregnancy. Results Adjusting for age, parity, perceived stress, gestational age, and prepregnancy weight, women who had at least one parent born in Puerto Rico/Dominican Republic (PR/DR) and both grandparents born in PR/DR had a significantly higher mean total gestational weight gain (0.9 kg for at least one parent born in PR/DR and 2.2kg for grandparents born in PR/DR) and rate of weight gain (0.03 kg/wk for at least one parent born in PR/DR and 0.06 kg/wk for grandparents born in PR/DR) vs. women who were of PR/DR born. Similarly, women born in the US had significantly higher mean total gestational weight gain (1.0 kg) and rate of weight gain (0.03 kg/wk) vs. women who were PR/ DR born. Spoken language preference and psychological acculturation were not significantly associated with total or rate of pregnancy weight gain. Conclusion We found that psychological acculturation was not associated with gestational weight gain while place of birth and higher generation in the US were significantly associated with higher gestational weight gain. We interpret these findings to suggest the potential importance of the US “obesogenic” environment in influencing unhealthy pregnancy weight gains over specific aspects of psychological acculturation.

Provision of fortified juices may provide a convenient method to maintain and increase blood fat-soluble vitamins.To determine whether children consuming orange juice fortified with calcium and combinations of vitamins D, E, and A could increase serum 25-hydroxyvitamin D [25(OH)D], α-tocopherol, and retinol levels.A 12-week randomized, double-blind, controlled trial.One hundred eighty participants (aged 8.04±1.42 years) were recruited at Tufts (n=70) and Boston University (n=110) during 2005-2006. Of those recruited, 176 children were randomized into three groups: CaD (700 mg calcium+200 IU vitamin D), CaDEA (700 mg calcium+200 IU vitamin D+12 IU vitamin E+2,000 IU vitamin A as beta carotene), or Ca (700 mg calcium). Children consumed two 240-mL glasses of CaD, CaDEA, or Ca fortified orange juice daily for 12 weeks.Serum 25(OH)D, α-tocopherol, and retinol concentrations.Changes in 25(OH)D, α-tocopherol, retinol, and parathyroid hormone concentrations were examined. Covariates included sex, age, race/ethnicity, body mass index, and baseline 25(OH)D, α-tocopherol, retinol, or parathyroid hormone levels. Multivariate models and repeated measures analysis of variance tested for group differences with pre-post measures (n=141).Baseline 25(OH)D was 68.4±27.7 nmol/L (27.4±11.10 ng/mL) ), with 21.7% of participants having inadequate 25(OH)D (50 nmol/L [20.03 ng/mL]). The CaD group's 25(OH)D increase was greater than that of the Ca group (12.7 nmol/L [5.09 ng/mL], 95% CI 1.3 to 24.1; P=0.029). The CaDEA group's increase in α-tocopherol concentration was greater than that in the Ca or CaD groups (3.79 μmol/L [0.16 μg/mL], 95% CI 2.5 to 5.1 and 3.09 μmol/L [0.13 μg/mL], 95% CI -1.8 to 4.3), respectively (P0.0001). Retinol levels did not change, and body weight remained as expected for growth.Daily consumption of orange juice providing 200 IU vitamin D and 12 IU vitamin E increased 25(OH)D and α-tocopherol concentrations in young children within 12 weeks.

Background There are disproportionately higher rates of overweight and obesity in poor rural communities but studies exploring children’s health-related behaviors that may assist in designing effective interventions are limited. We examined the association between overweight and obesity prevalence of 401 ethnically/racially diverse, rural school-aged children and healthy-lifestyle behaviors: improving diet quality, obtaining adequate sleep, limiting screen-time viewing, and consulting a physician about a child’s weight. Methods A cross-sectional analysis was conducted on a sample of school-aged children (6–11 years) in rural regions of California, Kentucky, Mississippi, and South Carolina participating in CHANGE (Creating Healthy, Active, and Nurturing Growing-up Environments) Program, created by Save the Children, an independent organization that works with communities to improve overall child health, with the objective to reduce unhealthy weight gain in these school-aged children (grades 1–6) in rural America. After measuring children’s height and weight, we17 assessed overweight and obesity (BMI ≥ 85th percentile) associations with these behaviors: improving diet quality18 (≥ 2 servings of fruits and vegetables/day), reducing whole milk, sweetened beverage consumption/day; obtaining19 adequate night-time sleep on weekdays (≥ 10 hours/night); limiting screen-time (i.e., television, video, computer,20 videogame) viewing on weekdays (≤ 2 hours/day); and consulting a physician about weight. Analyses were adjusted 21 for state of residence, children's race/ethnicity, gender, age, and government assistance. Results Overweight or obesity prevalence was 37 percent in Mississippi and nearly 60 percent in Kentucky. Adjusting for covariates, obese children were twice as likely to eat ≥ 2 servings of vegetables per day (OR=2.0,95% CI 1.1-3.4), less likely to consume whole milk (OR=0.4,95% CI 0.2-0.70), Their parents are more likely to be told by their doctor that their child was obese (OR=108.0,95% CI 21.9-541.6), and less likely to report talking to their child about fruits and vegetables a lot/sometimes vs. not very much/never (OR=0.4, 95%CI 0.2-0.98) compared to the parents of healthy-weight children. Conclusions Rural children are not meeting recommendations to improve diet, reduce screen time and obtain adequate sleep. Although we expected obese children to be more likely to engage in unhealthy behaviors, we found the opposite to be true. It is possible that these groups of respondent parents were highly aware of their weight status and have been advised to change their children’s health behaviors. Perhaps given the opportunity to participate in an intervention study in combination with a physician recommendation could have resulted in actual behavior change.

Background Research has shown that parental feeding styles may influence children’s food consumption, energy intake, and ultimately, weight status. We examine this relationship, among recent immigrants to the US. Given that immigrant parents and children are at greater risk for becoming overweight/obese with increased time in the US, identification of risk factors for weight gain is critical. Methods Baseline data was collected on 383 mother-child dyads enrolled in Live Well, a community-based, participatory, randomized controlled lifestyle intervention to prevent weight gain in recent immigrant mothers. Socio-demographic information together with heights and weights were collected for both mother and child. Acculturation, behavioral data, and responses to the Caregiver’s Feeding Styles Questionnaire (CFSQ) were also obtained from the mother. Results The children’s average age was 6.2 ± 2.7 years, 58% male. Mothers had been in the country for an average of 6.0 ± 3.3 years, and are Brazilian (36%), Haitian (34%) and Latino (30%). Seventy-two percent of the mothers were overweight/obese, while 43% of the children were overweight/obese. Fifteen percent of mothers reported their feeding style as being high demanding/high responsive; 32% as being high demanding/low responsive; 34% as being low demanding/high responsive and 18% as being low demanding/low responsive. In bivariate analyses, feeding styles significantly differed by child BMIz-score, ethnic group, and mother’s perceived stress. In multiple linear regression, a low demanding/high responsive feeding style was found to be positively associated (ß = 0.56) with a higher child weight as compared to high demanding/high responsive, controlling for known covariates (p = 0.01). Conclusions Most mothers report having a low demanding/high responsive feeding style, which is associated with higher child weight status in this diverse immigrant population. This finding adds to the growing literature that suggests this type of feeding style may be a risk factor for childhood obesity. Further research is needed to help understand the larger socio-cultural context and its influence on feeding dynamics among immigrant families and families of lower incomes. How parents establish a certain feeding style in their home country compared to when they move to the US “obesogenic” environment, should also be explored.

To build on a growing interest in community-based obesity prevention programs, methods are needed for matching intervention strategies to local needs and assets. We used the Community Readiness Model (CRM), a structured interview guide and scoring system, to assess community readiness to act on childhood obesity prevention, furthering a replication study of a successful intervention. Using the CRM protocol, we conducted interviews with 4 stakeholders in each of 10 communities of similar size, socioeconomic status, and perceived readiness to implement a community-wide obesity prevention intervention. Communities were in California, Florida, Illinois, Massachusetts, New York, North Carolina, Pennsylvania, and Tennessee. The 4 stakeholders were the mayor or city manager, the school superintendent, the school food service director, and a community coalition representative. Interviews were recorded and professionally transcribed. Pairs of trained reviewers scored the transcriptions according to CRM protocol. The CRM assesses 9 stages of readiness for 6 dimensions: existing community efforts to prevent childhood obesity, community knowledge about the efforts, leadership, community climate, knowledge about the issue, and resources. We calculated an overall readiness score for each community from the dimension scores. Overall readiness scores ranged from 2.97 to 5.36 on the 9-point scale. The mean readiness score, 4.28 (SD, 0.68), corresponds with a "preplanning" level of readiness. Of the 6 dimensions, community climate varied the least (mean score, 3.11; SD, 0.64); leadership varied the most (mean score, 4.79; SD, 1.13). The CRM quantified a subjective concept, allowing for comparison among 10 communities. Dimension scores and qualitative data from interviews helped in the selection of 6 communities for a replication study.

Background:Evidence supports the role of physical and social environments in active living, including perception of environment. However, measurement of perceived environments in rural settings is lacking. This study describes the development of the Rural Active Living Perceived Environmental Support Scale (RALPESS).Methods:Premised on social ecological and cognitive perspectives, 85 initial items were generated through a literature review and a mixed-methods investigation of “activity-friendly” environments. Items were organized by resource areas—town center, indoor and outdoor physical activity areas, schools, churches, and areas around the home/neighborhood—and submitted for expert panel review. In 2009, a revised questionnaire was disseminated to adolescents, parents, public school staff, and older adults in 2 rural southeastern United States counties. Principal component analysis with varimax rotation was used to explore factor structure (n = 542).Results:The final analysis yielded 33 items with 7 factors: 1) church facilities, 2) town center connectivity, 3) indoor areas, 4) around the home/neighborhood, 5) town center physical activity resources, 6) school grounds, and 7) outdoor areas.Conclusions:The RALPESS is a valid, internally consistent, and practically useful instrument to measure perceptions of rural environments in the context of physical activity across the lifespan. Confirmatory factor analysis is recommended to validate factor structure.

Background:Despite the recognized health benefits, few older women participate in strength-training exercises.Methods:The purpose of this study was to examine factors related to older women’s adherence to strength training after participation in the Strong Women Program, a nationally disseminated community program. Adherence was defined as ≥4 months of twice-weekly strength training. Surveys were sent to 970 program participants from 23 states and to participants’ corresponding program leaders. Five-hundred fifty-seven participants responded (57%).Results:Of respondents who completed surveys (527), 79% (415) adhered to strength training; adherers reported a mean of 14.1 ± 9.1 months of strength training. Logistic-regression analysis revealed that exercise adherence was positively associated with age (p = .001), higher lifetime physical activity levels (p = .045), better perceived health (p = .003), leader’s sports participation (p = .028), and leader’s prior experience leading programs (p = .006).Conclusion:These data lend insight to factors that may be related to exercise adherence among midlife and older women.

Parents play an important role in shaping children's eating habits. Few studies have evaluated the influence of both parenting style and parenting practices on child outcomes such as dietary intake. During spring 2007, 99 parent-child dyads from four rural US areas participated in this cross-sectional study. Child food intake was reported during two interviewer-administered, parent-assisted 24-hour recalls. Diet quality was defined as the average number of low-nutrient-dense (LND) foods consumed. Validated questionnaires were used to assess parental feeding practices and feeding style. Pearson correlations identified relationships among child food intake, parental feeding style typologies, and covariates. Regression analyses were used to predict child diet quality. Sixty percent of children and 76% of parents were overweight or obese. A permissive feeding style, which is highly responsive to a child's requests and sets few demands on him or her, was the most common (n=37) parental feeding style. This feeding style was associated with child intake of LND foods (r=0.3; P

Active living integrates physical activity into one's daily routine. Current understanding of active living among children and their families living in rural communities is limited. A community perspective is critical to understand the contextual factors that influence children's physical activity in rural areas.The purpose of this study was to identify the perceived environmental factors that support or hinder physical activity among rural children to develop testable hypotheses to inform future interventions for reducing unhealthy weight gain and preventing chronic diseases associated with physical inactivity.PhotoVOICE was used to explore active living opportunities and barriers for children living in four low-income, rural U.S. communities. In 2007, parents (n=99) and elementary school staff (n=17) received disposable cameras to document their perspective. Using their photographs and narratives, participants developed emergent themes during a facilitated group discussion. In 2008, study authors used the Analysis Grid for Environments Linked to Obesity (ANGELO) framework to categorize the themes.Microenvironment themes include physical (e.g., natural features, topography); sociocultural (e.g., isolation); policy (e.g., time for school recess); and economic (e.g., funding for physical activity programs). Macroenvironmental themes related to the built and natural environments and transportation infrastructure.This study identified rural environment elements that community members perceived as influencing children's physical activity patterns. Certain aspects were unique to rural areas, whereas other urban and suburban factors may be generalizable to rural settings. PhotoVOICE was a useful participatory research method to gain insight into perceived factors affecting rural children's physical activity behaviors.

Energy-restricted low glycemic load diets are being used increasingly for weight loss. However, the long-term effects of such regimens on mood and cognitive performance are not known. We assessed the effects of low glycemic load (LG) and high glycemic load (HG) energy-restricted diets on mood and cognitive performance during 6 months of a randomized controlled trial when all food was provided. Subjects were 42 healthy overweight adults (age 35+/-5 years; BMI 27.8+/-1.6 kg/m(2)) with a mean weight loss of 8.7+/-5.0% that did not differ significantly by diet randomization. Mood was assessed by using the Profile of Mood States (POMS) questionnaire. Cognitive performance was assessed by using computerized tests of simple reaction time, vigilance, learning, short-term memory and attention, and language-based logical reasoning. Worsening mood outcome over time was observed in the HG diet group compared to the LG for the depression subscale of POMS (p=0.009 after including hunger as a covariate). There was no significant change over time in any cognitive performance values. These findings suggest a negative effect of an HG weight loss diet on sub-clinical depression but, in contrast to a previous suggestion, provide no support for differential effects of LG versus HD diets on cognitive performance.

The purpose of this study was threefold: to investigate the association between three parenting behaviors (parenting style, feeding style, and feeding practices), to evaluate whether these behaviors were associated with child weight, and to determine whether style (parenting and feeding) moderated the relationship between feeding practice and child weight. Ninety-nine parent-child dyads were recruited for a cross-sectional study where parents self-reported their parenting style, feeding style, and feeding practices along with demographic characteristics. Height and weight were measured for each dyad. The relationship between parenting style and feeding style showed modest agreement. Feeding style, but not parenting style, was associated with child BMI z-score while controlling for known covariates. An indulgent feeding style was associated with a higher child weight status. Multiple regression analysis demonstrated that feeding style moderated the association between restrictive feeding practices and child BMI z-score. No moderating relationship was found between feeding style and the practices of pressure to eat or monitoring and child weight. This research suggests that an indulgent feeding style may be predictive of higher child weight and that future studies should examine the possible moderating role of feeding style in the parent feeding practice-child weight relationship.

Background The benefits of community-based health programs are widely recognized. However, research examining factors related to community leaders' characteristics and roles in implementation is limited. Methods The purpose of this cross-sectional study was to use a social ecological framework of variables to explore and describe the relationships between socioeconomic, personal/behavioral, programmatic, leadership, and community-level social and demographic characteristics as they relate to the implementation of an evidence-based strength training program by community leaders. Eight-hundred fifty-four trained program leaders in 43 states were invited to participate in either an online or mail survey. Corresponding community-level characteristics were also collected. Programmatic details were obtained from those who implemented. Four-hundred eighty-seven program leaders responded to the survey (response rate = 57%), 78% online and 22% by mail. Results Of the 487 respondents, 270 implemented the program (55%). One or more factors from each category – professional, socioeconomic, personal/behavioral, and leadership characteristics – were significantly different between implementers and non-implementers, determined by chi square or student's t-tests as appropriate. Implementers reported higher levels of strength training participation, current and lifetime physical activity, perceived support, and leadership competence (all p < 0.05). Logistic regression analysis revealed a positive association between implementation and fitness credentials/certification (p = 0.003), program-specific self-efficacy (p = 0.002), and support-focused leadership (p = 0.006), and a negative association between implementation and educational attainment (p = 0.002). Conclusion Among this sample of trained leaders, several factors within the professional, socioeconomic, personal/behavioral, and leadership categories were related to whether they implemented a community-based exercise program. It may benefit future community-based physical activity program disseminations to consider these factors when selecting and training leaders.

To examine the association of gestational weight gain and dietary factors with abnormal glucose tolerance (AGT).We conducted a prospective cohort study among 813 Hispanic prenatal care patients in Massachusetts. Gestational weight gain and oral glucose tolerance test results were abstracted from medical records. Dietary intake was assessed using a semi-quantitative food frequency questionnaire. Target weight gain was based on BMI-specific weekly weight gain rates established by the Institute of Medicine (IOM).We observed a statistically significant interaction between prepregnancy BMI and weight gain in relation to AGT (P0.01). Class II/III (BMIor = 35 kg/m2) obese women who had a high rate of weight gain (0.30 kg/week) or who exceeded target weight were 3-4 times as likely to develop AGT compared to women who gained within IOM ranges (OR = 4.2, 95% CI 1.1-16.0, OR = 3.2 95% CI 1.0-10.5, respectively). Decreasing levels of saturated fatty acids and energy-dense snack foods and increasing levels of fiber and polyunsaturated:saturated fat ratio were significantly associated with decreased risk of AGT, independent of gestational weight gain [corrected].Weight gain among class II/III obese women and certain dietary components may represent modifiable risk factors for AGT.

To examine how stress and health-related behaviors affect freshman weight change by gender.Three hundred ninety-six freshmen completed a 40-item health behavior survey and height and weight were collected at baseline and follow-up.Average weight change was 5.04 lbs for males, 5.49 lbs for females. Weight gain was related to increased alcohol consumption (P=0.014) in men and increased workload (P0.001) in women. Weight loss was associated with lower academic confidence at baseline (P=0.009) and peer pressure modified by alcohol increase (P=0.025) in men, and fruit/vegetable consumption at baseline (P=0.015) in women.Gender-specific approaches to weight management in this population are needed.

ObjectiveTo create, validate and assess the reliability of a checklist to measure calcium intake in children.DesignCalcium intakes from a checklist and parent-assisted 24-h dietary recall were compared. Checklist reliability was assessed separately.SettingAfter-school programmes in the United States.SubjectsForty-two children (18 males, 24 females, age = 8.0 ± 0.9 years) participated in the validation analysis and 49 children (28 males, 21 females, age = 7.5 ± 0.9 years) in the reliability analysis.ResultsNo differences in mean calcium intakes were found by method or gender. The checklist correlated well with recall among girls (r= 0.65,P= 0.01) but not boys (r= −0.33,P= 0.19). Agreement over time was above 80% for most foods.ConclusionThe calcium checklist is useful for assessing calcium intake among groups of 6–10-year-old children in settings that preclude parental assistance. More research is needed to improve accuracy among boys.

This chapter examines the specific tradeoffs between military spending and social welfare spending (the well-known guns vs. butter tradeoff) and the effects of expenditures in military budgets for recently expanding peacekeeping operations. The analysis confirms the negative relationship between mortality and the allocation of resources to military programs by the state. Citizens in countries with higher allocations to military programs have worse mortality outcomes. Greater percentages of state resources allocated to military programs are associated with higher infant mortality rate (IMRs) and lower overall life expectancy at birth (LEB) for the average citizen. The most basic aspect of freedom—the opportunity to live a life of choice—is restricted as resources are allocated away from domestic programs.

Interventions aiming to modify the dietary and physical activity behaviors of young children require precise and accurate measurement tools. As part of a larger community-based project, three school-based questionnaires were developed to assess (a) fruit and vegetable intake, (b) physical activity and television (TV) viewing, and (c) perceived parental support for diet and physical activity. Test-retest reliability was performed on all questionnaires and validity was measured for fruit and vegetable intake, physical activity, and TV viewing. Eighty-four school children (8.3+/-1.1 years) were studied. Test-retest reliability was performed by administering questionnaires twice, 1 to 2 hours apart. Validity of the fruit and vegetable questionnaire was measured by direct observation, while the physical activity and TV questionnaire was validated by a parent phone interview. All three questionnaires yielded excellent test-retest reliability (P0.001). The majority of fruit and vegetable questions and the questions regarding specific physical activities and TV viewing were valid. Low validity scores were found for questions on watching TV during breakfast or dinner. These questionnaires are reliable and valid tools to assess fruit and vegetable intake, physical activity, and TV viewing behaviors in early elementary school-aged children. Methods for assessment of children's TV viewing during meals should be further investigated because of parent-child discrepancies.

Purpose: This study examined how rural hospitals altered their postacute and long-term care strategies after the Balanced Budget Act of 1997 (BBA97). Design and Methods: A nationally representative sample of 540 rural hospital discharge planners were interviewed in 1997. In the year 2000, 513 of 540 discharge planners were reinterviewed. The study is a descriptive analysis of how rural hospitals formed new and altered existing organizational strategies during a time of turbulent changes in federal government reimbursement policy. We classify rural hospital strategic behavior in 1997 according to the Miles and Snow typology of Prospectors, Analyzers, Defenders, and Reactors, and then we examine how the various hospital types altered key strategies following BBA97. Results: Between 1997 and 2000, more than 26% of sampled rural hospitals that did not participate in the swing-bed program in 1997 (44/167) had chosen to do so in 2000, whereas only 3% of those using swing beds in 1997 had eliminated them (12/346). Other strategies such as divestiture of hospital-based nursing homes were related to concurrent swing-bed adoption. Rural hospitals also increased their reliance on formal linkages with external providers of long-term care. Implications: After the BBA97 reimbursement changes, rural hospitals increased their reliance on swing beds and formal linkages to external providers. We observed changes in overall strategy types, away from the Defender and toward the Prospector and Analyzer strategy types. Our findings illustrate the importance of swing beds as a critical buffer for rural hospitals challenged by the uncertainty of the postBBA97 environment.

Background Early environmental influences have been linked to child weight status, however further understanding of associations in diverse populations is needed. Methods A cross-sectional analysis of household and family factors associated with overweight was conducted on a culturally diverse, urban dwelling sample of 820 first through third graders (mean age 7.6 ± 1.0 years) residing in three eastern Massachusetts cities. Overweight was defined as BMI > 85th percentile, based on measured height and weight, and the CDC growth reference. Multivariate logistic regression was used to identify demographic, behavioral, and social environmental variables significantly related to weight status. Independent variables included race-ethnicity, age, sex, servings of sugar-sweetened beverages/week, hours of screen time/week, parent overweight, (calculated from self-reported weight/height), parent education, household food restriction rules regarding snacking and/or kitchen access, frequency of having dinner as a family (reported as “a lot” vs. “sometimes/rarely/never”) and child vitamin/mineral supplement use. Selected interactions were explored based on prior studies. Results Prevalence of overweight was 35.5% in girls and 40.8% in boys. In the final, adjusted model, compared to white children, the odds of overweight were higher in children of Hispanic race-ethnicity (odds ratio (OR) = 2.4, 95% CI = 1.4 - 4.1). In the same adjusted model, compared to children with no household food restriction rules, the odds of overweight were 2.6 (95% CI = 1.3-5.1) times higher and 3.5 (95% CI = 1.9-6.4) times higher for children having one rule or two rules, respectively. Parent report of frequent family dinner and child vitamin use were protective, with a halving of risk for overweight for each behavior (OR = 0.47, 95% CI = 0.31-0.71 and OR = 0.54, 95% CI = 0.37-0.78, respectively). Conclusions In the presence of other factors, frequent family dinner and vitamin use were associated with lower risk of overweight and household food restriction rules with higher risk. Although such relationships have previously been reported, this investigation is among the first to demonstrate these associations in a low-income, racially-diverse early elementary school population, and suggest potential targets of opportunity within the family context that could reduce child overweight risk in a subgroup of children at elevated risk of obesity.

Background Parents influence their children's behaviors directly through specific parenting practices and indirectly through their parenting style. Some practices such as logistical and emotional support have been shown to be positively associated with child physical activity (PA) levels, while for others (e.g. monitoring) the relationship is not clear. The objectives of this study were to determine the relationship between parent's PA-related practices, general parenting style, and children's PA level. Methods During the spring of 2007 a diverse group of 99 parent-child dyads (29% White, 49% Black, 22% Hispanic; 89% mothers) living in low-income rural areas of the US participated in a cross-sectional study. Using validated questionnaires, parents self-reported their parenting style (authoritative, authoritarian, permissive, and uninvolved) and activity-related parenting practices. Height and weight were measured for each dyad and parents reported demographic information. Child PA was measured objectively through accelerometers and expressed as absolute counts and minutes engaged in intensity-specific activity. Results Seventy-six children had valid accelerometer data. Children engaged in 113.4 ± 37.0 min. of moderate-vigorous physical activity (MVPA) per day. Children of permissive parents accumulated more minutes of MVPA than those of uninvolved parents (127.5 vs. 97.1, p < 0.05), while parents who provided above average levels of support had children who participated in more minutes of MVPA (114.2 vs. 98.3, p = 0.03). While controlling for known covariates, an uninvolved parenting style was the only parenting behavior associated with child physical activity. Parenting style moderated the association between two parenting practices - reinforcement and monitoring - and child physical activity. Specifically, post-hoc analyses revealed that for the permissive parenting style group, higher levels of parental reinforcement or monitoring were associated with higher levels of child physical activity. Conclusions This work extends the current literature by demonstrating the potential moderating role of parenting style on the relationship between activity-related parenting practices and children's objectively measured physical activity, while controlling for known covariates. Future studies in this area are warranted and, if confirmed, may help to identify the mechanism by which parents influence their child's physical activity behavior.

The 2005 Dietary Guidelines for Americans and MyPyramid recommend nutrient density as an approach for consumers to achieve nutrient adequacy while avoiding over-consumption of energy. However, from...