Objectives

To examine the relationships between characteristics of community programs and policies that are designed to prevent childhood obesity and are focused on Body Mass Index, diet, and physical activity in children.

Background

Childhood obesity is a major public health issue in the U.S. with 18.5% of children aged 2-19 having obesity (Hales, Caroll, Fryer, and Ogden, 2017). Children who have obesity are more likely to have cardiovascular risk factors (Freedman, Mei, Srinivasan, Berenson, & Dietz, 2007; Koskinen et al., 2018), type 2 diabetes (Goran, Ball, & Cruz, 2003) and are at increased risk for morbidity and mortality as adults (Reilly & Kelly, 2011) including increased risk of developing several types of cancer (World Cancer Research Fund/American Institute for Cancer Research, 2007).

Community programs and policies targeting childhood obesity are being implemented across the country, but their approaches have not been systematically studied. There is natural variation in many aspects of community programs and policies, including intensity level, duration, funding, target population, and how they are implemented. However, no previous studies have examined these variations and how such aspects of community programs and policies are related to childhood obesity outcomes. The Healthy Communities Study (HCS) was initiated to address the need for a study of community programs and policies and their relationship with childhood obesity.

The three aims of HCS are to: 1) determine the associations between characteristics of community programs and policies and obesity outcomes in children; 2) identify factors that modify or mediate the associations; and 3) examine the association between characteristics of program and policies and obesity outcomes in communities that have a high proportion of African American or Hispanic residents. This study was not designed to evaluate any one specific program, policy or community, but was designed to systematically assess if components or characteristics of programs/policies in communities across the country are related to BMI, diet, and physical activity in children.

Design

Community selection: For the purposes of HCS, a community was defined as a high school catchment area, and child participants were students at public elementary and middle schools (kindergarten through eighth grade) within the catchment areas. Communities were selected using a hybrid sampling approach. Some of the communities were “certainty” communities, which had implemented promising program and policies targeting childhood obesity. Other communities were sampled using a stratified national probability-based sample, using weights proportional to the number of children aged 4-15 in each Census Tract.

Participant recruitment At the school level, children were recruited from two public elementary and two public middle schools in each community. Materials were distributed to children in these schools and families who completed the forms were contacted by the study.

The HCS employed a complex study design that included a diverse sample of communities across the country and combines current/cross-sectional and retrospective data. Data were collected at multiple levels including at the child/household, schools, and community levels.

1. Cross-sectional component: Interviews conducted in households along with community and school assessments were the primary data collection activities for HCS. Cross-sectional data were collected on a) children and their families, b) schools, and c) communities:
1. Children and households: All children participated in the Standard Protocol measure consisting of: medical history, height, weight, and waist circumference measurements of the child; height and weight measurements (or self-reported measurements) of the two parent(s)/caregiver(s); general demographic and background questions; brief nutrition and physical activity behavior questionnaires; and a modified Windshield Survey of the home. A subset of children (approximately 14% of the children in the 130 communities) received an Enhanced Protocol, which included: all of the Standard Protocol measures listed previously plus (2) 24-hour dietary recalls during both of the home visits, the use of an accelerometer for a one-week period between the first and second home visit, and a previous day physical activity assessment questionnaire at the end of the second visit.
2. Schools: School assessments were comprised of web-based surveys and observations of the 4 participating schools. Observations in the 2 elementary and 2 middle schools included lunchroom observations, an interview of the physical education instructor, and a Physical Activity Resource Assessment (PARA) was administered to observe the school’s outdoor physical activity resources. Web-based surveys were administered to the district food service administrator/manager and a staff member from each school. The school staff completed a survey on school policies and practices related to physical activity and nutrition, whereas, the district –level personnel completed a food environment questionnaire for each of the recruited schools that were in their district.
3. Communities: In each community, interviews were conducted with key informants (10-14 persons per community) to review and gather characteristics on current community policies and programs and for communities programs and policies for up to 10 years prior.
2. Retrospective component:
1. Among children, medical records were abstracted for going back up to 10 years in approximately 65-70% the sample to develop longitudinal BMI trajectories.
2. Communities: Data were collected from key informants in each community on characteristics of programs and polices going back up to 10 years to assess how programs and policies unfolded over time in each community.

Demographics

Communities: A total of 130 diverse communities participated in the HCS. Communities were diverse with respect to low income (38.5%), urbanicity (38.5% urban, 38.5% suburban, 23.1% rural), and geographic region (42.3% South, 22.3% West, 20% Midwest, 15.4% Northeast). Communities with a high proportion of race-ethnic groups also were oversampled (32.3% Hispanic, 26.2% African American, 41.5% other). Data were collected in a total of 436 schools; 227 elementary (52%), 53 elementary/middle (12%), and 158 middle schools (36%).

There were 1,421 key informants interviewed across the 130 communities. Through the key informant interviews and document abstraction, 9,681 community programs and policies (CPPs) over the ten year retrospective study period were identified and characterized.

Participants: A total of 5,138 children and their parent(s)/caregiver(s) from 130 diverse communities across the country were recruited for the HCS study. Child participants were evenly distributed across ages 4–15 years and gender; 21.5% were African American and 43.5% were Hispanic. Nearly a third of households reported an annual income below $20,000.

Publications

Special supplement in the American Journal of Preventive Medicine on Protocol Papers

Arteaga SS, Loria CM, Crawford PB, Fawcett SB, Fishbein HA, Gregoriou M, John LV, Kelley M, Pate RR, Ritchie LD, Strauss WJ The Healthy Communities Study: Its Rationale, Aims, and Approach. Am J Prev Med. 2015 Oct;49(4):615-23. doi: 10.1016/j.amepre.2015.06.029.

Fawcett SB, Collie-Akers VL, Schultz JA, Kelley M. Measuring Community Programs and Policies in the Healthy Communities Study. Am J Prev Med. 2015 Oct;49(4):636-41. doi: 10.1016/j.amepre.2015.06.027.

Frongillo EA, Fawcett SB, Ritchie LD, Sonia Arteaga S, Loria CM, Pate RR, John LV, Strauss WJ, Gregoriou M, Collie-Akers VL, Schultz JA, Landgraf AJ, NagarajaJ. Community Policies and Programs to Prevent Obesity and Child Adiposity. Am J Prev Med. 2017 Nov;53(5):576-583. doi: 10.1016/j.amepre.2017.05.006. Epub 2017 Jul 5.

John LV, Gregoriou M, Pate RR, Fawcett SB, Crawford PB, Strauss WJ, Frongillo EA, Ritchie LD, Loria CM, Kelley M, Fishbein HA, Arteaga SS. Operational Implementation of the Healthy Communities Study: How Communities Shape Children's Health. Am J Prev Med. 2015 Oct;49(4):631-5. doi: 10.1016/j.amepre.2015.06.019

Pate RR, McIver KL, Colabianchi N, Troiano RP, Reis JP, Carroll DD, Fulton JE. Physical Activity Measures in the Healthy Communities Study. Am J Prev Med. 2015 Oct;49(4):653-9. doi: 0.1016/j.amepre.2015.06.020.

Ritchie LD, Wakimoto P, Woodward-Lopez G, Thompson FE, Loria CM, Wilson DK, Kao J, Crawford PB, Webb KL. The Healthy Communities Study Nutrition Assessments: Child Diet and the School Nutrition Environment. Am J Prev Med. 2015 Oct;49(4):647-52. doi: 10.1016/j.amepre.2015.06.016

Strauss WJ, Sroka CJ, Frongillo EA, Arteaga SS, Loria CM, Leifer ES, Wu CO, Patrick H, Fishbein HA, John LV. Statistical Design Features of the Healthy Communities Study. Am J Prev Med. 2015 Oct;49(4):624-30. doi: 10.1016/j.amepre.2015.06.021.

Sroka CJ, McIver KL, Sagatov RD, Arteaga SS, Frongillo EA. Weight Status Measures Collected in the Healthy Communities Study: Protocols and Analyses. Am J Prev Med. 2015 Oct;49(4):642-6. doi: 10.1016/j.amepre.2015.07.001.

Special supplement in Pediatric Obesity on Outcome papers

The longitudinal relationship between community programmes and policies to prevent childhood obesity and BMI in children: the Healthy Communities Study.
Strauss WJ, Nagaraja J, Landgraf AJ, Arteaga SS, Fawcett SB, Ritchie LD, John LV, Gregoriou M, Frongillo EA, Loria CM, Weber SA, Collie-Akers VL, McIver KL, Schultz J, Sagatov RDF, Leifer ES, Webb K, Pate RR; Healthy Communities Study Team. Pediatr Obes. 2018 Feb 28. doi: 10.1111/ijpo.12266. [Epub ahead of print] PMID:29493122

Objectives of community policies and programs associated with more healthful dietary intakes among children: findings from the Healthy Communities Study. Webb KL, Hewawitharana SC, Au LE, Collie-Akers V, Strauss WJ, Landgraf AJ, Nagaraja J, Wilson DK, Sagatov R, Kao J, Loria CM, Fawcett SB, Ritchie LD; Healthy Communities Study Team.Pediatr Obes. 2018 Jun 19. doi: 10.1111/ijpo.12424. [Epub ahead of print]PMID:29923334

Measuring the intensity of community programs and policies for preventing childhood obesity in a diverse sample of US communities: the Healthy Communities Study. Collie-Akers VL, Schultz JA, Fawcett SB, Landry S, Obermeier S, Frongillo EA, Forthofer M, Weinstein N, Weber SA, Logan A, Arteaga SS, Nebeling L, Au LE; Healthy Communities Study Team. Pediatr Obes. 2018 Jun 14. doi: 10.1111/ijpo.12423. [Epub ahead of print]

Relationship of objective street quality attributes with youth physical activity: findings from the Healthy Communities Study. Kaczynski AT, Besenyi GM, Child S, Morgan Hughey S, Colabianchi N, McIver KL, Dowda M, Pate RR. Pediatr Obes. 2018 Jun 14. doi: 10.1111/ijpo.12429. [Epub ahead of print]

Associations between community programmes and policies and children's physical activity: the Healthy Communities Study. Pate RR, Frongillo EA, McIver KL, Colabianchi N, Wilson DK, Collie-Akers VL, Schultz JA, Reis J, Madsen K, Woodward-Lopez G, Berrigan D, Landgraf A, Nagaraja J, Strauss WJ; Healthy Communities Study Research Group. Pediatr Obes. 2018 Jun 13. doi: 10.1111/ijpo.12426. [Epub ahead of print]

Regional comparisons of walking or bicycling for fun or exercise and for active transport in a nationally distributed sample of community-based youth. Saunders RP, Dowda M, McIver K, Pate RR; Healthy Communities Study Research Group. Pediatr Obes. 2018 Jun 14. doi: 10.1111/ijpo.12425. [Epub ahead of print]

Association between community characteristics and implementation of community programmes and policies addressing childhood obesity: the Healthy Communities Study. Schultz JA, Collie-Akers VL, Fawcett SB, Strauss WJ, Nagaraja J, Landgraf AJ, McIver KL, Weber SA, Arteaga SS, Nebeling LC, Rauzon SM; Healthy Communities Study Team. Pediatr Obes. 2018 Jun 19. doi: 10.1111/ijpo.12432. [Epub ahead of print]

Recruitment outcomes, challenges and lessons learned: the Healthy Communities Study. Sagatov RDF, John LV, Gregoriou M, Sonia Arteaga S, Weber S, Payn B, Strauss W, Weinstein N, Collie-Akers V.Pediatr Obes. 2018 Sep 12. doi: 10.1111/ijpo.12455. [Epub ahead of print]

Community characteristics modify the relationship between obesity prevention efforts and dietary intake in children: the Healthy Communities Study. Woodward-Lopez G, Gosliner W, Au LE, Kao J, Webb KL, Sagatov RD, Strauss WJ, Landgraf AJ, Nagaraja J, Wilson DK, Nicastro HL, Nebeling LC, Schultz JA, Ritchie LD; Healthy Communities Study Team. Pediatr Obes. 2018 Jul 10. doi: 10.1111/ijpo.12434. [Epub ahead of print]

Associations of community programs and policies with children's dietary intakes: the Healthy Communities Study. Ritchie LD, Woodward-Lopez G, Au LE, Loria CM, Collie-Akers V, Wilson DK, Frongillo EA, Strauss WJ, Landgraf AJ, Nagaraja J, Sagatov RDF, Nicastro HL, Nebeling LC, Webb KL; Healthy Communities Study Team. Pediatr Obes. 2018 Jul 10. doi: 10.1111/ijpo.12440. [Epub ahead of print]

References

Goran, M. I., Ball, G. D., & Cruz, M. L. (2003). Obesity and risk of type 2 diabetes and cardiovascular disease in children and adolescents. J Clin Endocrinol Metab, 88(4), 1417-1427. doi:10.1210/jc.2002-021442

Hales, C. M., Carroll, M. D., Fryar, C. D., & Ogden, C. L. (2017). Prevalence of Obesity Among Adults and Youth: United States, 2015-2016. NCHS Data Brief(288), 1-8.

Koskinen, J., Juonala, M., Dwyer, T., Venn, A., Thomson, R., Bazzano, L., . . . Magnussen, C. G. (2018). Impact of Lipid Measurements in Youth in Addition to Conventional Clinic-Based Risk Factors on Predicting Preclinical Atherosclerosis in Adulthood: International Childhood Cardiovascular Cohort Consortium. Circulation, 137(12), 1246-1255. doi:10.1161/CIRCULATIONAHA.117.029726

Reilly, J. J., & Kelly, J. (2011). Long-term impact of overweight and obesity in childhood and adolescence on morbidity and premature mortality in adulthood: systematic review. Int J Obes (Lond), 35(7), 891-898. doi:10.1038/ijo.2010.222

World Cancer Research Fund/American Institute for Cancer Research. (2007). Food, Nutrition, Physical Activity, and the Prevention of Cancer: a Global Perspective.

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