W2194: Children's Healthy Living Network (CHLN) in the U.S. Affiliated Pacific Region

(Multistate Research Project)

Status: Active

W2194: Children's Healthy Living Network (CHLN) in the U.S. Affiliated Pacific Region

Duration: 10/01/2021 to 09/30/2026

Administrative Advisor(s):

NIFA Reps:

Non-Technical Summary

Statement of Issues and Justification

The Children’s Healthy Living Program for Remote Underserved Minority Populations in the Pacific Region Network (CHLN) Multistate is a partnership among remote Pacific states and other jurisdictions of the US: Alaska, Arizona, American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI), Guam, Federated States of Micronesia (FSM), Hawai‘i, Republic of Palau, the Republic of the Marshall Islands (RMI) and West Virginia. All CHLN partners are connected via the US Land Grant College system and an interest in addressing disparities in health that are experienced by ethnic minorities and indigenous populations and those living in rural communities. CHLN partners, inclusive of land grant colleges and public health partners, share a purpose to build capacity to address relevant health issues through research, training and extension. These partnerships aim to affect policies, systems and environments that affect health and are explicitly called for in the 2019 USDA Healthy Food Systems, Healthy People call to action, and the USDA Cooperative Extension Framework for Health and Wellness (Braun et al. 2014).  The goal of the CHLN is to develop social/cultural, physical/built, and political/economic environments that will promote active play and intake of healthy food to prevent young child obesity in the Pacific Region. To do this, CHL engages the community, and focuses on capacity building and sustainable environmental change.

The Pacific region has some of the highest rates of non-communicable disease in the world. The Marshall Islands and Guam are in the top ten for diabetes prevalence in the world (30.5% and 18.7%, respectively, International Diabetes Federation 2019). Diabetes, heart diseases, stroke, cancers and other non-communicable diseases are affecting Pacific peoples at a disproportionate rate compared to other populations, placing a significant burden on their daily functionality, and threatening the national security of these island countries and territories (PIHOA 2010). All of these conditions have a primary common factor: obesity. The number of adults with obesity is among the highest in the world in these countries, especially among women (FSM 58%, RMI 48%, Ng et al 2013). Pacific lifestyles continue to transition from native crops to imported foods, and from active forms of work and play to sedentary ones, as in most of the world (World Health Organization, 2015). These populations face a dual burden of food insecurity and obesity, where estimates of nearly half of children sampled by the CHL research program on Guam were living in households who lacked sufficient food or resources to feed the household (Li et al, 2016). 

Data are limited on children of the region. Obesity in children is an important determinant of obesity in adulthood. CHL has been successful in collecting data on child growth in the region, where 30% of children in the CHL sample suffered from overweight or obesity (Li et al, 2016). Children with obesity have a higher chance of developing obesity, premature death and disability in adulthood. Children with obesity have breathing difficulties, increased risk of fractures, hypertension, early markers of cardiovascular disease, insulin resistance and psychological effects. Contributors to obesity occur across the life course and include both early undernutrition and nutrition excess. Obesity is associated with social and health problems. Prevention is the best long term solution.

This multistate project continues to support and extend the CHL network's training, intervention activities and research programs initiated through CHL, which has demonstrated feasibility of the approach. The land grant institutions held community meetings that resulted in the CHL application.  The community engagement process included over 900 community members that included parents, teachers, and community leaders; who identified the need for environmental interventions that address six key behavioral outcomes that became the six CHL target behaviors (Fialkwoski, 2013). The priorities and intervention strategies remain relevant as evidenced by sustained CHL interventions and partner programs. This multistate project has continued to be an important mechanism that maintains the stable partnership and coordinated activities and has facilitated the expansion to include Arizona and West Virginia partners. These partners bring a wealth of new resources and interventions that can be adapted for our region and CHL interventions can be adapted to inform strategies to promote child health in Arizon and West Virginia communities as well. Without this multistate the group will need to rely on grant opportunities that are now smaller and will likely result in smaller less coordinated subsets of the partners working together.  This project has the potential to model multistates as platforms for coordinated health extension coalitions to facilitate and support broad sector partnership for health.


Related, Current and Previous Work

The CHLN team represents US affiliated Pacific jurisdictions, states, and partners across the contiguous U.S., with a base in the land grant colleges and has evolved from past collaborations among its participants. The largest collaboration was from a USDA NIFA CAP grant (Grant number 2011-68001-30335), and most recent was the Child Healthy Living Center grant (Grant number 69001-27551). CHL evolved from 20 years developing land grant partnership through the Agricultural Development of the American Pacific Program, and its outgrowth, Healthy Living in Pacific Islands (Novotny et al 2013).  Developments as a result of CHL, include a functioning management structure that spans the region, PSE-oriented multi-level intervention research, built capacity and credit and non-credit curriculum in PSE-oriented work to prevent obesity in childhood, collection, analysis, and dissemination of data that filled the gap of missing nutrition surveillance systems in the region, and continued leveraging of these systems to contribute new knowledge through peer reviewed research and publication that informs programs and policies relevant to the underserved population of the Pacific. In addition two training programs, the Child Health Assessment in the Pacific and Children’s Healthy Living Program Dietetic Scholars, have built capacity in the region around child assessment, child health, and dietetics professionals. Since NHANES does not sample the Pacific region, nor present data on Native Hawaiian, Native Alaskan or Pacific Islander race/ethnic groups, measured data on obesity, dietary intake and physical activity are not available without CHL, and are critical to guide programs and policies. Further, since Pacific foods are not identified in these surveys, they will not be analyzed by national labs for nutritional composition, to guide nutrition guidance and programs in the region.

Since the establishment of the CHLN Multistate (W1194),  an additional $2,325,903 in USDA funds has been awarded in the Pacific, over 200 individuals have received formal education on Pacific child nutrition and health through the online Children’s Healthy Living Program Summer Institute courses, four Native Hawaiian students pursuing degrees in Dietetics have been provided partial scholarships,  standardized protocols for collecting anthropometric measures (weight, height, waist circumference) have been developed and adopted across the Network partners, data on the nutritional status of individuals and communities in the region has been collected by measuring 1,753 individuals and assessing 548 community environments and CHL data has yielded 12 peer-reviewed publications and been utilized by 30 students in pursuit of higher education. The foundational groundwork for this was accomplished through the CHL CAP grant where CHL gathered data on 51 communities in 11 jurisdictions on over 5,000 children, their households, and their communities. 27 of these communities in 5 jurisdictions were involved in a multilevel community randomized controlled trial (Wilkens et al 2014) and the other 25 communities collected the same data in a one-time prevalence survey.  Data include acanthosis nigricans screening, weight, height and waist circumference assessment, 2 randomly selected days of 6,453 food and activity logs (food records and physical activity logs) from 2-8yo children throughout the region, community environment assessments (store, park, church, walkability and food and utility cost assessments), data which will be evaluated to help fill the void in data for policy and program planning, and which will provide a foundation from which ongoing monitoring systems will be developed and sustained. 

Further, CHL has developed a community based intervention program (Braun et al. 2014, Fialkowski et al. 2013, Wilken et al 2013) and CHLN works to disseminate it and continues to serve as a data hub and a facilitator of coalition building and training in the community (Fialkowski et al 2015). 

The CHL work was conducted through a community engaged process (Fialkowski et al 2013) that involved development of Local Advisory Committees (LAC’s) in each jurisdiction, that included all sectors and provide groups identified that might influence child health.  These LAC’s meet at least annually and evolved into community and jurisdiction level coalitions that organized and sustained key efforts.  CHL was recognized as a backbone organization that facilitates the work and provides a key evaluation and training role that we aim to sustain with this multistate project; this role suited to the land grant mission of facilitation of community work (extension), evaluation (research) and training (instruction).

Renewal of the CHLN multistate project  will extend the continued partnership in the region to adress child obesity by focusing on the Pacific Region and the policy, systems and environmental approaches to obesity prevention and support of child health and wellness, while expanding to address child health as it relates to issues around food cost, food insecurity, and food systems that have been brought to light by the COVID-19 pandemic and increasingly frequent natural disasters that affect the region and its communities.



  1. To conduct research on food cost, local food availability, and local food consumption availability across jurisdictions.
  2. To review existing tools and develop valid tools, as needed, for estimating food security appropriate to the USAP jurisdictions.
  3. To evaluate, using appropriate methods, the impact of training program activities’ facilitated by CHL to address capacity in child health.


1. To conduct research on food cost, local food availability, and local food consumption across jurisdictions. The CHLN team will utilize food cost survey data collected from across the USAP region to explore differences in local food cost and availability, specifically examining differences in costs based on the thrifty food plan (TFP) foods and supplemental foods that were identified as the foods most frequently consumed by children in the region. Differences will be compared across store types and jurisdictions.

2. To review existing, and/or develop valid tools for estimating food security for the USAP jurisdictions. In the absence of Federal nutrition surveillance and significant USAP populations in the validation of standard food security questions utilized by programs such as EFNEP and BRFSS, the CHLN team will develop and validate questions that aim to understand food security in the context of environments where non-monetary exchanges of food occur (i.e., growing, gathering, fishing, hunting). The CHLN team will work with EFNEP programs in the region to pilot test the question and conduct key informant interviews with EFNEP staff and directors to understand how the food security questions are interpreted by EFNEP participants.

3. To investigate appropriate tools to evaluate the CHL training program activities’ impact on the capacity to address child health. This research will also contribute to scholarship of teaching, informing teaching methodologies and impact of place-based open access training materials. The CHLN team conducts a number of training activities (i.e., research mentorship, assistantships to support individuals to pursue graduate training, curriculum development, and learning resource creation) that aim to address child health and nutrition. The team will work to develop appropriate tools that will be used to evaluate the impacts of these efforts in order to quantify the impact on the USAP region’s capacity to address child health. to include evaluation of the impact of innovative pedagogical methods (i.e. flipped classroom approach and integrated learning activities in Open Education Resource textbooks) on student learning of nutrition curriculum

The CHLN will have available data from the CHL prevalence, intervention studies and follow-up studies, tools used to collect those data (accelerometers, stadiometers, scales, measuring tapes, Pacific Tracker diet and activity software), training material developed (Pacific Food Guide, CHL Summer Institute, Open Education Resource Human Nutrition TextBook https://pressbooks.oer.hawaii.edu/humannutrition), and CHL intervention materials (Role Model Training Guide, Master Gardening and Food Preservation Materials). 

These resources, data, and collaborations will form the basis of new grant proposals, training programs, extension and outreach activities and capacity building within each jurisdiction.

Measurement of Progress and Results


  • Updated food cost including identification of local foods in jurisdictions
  • Validated questions for measuring food insecurity in the USAP
  • Validated instrument/protocol for quantifying impact of the training program activities on the capacity of the region to address child health.
  • Evidence-based strategies for training program implementation
  • Reports, manuscripts, and presentations reflecting the work of the CHLN participants and collaborating partners
  • • WEBSITE CHL research-based interventions, training resources, community reports, and peer reviewed publications disseminated on the CHL website (chl-pacific.org) .

Outcomes or Projected Impacts

  • Food cost survey efforts to help inform Federal policy and activities that impact nutrition assistance programs in the region.
  • Tools for quantifying the impact of training programs on capacity for addressing child health.
  • Enhanced knowledge and availability of effective resources that support the research training of individuals working on child health in the USAP.
  • Overall, research activities will elucidate relationships between multiple factors (environment, institutional, household, individual) influences on child health.


(2022):Objective1-Analyze food cost data from across the USAP, which includes foods from the thrifty food plan (TFP) and frequently consumed foods by children from CHL intervention diet data, across the region. Objective 2-Analyze existing food security data over time (past 9 years) from EFNEP programs across the region. Objective 3-Develop curriculum and open education resources (OER) to improve training of nutrition and health professionals. Develop a list of jurisdiction-level signature foods to inform future food cost analysis and consumption.

(2023):Objective 1- Publish food cost data from across the USAP including comparisons of food cost and availability of local foods and comparisons of availability by store type. Objective 2- Coordinate among EFNEP leaders to develop a food insecurity question to be added to EFNEP surveys to understand impacts of other food resources (non-monetary). Objective 3- Design evaluation measures for training program efforts. Analyze data collected from OER and curriculum innovations.

(2024):Objective 1- Food cost data collected for signature foods and analyze consumption data for signature foods across the USAP. Objective 2- Food insecurity questions added to jurisdiction level EFNEP surveys. Surveys and qualitative interviews with EFNEP coordinators to gain feedback on new food insecurity questions. Objective 3- Implement evaluation for training program efforts. Publish manuscript on OER and curriculum innovations.

Projected Participation

View Appendix E: Participation

Outreach Plan

The CHL (http://www.chl-pacific.org/) and CHLN (www.chln.extension.org) websites will be maintained to provide access to publications, intervention material and community reports and scientific reports, and data dashboards.  Peer-reviewed publications will be accessible to the scientific community through national research databases and the CHL website.

Classes will be offered through an online platform (CHL Summer Institute) through Outreach College at the University of Hawai‘i in child obesity policy, systems and environmentally focused multi-level prevention, child health, nutrition assessment and monitoring. This method allows anyone to take these courses at the in-state tuition rate for credit. Non-credit classes for continuing education will also be offered. In addition, the content of these courses is readily available for all to view.

Training and partnership in child health assessment and monitoring will be available through the CHLN.


The proposed multi-state group (CHLN) has a history of using a collaborative approach in implementing their research projects.  This relationship started with the Agricultural Development of the American Pacific Program and Healthy Living in Pacific Islands, and was fortified further with our largest collaboration (CHL) and now the CHAP.  The research team has established common procedures, protocols, and organizational structure. The CHL Coordinating Center will be maintained with guidance provided by the CHL Program Steering Committee (PSC) composed of a representative from each jurisdiction that participated in CHL (Hawai‘i, Alaska, American Samoa, Guam, Commonwealth of the Northern Mariana Islands, Palau, RMI, FSM).  CHL data and publication guidelines will be followed and will provide opportunity for submission and review of manuscript proposals from any interested party.

An annual meeting will take place to evaluate progress and to plan for the upcoming year. The attendees at the supporting CHLN annual meeting will nominate and elect a chair, a vice chair and a secretary to oversee the annual plan of work. The chair will appoint subcommittees to complete specific objectives and tasks; subcommittees will meet on a monthly basis. The vice-chair will succeed the chair and support the chair in performing his/her duties and serve for a one-year term.  The secretary will distribute documents prior to meetings, provide minutes describing the discussion and actions suggested during the meetings maintain an updated members roster, and help the chair/vice-chair prepare the accomplishments report.  The secretary will succeed the vice-chair.

Conference calls for multistate representatives will be held, at minimum, quarterly. Sub-committees will share updates on progress towards meeting specific objectives.

Jurisdiction local advisory committee meetings will be held to ensure cross-sector partnership.


Literature Cited

Braun B, Bruns K, Cronk L, Fox LK, Koukel S, Le Menestrel S, Lord LM, Reeves C, Rennekamp R, Rice C, Rodgers M, Samuel J, Vail A, Warren T. Cooperative Extension’s National Framework for Health and Wellness, March 2014.

Fialkowski MK, DeBaryshe B, Bersamin A, Nigg C, LeonGuerrero RT, et al. A community engagement process identifies environmental priorities to prevent early childhood obesity: the Children’s Healthy Living Program for Remote Underserved Populations in the Pacific Region (CHL). Maternal Child Health J, 2013;18:2261-2274. DOI 10.1007/s10995-013-1353-3. (PMID: 24043557)

Fialkowski MK, Delormier T, Hattori-Uchima M, Leslie JH, Greenberg J, Kim J, Deenik JL, Dunn MA, Areta A, Novotny R. Indigenous Workforce Training by the Children’s Healthy Living Program (CHL) to Prevent Childhood Obesity in the Underserved US Affiliated Pacific Region. J Health Care Poor Underserved. 2015; 26(2 Supplement): 83-95.

Interagency Committee on Human Nutrition Research. National Nutrition Research Roadmap 2016‒2021: Advancing Nutrition Research to Improve and Sustain Health. Washington, DC: Interagency Committee on Human Nutrition Research; 2016.

International Diabetes Federation. IDF Diabetes Atlas, 9th edn. Brussels, Belgium: 2019. Available at: https://www.diabetesatlas.org

Li, F., Wilkens, L. R., Novotny, R., Fialkowski, M. K., Paulino, Y. C., Nelson, R., Boushey, C. J. Anthropometric measurement standardization in the US-affiliated pacific: Report from the Children's Healthy Living Program. American Journal of Human Biology, 2015. doi: 10.1002/ajhb.22796

Li F, Novotny R, Wilkens LR, Fialkowski MK, Guerrero RT, Coleman P, Bersamin A, Fleming T, and Deenik J. Food Insecurity and Young Child BMI Status in the U.S. Affiliated Pacific (USAP) Region: Findings from the Children’s Healthy Living Program. The FASEB Journal 2016 30:1_supplement, 273.7-273.7.

Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2014;384(9945).

Novotny R, Fialkowski MK, Areta AA, Bersamin A, Braun K, DeBaryshe B, Deenik J, Dunn M, Hollyer J, Kim J, Leon Guerrero RT, Nigg CR, Takahashi R, Wilkens LR. University of Hawai'i Cancer Center Connection: 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, 2013; Nov;72(11):406-8. (PMCID: PMC3831571)

Novotny R, Fialkowski MK, Li F, Paulino YSN, Vargo D, Jim R, Coleman P, Bersamin A, Nigg CR, Leon Guerrero RT, Deenik, J, Kim JH, Wilkens LR. Systematic review of prevalence of young child overweight and obesity in the United States Affiliated Pacific region compared to the 48 contiguous states: a the Children’s Health Living Program. Am J Pub Health, 2014;DOI:10.2105/AJPH2014.302283. (PMID: 25393168)

Pacific Island Health Officer's Association (PIHOA) 2010. State of Emergency due to Non communicable Disease. http://www.pihoa.org/initiatives/policy/ncds.php

USDA Healthy Food Systems, Healthy People, 2016.

Wilkens LR, Novotny R, Fialkowski MK, Boushey CJ, Nigg C, Paulino YSN, LeonGuerrero RT, Bersamin A, Vargo D, Kim J, Deenik J. Children’s Healthy Living (CHL) Program for Remote Underserved Populations in the Pacific Region: rationale and design of a community randomized trial to prevent early childhood obesity. BMC Public Health, 2013;13(1):944. (PMCID: PMC3851862)

World Health Organization, 2015, Obesity. Available at:http://www.who.int/mediacentre/factsheets/fs311/en.



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