The Youth-Nex Conference on Physical Health and Well-Being for Youth, Oct 10 & 11, 2013, University of Virginia "Developing Sustainable Family-Centered Obesity Interventions: What Can We Learn from Developmental Psychology and Implementation Science?" - Kirsten Davison, Ph.D. Davison is an Associate Professor of Nutrition at the Harvard School of Public Health. She completed her PhD at the Pennsylvania State University in Child and Family Development. Panel 3 — Nutrition and Healthy Eating. As we understand more about what defines good nutrition for youth, we are also increasingly understanding the importance of instilling healthy eating habits for youth in the context of family, school, and sport. This varied panel covers major topics within this under-considered but important area of youth development.

1. Developing Sustainable Family-Centered
Obesity Interventions:
What Can We Learn from Developmental Psychology
and Implementation Science
PRINCIPAL INVESTIGATORS:
CO-INVESTIGATORS
Kirsten K. Davison, PhD (PI)
Janine M. Jurkowski, PhD, MPH (PI)
Hal Lawson (co-I),
Sibylle Kranz (co-I)
Lawrence Schell (co-I)
Glenn Deane (co-I)
Funded by NIH R24 MD004865
Davison et al. (2013). A childhood obesity intervention developed by families for families: results
from a pilot study. International Journal of Behavioral Nutrition and Physical Activity, Jan 5;10:3.

2. Key challenges of family-based childhood
obesity interventions
• Reaching families
• Passive refusals (consent but don’t show up)
• Parents not interested if don’t see immediate need
• Priorities for intervention do not match family priorities

3. Possible strategies
• Maintain contact with families over time
• Partner with organizations that reach families
• Use electronic means to collect data
• Build intervention into other appointments
• Design programs around the needs and interests of
families
• Ask families members what they hope to gain from
participating

4. Goals
1. Utilize community-based participatory research
(CBPR) to develop and pilot test a family-centered
obesity prevention program for children enrolled in
Head Start.
2. Incorporate the resulting intervention into systems of
care (e.g., Head Start, WIC, pediatric care).

5. Family Action-based Model of Intervention Layout
and Implementation (FAMILI)
Phase 1: Theory
Phase 2: Research
Phase 3: Intervention
Design & Implementation
Utilize theories of family
development to frame
family-centered research
Use a mixed methods
approach to examine
factors impacting on
parents and families that
are relevant for intervention
design.
Utilize a CBPR paradigm to
develop interventions that
empower parents and
caregivers to foster healthy
family lifestyles and establish
systems-level change that
reinforces family change.
CBPR = community-based participatory research
Davison, Lawson, & Coatsworth (2011). Health Promotion Practice

6. Family Ecological Model
Family
Demographics
Policies and the
Media
• School PE and food
policies
• Advertising to
children
• Nutrition labeling
Knowledge and Beliefs about
behaviors that educe/promote
obesity risk behaviors
Accessibility of healthy and
unhealthy eating and
physical activity options
Community
Characteristics
• Neighborhood walkability
•Crime levels
•Access to healthy foods
and recreational spaces
PARENTING
• Family income
• Single versus two
parent household
• Ethnicity
• Education
Modeling of healthy
and unhealthy eating
and activity behaviors
Shaping children’s eating and
physical activity behaviors by
the use of reward and
punishment systems
Child
Characteristics
• Age
• Gender
• Weight status
• Athletic competence
Organizational
Characteristics
•
•
•
School environment
Job characteristics
Work demands
Davison & Campbell (2005). Public health approaches to the prevention of obesity. Oxford University Press

7. Setting
• Small city in upstate New York
• Five Head Start centers (423 2-5-year olds)
38.5% non-Hispanic White
17.8% non-Hispanic Black
6.1% Hispanic or Latino
13.5% biracial
24% unknown
•
Primary household language
90% English
6% Spanish

8. Phase 1
Community Advisory Board
– Majority were parents/grandparents of children in Head
Start
Participated in all aspects of project
– Development of the mission, logo, topics to explore
– Recruitment, data collection (IRB trained), workshops and
conferences, research team meetings

9. Phase 2
Community Assessment
–
–
–
–
–
–
–
Focus groups
Key informant interviews
Photovoice
24 hour dietary recall (children); Sibylle Kranz
7-day accelerometery (children); Karin Pfeiffer
Surveys, follow-up interview
Behavioral observation in centers
Findings were presented to the community in two town hall
meetings. Solicited ideas on what the program should entail.

10. What did we learn?
Children
• Watched TV extensively; a coping strategy
• Excessive consumption of sugar-sweetened beverages
• 35% overweight or obese; 14% met PA recommendations
Parents
• failed to recognize when their children were overweight
• didn’t like how physicians interacted with them
• wanted
•
to gain advocacy skills
•
to connect with other parents
•
the program to be center-based
•
their children to gain something from the program

11. What did we learn?
Children
• watched TV extensively; a coping strategy
• excessive consumption of sugar-sweetened beverages
• 35% overweight or obese; 14% met PA recommendations
Parents
• Failed to recognize when their children were overweight
• Didn’t like how physicians interacted with them
• Wanted
•
to gain advocacy skills
•
to connect with other parents
•
the program to be center-based
•
their children to gain something from the program

12. What did we learn?
Community
• No where to send parents concerned about their child’s
weight
• Some programs available in community to promote
healthy living, but underutilized

13. Phase 3
The CHL program
Multiple components
1. Health communication campaign
2. BMI letters sent home
3. Family coffee hour with nutrition counseling
4. Parent’s Connect for Family Wellness program

15. Phase 3
The CHL program
Multiple components
1. Health communication campaign
2. BMI letters sent home
3. Family coffee hour with nutrition counseling
4. Parent’s Connect for Family Wellness program

16. Parents Connect for Healthy Living
•
•
•
•
6 week parent-led program
2 hour session each week; meal provided
Center-based
Sessions focused on:
–
–
–
–
Resource empowerment
Nutrition, media literacy, and communication (workshops)
Conflict resolution, social networking and stress (hands-on)
Effective communication with health professionals (panel
discussions with pediatricians)

17. Intervention and Evaluation Timelines
Sept
Oct
Baseline
Survey
(N=154)
Nov
Dec
Jan
Feb
Mar
Intervention Implemented
Survey
(N=88)
Apr
May
Jun
Follow-up
Survey
(N=109)
Activity
Monitors
(N=90)
Activity
Monitors
(N=57)
Diet recall
(N=55)
Diet recall
(N=33)

18. Evaluation sample and methods
Recruited from all five Head Start centers
White (45%); African American (15%)
Some high school (21%); high school graduate (37%);
some college (42%)
Construct
Method
Child BMI; obesity
Record extraction:
measured height and
weight
152
136
Parenting, empowerment,
demographics, intervention
exposure
Parent survey
145
102
Child dietary recall
24 Hour Dietary Recall
55
33
Child physical activity
7-day accelerometry
83
57
Sample size Sample size
(Pre-test)
(Pre-test)

19. Community Advisory Board
Participation Rates
Parents (N= 13)
Range 3-19 out of 23 meetings
Average = 41% of meetings attended
Median = 35% of meetings attended
Community members
& Agency staff (N= 8)
Range = 4-17 of 23 meetings
Average = 42% of meetings attended
Median = 43% of meetings attended

20. Results
Program exposure
•Health communication campaign: 90%+ parents reported
seeing posters, 85% reported reading posters
•Family coffee hour: 40% parents heard about, 29% spoke
with a nutrition counselor
•Parents Connect program: 69% heard about program, 20%
attended at least one session.
•Total number of components parents exposed to:
1 (16%), 2 (50%), 3+ (30%)
0 (4%),

21. Results
Pre-post intervention differences
in child and parent outcomes
• Paired t-tests examined pre-post intervention change in
measures of:
– child BMI, dietary intake, and physical activity
– food, physical activity, and screen-related parenting,
parent resource empowerment
• Performed as intent to treat analyses

22. Child Outcomes
Pre intervention
Mean (std)
Child weight status
BMI z-score
Obesity (%)
Child TV viewing (min/day)
Child diet – dietary recall
Total energy (kcals)
Total fat (gm)
Total carbohydrate (gm)
Total protein (gm)
* p< .05
** p< .01
*** p< .001
t-value
0.72 (1.12)
15.8%
1.69
10.7**
33.3 (4.0)
21.2 (2.9)
4.7 (1.5)
32.6 (1.82)
21.7 (3.2)
4.9 (1.5)
1.82
-2.04*
-1.76
141.9 (77.0)
94.10 (61.2)
8.62**
0.86 (1.24)
19.7%
Child physical activity (min/day)
Sedentary
Light physical activity
Moderate physical activity
Post intervention
Mean (std)
1531.2 (405.3)
50.1 (18.6)
214.6 (57.4)
58.1 (18.7)
1395.7 (423.8)
47.3 (20.1)
199.1 (59.4)
52.9 (17.5)
3.20**
2.27*
2.60*
3.15**

23. Parent outcomes
Pre intervention Post intervention
Mean (std)
Mean (std)
t-value
Parent resource empowerment
Weight
Physical activity
Diet
3.37 (.63)
3.21 (.63)
3.33 (.61)
3.53 (0.82)
3.40 (.66)
3.48 (.59)
3.19**
4.24***
3.96**
Parenting: Diet
Freq. eat fast food
Freq. offer fruits and vegetables
Self efficacy to offer healthy foods
1.19 (.61)
4.43 (1.15)
4.64(.50)
1.15 (.59)
4.56 (1.14)
4.78 (.39)
.69
-1.87
-4.08***
Parenting: Physical activity
Support for physical activity
3.37 (.51)
3.50(.50)
-3.36***
3.34 (.53)
66%
3.33 (.60)
65%
.57
0.69
Parenting: Television viewing
Monitor child screen time
TV in child’s bedroom
* p< .05
** p< .01
*** p< .001

24. Dose effects
Dose = # components of CHL to which parents were exposed
Multiple regression analysis
Outcome (post test) = outcome (pre test) + dose
Estimate
Outcome: Child BMI z-score (post)
BMI z-score (pre)
Dose
Outcome: Child moderate PA (post)
Child moderate PA (pre)
Dose
Outcome: Child TV viewing (post)
Child TV viewing (pre)
Dose
Outcome: Child energy intake1 (post)
Child energy intake (pre)
Dose
SE
t-value P-value
0.71
.0.1
.058
.05
12.09
0.137
<.0001
.89
0.72
0.08
.08
.09
8.68
0.86
<.0001
0.39
0.66
-16.59
0.05
2.73
12.56
-6.08
<.0001
<.0001
0.83
-48.92
.10
28.35
8.67
-1.73
<.0001
0.09
To reduce the risk of type II error, dose effects were only assessed for one key
indicator for each construct.
1

25. Dose
effects Estimate
Outcome: Parent empowerment1 (post)
Parent weight-related empowerment (pre)
Dose
Outcome: Parent support for child PA (post)
Parent support for child PA
Dose
Outcome: Parent self efficacy-healthy foods
Parent self efficacy (pre)
Dose
SE
t-value P-value
.634
.09
.083
.046
7.63
1.97
<.0001
.05
0.66
0.06
0.06
0.02
11.35
2.74
<.0001
.006
0.51
0.05
10.51
<.0001
0.05
0.02
2.84
0.005
To reduce the risk of type II error, dose effects were only assessed for one
key
indicator for each construct.
1

26. Summary of Results
• Successful parent and community engagement
• Broad exposure to CHL
• Improvements in child and parent outcomes
• Dose effects were observed
Limitations
•Absence of a control group
•Small sample size

27. What now?
Scaling up a CBPR-based program
•Focus on best processes rather than best practices
Component
Practice
Process
Health
communication
campaign
Posters illustrating myths
endorsed by parents and
research dispelling such
myths
Parent awareness and
understanding of their child’s
weight status
Family nutrition
counseling
Nutrition graduate student is
available during “pick up” to
answer parents’ questions
Nutrition knowledge; parent
social networking; knowledge
of relevant community
resources

28. Implementation science
as a framework for future research
Challenges us to:
•Utilize methods to efficiently move research to
practice
•Focus on ecological validity (applicability, utility,
feasibility, implementation effectiveness)
•Collect measures relevant to stakeholders and key
decision makers
•Ensure representative samples