This scoping review examines the current literature on technology-based, eHealth interventions that integrate community and clinical approaches for family-based pediatric weight management.
...Telehealth and eHealth interventions for weight management are increasingly commonplace; however, it is unclear in the current literature how family-based, pediatric, healthy-weight interventions integrate technology. Additionally, multilevel approaches to address childhood obesity, including working with clinical and community partners, are currently considered best practice and within the socioecological framework for sustainability of outcomes. Little is known how current family based pediatric healthy weight interventions integrate eHealth and multi-level approaches.
Guided by Arksey and O'Malley's scoping review framework, a scoping literature review was conducted. Four databases were searched to identify studies conducted between 2010 and 2022 that addressed multilevel, family-based, pediatric weight management interventions that also integrated technology. Studies were excluded that did not include at least 2 of the 4 components and that did not include technology to some degree.
A total of 15 articles were included in the scoping review. All articles included some type of technology in the intervention. Twelve articles included a family-based approach, and only 1 article fully used a holistic approach to family-based, pediatric weight management that included technology and integrated clinical and community approaches to address the complexity of childhood obesity.
There are several family-based, pediatric weight management interventions that incorporate an eHealth component. There is a gap in the literature about programs that use both technology and integrate multilevel clinical and community approaches for treatment. Additionally, gaps exist in information about adolescent, family-based, weight management interventions, and there are opportunities for nutrition and dietetic professionals to become more involved with technological and multilevel approaches in family-based pediatric weight management.
American Indian and Alaska Native (AI/AN) people have high rates of diabetes and limited access to nutrition education. The “What Can I Eat? Healthy Choices for People With Type 2 Diabetes” (WCIE) ...diabetes nutrition education program was culturally adapted for AI/AN adults.
This analysis was designed to evaluate the reliability and validity of items developed to measure diabetes nutrition self-efficacy (ie, confidence one can engage in specific behaviors) and diabetes nutrition behavior among participants in the WCIE program for AI/AN adults.
This study was a secondary analysis of data from a randomized controlled trial designed to evaluate the WCIE program for AI/AN adults. Baseline data were used to assess the reliability and validity of the self-efficacy and behavior items, which were collected via survey. Due to COVID-19 safety protocols, the intervention was conducted via Zoom (Zoom Video Communications), and both survey and clinical data were collected at home by participants.
The study was conducted from January to December 2021 with 5 AI/AN-serving health care programs in Oklahoma, Illinois, North Carolina, California, and New York. AI/AN adults with type 2 diabetes who spoke English and had internet access were eligible. Sixty people participated.
Analyses examined validity and reliability of diabetes nutrition self-efficacy and behavior items.
To test reliability, internal consistency and factor structures of the scales were examined. To evaluate convergent validity, Pearson correlations were computed to examine the association of the self-efficacy and behavior measures with each other and with clinical indicators (ie, body mass index, blood pressure, and hemoglobin A1c).
Two self-efficacy factors were identified. Each showed strong internal consistency (Cronbach α ≥ 0.85; McDonald ω ≥ 0.88) and was directly associated with diabetes nutrition behavior (P < .001). The factor assessing Confidence in Using the Diabetes Plate was inversely associated with hemoglobin A1c (Pearson correlation = –0.32, P = .0243). The behavior measure capturing Healthy Nutrition Behavior showed strong internal consistency (α = 0.89; ω = 0.92) and was inversely associated with hemoglobin A1c (Pearson correlation = –0.38, P = .0057).
Diabetes nutrition self-efficacy and behavior items developed for the WCIE program for AI/AN adults are valid and reliable. These items can facilitate rigorous and consistent evaluation of the AI/AN WCIE program.
The Worldwide Voyage (WWV) was a 3-year (2014-2017) open-ocean voyage to circumnavigate the world using Indigenous knowledge and navigational skills aboard Hōkūle'a, a traditionally designed Native ...Hawaiian (NH) voyaging canoe (wa'a kaulua). Each WWV segment included experienced crew and leadership who were recognized by their voyaging peers as highly experienced in Polynesian oceanic voyaging. This study explored the perceptions and insights of WWV-experienced ocean voyagers on the interconnection between human health and oceanic voyaging.
A constructivist approach with a storytelling-based moderator guide was used to conduct focus groups and informant interviews of experienced crew and voyaging leadership. Participants were interviewed and recorded transcripts were analyzed using content analysis. Triangulation of analysis included secondary thematic review by two independent NH cultural practitioners and participant member checking. Purposive sampling was used to enroll 34 of 66 eligible highly experienced voyagers (leadership n = 6; crew n = 28) in 5 focus groups and 4 informant interviews.
Six themes emerged: 1) Indigenous context (spiritual and natural environment); 2) Importance of relationships and community; 3) Description of life on the canoe; 4) Holistic health; 5) Mindfulness, stress reduction and emotional health; and 6) Opportunities for intervention. Themes 1-5 were inductive and intricately interrelated, and theme 6 was deductive in that it directly resulted from a moderator guide question. Theme 6 offers strategies to improve the impact of voyaging and health well beyond the physical voyage with recommendations for improved transition back to land and developing a wa'a community context, which reflects a traditional voyaging experience.
Polynesian oceanic voyaging is strongly perceived as a positive and transformative holistic-health-promoting experience.
Recommendations to promote generalizable health benefits of a voyaging lifestyle offers a promising and culturally grounded approach warranting future studies to understand mechanism and potential impact for improving health inequities.
Increased fruit and vegetable (FV) intake is associated with decreased risk of nutrition-related chronic diseases. Sociodemographic disparities in FV intake indicate the need for strategies that ...promote equitable access to FVs. The United States Department of Agriculture's Gus Schumacher Nutrition Incentive Program (GusNIP) supports state and local programs that offer nutrition incentives (NIs) that subsidize purchase of FVs for people participating in the Supplemental Nutrition Assistance Program (SNAP). While a growing body of research indicates NIs are effective, the pathways through which GusNIP achieves its results have not been adequately described. We used an equity-focused, participatory process to develop a retrospective Theory of Change (TOC) to address this gap. We reviewed key program documents; conducted a targeted NI literature review; and engaged GusNIP partners, practitioners, and participants through interviews, workshops, and focus groups in TOC development. The resulting TOC describes how GusNIP achieves its long-term outcomes of increased participant FV purchases and intake and food security and community economic benefits. GusNIP provides NIs and promotes their use, helps local food retailers develop the capacity to sell FVs and accept NIs in accessible and welcoming venues, and supports local farmers to supply FVs to food retailers. The TOC is a framework for understanding how GusNIP works and a tool for improving and expanding the program.
American Indians and Alaska Natives (AI/AN) are disproportionately affected by adolescent obesity, adolescent pregnancy and gestational diabetes mellitus (GDM). GDM is associated with increased risk ...for perinatal death, obesity, and subsequent type 2 diabetes (T2D) for the offspring. Moreover, mothers with GDM are also at increased risk for T2D post-partum. Yet few lifestyle interventions exist to reduce GDM risk prior to pregnancy. We describe the process of adapting an existing validated preconception counseling intervention for AI/AN adolescent girls at-risk for GDM and their mothers. Perspectives and recommendations were gathered from a diverse array of stakeholders to assure the new program called Stopping GDM was culturally responsive and developed with tribal voices and perspectives represented.
We conducted focus groups and individual interviews with multiple AI/AN stakeholders (n = 55). Focus groups and interviews were digitally recorded, transcribed verbatim, and analyzed using a thematic content approach to construct cross-cutting themes across the focus groups and interviews.
Four key themes emerged reflecting issues important to planning a reproductive health intervention: 1) Limited awareness, knowledge, and health education resources about GDM; 2) The importance of acknowledging traditional AI/AN values and the diversity of traditions and culture among AI/AN tribes; 3) The need to cultivate healthy decision-making skills and empower girls to make safe and healthy choices; and 4) Lack of communication about reproductive health between AI/AN mothers and daughters and between AI/AN women and health care professionals.
Findings have been used to inform the cultural tailoring and adaptation of an existing preconception counseling program, originally designed for non-AI/AN adolescent girls with diabetes, for AI/AN adolescents at-risk for GDM in future pregnancies.
Food is Medicine (FIM) programs to improve the accessibility of fruits and vegetables (FVs) or other healthy foods among patients with low income and diet-related chronic diseases are promising to ...improve food and nutrition security in the United States (US). However, FIM programs are relatively new and implementation guidance for healthcare settings using an implementation science lens is lacking. We used a narrative review to describe the evidence base on barriers and facilitators to FIM program integration in US healthcare settings following the Exploration, Preparation, Implementation, and Sustainment (EPIS) Framework. Evidence surrounding the EPIS Inner Context was a focus, including constructs Leadership, Organizational Characteristics, Quality and Fidelity Monitoring and Support, Organizational Staffing Processes, and Individual Characteristics. Peer-reviewed and grey literature about barriers and facilitators to FIM programs were of interest, defined as programs that screen and refer eligible patients with diet-related chronic disease experiencing food insecurity to healthy, unprepared foods. Thirty-one sources were included in the narrative review, including 22 peer-reviewed articles, four reports, four toolkits, and one thesis. Twenty-eight sources (90%) described EPIS Inner Context facilitators and 26 sources (84%) described FIM program barriers. The most common barriers and facilitators to FIM programs were regarding Quality and Fidelity Monitoring and Support (e.g., use of electronic medical records for tracking and evaluation, strategies to support implementation) and Organizational Staffing Processes (e.g., clear delineation of staff roles and capacity); although, barriers and facilitators to FIM programs were identified among all EPIS Inner Context constructs. We synthesized barriers and facilitators to create an EPIS-informed implementation checklist for healthcare settings for use among healthcare organizations/providers, partner organizations, and technical assistance personnel. We discuss future directions to align FIM efforts with implementation science terminology and theories, models, and frameworks to improve the implementation evidence base and support FIM researchers and practitioners.
AI/ANs are unduly impacted by GDM and food insecurity. Employing a clinical trials design, this secondary analysis used Stopping GDM trial data to describe and explore food insecurity as a moderator ...of the efficacy of a GDM risk reduction intervention on healthy eating behaviors and self-efficacy at 3 months among AI/AN FAYAs. Participants were AI/AN FAYAs and their mothers. Assessments included mother’s food insecurity using USDA Household Food Security Survey Module and FAYA’s healthy eating self-efficacy using Self-Efficacy for Healthy Eating and healthy eating behaviors from CDC Youth Risk Behavior Surveillance System. The sample (N=149 dyads) was FAYAs (mean age 16.7±3.0 years) and their mothers, with 64% (n=95) living together. More than one-third (38.1%) reported food insecurity. At baseline food insecurity was associated with higher levels of eating vegetables and fruit for the full sample (p=.045) and cohabitating dyads (p=.002). By 3 months healthy eating self-efficacy (p=.048) and limiting snacking between meals (p=.031) improved more in the control group than the intervention group but only for cohabitating dyads. For the full sample the intervention group had increases in times eating vegetables (p=.022) and fruit (p=.015), while the control group had declines. In the full sample food insecurity did not moderate the group by time interaction for self-efficacy for healthy eating (p≥.05) but did moderate the group by time interaction for times drinking soda (p=.004) and days eating breakfast (p=.013). For cohabitating dyads food insecurity did moderate self-efficacy for eating 3 meals a day (p=.024) and days eating breakfast (p=.012). These results suggest food insecurity is an important factor regarding the efficacy of interventions designed to reduce GDM risk and offer unique insight on ‘upstream causes’ of GDM health disparities among AI/AN communities.
Disclosure
S.M.Sereika: None. S.A.Stotz: None. L.E.Hebert: None. L.Scarton: None. K.R.Moore: Consultant; Novo Nordisk. D.Charron-prochownik: None. The stopping gdm study group: n/a.
Funding
National Institutes of Health (R01NR014831)
The purpose of this study was to re-engage participants of a GDM risk reduction study along with additional key informants to explore GDM risk reduction opportunities among young Indigenous females ...who experience food insecurity. Participants were adult American Indian (AI) women who had GDM or who have female relatives (e.g., daughters) between 12-24 yo (n= 41), AI females between 12-24 yo (n=18), and key informants with expertise in food/nutrition and health within Indigenous communities (n=32) across the US. Data were collected using a semi-structured, conversation-based moderator guide. Zoom interviews were recorded, transcribed, and coded using thematic content analysis methods. Three themes emerged, which emphasize supporting wellness among young Indigenous females through culturally centered approaches and describe how colonization has interrupted healthful dietary practices. Themes include: 1) Guidance on how to support young female's holistic wellness (e.g., strong cultural identity, physical activity, and support from multigenerational family and community); 2) Generations of colonial violence including forced removal, forced poverty, and the imposition of a western based food system of high fat and sugary foods causes deeper, systemic fracturing of traditional cultural food knowledge and practice; 3) Opportunities for support may include investment in place-based, community-driven Indigenous food sovereignty efforts with economy and relationship building including traditional food teachings (e.g., gardening, gathering, farming, seed and land stewardship, hunting, fishing, and food/meal planning and preparation). These themes suggest alternative understanding about the relationships between food insecurity and GDM risk drawing from Indigenous values, strengths, and knowledge, within the context of colonialism, and can guide next steps of decreasing GDM disparities in Indigenous communities.
Disclosure
S.A.Stotz: None. L.E.Hebert: None. L.Scarton: None. K.R.Begay: None. K.L.Gonzales: None. H.Garrow: None. M.L.Aspaas: None. M.Charley: None. D.Charron-prochownik: None.
Funding
National Institute on Minority Health and Health Disparities (R21MD016126 to S.A.S.)
Food insecurity is well documented as a social determinant of health and as a barrier to healthful eating and diabetes management. American Indians and Alaska Natives (AI/ANs) are twice as likely to ...experience food insecurity and type 2 diabetes (T2D) as non-Hispanic Whites. The purpose of this project was to identify themes regarding food insecurity and healthful eating in relation to diabetes management among AI/AN adults with T2D. The reported analysis used qualitative data originally collected to inform adaptation of an existing American Diabetes Association diabetes nutrition education program for AI/AN adults with T2D. Qualitative data were collected through focus groups and interviews with AI/ANs with T2D, their family members, and key stakeholders such as healthcare administrators, registered dietitians, and diabetes educators. Two coders analyzed transcripts in their entirety using the constant-comparison method for qualitative content analysis. Key themes included the following: (1) Rural and urban AI/ANs have different primary food security challenges. AI/ANs who live in rural reservation locations discussed loss of traditional foods and loss of access to land where these foods were once found. Urban-dwelling AI/ANs, on the other hand, highlighted the cost of healthful food as their primary food security challenge. (2) AI/ANs discussed logistical problems with accessing healthy food (i.e., lack of time, need for convenience, easy access to fast and processed food, high cost of healthful food, loss of traditional food) whereas nutrition educators focused on solutions, such as cooking and nutrition education. (3) When discussing the high cost of healthful foods, focus group participants concentrated almost exclusively on the high cost of fresh produce as opposed to other healthful food products. Findings from this analysis will help inform the development of food security resources for AI/ANs with T2D.
Disclosure
S.A. Stotz: None. S. Lockhart: None. A.G. Brega: None. K.R. Moore: None.
Funding
American Diabetes Association (4-18-SMSC-01 to K.R.M.); National Institutes of Health (P30DK092923); Center for American Indian and Alaska Native Diabetes Translational Research
To explore the perspectives of urban-dwelling American Indian and Alaska Native (AI/AN) older adults regarding determinants of healthy eating, food insecurity, and opportunities for an urban clinic ...to improve resources.
Semistructured interviews (n = 24) with older adults (aged ≥ 60 years) at 1 urban AI/AN serving clinic. Telephone-based interviews were audio-recorded, professionally transcribed, and analyzed using thematic analysis.
Four overarching themes were revealed: (1) hunger-mitigating resources exist but do not necessarily lessen food insecurity; (2) multiple layers of challenges related to social determinants of health present barriers to healthy nutrition for AI/AN older adults; (3) unique facilitators rooted in AI/AN culture can help decrease food insecurity; and (4) many clinic-based opportunities for programs to improve food insecurity exist.
Findings provide a foundation for urban-serving AI/AN clinics to develop healthy eating resources for their older adult patients. Greater benefit would result from resources that build on cultural strengths and address older adult-specific challenges to healthy eating.
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