Duration: 10/01/2006 to 09/30/2012

Administrative Advisor(s):

NIFA Reps:

Non-Technical Summary

Statement of Issues and Justification

Overweight and obesity have reached epidemic proportions in the United States. The proportion of adults who are overweight increased substantially between 1980 and 2002 (CDC, 2005). By 2002, 65% of U.S. adults (20-74 yrs of age) were overweight and 31% were obese. Likewise, obesity has become the most prevalent nutritional disease of children and adolescents (Dietz, 1998, CDC, 2005). Children from low SES and racial/ethnic minority groups tend to have higher rates of obesity in comparison to other groups (Nesbitt et al., 2004; Thompson et al., 2003). Among adults, obesity rates are about 28% for men regardless of racial/ethnic group membership. Adult women have higher rates of obesity than males. Obesity rates are higher among Hispanic women (39%) than White women (31%) and even higher (50%) among African-American women (CDC, 2005). It is well known that chronic disease risks increase with increasing body weight (Mokdad et al., 2001). It is also clear that overweight and obese children are likely to remain overweight and obese adults and to develop chronic diseases at younger ages (Ebbing et al., 2002).

Obesity was first declared a major public concern in 1952 (Nestle and Jacobson, 2000). Since then billions of dollars have been spent to prevent and intervene with no discernable effect. It is obvious that we need new approaches. The complexity and multifaceted nature of obesity development and its intractability strongly argue for multi-disciplinary approaches. Clearly, obesity has genetic roots. However, the argument that genetic predisposition to obesity makes obesity inevitable (Speakman, 2004) is no more productive in terms of prevention/intervention than the traditional "eat less, exercise more" solution (Fairburn and Cooper, 1996; Wardle, 1996, Nestle and Jacobson, 2000). Safe, effective and affordable pharmacologic and genetic interventions are, at best, years away from discovery. Stakeholders, individuals, the scientific community, educators and health care providers, cannot and should not wait for drug or genetic "cures" for obesity. Unfortunately, long-term, multi-million dollar campaigns to change behavioral and environmental risks for obesity development have not been able to document success in slowing the rise in obesity prevalence (Nestle and Jacobson, 2000).
While children learn eating behaviors from adults and peers (Jansen et al., 2003), there are relatively few studies examining the role of the family in shaping and supporting behaviors leading to weight gain, loss, or maintenance (IOM, 2000;).

Resilience
Resilience is a characteristic that exists only in a condition of adversity. Such is the current situation: families find themselves living within an obesogenic environment. Examples of what they face include exposure to television advertising; large portions; frequent eating away from home experiences; limited physical activity; etc. Since not all low-income children are overweight, it safely can be assumed that some low-income families negotiate through this environment without their children becoming at risk for, or overweight (regardless of genetic influence). What makes these families different (e.g. resilient) from others in the same environment? Only by comparing families can this question be resolved. Once differences are revealed, then realistic interventions can be designed, presented and evaluated.

Targeted Behaviors
Much has been written about which factors are associated with the development, treatment and prevention of childhood overweight (Agras & Mascola, 2005, Boon & Clydesdale 2005, Dehghan et al. 2005, Must & Tybor, 2005, Patrick & Nicklas, 2005, Phillippas & Lo, 2005, Sherry, 2005.) Key behaviors identified are listed below. The assumption has been that if these behaviors could be mitigated, the prevalence of childhood overweight would decrease. Therefore, these are topics suggested to be targeted for interventions.

" high intake of sweetened beverages (including fruit juice)
" sedentary behaviors vs. regular physical activity
" lower intakes of fruit and vegetable
" few family meals
" frequent eating out
" skipping breakfast
" large portion sizes
" unlimited TV/media viewing
" high intake of energy-dense, nutrient poor snack foods
" specific parenting behaviors (e.g. restrictive feeding practices; parental control over child's food intake; pressuring child to eat; rewarding with food; parental dietary intake and dieting practices; parental concern of child's weight and family functioning).

In a review of household behaviors, Whitaker (Whitaker 2004) noted the following as the highest ranked behaviors for four behavioral domains. Specifically, these are reducing screen time (physical activity/inactivity domain); limiting portion sizes and eating meals away from home (eating context domain); limiting sugar-sweetened beverages (foods consumed domain); and breastfeeding (parent feeding domain). In another review, restriction was the only feeding domain associated with increased food consumption and weight status of children (Faith, K.S. Scanlon et al. 2004).

The American Dietetic Association commissioned a group of researchers to explore the strength of evidence of the relationship of many of these key targeted behaviors to childhood overweight(http://www.adaevidencelibrary.com/).
None of these behaviors were given a Grade of I (considered to be supported by good/strong evidence). At best, a few were deemed to be supported by evidence of fair value (II). Most on the list were supported by limited or weak data (III).

Yet these are the very topics that are promoted as targets for preventing childhood overweight. As such, community nutrition educators and other health professionals may be directing efforts towards these topics by providing classes, designing written materials, making videotapes, planning social marketing campaigns, etc. in an attempt to help low-income families make food and activity choices that will prevent childhood obesity. A paucity of information exists at the community level as to whether or not these topics are being covered; the amount of time, money, and other resources being devoted to these topics; and the extent of the impact of these efforts.

Logic Model
One way to try to capture impact of community interventions (as opposed to randomized clinical trials) is to use the Logic Model (McCawley 2001; Medeiros, Butkus et al. 2005). By collecting information in a systematic way, agencies can determine the extent of the impact of their work on a variety of community members over time. The goal of the Community Nutrition Education Model (Medeiros, Butkus et al. 2005) is to provide educational programs and social marketing activities that increase the likelihood of people making healthy food choices consistent with the most recent dietary advice as reflected in the Dietary Guidelines for Americans and the Food Guidance System, with special attention to people with limited budgets. This model can be adapted for the purposes of developing and evaluating interventions to prevent childhood obesity in low income families.

Practice Informs Research
Traditionally, health practitioners working within the community setting have relied on researchers to inform their practice (e.g. to help them direct their efforts to improve the health and well-being of members of their community). This approach is the final step in the medical model: results of randomized clinical trials (or other types of research studies) are shared with experts and practitioners who then translate the research outcomes into usable strategies for consumers. The underlying assumption of this approach is that once people know what is good or right, they will change their behaviors. For issues regarding communicable diseases, this procedure has been very effective. This can be seen with the disappearance of many infectious diseases. It also has been effective, over a period of 25 years or so, in relation to the reduced incidence of smoking and increased seat belt use.
However, there is increasing evidence that this process may not be as effective when it involves behaviors related to overall health and well-being, e.g. reduction of chronic diseases (Buchanan 2000). That is, it is not simply a matter of translating research information about healthful eating and physical activity choices into oral or written messages. Knowledge does not automatically lead to changes in behavior when it relates to practices that have strong economic and cultural implications. Furthermore, to research the impact of community-level intervention requires different models than clinical trials. Often, randomized controlled studies cannot be done. Furthermore, human behavior is not predictable; therefore, using standardized strategies to collect valid information may be cumbersome or unrealistic.

Perhaps it is time for practice to inform research. In other words, before attempting to take all the new information constantly flowing from research institutions, it might be best to do the type of field research that will identify what changes individuals and families might be able and willing to consider. It also would be informative to see what tools practitioners need BEFORE attempting to initiate an intervention so that the impacts could be measured.

This proposal deviates from the traditional model of research informing practice by first exploring what is currently being done by practitioners with a concurrent exploration into more useable physical screening tools(McDowell, Fryar et al. 2005). These activities are followed by ethnographic studies of families with children between the ages of 4-10 years old to distinguish parental behaviors that override the obesogenic environment. Upon completion of activities and integration of results, a framework for implementing realistic intervention strategies will emerge.

This research requires a transdisciplinary approach. Expertise is required in nutrition, family and child ecology, health behavior change theory, nutrition education, communications, social statistics and qualitative research methodology. The Multistate Research approach is ideal for fostering this type of transdisciplinary work. Bringing researchers with a wide range of expertise together will provide a platform for developing innovative, multidimensional methods for obesity assessment, prevention and intervention in a community based setting. Multistate research will allow for increased resource capacity, including larger sample sizes. This will provide more confidence in the reliability and validity of results and, in turn, a stronger foundation for devising and testing interventions.

Hypothesis: 1 Parent-child relationships underlie key behaviors associated with resilience to childhood overweight. 2 Anthropometric and physiological measures exist that can distinguish between resilient and overweight children in low-income families within the community setting.

1 Key behaviors associated with childhood obesity (and hence targeted for intervention) include high intake of sweetened beverages; sedentary behaviors; lower intakes of fruit and vegetable consumption; few family meals; unlimited TV/media viewing; high intake of energy-dense, nutrient poor foods; and specific parenting behaviors (e.g. restrictive feeding practices; parenting style).

2 Resilience is a characteristic that exists only in a condition of adversity. Such is the situation of the current "obesogenic" environment in which families live (e.g. exposure to television advertising; large portions; frequent eating away from home experiences; limited physical activity; etc.).

Related, Current and Previous Work

A CRIS search for active projects in human obesity research resulted in a list of approximately 40 studies. Of these, the main objectives of 12 studies had limited relationship to assessment, prevention or intervention in human obesity (e.g. examining bone loss during body weight reduction; examining swine metabolism for optimizing economic value). The objectives of six projects included single nutrient effects on obesity, surgical procedure comparison, and analysis of secondary data sets. The objectives of seven of the studies were to examine obesity at the molecular, genetic or metabolic level. The remaining studies stated objectives related to food choice behavior, intervention efficacy and diverse populations (e.g. Native Americans and Korean Americans). The behavioral studies are focused mainly on underserved or rural populations. Many of the researchers with obesity-related projects within CRIS have expressed interest in participating in the current proposed study. Only one Multistate Project addresses obesity. This is a new project entitled NC1028: Promoting healthful eating to prevent excessive weight gain in young adults scheduled to begin October 1, 2006. It is focused on young adult college age students. It will not be looking at low income groups nor will it focus on family relationships. While there is no overlap between the North Central project and the proposed Western project, opportunities for communication will be sought facilitated by the same CSREES representative on both projects.

There is no question that more research on the role of family influences that would moderate obesity is essential to address the growing obesity problem. The 2005 Dietary Guidelines Committee (2004) recommended 17 areas directly related to obesity that require research. These areas range from identifying "mechanisms to motivate individual change of eating behaviors and habits" to defining the term "nutrient density." Ten additional recommendations including the need for clinical trials, identifying macronutrient impacts on metabolism, and examining food composition reflect the strong emphasis this publication places on all aspects of obesity research. Likewise the 2004 Strategic Plan for NIH Obesity Research (NIH, 2004) lists six broad areas for research including, "Behavioral and environmental approaches to modifying lifestyle to prevent or treat obesity; Research on special populations at high risk for obesity, including children, ethnic minorities, women and older adults"; and "Translating basic science results into clinical research and then into community intervention studies."
In 2004, several USDA agencies jointly sponsored a National Summit on Obesity Prevention and USDA's CSREES sponsored a workshop for CSREES grantees working on obesity prevention. Both groups were charged with identifying research needs and both groups identified the need for multidisciplinary research to address the multifaceted problem of obesity. As stated above, the Multistate Research approach is ideal for developing and conducting research that will bring us closer to stemming the increase in obesity rates.

This Multistate Research project will be integrated research, Extension and graduate education. Nitzke et al. (2004) describe the benefits of collaborations where Research and Extension professionals combined their expertise.

In summary, previous methods to prevent obesity and interventions to promote weight loss/weight control have been unsuccessful at stemming the increase in weight gain among both children and adults. Low income and minority populations are especially vulnerable to obesity but reasons for this are unknown. It is clear that the causes of obesity are multi-factorial involving complex interactions between physiological, behavioral, social and environmental variables.

Objectives

1. Conduct an expert field review of key behavioral measures purported to contribute to excessive weight gain in children aged 4-10 years old.
   
2. Identify anthropometric and physiological measures that could be used to differentiate families within the target population in the community setting
   
3. To assess parent-child interactions in the target population as they relate to key behaviors identified as being associated with resilience to overweight
   
4. Determine appropriate tools to effectively measure salient behavioral differences between low-income families in the parent-child relationships identified in Objective 3 for the community setting
   
5. Design a framework for prevention strategies targeting the development of resilience behaviors.
   

Methods

1. Objective 1 is to conduct an expert field review of key behavioral measures purported to contribute to excessive weight gain in children aged 4-10 years old. The purpose is to support, reject or revise research-based suggestions of behaviors that influence child overweight in the target population. Fourteen of the fifteen participating universities will contribute to Objective 1. An interview protocol will be jointly developed for use in each state. A decision will be made concerning the type and number of key informants to be interviewed in each state. Key informants that will be considered include those in the Cooperative Extension System, the Expanded Food and Nutrition Education Program, the Food Stamp Nutrition Education program, the school system and public health departments. Details to investigate include: What behaviors do they consider most important to target? What are they currently teaching? What methods they currently use in teaching? What insights they have into the extent that each behavior is relevant to their audience? An instrument for analysis of this type of qualitative data will be identified and tested to determine recurrent themes and practices. Each state will have their own data for local use as well as the compiled data for joint reports and publications. Based on the results of the interviews, a decision will be made about the need for and feasibility of conducting a more national quantitative survey. If needed, it is expected that a subset of the participating universities would seek outside funding for such a survey. 2. Objective 2 is to identify anthropometric and physiological measures that could be used to differentiate families within the target population in the community setting. The purpose is to develop a robust methodology that can be used uniformly by the participating states. Eleven of the fifteen participating universities will contribute to Objective 2. Each will collect information from key informants in their states such as those identified under Objective 1 to determine current practices and perceived needs related to assessments of body weight or lean/fat mass. The literature and research community, especially researchers in the participating states, will be queried about practical alternatives such as percent body fat measured through a simple skin test of electrical impedance, self selection of pictures of body shapes, etc. The testing of the sensitivity and specificity of alternatives might be a separate spin-off project carried out by a subset of the participating universities for which they would seek outside funding. 3. Objective 3 is to assess parent-child interactions in the target population as they relate to key behaviors identified as being associated with resilience to overweight. The purpose is to characterize key parent-child relationships that may underlie behaviors associated with resilience to overweight in low income families. Eight of the fifteen participating universities will contribute to Objective 3. Using the measurement tool(s) identified under Objective 2, the principal investigators in each state will identify an agreed upon number of resilient and non-resilient families. An interview protocol will be jointly developed and pilot tested by the participating institutions with input from family life specialists. An instrument for analysis of interview data collected will be used to characterize the parent-child relationship which may be linked to resilience and to the behaviors identified under Objective 1. Each state will have their own data for local use as well as the compiled data for joint reports and publications. 4. Objective 4 is to determine appropriate tools to effectively measure salient behavioral differences between low-income families in the parent-child relationships identified in Objective 3 for the community setting. The purpose is to find research-based tools for measuring the behaviors and parent-child relationships associated with resilience to overweight. Nine of the fifteen participating universities will contribute to Objective 4. The literature and the research community will be queried to identify existing validated tools that can be used in a practical setting to help focus and evaluate interventions. Unmet needs for tools will be identified as a basis for future research. 5. Objective 5 is to design a framework for prevention strategies targeting the development of resilience behaviors. The purpose is to develop a guide for that identifies behaviors to be targeted in interventions and identifies methods for evaluating success. The guide is seen as being not only useful to the Cooperative Extension System, but to others working towards obesity prevention in low-income families in community settings. Nine of the fifteen participating universities will contribute to Objective 5. They will jointly develop the framework of prevention strategies and the template of evaluation questions and methods. The entire group of universities participating in the project is expected to review and comment on drafts developed under Objective 5.

Measurement of Progress and Results

Outputs

• Reliable methods for measuring the stated objective-associated goals.
• Development of new or improvement of existing intervention strategies with aims of effective and efficient implementation in the community setting.
• Development of new or improvement of existing tools for measuring the effectiveness of the interventions targeted to childhood overweight in low income families.
• Identification of objective, physiological-based measures that correspond to target behaviors (bio-behavioral markers) for use later as measures of intervention progress and success or means for tailoring interventions in ways that will be most effective for specific groups and subgroups.
• Identification of key parent-child relationships that reflect resiliency and the interaction of these relationships with targeted behaviors, including the identified major contributing behaviors to childhood overweight and resiliency thereof in this population.
• These methods will become the standards of methods and measurement allowing later studies to build on findings from this study.

Outcomes or Projected Impacts

• More effective programs and student experiences with extension and research will result from this project.
• Advances in the study of obesity, particularly an understanding of various inputs and interactions of family and child, SES, nutrition, physiology and behavior, will result from this work, opening doors of opportunity for development of effective solutions to reverse trends in childhood obesity.
• " The need to communicate with key researchers and educators in each state should result in the formation of networks focused on obesity prevention and facilitate further collaborations.

Milestones

(2007): Support, reject or revise research suggestions of behaviors that influence child overweight in the target population

(2008): Determine research measurements that can be used within the community setting as opposed to a research setting

(2009): Characterize parent-child relationships that reflect resiliency Pinpoint the key parent-child relationships that underlie behaviors associated with resilient low income families

(2010): Evaluate existing tools for measuring the effectiveness of interventions targeted to childhood overweight in low income families Identify missing domains/ parameters/ measures that need to be included to complete existing tools

(2011): Develop a protocol of prevention strategies and initiatives aimed at increasing resilience to childhood overweight. Develop a template of questions to be considered for evaluating interventions aimed at increasing resiliency in low-income families living within an obesogenic environment

Projected Participation

View Appendix E: Participation

Outreach Plan

Results will be disseminated through referred publications, non-referred but peer reviewed publications, and presentations at regional and national professional meetings. A particular effort will be made to reach local partners in public health, schools, youth development groups and government who are also trying to address the problem of obesity.

Organization/Governance

The organizational structure consists of a chair and secretary nominated and elected annually by the technical committee. The chair will appoint subcommittees to complete the specific tasks. Conference calls will be held at minimum quarterly and an annual meeting will take place to address progress on project.

Literature Cited

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Agras WS, Mascola AJ. (2005) Risk factors for childhood overweight.
Curr Opin Pediatr 2005 17(5):648-52.

Boon CS, Clydesdale FM. (2005) A review of childhood and adolescent obesity interventions. Crit Rev Food Sci Nutr 45(7):511-25.

Buchanan, D. R. (2000). An ethic for health promotion: rethinking the sources of human well-being. New York, Oxford University Press.

CDC. National Center for Health Statistics. Health, United States, 2004, http://www.cdc.gov/nchs/hus.htm, January 3, 2005 (accessed January 11, 2005)

Dehghan M, Akhtar-Danesh N, Merchant AT. (2005) Childhood obesity, prevalence and prevention. Nutr J 2;4(1):24.

Dietz W.H.(1998). Health Consequences of Obesity in Youth: Childhood Predictors of Adult Disease. Pediatrics. 101: 518-525.

Ebbing CB, Pawlak DB, Ludwig DS. (2002). Childhood obesity: public-health crisis, common sense cure. Lancet, 360:473-482.

Fairburn CG, Cooper Z. New perspectives on dietary and behavioral treatments for obesity. Internatl J Obesity 20(S1):9-13, 1996.

Faith, M. S., K.S. Scanlon, et al. (2004). "Parent-child feeding strategies and their relationships to child eating and weight status." Obesity Research 12(11): 1711-1722.

IOM. Health and behavior: The interplay of biological, behavioral, and societal influences. Washington DC:National Academy Press, 2001.

Jansen A, Theunissen N, Slechten K, Nederkoorn C, Boon B, Mulkens S, Roefs A. (2003) Overweight children overeat after exposure to food cues. Eat Behav, 4:197-209.

McCawley, P. F. (2001). The logic model for program planning and evaluation. Moscow, ID, University of Idaho Extension: 5.

McDowell, M., C. D. Fryar, et al. (2005). Anthropometric reference data for children and adults: U.S. population, 1999-2002. Hyattsville MD, National Center for Health Statistics: 32.

Medeiros, L. C., S. N. Butkus, et al. (2005). "A Logic Model Framework for Community Nutrition Education." J Nutr Educ Behav. 37: 197-202.

Mokdad AH, Ford E, Bowman B (2001). Prevalence of Obesity, Diabetes, and Obesity Related Health Risk Factors. JAMA, 289:76-79.

Must A, Tybor DJ. (2005) Physical activity and sedentary behavior: a review of longitudinal studies of weight and adiposity in youth. Int J Obes 29 Suppl 2:84-96.

Nesbitt, S.D., Ashaya, M.O., Stettler, N., Sorof, J.M., Goran, M.I., Parekh, R., Falkner, B.E.(2004). Overweight as a Risk Factor in Children: A Focus on Ethnicity. Ethn and Dis. 14: 94-110.

Nestle M, Jacobson MF. Halting the obesity epidemic: A public health policy approach. Public Health Reports 115:12-24, 2000.

NIH. Strategic Plan for NIH Obesity Research. http://www.obesityresearch.nih.gov/About/strategic-plan.htm August 19, 2004 (accessed January 12, 2005).

Nitzke S, Kritsch K, Lohse B, Horacek T, White A, Greene G, Georgiou C, Betts N, Boeckner L. (2004) Extension and Research Professionals Join Forces to
Address a Critical Nutrition Issue. Journal of Extension, 42(5):online, http://www.joe.org/joe/2004august/iw1.shtml. (accessed January 13, 2005).

Patrick H, Nicklas TA. (2005) A review of family and social determinants of children's eating patterns and diet quality. J Am Coll Nutr 24(2):83-92.

Philippas NG, Lo CW. (2005) Childhood obesity: etiology, prevention, and treatment. Nutr Clin Care 8(2):77-88.

Sherry B. (2005) Food behaviors and other strategies to prevent and treat pediatric overweight. Int J Obes 29 Suppl 2:S116-26.

Speakman JR. (2004). Obesity: The Integrated Roles of Environment and Genetics. Journal of Nutrition, 134: 2090S 2105S, 2004.

Thompson, V.J., Baranowski, T., Cullen, K.W., Rittenberry, L., Baranowski, J., Taylor, W.C., Nicklas, T. (2003). influence on Diet and physical Activity Among Middle Class African-American 8 to 10 year Old Girls at Risk of Becoming Obese. J Nutr Edu Behav. 35: 115-123

Wardle J. Obesity and behavior change: Matching problems to practice. Internatl J Obesity 20(S1):1-8, 1996.

Whitaker, R. C. (2004). A review of household behaviors for preventing obesity in children. Rockville MD, Mathematica Policy Research, Inc.: 42.

Attachments

Land Grant Participating States/Institutions

AZ, CA, DC, FL, GA, HI, IA, IL, MA, MI, MS, NE, NJ, NM, NV, NY, OK, TX, UT, WI

Non Land Grant Participating States/Institutions

NIFA, Research, South Carolina State University