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Novotny, R., F. Li, L. Wilkens, M. Fialkowski, T. Fleming, P. Coleman, R. Leon Guerrero, A. Bersamin, and J. Deenik. 2017. Economic Influences on Child Growth Status, from the Children’s Healthy Living Program in the US-Affiliated Pacific Region. ADBI Working Paper 698. Tokyo: Asian Development Bank Institute. Available: https://www.adb.org/publications/economic-influences-child-growth-status. (pdf)

Mean obesity level of the 2–8-year-old children in the region was 14.4%, 14.1% were overweight, 2.7% were underweight, 1.4% were stunted, and 6.8% were stunted at birth. Acanthosis nigricans prevalence was 5%, an indicator of pre-diabetes. Sixty-one percent of the children were Native Hawaiian or Pacific Islander and 20% were of more than one race. Food insecurity was common. It was especially high in the Federated States of Micronesia and the Republic of the Marshall Islands at over 70%. Twenty-five percent of households in the region earned less than $10,000 per year. World Bank-defined upper middle-income jurisdictions had relatively high levels of both undernutrition and obesity. Jurisdiction income level was the most important factor influencing growth status in multivariate models. Policies and strategies for jurisdiction economic development and improvement of child growth status should protect local food systems and active living during economic transition. The terms of the renegotiated compact of free association with the United States, especially in the upper middle-income countries (Palau and the Republic of the Marshall Islands) that are experiencing a dual burden of undernutrition and overnutrition, are expected to play a key role in the future health of residents of these jurisdictions.

Rachel Novotny, Fenfang Li , Rachael Leon Guerrero , Patricia Coleman, Aifili J. Tufa , Andrea Bersamin , Jonathan Deenik and Lynne R Wilkens. Dual burden of malnutrition in US Affiliated Pacific jurisdictions in the Children’s Healthy Living Program. Novotny et al.BMC Public Health (2017) 17:483 DOI 10.1186/s12889-017-4377-6. (pdf)

Background: Few data are available on dual burden of under and over nutrition of children in the Pacific region. The objective was to examine prevalence of stunting at birth and current stunting and their relationship to obesity in US Affiliated Pacific (USAP) jurisdictions. Methods: Cross sectional survey with cluster sampling by community. 5558, 2–8 years olds were measured in 51 communities in 11 USAP jurisdictions. The main outcome measures were stunting at birth, current stunting and obesity by body mass index. Prevalences of stunting at birth, current stunting and obesity were determined, adjusting for age distribution and community clustering. Differences by among age, sex, race and jurisdiction income levels were evaluated by chi-square analysis. Relationships of stunting at birth and current stunting with obesity were examined using a hierarchical model accounting for the study design. Results: Prevalences were stunting at birth 6.8% (Standard Error, SE = 0.9%), current stunting 1.4% (SE = 0.2%) and obesity 14.03.8% (SE = 0.9%). Obesity was highest in upper middle income jurisdictions (UMIJ) at 17.5%. Stunting at birth differed by race (p = 0.0001) with highest prevalence among Native Hawaiian/Pacific Islanders (10.7%). Prevalence of stunting at birth was different by jurisdiction income level with 27.5% in lower middle income jurisdictions (LMIJ), and 22. 2% in UMIJ, and 5.5% in higher than high income jurisdictions (HIJ) at 5.5% (p < 0.0001). Prevalence of current stunting was higher in LMIJ than HIJ (p = 0.001), although children with current stunting were less likely to have been stunted at birth. The association between stunting at birth and current stunting was negative (OR = 0.19, 95% CI: 0.05–0.69). Conclusions: Currently stunted children were marginally less likely to be obese than not stunted children in the USAP, where the prevalence of current stunting is low. Stunting (at birth and current) was highest in LMIJ, while UMIJ jurisdictions had the highest dual burden of malnutrition (that is the highest combination of both stunting at birth and obesity). Trial registration: National Institutes for Health clinical trial # NCT01881373 (clinicaltrials.gov). Keywords: Pacific, Race, Income, Obesity, Stunting, Country

Esquivel MK, Fialkowski MK, Aflague T, Novotny R (2016) Engaging Head Start Teachers on Wellness Policy Implementation to Improve the Nutrition and Physical Activity Environment in Head Start Classrooms: A Qualitative Study of the Children’s Healthy Living Program (CHL) in Hawai’i. J Family Med Community Health 3(5): 1094. (pdf)

Child care center policies have the potential to contribute to childhood obesity prevention. Policies at these centers vary by state and funding agency and barriers to implementation decreases compliance. The objective of this study was to engage Head Start (HS) teachers to inform a preschool wellness policy intervention for childhood obesity prevention. Two focus groups on preschool wellness policy were composed of HS teachers from two previously randomized communities. Focus groups were facilitated by one researcher and took place in May 2014 in Hawai‘i. Sixteen teachers participated in one of two focus groupsChild care center policies have the potential to contribute to childhood obesity prevention. Policies at these centers vary by state and funding agency and barriers to implementation decreases compliance. The objective of this study was to engage Head Start (HS) teachers to inform a preschool wellness policy intervention for childhood obesity prevention. Two focus groups on preschool wellness policy were composed of HS teachers from two previously randomized communities. Focus groups were facilitated by one researcher and took place in May 2014 in Hawai‘i. Sixteen teachers participated in one of two focus groups (n=6 and n=10) and were asked to give recommendations for policies to support childhood obesity prevention in their classrooms. Audio recordings were transcribed verbatim. Three researchers identified themes following an inductive method. Teachers 1) valued being a positive influence on the development of children, 2) saw that policy supported a safe classroom environment and encouraged consistent role modeling, and 3) saw gaps in resources as a barrier to promoting health. Policies are needed that facilitate teachers being role models of health and teachers’ efficacy in addressing nutrition with parents through training and technical assistance. The necessity of a Registered Dietitian Nutritionist was identified to support these efforts. Findings informed policy changes for an intervention study.(n=6 and n=10) and were asked to give recommendations for policies to support childhood obesity prevention in their classrooms. Audio recordings weretranscribed verbatim. Three researchers identified themes following an inductive method. Teachers 1) valued being a positive influence on the development of children, 2) saw that policy supported a safe classroom environment and encouraged consistent role modeling, and 3) saw gaps in resources as a barrier to promoting health. Policies are needed that facilitate teachers being role models of health and teachers’ efficacy in addressing nutrition with parents through training and technical assistance. The necessity of a Registered Dietitian Nutritionist was identified to support these efforts. Findings informed policy changes for an intervention study.

Nigg, C.R., Ul Anwar, M.M., Braun, K.L., Mercado, J., Fialkowski, M.K., Areta, A., Belyeu Camacho, T., Bersamin, A., Leon Guerrero, R., Castro, R., DeBaryshe, B., Vargo, A.M., Braden, K.W., Novotny, R. A review of promising multicomponent environmental child obesity prevention intervention strategies by the children’s healthy living program. Journal of Environmental Health. 2016; 79(3): 18-26. (pdf)

Childhood obesity has increased rapidly over the last three decades in the U.S. Individual-level interventions targeting healthy eating and physical activity have not significantly impacted clinical measures of obesity in children. Focusing “upstream” on physical, social, cultural, political, and economic environments may be more effective. The purpose of this qualitative review is to analyze published environmental interventions that effectively prevented or reduced obesity in children ages 2–10 years by working within their family, school, and/or community environment to increase physical activity, reduce sedentary behaviors, or improve healthy diet. Through an electronic database search, 590 original articles were identified and 33 were read in full. Using Brennan and coauthors’ (2011) rating system, 18 were rated as effective intervention studies. This analysis showed that interventions targeting multiple environments (e.g., family, school, and community) show promise in reducing childhood obesity. Further research is needed to test interventions targeting multiple environments in different communities and populations.

Mikkelsen, B.E., Novotny, R., Gittelsohn, J. Multi-Level, Multi-Component Approaches to Community Based Interventions for Healthy Living—A Three Case Comparison. Int. J. Environ. Res. Public Health. 2016; 13:1023. doi:10.3390/ijerph13101023 (pdf)

There is increasing interest in integrated and coordinated programs that intervene in multiple community settings/institutions at the same time and involve policy and system changes. The purpose of the paper is to analyse three comparable cases of Multi Level, Multi Component intervention programs (ML-MC) from across the world in order to give recommendations for research, policy and practice in this field. Through the comparison of three cases: Health and Local Community (SoL-program), Children’s Healthy Living (CHL) and B’More Healthy Communities for Kids (BHCK), this paper examines the potential of ML-MC community-based public health nutrition interventions to create sustainable change. The paper proposes methodology, guidelines and directions for future research through analysis and examination strengths and weaknesses in the programs. Similarities are that they engage and commit local stakeholders in a structured approach to integrate intervention components in order to create dose and intensity. In that way, they all make provisions for post intervention impact sustainability. All programs target the child and family members’ knowledge, attitudes, behavior, the policy level, and the environmental level. The study illustrates the diversity in communities as well as diversity in terms of which and how sites and settings such as schools, kindergartens, community groups and grocery stores became involved in the programs. Programs are also different in terms of involvement of media stakeholders. The comparison of the three cases suggests that there is a need to build collaboration and partnerships from the beginning, plan for sufficient intensity/dose, emphasize/create consistency across levels and components of the intervention, build synchronization across levels, and plan for sustainability.

Novotny R., Li F., Fialkowski M.K., Bersamin A., Tufa A., Deenik J., Coleman P., Leon Guerrero R., Wilkens, L.R. Prevalence of obesity and acanthosis nigricans among young children in the children’s healthy living program in the United States Affiliated Pacific. Medicine (2016) 95:37(e4711). http://dx.doi.org/10.1097/MD.0000000000004711 (pdf)

Estimate prevalence of obesity and acanthosis nigricans (AN) among children in United States Affiliated Pacific (USAP) jurisdictions. Cross-sectional measurement of weight, height, and AN in 5775, 2 to 8 years old in 51 communities—Hawai‘i, Alaska, Commonwealth of the Northern Mariana Islands, Guam, American Samoa, Palau, Republic of the Marshall Islands (RMI), 4 Federated States of Micronesia (Pohnpei, Yap, Kosrae, Chuuk). Analyses weighted to jurisdiction-specific sex and age distributions accounting for clustering of communities within jurisdictions. Prevalence of obesity was 14.0%, overweight 14.4%, healthy weight 68.9%, and underweight 2.6%, higher in males (16.3%) than females (11.6%), higher among 6 to 8 years old (16.3%) than 2 to 5 years old (12.9%), highest in American Samoa (21.7%), and absent in RMI. In total, 4.7% of children had AN, with no sex difference, higher in 6 to 8 years old (6.8%) than 2 to 5 years old (3.5%) and highest in Pohnpei (11.9%), and absent in Alaska. Obesity was highly associated with AN (odds ratio=9.25, 95% confidence interval=6.69–12.80), with the strongest relationships among Asians, followed by Native Hawaiians and Pacific Islanders (NHPI). Obesity, age, and Asian and NHPI race were positively associated with AN.

Yamanaka, A., Fialkowski, M., Wilkens, L., Li, F., Ettiene, R., Fleming, T., Power, J., Deenik, J., Coleman, P., Leon Guerrero, R., Novotny, R. Quality assurance on data collection in the multi-site community randomized trial and prevalence survey of the children’s healthy living program. BMC Research Notes. 2016; 9:432. doi:10.1186/s13104-016-2212-2 Yamanaka_2016

Background: Quality assurance plays an important role in research by assuring data integrity, and thus, valid study results. We aim to describe and share the results of the quality assurance process used to guide the data collection process in a multi-site childhood obesity prevalence study and intervention trial across the US Affiliated Pacific Region. Methods: Quality assurance assessments following a standardized protocol were conducted by one assessor in every participating site. Results were summarized to examine and align the implementation of protocol procedures across diverse settings. Results: Data collection protocols focused on food and physical activity were adhered to closely; however, protocols for handling completed forms and ensuring data security showed more variability. Conclusions: Quality assurance protocols are common in the clinical literature but are limited in multi-site community-based studies, especially in underserved populations. The reduction in the number of QA problems found in the second as compared to the first data collection periods for the intervention study attest to the value of this assessment. This paper can serve as a reference for similar studies wishing to implement quality assurance protocols of the data collection process to preserve data integrity and enhance the validity of study findings. Trial registration: NIH clinical trial #NCT01881373

Esquivel MK, Nigg C, Fialkowski JK, Braun K, Li F, Novotny R. Influence of teachers’ personal health behaviors on operationalizing obesity prevention policy in Head Start preschools: A project of the Children’s Healthy Living Program (CHL). Journal for Nutrition Education and Behavior. 2016; 48 (5) (pdf)

Background: The increased prevalence of childhood overweight and obesity across the United States and the Pacific has become a serious public health concern, with especially high prevalence among Native Hawaiian and Pacific Islander (NHPI) children. This study aimed to measure the effect of a Head Start (HS) policy intervention for childhood obesity prevention. Methods: Twenty-three HS classrooms located in Hawaii participated in the trial of a 7-month policy intervention with HS teachers. Classroom- and child-level outcome assessments were conducted, including: the Environment and Policy Assessment and Observations (EPAO) of the classroom environment; plate waste observations to assess child intake of fruit and vegetables; and child growth. Results: The intervention showed a positive and significant effect on classroom EPAO physical activity (PA) and EPAO total scores. Although mean BMI X-score (xBMI) increased at post intervention for both intervention (mean=0.60; standard deviation [SD], 1.16; X=114) and delayed-intervention groups (mean=0.35; SD, 1.17; X=132), change in XBMI was not significantly different between the groups (X=0.50; X=0.48). Conclusions: These findings contribute evidence on the potential for HS wellness policy to improve the PA environment of HS classrooms. More research is needed to link these policy changes to other child outcomes.

Ettienne R., Nigg C., Fenfang L., Yuhua S., McGlone K., Luick B., Tachibana A., Carran C., Mercado J., Novotny R. Validation of the Actical Accelerometer in multiethnic Preschoolers: The Children’s Healthy Living Program.Hawaii Journal of Medicine and Public Health. 2016; April 76 (4) 95-100.

This study aimed to determine the validity and reliability of the Actical accelerometer for measuring physical activity (PA) in preschool children of mixed ethnicity, compared with direct observation via a modified System for Observing Fitness Instruction Time (SOFIT) protocol and proxy parental reports (PA Logs). Fifty children in Hawai‘i wore wrist-mounted accelerometers for two 7-day periods with a washout period between each week. Thirty children were concurrently observed using SOFIT. Parents completed PA Logs for three days. Reliability and validity were measured by intra-class correlation coefficient and proportions of agreement concurrently. There was slight agreement (proportion of agreement: 82%; weighted Kappa=.17, P<.001) between the accelerometer and SOFIT as well as between the accelerometer and the PA Logs (proportions of agreement: 40%; weighted Kappa=0.15, P<.001). PA logs underestimated the PA levels of the children, while the Actical was found to be valid and reliable for estimating PA levels of multiethnic, mixed ethnicity preschoolers. These findings suggest that accelerometers can be objective, valid, and accurate physical activity assessment tools compared to conventional PA logs and subjective reports of activity for preschool children of mixed ethnicity.

Fialkowski, Marie Kainoa PhD, RDN, LDN; Matanane, Lenora BS, MS; Gibson, W. Jay BA, BBA; Yiu, Ericka; Hollyer, Jim MS; Kolasa, Kathryn PhD, RDN, LDN; Novotny, Rachel PhD, RDN, LDN. 2016. Pacific Food Guide.  Nutrition Today. March/April 2016 – Volume 51 – Issue 2 – p 72–81. doi: 10.1097/NT.0000000000000145 (pdf)

The US Affiliated Pacific Region includes 10 jurisdictions with unique foods and food practices. Providing nutrition education to participants in this region is challenging because 2 different dietary guidelines are used: the US Dietary Guidelines with MyPlate and the Secretariat for the Pacific Community Dietary Guidelines. The purpose of this article is to describe the process used to develop a Pacific Food Guide, a conduit for linking the 2 dietary guidelines applied in the region. The Pacific Food Guide was developed, piloted, and evaluated as being useful in an introductory college-level nutrition course that serves the diverse student population of the US Affiliated Pacific Region. Nutr Today. 2016;51(2):72Y81

Marie K. Fialkowski, Ashley Yamanaka, Lynne R. Wilkens, Kathryn L. Braun, Jean Butel, Reynolette Ettienne, Katalina McGlone, Shelley Remengesau, Julianne M. Power, Emihner Johnson, Daisy Gilmatam, Travis Fleming, Mark Acosta, Tayna Belyeu-Camacho, Moria Shomour, Cecilia Sigrah, Claudio Nigg, Rachel Novotny.  Recruitment Strategies and Lessons Learned from the Children’s Healthy Living Program Prevalence Survey. 2016. doi: 10.3934/publichealth.2016.1.140  Fialkowski et al 2016 recruitment strategies CHL AIMS Public Health

The US Affiliated Pacific region’s childhood obesity prevalence has reached epidemic proportions. To guide program and policy development, a multi-site study was initiated, in collaboration with partners from across the region, to gather comprehensive information on the regional childhood obesity prevalence. The environmental and cultural diversity of the region presented challenges to recruiting for and implementing a shared community-based, public health research program. This paper presents the strategies used to recruit families with young children (n = 5775 for children 2 – 8 years old) for obesity-related measurement across eleven jurisdictions in the US Affiliated Pacific Region. Data were generated by site teams that provided summaries of their recruitment strategies and lessons learned. Conducting this large multi-site prevalence study required considerable coordination, time and 141 AIMS Public Health Volume 3, Issue 1, 140-157. flexibility. In every location, local staff knowledgeable of the community was hired to lead recruitment, and participant compensation reflected jurisdictional appropriateness (e.g., gift cards, vouchers, or cash). Although recruitment approaches were site-specific, they were predominantly school-based or a combination of school- and community-based. Lessons learned included the importance of organization buy-in; communication, and advance planning; local travel and site peculiarities; and flexibility. Future monitoring of childhood obesity prevalence in the region should consider ways to integrate measurement activities into existing organizational infrastructures for sustainability and costeffectiveness, while meeting programmatic (e.g. study) goals.

Esquivel MK., Nigg C., Fialkowski M., Braun K., Li F., Novotny R.. Headstart Wellness Policy Intervention in Hawaii: A Project of the Children’s Healthy Living Program (CHL). Childhood Obesity. 2016; 12(1): 1-7. doi:10.1089/chi.2015.0071 (pdf)

Background: The increased prevalence of childhood overweight and obesity across the United States and the Pacific has become a serious public health concern, with especially high prevalence among Native Hawaiian and Pacific Islander (NHPI) children. This study aimed to measure the effect of a Head Start (HS) policy intervention for childhood obesity prevention. Methods: Twenty-three HS classrooms located in Hawaii participated in the trial of a 7-month policy intervention with HS teachers. Classroom- and child-level outcome assessments were conducted, including: the Environment and Policy Assessment and Observations (EPAO) of the classroom environment; plate waste observations to assess child intake of fruit and vegetables; and child growth. Results: The intervention showed a positive and significant effect on classroom EPAO physical activity (PA) and EPAO total scores. Although mean BMI X-score (xBMI) increased at post intervention for both intervention (mean=0.60; standard deviation [SD], 1.16; X=114) and delayed-intervention groups (mean=0.35; SD, 1.17; X=132), change in XBMI was not significantly different between the groups (X=0.50; X=0.48). Conclusions: These findings contribute evidence on the potential for HS wellness policy to improve the PA environment of HS classrooms. More research is needed to link these policy changes to other child outcomes.

Li F., Wilkens L., Novotny R., Fialkowski MK., Paulino Y., Nelson R., Marin U., Deenik J., Bersamin A., Boushey C.. Anthropometric Measurement Standardization in the U.S. Affiliated Pacific: Report from The Children’s Healthy Living Program. American Journal of Human Biology. 2015. doi: 10.1002/ajhb.22796 (pdf)

Addressing complex chronic disease prevention, like childhood obesity, requires a multi-level, multicomponent culturally relevant approach with broad reach. Models are lacking to guide fidelity monitoring across multiple levels, components, and sites engaged in such interventions. The aim of this study is to describe the fidelity-monitoring approach of The Children’s Healthy Living (CHL) Program, a multi-level multi-component intervention in five Pacific jurisdictions. A fidelitymonitoring rubric was developed. About halfway during the intervention, community partners were randomly selected and interviewed independently by local CHL staff and by Coordinating Center representatives to assess treatment fidelity. Ratings were compared and discussed by local and Coordinating Center staff. There was good agreement between the teams (Kappa=0.50, p<0.001), and intervention improvement opportunities were identified through data review and group discussion. Fidelity for the multi-level, multi-component, multi-site CHL intervention was successfully assessed, identifying adaptations as well as ways to improve intervention delivery prior to the end of the intervention.

Butel J., Braun K., Novotny R., Acosta M., Castro R., Fleming T., Powers J., Nigg C.. Assessing intervention fidelity in a multi-level, multi-component, multi-site program: the Children’s Healthy Living program. TBM. 2015. (DOI) 10.1007/s13142-015-0334-z. (pdf)

Background: Almost 40% of children are overweight or obese by age 8 years in the US-Affiliated Pacific, inclusive of the five jurisdictions of Alaska, Hawaii, American Samoa, Guam, and the Commonwealth of the Northern Mariana Islands. This article describes how the Children’s Healthy Living (CHL) Program used the ANGELO (Analysis Grid for Environments/Elements Linked to Obesity) model to design a regional intervention to increase fruit and vegetable intake, water consumption, physical activity, and sleep duration and decrease recreational screen time and sugar-sweetened beverage consumption in young children ages 2–8 years. Methods: Using the ANGELO model, CHL (1) engaged community to identify preferred intervention strategies, (2) reviewed scientific literature, (3) merged findings from community and literature, and (4) formulated the regional intervention. Results: More than 900 community members across the Pacific helped identify intervention strategies on importance and feasibility. Nine common intervention strategies emerged. Participants supported the idea of a regional intervention while noting that cultural and resource differences would require flexibility in its implementation in the five jurisdictions. Community findings were merged with the effective obesity-reducing strategies identified in the literature, resulting in a regional intervention with four crosscutting functions: (1) initiate or strengthen school wellness policies; (2) partner and advocate for environmental change; (3) promote CHL messages; and (4) train trainers to promote CHL behavioral objectives for children ages 2–8 years. These broad functions guided intervention activities and allowed communities to tailor activities to maximize intervention fit. Conclusions: Using the ANGELO model assured that the regional intervention was evidence based while recognizing jurisdiction context, which should increase effectiveness and sustainability.

Braun K, Nigg C, Fialkowski MK, Butel J, Hollyer J, Barber LR, Teo-Martin U, Flemming T, Vargo A, Coleman P, Bersamin A, Novotny R.  Using the ANGELO Framework to Develop the Children’s Healthy Living Program Multilevel Intervention to Promote Obesity Preventing Behaviors for Young Children in the US Affiliated Pacific Region. Child Obes. 2014; 10(6): 474 – 281.  (pdf)

We estimated overweight and obesity (OWOB) prevalence of children in USAffiliated Pacific jurisdictions (USAP) of the Children’s Healthy Living Program compared with the contiguous United States. We searched peer-reviewed literature and government reports (January 2001–April 2014) for OWOB prevalence of children aged 2 to 8 years in the USAP and found 24 sources. We used 3 articles from National Health and Nutrition Examination Surveys for comparison. Mixed models regressed OWOB prevalence on an age polynomial to compare trends (n = 246 data points). In the USAP, OWOB prevalence estimates increased with age, from 21% at age 2 years to 39% at age 8 years, increasing markedly at age 5 years; the proportion obese increased from 10% at age 2 years to 23% at age 8 years. The highest prevalence was in American Samoa and Guam. (Am J Public Health. Published online ahead of print November 13, 2014: e1–e14. doi:10.2105/AJPH. 2014.302283)

Novotny R, Fialkowski MK, Li F, Paulino Y, Vargo D, Jim R, Coleman P, Bersamin A, Nigg CR, Leon Guerrero RT, Deenik J, Kim JH, Wilkens LR. Prevalence of Young Child Overweight and Obesity in the United States Affiliated Pacific Region as Compared to the 48 Contiguous States: A Systematic Review and Meta-regression by the Children’s Healthy Living Program. Am J Public Health. 2015; 105(1): e22 – e35.  (pdf)

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Aflague TF, Leon Guerrero RT, Boushey CJ. Adaptation and Evaluation of the WillTry Tool Among Children in Guam. Prev Chronic Dis 2014;11:140032. DOI: http://dx.doi.org/10.5888/PCD11.140032  (pdf)

Child care center policies have the potential to contribute to childhood obesity prevention. Policies at these centers vary by state and funding agency and barriers to implementation decreases compliance. The objective of this study was to engage Head Start (HS) teachers to inform a preschool wellness policy intervention for childhood obesity prevention. Two focus groups on preschool wellness policy were composed of HS teachers from two previously randomized communities. Focus groups were facilitated by one researcher and took place in May 2014 in Hawai‘i. Sixteen teachers participated in one of two focus groups (n=6 and n=10) and were asked to give recommendations for policies to support childhood obesity prevention in their classrooms. Audio recordings were transcribed verbatim. Three researchers identified themes following an inductive method. Teachers 1) valued being a positive influence on the development of children, 2) saw that policy supported a safe classroom environment and encouraged consistent role modeling, and 3) saw gaps in resources as a barrier to promoting health. Policies are needed that facilitate teachers being role models of health and teachers’ efficacy in addressing nutrition with parents through training and technical assistance. The necessity of a Registered Dietitian Nutritionist was identified to support these efforts. Findings informed policy changes for an intervention study.

Rachel Novotny, PhD, RD, Marie K Fialkowski, PhD, RD, Aufa’i Apulu Ropeti Areta, MA, Andrea Bersamin, PhD, Kathryn Braun, DrPH, Barbara DeBaryshe, PhD, Jonathan Deenik, PhD, Michael Dunn, PhD, James Hollyer, MS, Jang Kim, PhD, Rachael T Leon Guerrero, PhD, Claudio R Nigg, PhD, Ron Takahashi, MA, and Lynne R Wilkens, DrPH.  2013.  The Pacific Way to Child Wellness: The Children’s Healthy Living Program for Remote Underserved Minority Populations of the Pacific Region (CHL).   Hawaii J Med Public Health. Nov 2013; 72(11): 406–408.

The Children's Healthy Living Program for Remote Underserved Minority Populations of the Pacific Region (CHL) is a partnership among land grant colleges in the US Affiliated Pacific region. The jurisdictions in the CHL partnership are American Samoa, Alaska, the Commonwealth of the Northern Mariana Islands, the Federated States of Micronesia (Chuuk, Kosrae, Pohnpei, and Yap), Guam, Hawai‘i, the Marshall Islands, and Palau.

Wilken LR1, Novotny R, Fialkowski MK, Boushey CJ, Nigg C, Paulino Y, Leon Guerrero R, Bersamin A, Vargo D, Kim J, Deenik J.  2013. Children’s Healthy Living (CHL) Program for remote underserved minority populations in the Pacific region: rationale and design of a community randomized trial to prevent early childhood obesity.   BMC Public Health. 2013 Oct 9;13:944. doi: 10.1186/1471-2458-13-944.

BACKGROUND: Although surveillance data are limited in the US Affiliated Pacific, Alaska, and Hawaii, existing data suggest that the prevalence of childhood obesity is similar to or in excess of other minority groups in the contiguous US. Strategies for addressing the childhood obesity epidemic in the region support the use of community-based, environmentally targeted interventions. The Children's Healthy Living Program is a partnership formed across institutions in the US Affiliated Pacific, Alaska, and Hawaii to design a community randomized environmental intervention trial and a prevalence survey to address childhood obesity in the region through affecting the food and physical activity environment. METHODS/DESIGN: The Children's Healthy Living Program community randomized trial is an environmental intervention trial in four matched-pair communities in American Samoa, the Commonwealth of the Northern Mariana Islands, Guam, and Hawaii and two matched-pair communities in Alaska. A cross-sectional sample of children (goal n = 180) in each of the intervention trial communities is being assessed for outcomes at baseline and at 24 months (18 months post-intervention). In addition to the collection of the participant-based measures of anthropometry, diet, physical activity, sleep and acanthosis nigricans, community assessments are also being conducted in intervention trial communities. The Freely Associated States of Micronesia (Federated States of Micronesia, and Republics of Marshall Islands and Palau) is only conducting elements of the Children's Healthy Living Program sampling framework and similar measurements to provide prevalence data. In addition, anthropometry information will be collected for two additional communities in each of the 5 intervention jurisdictions to be included in the prevalence survey. The effectiveness of the environmental intervention trial is being assessed based on the RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework. DISCUSSION: The Children's Healthy Living Program environmental trial is designed to focus on capacity building and to maximize the likelihood of sustainable impact on childhood obesity-related behaviors and outcomes. The multiple measures at the individual, community, and environment levels are designed to maximize the likelihood of detecting change. This approach enhances the likelihood for identifying and promoting the best methods to promote health and well-being of the children in the underserved US Affiliated Pacific Region. TRIAL REGISTRATION: NIH clinical trial # NCT01881373.

Fialkowski, M. K., DeBaryshe, B., Bersamin A., Nigg, C., Leon Guerro, R., Rojas, G., Areta, A. A. R., Vargo, A., Belyeu-Camacho, T., Castro, R., Luik, N., Novotny, R., & the CHL Team (2013). A community engagement process identifies environmental priorities to prevent early child obesity: The Children’s Healthy Living (CHL) program for remote underserved populations in the US affiliated Pacific Islands, Hawaii, and Alaska. Maternal and Child Health Journal. DOI 10.1007/s10995-013-1353-3.

Underserved minority populations in the US Affiliated Pacific Islands (USAPI), Hawaii, and Alaska display disproportionate rates of childhood obesity. The region’s unique circumstance should be taken into account when designing obesity prevention interventions. The purpose of this paper is to (a), describe the community engagement process (CEP) used by the Children’s Healthy Living (CHL) Program for remote underserved minority populations in the USAPI, Hawaii, and Alaska (b) report community-identified priorities for an environmental intervention addressing early childhood (ages 2–8 years) obesity, and (c) share lessons learned in the CEP. Four communities in each of five CHL jurisdictions (Alaska, American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Hawai‘i) were selected to participate in the community randomized matched-pair trial. Over 900 community members including parents, teachers, and community leaders participated in the CEP over a 14 month period. The CEP was used to identify environmental intervention priorities to address six behavioral outcomes: increasing fruit/vegetable consumption, water intake, physical activity and sleep; and decreasing screen time and intake of sugar sweetened beverages. Community members were engaged through Local Advisory Committees, key informant interviews and participatory community meetings. Community-identified priorities centered on policy development; role modeling; enhancing access to healthy food, clean water, and physical activity venues; and healthy living education. Through the CEP, CHL identified culturally appropriate priorities for intervention that were also consistent with the literature on effective obesity prevention practices. Results of the CEP will guide the CHL intervention design and implementation. The CHL CEP may serve as a model for other underserved minority island populations.