OBESITY RISK, PARENTING & DIET QUALITY ASSESSMENT FOR SPANISH-SPEAKING FAMILIES WITH PRESCHOOL CHILDREN: EFNEP, HEAD START, MEDICAL CLINIC

• Sponsoring Institution: National Institute of Food and Agriculture
• Project Status: TERMINATED
• Funding Source: AFRI COMPETITIVE GRANT
• Reporting Frequency: Annual
• Accession No.: 1005700
• Grant No.: 2015-68001-23280
• Project No.: CA-D-NTR-2285-CG
• Proposal No.: 2014-08341
• Program Code: A2101
• Project Start Date: Apr 1, 2015
• Project End Date: Mar 31, 2021
• Grant Year: 2019

Project Director
Townsend, M. S.

Recipient Organization
UNIVERSITY OF CALIFORNIA, DAVIS
410 MRAK HALL
DAVIS,CA 95616-8671

Performing Department
Office of Research

Non Technical Summary
Although child obesity is the result ofan imbalance between energy intake and expenditure, it ismediated early by parent-controlled environments and practices related to food, screen time, sleep and physical activity.Our proposed research, education and extension plan aims to achieve 4major objectives that advance the fightagainst pediatric obesity:1) produce final versions of two validated Healthy Kids (HK) obesity risk assessment tools for low-literacy Spanish-speaking parents with data collection (biomarkers, anthropometrics & dietary recalls) at Head Start sites;2) Develop and validate a visual diet quality tool for low-literacy English and Spanish-speaking parents at Head Start sites;3) assess feasibility and synergy of outcomes of embedded medical clinic EFNEP site with physician-referred Medicaid patients receiving EFNEP nutrition intervention utilizing guided goal setting behavior change strategies designed for this audience;4) assess feasibility and relevance of HK tools for pediatricians.Year 1 focuses on developing and cognitive testing of Spanish-language tools (HK and diet quality); tailoring English/Spanish EFENP interventions for a medical clinic environment; developing HK computer kiosk; and pre-test biomarker and assessmentmethods with Spanish-speaking parent-child pairs.Years 2-3 focuses on data collection and analyses; assessing feasibility of EFNEP intervention and HK kiosk for physicians and EFNEP administration; developing the Healthy Kids for Spanish-speakers Education Package for USDAfoodassistanceprograms; and producing a national webinar. The approach's efficacy, accessibility and economy of scale will serve millions of English- and Spanish-speaking, limited-resource families participating in federal programs and expand the reach of EFNEP into medical clinics.

Animal Health Component

0%

Research Effort Categories

Basic

20%

Applied

20%

Developmental

60%

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
703	6020	3020	100%

Knowledge Area
703 - Nutrition Education and Behavior;

Subject Of Investigation
6020 - The family and its members;

Field Of Science
3020 - Education;

Keywords

pediatric obesity

overweight

preschooler

low-income

efnep

goal-setting

validation

latino

hispanic

Goals / Objectives
Although child obesity is the result of an imbalance between energy intake and expenditure, it is mediated by the child's environment under the control of the parent and important parenting practices related to food, screen time, sleep and physical activity. Our proposed integrated plan [research, education and extension] aims to achieve the long term goal of advancing the fight against pediatric obesity by focusing on expansion of: 1) Healthy Kids to the Spanish-speaking population in California (CA) and Nevada (NV) and 2) traditional EFNEP programming in a medical clinic setting (shown in Logic Model that was part of the original propsal submission).Our two goals will be achieved through attainment of these general objectives:♦Produce final versions of two validated obesity risk assessment tools for low-literacy Spanish speaking parents with data collection (biomarkers, anthropometrics, dietary recalls);♦Assess feasibility and relevance of these tools to the child's pediatrician;♦Develop and validate a visual diet quality tool for English and Spanish-speaking parents;♦Determine feasibility and potential synergy from placing an EFNEP intervention with guided goal setting in a medical clinic.

Project Methods
Specific objective: SO.A. Produce final versions of two pediatric obesity risk assessment tools, Healthy Kids [HK] and My Child at Meal Time [MCMT], for Spanish speakers in CA and NV through content, face and convergent validation [Research component].Method and Timeline: ♦Assess convergent validity using parent-report measures: 24-hour logs for child's diet, sleep, physical activity, screen time, parenting style. Year 2,3♦Assess validity using factor analysis. Assess criterion validity of MCMT using videotapes of parent-child pairs during family meal time. Y2,3Hypotheses: Ho Healthy Kids [Spanish-speaking audience] is a valid risk assessment tool demonstrated by its convergent validity for mediators of obesity using three 24-hour dietary recalls, physical activity log, TV/computer time log, sleep log.Ho My Child at Meal Time [Spanish-speaking audience] is a valid parenting style assessment demonstrated by factor validity for demandingness and parent control and convergent validity with measures of parenting style.Specific objective: SO.B. Using results from current biomarker work, select best biomarkers and use for assessing obesity risk in this Spanish speaking audience for criterion validation of HK & MCMT [Spanish] [Research component].Method and Timeline: ♦Assess criterion validity of HK & MCMT using non parent-report measures: chemical biomarkers of obesity risk from blood samples, measured BMI, and waist circumference. Y2,3Hypotheses: Ho Healthy Kids [Spanish-speaking audience] is a valid risk assessment tool demonstrated by an assessment of criterion validity on mediators of obesity and chronic disease using chemical biomarkers (e.g. leptin, carotenoids, C- reactive protein, HDL, LDL, HDL/total cholesterol, interlukin 6, IL8, glucose ) and anthropometry (measured BMI)Specific objective: SO.C. Using remains of existing blood samples from 70 young children [English speakers] in current ARFI study, conduct additional chemical analyses [Research component].Method and Timeline: ♦Assess criterion validity using non parent-report measures: chemical biomarkers of obesity risk from blood sample remains stored in freezer. Y1Hypotheses: Ho Healthy Kids [English-speaking audience] is a valid risk assessment tool demonstrated by an assessment of criterion validity on mediators of obesity using additional chemical biomarkers (e.g.TAS-total antioxidant status; allantoin, ICAM, RBC Fatty acid profile, oxidized LDL, RBP-4).Specific objective: SO.D. Determine if HK, MCMT with corresponding guided goals function in medical clinic with large Medicaid patient load from the perspective of both physician and patient. [Extension component]Method and Timeline: ♦Develop a program for use in a computer kiosk based on existing http://HealthyKids.UCDavis.edu algorithms for testing at UC Davis Medical Center Pediatrics Clinic for use by parents in Clinic waiting room: English and Spanish.Y1,2♦Develop tool scoring system based on results from SO.A,B. Y2,3♦Use additional programming to send results of HK scores integrated with guided goal setting to pediatrician in time for appointment.Y1,2Hypotheses: Ho Use of Healthy Kids is feasible with pediatricians in a clinic setting serving Medicaid patients.Ho Use of My Child at Meal Time is feasible as a parenting style assessment with pediatricians at a University setting.

Progress 04/01/15 to 03/31/21

Outputs
Target Audience:Validation Study Participants (n = 273 parent-child dyads) were recruited by direct solicitation and at information sessions at Head Start (n = 21) and WIC sites (n = 3) in 2 counties in northern California. The adults were parents or caregivers, ≥18 years, who declared Spanish as their preferred language, had at least one child aged 3-5 years. All caregivers were female (100%) and most were not employed (71%). The majority reported earning a monthly household income of less than $2000 (57%). Additionally, families enrolled in the study participated in at least one USDA assistance program, with WIC (83%), Head Start (80%), Medicaid (70%) and SNAP (40%) being reported most frequently. All parents (100%) self-reported their and their child's race/ethnicity as Hispanic/Latino. Most parents (81%) were born in Mexico, the majority (79%) had been living in the US for more than 10 years and 86% reported speaking Spanish at home. Parents were 33.6 ± 6 years old female (99%) married (65%) with a majority reporting having completed some high school or receiving a high school diploma (79%). Only 20% of the parents had a normal BMI with 80.5% having a BMI greater than 25. All children (54% female) were born in the US and were on average 44.7 months old at enrollment. Medical Clinic Intervention Physicians (n = 92) from 1 large university teaching and research hospital and 4 small Medicaid serving medical clinics generated patient referrals for the intervention. Spanish-speaking parents represented 29% of the referrals. More than one-third (n = 264; 38% Spanish-speaking) of these patients expressed interest in attending the EFNEP intervention. Parents who attended at least 1 session (n = 106; 52% Spanish-speaking) were mostly female (95%), Hispanic (67.9%) and low-income (81% participated in an assistance program). Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?Over the grant duration, trainings were conducted with EFNEP educators (n=3), pediatricians (n=18), pediatric and family medical residents (n=117) and undergraduate (n= 33) and graduate (n=5) students from three universities (UC Davis, UC Merced, CSU Sacramento) spanning five departments (Nutrition, Public Health, Statistics, Human Ecology and Family and Consumer Sciences). Y6: Three students received statistical training at UC Davis during the current year as interns. The students provided statistical support and were trained in using the statistical package SAS. They participated in weekly meetings and observed the role of statisticians as members of a collaborative project. Parts of the project were also used in a group learning project in which graduating seniors in statistics learned how to manage large data merge and stack data and analyze real world data. Students (n=11) were enrolled in the special seminar. Two undergraduate students from UC Merced were trained in qualitative methods and assisted in the analysis of exit interviews conducted with participating parents. This training included developing a codebook to use in coding the data for content analysis. Both students graduated in May 2020, and one of them continued working on completing the analysis and reporting on the results by reviewing the literature and drafting a manuscript for peer review. This student will start graduate school in the Fall 2021. How have the results been disseminated to communities of interest?Research results (n=14 peer-reviewed journal articles)have been disseminated via eight national and international journals including: Journal of Nutrition Education and Behavior;Childhood Obesity Journal; Appetite; Human Sciences and Extension; Mind, Brain and Education; Nutrients; Journal of Primary Care and Community Health; and Early Child Development and Care. Symposia, webinars, trainings, and abstracts were presented at the following society meetings and conferences:National EFNEP Coordinator's Conference(abstracts=2); Society for Research in Child Development Biennial Meeting (symposia=2, abstracts=2); Society for Nutrition Education and Behavior Conference (symposia=4, webinar=1,abstracts=13);Biennial Childhood Obesity Conference (abstracts=2); International Society for Behavioral Nutrition and Physical Activity (symposia=3, abstract=1, workshop=1). Results have also been disseminated locally with collaborators atCA Expanded Food and Nutrition Education Program,WellSpace Health, and University California Davis Medical Center. What do you plan to do during the next reporting period to accomplish the goals? Nothing Reported

Impacts
What was accomplished under these goals? OBJ 1) Produce final versions of two validated obesity risk assessment toolsfor low-literacy Spanish speaking parents We successfully estimated the criterion validity of an obesity risk assessment tool Niños Sanos [translation Healthy Kids] targeting Spanish-speaking families of Mexican origin using anthropometric measures and blood values of their young children. Using a cross-sectional study design, we collected data from parents at five data collection sessions over an eight-week period. Niños Sanos (NS) scores were inversely related to child BMI-for-age percentiles (p = 0.02), waist-for-height ratios (p = 0.05) and inversely related to blood biomarkers for the metabolic index (p = 0.03) and lipid index (p = 0.05) and positively related to the anti-inflammatory index (p = 0.047). Overall, children with higher NS scores had more healthful lipid, metabolic and inflammatory profiles, as well as lower BMI-for-age percentiles and waist-to height ratios, providing evidence for the criterion validity of the tool. NS can be used by child obesity researchers, by counselors and medical professionals during clinic visits as a screening tool and by educators as a tool to set goals for behavior change. The paper was published in the journal Nutrients in 2020. Mi Niño a la Hora de Comer [translation My Child At Mealtime], is an assessment tool of food-related parenting behaviors. Spanish speaking parents used more controlling behaviors (mean rpm = .62) than English speaking parents at mealtimes (mean rpm = .01) (t (107) = -7.20, p < .00) but there was no significant difference in warmth. Results of MLR analyses predicting child dietary quality from controlling behaviors and warmth (r2 = .14, f = 3.98, p = .01) indicate a significant interaction between controlling behaviors and warmth whereby controlling behaviors predicted higher child dietary quality in the context of higher warmth. Our photographic team visited homes of Hispanic and Native American Head Start families for the purpose of expanding our image data bank using actual program participant families. Parents and children were photographed illustrating the Nino Sanos behaviors. These photographs were added to the Healthy Kids Website http://healthykids.ucdavis.edu/ to allow further racial customization of the HK and MCMT obesity risk assessment tools. The HK website was also updated to include Spanish language versions of Healthy Kids-45 and My Child at Meal Time and the newly validated Healthy Kids 19-item tool. OBJ 2) Assess feasibility and relevance of these tools to the child's pediatrician To stimulate parent interest and physician referrals to the Healthy Kids-EFNEP nutrition classes, the pilot testing of an iPad kiosk for the clinic waiting room was completed. The kiosk provided parents with tailored family nutrition tips based on 22 items from the HK and MCMT tools and is available free of charge http://healthykids.ucdavis.edu/Home/KioskEmail. A step-by-step guide was developed for other researchers and clinicians to use the HK Kiosk in their medical clinicshttp://townsendlab.ucdavis.edu/evaluation-research-tools/validation-research/. OBJ 3) Develop and validate a visual diet quality tool for English (My Veggies) and Spanish-speaking (Mis Vegetales) parents Building on earlier results from our USDA National Research Initiative-funded study about vegetable variety (published in JAND,2013), a vegetable variety tool to measure diet quality wasdeveloped in English (My Veggies) and then adapted to be used with Spanish speakers (Mis Vegetales) using resources from our current NIFA/AFRI grant. The purpose of the new tools was to identify a less intrusive and complex method of estimating diet quality via the 24-hour diet recall.Community nutrition education programs have a need for an inexpensive, simple to administer method to assess diet quality.The qualitative method included applying a multistep, iterative process to draft each subsequent version of the tool, first in English. The adaptation of the English tool to the Spanish version included 4 rounds of cognitive interviews, involving a total of 16 Spanish-speaking parents from WIC and Head Start, and subject-matter experts. Design, food photography of culturally specific foods, and layout were completed. Beyond the scope of this NIFA grant, data for criterion and convergent validations have already been collected using resources (ARS CRIS projects 2032-51530-025-00D and 2032-51530-026-00D) at the Western Human Nutrition Research Center accessible to co-investigator Nancy Keim.Analyses are in process. OBJ 4) Determine feasibility and potential synergy from placing an EFNEP intervention in a medical clinic Twenty intervention series with parents of patients (n = 106) were conducted at 5 clinics.Physicians (n = 92) generated 686 referrals. Every 6 referrals generated 1 enrolled parent. Physicians (91%, n = 34) reported the intervention as useful to families.A greater proportion of Spanish-speaking parents expressed interest in the intervention (P = .0004) and completed 4 or more sessions compared to English-speaking parents (P = .0006). Parents (n = 82) reported improved child behaviors for sleep, screen time, physical activity, and food and beverage offerings (P < .0001) and at family mealtime (P < .001). Focus group interviews (n = 26) with 65 participants indicated that parents (97%) reacted positively to participating in the intervention with about a third indicating the classes were relevant to their needs. The intervention was a feasible strategy for the 5 medical clinics. Physicians referred and parents enrolled in the intervention with both physicians and parents indicating positive benefits. Feasibility was contingent upon physician awareness of the intervention and motivation to refer patients and additional EFNEP and clinic staff time. Results were published in 2021. OBJ 5) Coordinate a USDA/NIFA/AFRI obesity grant program journal supplement and plan annual Project Director meeting. The journal selection process took four months and included the comparison of three journal offers and subsequent negotiations before the journal Childhood Obesity was selected. This journal aligned well with the scope of AFRI Obesity Grant Program research conducted, offered unlimited open access, and met budget criteria. An online proposal form was sent out to project directors who received grants from 2011 to 2017. Forty-seven abstract proposals were submitted and 12 were selected. Ten manuscripts were submitted for peer review and the final journal supplement titled, "USDA Research Combats Childhood Obesity" included an editorial written by the principal investigators for our team and 6 original research articles representing a spectrum of NIFA/AFRI funded research. The supplement was published in August 2020 and is entirely open access.https://www.liebertpub.com/toc/chi/16/S1 Four Annual AFRI Childhood Obesity Project Director (PD) meetings were coordinated by our team and held in conjunctionwith the Society for Nutrition Education and Behavior conferences in San Diego (2016), Washington DC (2017), Minneapolis (2018) and Orlando (2019). Project directors (n = 40-50) from around the country attended the two-day meetings which included a symposiatitled, "Conversations with USDA & Funding Opportunities" and an evening reception for PD's and graduate students to network and share materials. Well-attended poster presentation sessions show-cased the innovative research. The meetings concluded with a final symposium highlighting impactful work of selected NIFA childhood obesity projects.

Publications

• Type: Journal Articles Status: Published Year Published: 2021 Citation: Shilts, MK., Diaz Rios, LK, Panarella, KH, Styne, DM, Lanoue, LL, Drake, CM, Ontai, L, & Townsend, MS. Feasibility of Colocating a Nutrition Education Program into a Medical Clinic Setting to Facilitate Pediatric Obesity Prevention. Journal of Primary Care & Community Health 2021; Vol 12:1-13. https://doi.org/10.1177/21501327211009695
• Type: Journal Articles Status: Published Year Published: 2020 Citation: Townsend MS, Shilts MK, Lanoue L, Drake C, Styne DM, Woodhouse L, Ontai L. Healthy Kids Study among 3-5 year olds: Validation with biomarkers of low-grade chronic inflammation. Childhood Obesity 2020;16(1):S23-32. DOI: 10.1089/chi.2019.0237
• Type: Journal Articles Status: Published Year Published: 2020 Citation: Townsend MS, Shilts MK, Chester D. EDITORIAL&USDA Research Combats Childhood Obesity: A Collection of Projects that Integrate Research, Education, and Extension Targeting Low-Income, Ethnically Diverse Children and Families. Childhood Obesity 2020;16(1):S1-3. DOI: 10.1089/chi.2020.29006.mst
• Type: Journal Articles Status: Published Year Published: 2020 Citation: Townsend MS, Shilts MK, Lanoue L. Drake C, Diaz Rios K, Styne DM, Keim NL, Ontai L. Obesity risk assessment tool for low-income Spanish speaking immigrant parents with young children: validity with BMI and biomarkers of obesity. Nutrients 2020, 12(11), 3582; tps://doi.org/10.3390/nu12113582
• Type: Journal Articles Status: Published Year Published: 2020 Citation: Ontai LL, Sutter C, Sitnick S, Shilts MK, Townsend MS. Parent food-related behaviors and family-based dietary and activity environments: Associations with BMI z-scores in low-income preschoolers. Childhood Obesity 2020;16(1):S55-63. DOI: 10.1089/chi.2019.0105
• Type: Journal Articles Status: Published Year Published: 2020 Citation: Townsend MS, Shilts MK, Diaz Rios K, Panerella K. Designing Retrospective evaluation tools with limited-literacy adults. J Nutr Educ Behav. 2020;52(6):658?662.
• Type: Journal Articles Status: Published Year Published: 2019 Citation: Ontai L, Sutter C, Sitnick S, Shilts MK, Townsend MS. My Child at mealtime parent self-assessment of food related behaviors: Validation with mealtime behaviors. Appetite 2019; 136:6269.
• Type: Journal Articles Status: Published Year Published: 2018 Citation: Sutter C, Ontai LL, Shilts MK, Lanoue LL, Allen LH, Townsend MS. Associations between School Readiness, Obesity- and Inflammation-related Biomarkers in Low-Income Preschoolers within the Healthy Kids Study. Mind, Brain, & Education 2018; Vol 12(No 1): 28-38.
• Type: Journal Articles Status: Published Year Published: 2018 Citation: Townsend MS, Shilts MK, Styne DM, Drake C, Lanoue LL, Ontai L. An obesity risk assessment tool for young children: validity with BMI and nutrient values. J Nutr Educ Behav. 2018;50:705717.
• Type: Journal Articles Status: Published Year Published: 2018 Citation: Shilts MK, Sitnich SL, Ontai L, Townsend MS. Guided goal setting: A feasible obesity prevention behavior change strategy for low-income parents with young children. J Human Sciences & Extension 2018;6(3): 161-179.
• Type: Journal Articles Status: Published Year Published: 2016 Citation: Ontai L, Sitnick S, Shilts MK, Townsend MS. My child at mealtime: A visually enhanced self-assessment of feeding styles for low-income parents of preschoolers. Appetite 2016; 99:76-81.
• Type: Journal Articles Status: Published Year Published: 2016 Citation: Carolyn Sutter, Lenna L. Ontai, Adrienne Nishina, Katherine J. Conger, Mical K. Shilts & Marilyn S. Townsend. Utilizing the desired results developmental profile as a measure of school readiness: evaluating factor structure and predictors of school readiness. Early Child Development and Care. 2017; 187:9, 1433-1445, DOI: 10.1080/03004430.2016.1174933
• Type: Journal Articles Status: Published Year Published: 2016 Citation: Townsend MS, Shilts MK, Styne DM, Drake C, Lanoue L, Woodhouse L, Allen LH. Vegetable behavioral tool demonstrates validity with MyPlate vegetable cups and carotenoid and inflammatory biomarkers. Appetite 2016; 107:628-638.
• Type: Journal Articles Status: Published Year Published: 2016 Citation: Shilts MK, Johns MC, Lamp C, Schneider C, Townsend MS. A Picture is Worth a Thousand Words: Customizing My Plate for Low-literate, Low-income Families in 4 Steps. J Nutr Educ Behav. 2015;47:394-396. http://dx.doi.org/10.1016/j.jneb.2015.04.324
• Type: Journal Articles Status: Other Year Published: 2021 Citation: Diaz Rios LK, Shilts MK, Ontai L, Lanoue, L, Keim NL, Townsend MS. Formative evaluation of an educational component to enhance motivation to modeling healthy eating behavior among parents with young children. In progress.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2021 Citation: Ontai LL, Li J, Diaz Rios LK, Shilts MK, Lanoue LL, & Townsend MS. Food Parenting Practices in Latinx Families. Society for Research in Child Development Biennial Meeting, Virtual, April 8, 2021.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2021 Citation: Shilts, MK, Diaz Rios, LK, Ontai, L, Lanoue, LL, Panarella, KH, Drake, CM, Styne, DM, Navarro, S, Loera,A, & Townsend, MS. English and Spanish-Speaking Parents Interest and Acceptability of a Clinic Based EFNEP Intervention for Pediatric Obesity Prevention. Society for Nutrition, Education & Behavior Annual Conference, New Orleans (virtual). August 8,2021.
• Type: Journal Articles Status: Other Year Published: 2021 Citation: Diaz Rios LK, Ontai L, Shilts MK, Townsend MS. Cross-cultural adaptation and validation of a tool to measure parent food-related practices of Spanish-speaking parents with young children.

Progress 04/01/19 to 03/31/20

Outputs
Target Audience:No new participant data was collected during this reporting period. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?One undergraduate student from UC Merced was trained to complete the transcription of exit interview audio recordings, conducted with participants after they completed the 8-session program. The same student was trained to create a codebook and to use it to code the interviews for content analysis. In January 2020, another student joined the team as a second analyst to independently code the interviews. Both students are also contributing to a literature review for a manuscript to report the findings. One undergraduate student from UC Davis was trained in statistical consulting, programming in the statistical package SAS and provided weekly data analysis for 20 weeks, 10 hours each week. Two graduate students in the UC Davis MS statistics program also were trained in programming in SAS and/or R and both students provided weekly data analysis for fall quarter 2019, 20 hours per week which included training in SAS. One of the master's students also provided statistical support during spring quarter 2019, 20 hours per week, and during summer 2019. All three statistics students participated in weekly meetings and were trained in statistical consulting. Four undergraduate students from UC Davis Human Ecology Department were trained to code meal time video recordings. Two undergraduate students from CSU Sacramento Nutrition and Food Program were trained to use Excel to manage the medical clinic intervention database, prepare descriptive statistics and tables. How have the results been disseminated to communities of interest?Research results have been presented at the International Society for Behavioral Nutrition and Physical activity conference in Prague, Czech Republic. The education package was presented at the Society for Nutrition Education and Behavior conference in Orlando, Florida. Results have also been disseminated locally with collaborators at WellSpace Health and University California Davis Medical Center. What do you plan to do during the next reporting period to accomplish the goals?In Y6, the focus will be concluding data analyses validating the obesity risk assessment tools with for Spanish Speaking parents with child dietary, biomarker and anthropometric data. The Ninos Sanos tool will be graphically designed, printed and disseminated online. In addition, the journal supplement comprised of 6-7 manuscripts and an editorial will be completed and published. Additional dissemination of results will include prestations at the Society for Nutrition Education and Behavior conference in San Diego, California plus other relevant conferences and drafting of manuscripts related to development and validation of the tools and feasibility results of the EFNEP medical clinic intervention.

Impacts
What was accomplished under these goals? OBJ 1) Produce final versions of two validated obesity risk assessment tools (Niños Sanos) for low-literacy Spanish speaking parents In year 5 (YR5), the parent (n=208) answers to all possible Ninos Sanos items (n=45) were analyzed for association with four children anthropometric markers (waist to height, BMI-z scores, BMI-for-age percentiles, BMI-WHO percentiles). Sixteen items (from 45) were selected as they were associated with obesity markers to create Ninos Sanos-16 (NS16). We 1) completed various assays for the analysis of blood biomarkers; 2) evaluated the biomarkers data 3) commenced the statistical analysis. Analysis: we collaborated with the USDA-WHNRC to establish a framework for the different biomarker assays. We determined the matrix,the rank, and the number of replicates for each biomarker. We developed and optimized the analytical assay for 2 novel biomarkers (resistin and IGFBP1). Evaluation: we used percent coefficient of variability (%CV) of replicates to evaluate the data accuracy. For triplicates with %CV greater than 10%, the average of best duplicates was used. Duplicates below %CV of 10% and no assay points were removed from the data set due to poor reproducibility. A small number of cytokine data below the detection limit of the assay were removed. Data points flagged as statistical outliers were kept in the dataset if they met criteria for metabolic plausibility and rejected if not justifiable. Statistical Analyses: We converted the biomarkers raw data into weighted percentile ranks. As percentile ranks, biomarkers within a functional family were summed to generate lipid, metabolic and pro-inflammation indices. We examined the distribution of biomarkers to child BMI-for-age-percentiles and NS16 scores. Overall, obese children exhibited higher circulating levels of lipid and metabolic biomarkers. With few exceptions (CRP and adiponectin), plasma levels of cytokines and vitamins were independent of the child BMI. For NS16, data show limited to no association between levels of biomarkers and NS16 scores. Niños Sanos Food Intake Data Validation of NS16 food related behaviors (13 items) using food intake data from participants is ongoing. Participants reported three-24-hour dietary recalls to our data collectors using ASA24. The ASA24 data files were cleaned, corrected for known issues, and readied for statistical analyses. Healthy Eating Index (HEI 2015) scores were calculated for all participants. There was a significant association between NS13 and HEI scores. These preliminary data indicate that NS16 tool is effective in evaluating dietary quality. Niños Sanos Activity Data We validated the NS16 items related to sleep, play and screen behaviors with child activity logs collected from parents. A higher score on the NS16 play question was associated with higher average play time (p=0.05) and lower average screen time (p=0.01). A healthier bedtime score was validated by parents disclosing longer sleep nights (p=0.01). A healthier screentime score was indicative of reduced screen time (p=0.0001). MCMT To validate the food-related parenting MCMT obesity risk assessment tool, coding of observed parent and child behaviors was finalized with the final sample of 60 parent-child dyads using the previously adapted protocol. During this project period, 8 new videotapes were collected. All coders were undergraduate students and a Spanish speaking masters student provided oversight of the coding and reliability. Preliminary data analysis revealed good correspondence between observed mealtime behaviors and the parent-centered subscale of MCMT. No correspondence was found between observed behaviors and the child-centered subscale. These results are consistent with what was found with the English language version of this tool. OBJ 2) Assess feasibility and relevance of these tools to the child's pediatrician No new data to report. OBJ 3) Develop and validate a visual diet quality tool for English (My Veggies) and Spanish-speaking (Mis Vegetales) parents Healthy adults who participated in a cross-sectional phenotyping study conducted at USDA-WHNRC, completed the English version of the "My Veggies" questionnaire as part of the grants: CRIS 2032-51530-025-00D and CRIS 2032-51530-026-00D. A total of 258 participants completed the My Veggies questionnaire, the Block food frequency questionnaire (FFQ), and at least 2 days of dietary recalls using the ASA-24 system (used to generate 2010 HEI). The HEI data will be used as the metric of diet quality and compared to scores for the number of vegetables eaten over the course of one week, which could range between 0 to 28. OBJ 4) Determine feasibility and potential synergy from placing an EFNEP intervention in a medical clinic Focus of Y5 was continued data analysis, manuscript preparation and assisting EFNEP in implementing the Healthy Kids (HK) intervention in a medical clinic setting. New analysis focused on assessing the goal-setting behaviors of Spanish and English speaking EFNEP participants attending the HK intervention. Nutrition and parenting goal selections, effort, and attainment were tracked weekly. Twenty intervention series with parents or caregivers (n=106, 50% Spanish speaking; 79% low-income). All parents engaged in guided goal setting (GGS) with most making nutrition and parenting goal effort and achievement. Parents selected fruit and vegetable goal topics frequently and rarely selected contingency management topics. Improvement in the HK 10-item vegetable subscale was shown with parents buying, serving, and modeling vegetable intake more often after the intervention (p< 0.0001). Most parents selected a new goal each session with Spanish speaking parents more likely to select a guided option (72% vs 61%). Scaffolding with the local county EFNEP program continued in Y5 in collaboration with the UC ANR EFNEP Supervisor and EFNEP bi-lingual educator. Expansion of EFNEP into three new WellSpace Health clinics was achieved. Notably the physician referral system was incorporated into the electronic medical record. Referral training was also conducted with WellSpace Health pediatricians. WellSpace health educators were trained on facilitating enrollment into the intervention. OBJ 5) Coordinate a USDA/NIFA/AFRI obesity grant program journal supplement and plan annual Project Director meeting. The journal selection process took four months and included the comparison of three journal offers and subsequent negotiations before Childhood Obesity was selected. This journal aligned well with the scope of AFRI Obesity Grant Program research conducted, offered unlimited open access, and met budget criteria. An online proposal form was sent out to project directors who received grants from 2011 to 2017. Forty-seven abstract proposals were submitted and 12 were selected to submit a full manuscript to undergo the journal peer review process. A training with all invited project director's was conducted on May 30th focusing on journal submission requirements, study design, and statistical analysis. To date, 10 of the 12 manuscripts were submitted with 1 accepted, 5 under re-submission and 4 rejected or withdrawn. Spring/summer 2020 is the target for publication of the journal supplement which will include up to seven original research articles and one editorial. The annual project directors meeting was held in Orlando, Florida July 29-30, 2019. Project directors from around the country attended the two-day meeting which started with a symposium titled, "Conversations with USDA & Funding Opportunities" and an evening reception for PD's and graduate students (n=47) to network and share materials. The second day included a well-attended poster presentation session with 35 posters displayed. The meeting concluded with a symposium highlighting impactful work of 6 selected NIFA childhood obesity projects.

Publications

• Type: Journal Articles Status: Under Review Year Published: 2020 Citation: Townsend MS, Shilts MK, Lanoue L, Drake C, Styne DM, Woodhouse L, Ontai L. Healthy Kids Study among 3-5 year olds: Validation with biomarkers of low-grade chronic inflammation. Childhood Obesity, AFRI Supplement 2020. Under Review.
• Type: Journal Articles Status: Accepted Year Published: 2020 Citation: Townsend MS, Shilts MK, Diaz Rios K, Panarella K. Designing retrospective evaluation tools for limited-literacy adults. J Nutr Educ Behav. In press.
• Type: Journal Articles Status: Accepted Year Published: 2020 Citation: Ontai LL, Sutter C, Sitnick S, Shilts MK, Townsend MS. Parent food-related behaviors and family-based dietary and activity environments: Associations with BMI z-scores in low-income preschoolers. Childhood Obesity 2020. In press.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2019 Citation: Townsend MS, Shilts MK, Diaz Rios, KL, Leavens L, Panarella K. Designing Retrospective Evaluation Tools with Low-Literacy Adults: Development Process J Nutr Educ Behav. 2019; 51 (7): S15-16. https://doi.org/10.1016/j.jneb.2019.05.337
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2019 Citation: Shilts MK, Lake A, Washington C, Leavens L, Diaz Rios K, Ontai L, Panarella K, Styne D & Townsend MS. Guided Goal Setting Behaviors of Spanish and English-Speaking EFNEP Participants in a Medical Clinic Setting. Journal of Nutrition Education and Behavior. Orlando, FL. 2019;51(7): S15.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2019 Citation: Townsend MS, LK Diaz Rios, L Ontai, Shilts MK, Chester D. Learn Techniques to Tailor Obesity Risk Assessment Tools to the Literacy, Socioeconomic, Language, and Cultural Practices of your Target Audience and Select Appropriate Validation Methods. International Society for Behavioral Nutrition and Physical Activity Pre-Conference Workshop Prague, Czech Republic June 4, 2019.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2019 Citation: Ontai, L., Diaz Rios, K., Shilts, MK, Townsend, MS (2019, July). Measuring Parent Food-Related Behaviors with Spanish-speaking Parents of Preschool Aged Children: Reliability and Validation of Mi Ni�o a la Hora de Comer-Year 4. Poster presented at the AFRI Project Directors Meeting at the Society for Nutrition Education and Behavior Annual Meeting, Orlando, FL.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2019 Citation: Ontai, L, Sutter, C, Sitnick, S, Shilts, MK, Townsend, MS (2019, April). Parent Responses to Difficult Child Behavior During Mealtime. Paper presented at the Society for Research in Child Development Biennial Meeting, Baltimore, MD.
• Type: Theses/Dissertations Status: Accepted Year Published: 2019 Citation: Galindo Cardenas, L. R. (2019). Parent-Child Interactions Influence on Preschool-Aged Childrens Weight and Dietary Intake. (Unpublished master's thesis). University of California, Davis, CA
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2019 Citation: Bellows L, Francis L, Sharkey J, Teran-Garcia M, Townsend MS. USDA Highlights: Child Obesity Prevention. Society for Nutrition Education and Behavior Annual Conference. Orlando, FL 7/30/2019
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2019 Citation: Moderator: Chester D. Speakers: Townsend MS, Diaz Rios LK, Ontai L & Shilts MK. Combating Childhood Obesity Among Spanish Speaking Families: New Valid Evaluation and Education Tools for Practitioners and Researchers. Society for Nutrition Education and Behavior Annual Conference. Orlando, FL 7/28/2019.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2019 Citation: Navarro SP, Townsend MS, Diaz Rios LK. Relevance of stories & emotion-based messages to improve parent modeling behaviors and feeding practices. UC Merced Summer Undergraduate Research Symposium. Merced, CA, August 2019

Progress 04/01/18 to 03/31/19

Outputs
Target Audience:Participant enrollment and data collection continued into year 4 (Y4) with a goal of 200 subjects completing the validation portion of the study. Data collection ended in June 2018 when 2239 participants completed the 5 data collection points and a blood sample (n=169 children). We performed preliminary statistics on a subset of our participants (n = 167 parents; n=148 children). The primary caregiver/parent enrolled in our study is a 33 year female (>98%), Hispanic (>99%), born in Mexico (>83%), who is more comfortable speaking Spanish (>95%). The children are 56.3% females with an average age of 52 months. To date, our data show that 26% of children are overweight and obese (BMI percentiles-for age > 85) and ~16% are obese (BMI percentiles-for-age >95); the obesity rate in our cohort is higher than the national obesity prevalence in 2-5 year old children (13.9%, NHANES, 2015-2016). High BMI percentiles adversely affected the metabolism of these children. Children in the highest BMI percentiles-for-age quartile have significantly higher lipid (229 ± 82), and metabolic (118± 33) indices, and larger waist circumference (58.8 ± 5.7) than children in the lowest BMI percentile-for-age quartile (188 ± 95, 95± 38) and (49.9± 2.6) respectively. Changes/Problems:Nothing to report What opportunities for training and professional development has the project provided?Training of EFNEP educators (n=3), medical residents (n=44), pediatricians (n=18) has been completed. Undergraduate students coding videotapes of family meals will continue until spring 2019. The undergraduates are all recruited for credit units applied to research training. As such, there is some turnover each quarter and new students are taken on and trained while others have continued with the project for the full year. To fulfill their unit hours all undergraduates are trained on the coding system and must achieve reliability with the gold-standard prior to independently coding. This process takes each student approximately 20 hours (8 weeks) which equals one academic quarter. The students can then begin coding their second quarter on the project. In addition to the coding, they are trained on data collection procedures and are asked to accompany the videotaping research assistant on at least one visit each quarter in order to experience the data collection process. Finally, students are required to attend lab meetings once a week and meet with the project manager once every other week to discuss the coding and debrief on any issues that have arisen with the coding or data processing. Finally, all students engage in a journal club as part of the lab meetings whereby selected articles related to the project are presented and discussed. Each student must select an article from the list and present to the group one week of the quarter. This allows the students to understand how the work fits within the larger field of research. How have the results been disseminated to communities of interest?Results have been presented at national and international conferences and locally with collaboratorsat Head Start, WIC, and University California Davis Medical Center. What do you plan to do during the next reporting period to accomplish the goals?In year five, the focus will be concluding data cleaning and analyses and presentation of the education package. Focus will shift to development and publishing of the NIFA Childhood Obesity Grant Evaluation journal supplement. Lastly, the team will continue to coordinate the 2019 NIFA annual project director meeting.

Impacts
What was accomplished under these goals? OBJ 1) Produce final versions of two validated obesity risk assessment tools (Niños Sanos) for low-literacy Spanish speaking parents We have begun to analylize data to explore the association between Niños Sanos subscales and child lipid and metabolic index. Preliminary analyses of our data showed that a higher score (healthier SSB behaviors) on the 3-item sweet sugar beverages (SSB) subscale is associated with a lower child lipid index (P=0.09). Although most families (52/63) reported the daily consumption of ready-made box cereals, more than half of the families consumed tortillas and taco shells (41/63) rather than breads or bagels. In contrast, families predominantly (63/63) included fruits and vegetables common to the American diet (carrots, apple, banana, etc); only a handful of families (17/63) listed choices such as mangos, papayas, plantain or cactus in their daily diet. These choices may reflect greater accessibility and lower cost. Photographs taken in Y3 to expand our image data bank of Hispanic and American Indian families illustrating the HK behaviors using typical foods, meals and local settings of the community were reviewed, edited and assigned to relevant assessment tool questions in Y4. These photographs were added to the Healthy Kids Website http://healthykids.ucdavis.edu/ to customize the HK and MCMT obesity risk assessment tools. The HK website was also updated to include Spanish language versions of Healthy Kids and My Child at Meal Time and the newly validated Healthy Kids 19-item tool. Efforts to collect and code videotape data of mealtimes continued for the validation of the Spanish MCMT tool. Recruitment and data collection of 8 additional parent-child pairs for videotaping in the family home continued through July 2018 and a final videotaping sample of 60 families was reached. Coding of the parent behaviors continued with the previously adapted protocol. Additionally, an adaptation of a previously developed coding protocol for child behaviors during mealtime in English speaking families was completed. Currently,100% 55 (of 60; 92%) of the videotapes have been coded for parent behaviors and 20% for child behaviors. BIOMARKERS SELECTION AND PREPARATION -NIÑOS SANOS-: During Y4 the following progress has been made regarding child obesity biomarkers: • made an inventory of the children's' blood samples. • identified and selected the relevant biomarkers to be measured, and the matrix in which to measure them. • optimized an analysis plan with Meso Scale Discovery and ordered 7 different assay kits. • completed the analytical phase with:resistin and IGFBP1, Leptin/Insulin, Adiponectin, Cytokines, CRP, RBP4. Only carotenoid, tocopherol, cortisol analyses remain to be completed. OBJ 2) Assess feasibility and relevance of these tools to the child's pediatrician To stimulate parent interest and physician referrals to the HK EFNEP nutrition classes, the pilot testing of an iPad kiosk for the clinic waiting room was completed in Y4. The kiosk provides parents with tailored family nutrition tips based on 22 items from the HK and MCMT tools and is available free of charge http://healthykids.ucdavis.edu/Home/KioskEmail . A step-by-step guide was developed for other researchers and clinicians to use the HK Kiosk in their medical clinic http://townsendlab.ucdavis.edu/evaluation-research-tools/validation-research/. OBJ 3) Develop and validate a visual diet quality tool for English (My Veggies) and Spanish-speaking (Mis Vegetales) parents A vegetable variety tool to measure diet quality, was developed in English (My Veggies) in Y2 and adapted to be used with Spanish speakers (Mis Vegetales) in Y3 applying a multistep, iterative process that included 4 rounds of cognitive interviews, involving a total of 16 Spanish-speaking parents, and subject-matter experts. In Y4, design, food photography, and layout were completed for Mis Vegetales. OBJ 4) Determine feasibility and potential synergy from placing an EFNEP intervention in a medical clinic A total of 771 (30% Spanish speaking) patients have been referred. More than one-third (n=264) of patients referred expressed interest in attending the intervention with 195 verbally agreeing to be enrolled. Parents (n=106) attended at least one EFNEP intervention session. The profile of the parent attending the classes is mostly female (94%), Hispanic (70%) and low income (82% participated in an assistance program). Mostparents (78%)complete four or more classes with many bringing their children to the classes. Feasibility survey (n=70) results suggest a high acceptability with nutrition topics (94%), goal setting activities (87%), food tasting (90%) and parenting (90%) topics as "liked very much." Almost ¾ of parents (73%) reported classes in their medical clinic as important or very important reason for coming to the classes and 83% identified physician referral as an "important" or "very important" reason for enrolling. Exit interviews with parents corroborate this feedback, with parents stating the classes "motivated [them] to be more responsible when choosing what to eat and feed [their] families" and make them feel empowered "because [by] choosing to eat better, [they] feel better." To date 28 physicians have completed the feasibility survey indicating that the EFNEP intervention was useful to parent/patients (89%) and physicians (86%). One physician reported, "I think it's a great opportunity to get patients nutritional advice! I would expect other doctors to be excited about this opportunity as well." Y4 focus has also been on preparation of the local Cooperative Extension program staff to take responsibility for enrollment of parents from the medical clinics. We are using a "scaffolding" approach where our research staff are conducting one-on-one trainings session with the UCCE EFNEP educator on how to retrieve referral slips from the clinic, track referrals, schedule classes, and enroll parents. The educator practices with the research staff retrieving slips and calling patients until she is comfortable doing each task on her own. Parents (n=72) have been interviewed upon completing the nutrition classes to assess the relevance and appeal of the behavioral strategy Motivational Modeling (i.e., story-telling and emotion based messaging). Data has been compiled, transcribed, and organized for content analysis. Interviews confirm recounts from the previous year indicating the story-telling part of the strategy is relevant, for both English- and Spanish- speaking parents; however parents do not remember the emotion-based messages in the format presented. OBJ 5) Coordinate a USDA/NIFA/AFRI obesity grant program journal supplement and plan annual Project Director meeting. We are in communication with three journals as possible venues for the journal supplement. We are working with the USDA NIFA program leader and staff to gather data on each grant awarded. For example, 82 grants were awarded from 2011 to 2017 with a funding rate of 9.8% (2-16%). We have created a Google survey proposal form to send out to all project directors. The submissions will be reviewed by a committee and the selections will be made in spring 2019. The annual project directors meeting was held in Minneapolis, Minnesota in conjunction with the Society for Nutrition Education and Behavior. Forty project directors from around the country attended the two-day meeting which started with a symposium titled, "Conversations with USDA & Funding Opportunities" and an evening reception for PD's to network and share materials on day one. The second day included a well-attended poster presentation session with 37 posters displayed. The meeting concluded with a final symposium highlighting impactful work of four selected NIFA childhood obesity projects.

Publications

• Type: Journal Articles Status: Accepted Year Published: 2018 Citation: Sutter C, Ontai LL, Shilts MK, Lanoue LL, Allen LH, Townsend MS. (2018) Associations between School Readiness, Obesity- and Inflammation-related Biomarkers in Low-Income Preschoolers within the Healthy Kids Study. Mind, Brain, & Education. 2018; 12(1), 28-38 doi: 10.1111/mbe.12165.
• Type: Journal Articles Status: Accepted Year Published: 2018 Citation: Townsend MS, Shilts MK, Styne DM, Drake C, Lanoue LL, Ontai L. (2018) An obesity risk assessment tool for young children: validity with BMI and nutrient values. J Nutr Educ Behavior, 50(7), 705717.
• Type: Journal Articles Status: Accepted Year Published: 2018 Citation: Shilts MK, Sitnich SL, Ontai L, Townsend MS. (2018) Guided goal setting: A feasible obesity prevention behavior change strategy for low-income parents with young children. J Human Sciences & Extension. 6(3):161-179.
• Type: Journal Articles Status: Accepted Year Published: 2018 Citation: Ontai L, Sutter C, Sitnick S, Shilts MK, Townsend MS. (2019) My Child at mealtime parent self-assessment of food related behaviors: Validation with mealtime behaviors. Appetite 136:6269.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2018 Citation: Shilts MK, Diaz Rios LK, Ontai L, Panarella KH, Styne DM, Townsend MS. Scaling Up Childhood Obesity Prevention Interventions from Feasibility, RCT to Translation. International Society for Behavioral Nutrition and Physical Activity Conference Symposium. Hong Kong. June 4, 2018, p. 18.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2018 Citation: Townsend MS, Shilts MK, Styne DM, Drake CM, Lanoue L, Woodhouse L, Allen LH. Policy relevant tools to measure obesity-related behaviors in young children: methodological advances guiding short tool development and validation. Convener: Golle R. International Society for Behavioral Nutrition and Physical Activity Conference Symposium. Hong Kong. June 6, 2018, p. 77.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2018 Citation: Townsend MS, Shilts MK, Ontai, L, Drake C, Lanoue L, Styne, DM, Keim N, Diaz Rios, KL, Panarella K. Obesity Risk, Parenting & Diet Quality Tools for Hispanic Families with Preschoolers: EFNEP, Head Start, Medical Clinic-Year 3. J Nutr Behav Educ. 2018: 50(7):S108.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2018 Citation: Ontai L, Diaz Rios LK, Shilts MK, Lanoue L, & Townsend MS. Mi Ni�o a La Hora De Comer: Concurrent Validation Methods Through Mealtime Observations and Preliminary Analyses. J Nutr Educ Behav. 2018: 50(7):S107-8.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2018 Citation: Sutter C, Shilts MK, Lanoue L, Townsend MS, Ontai L. School Readiness, Obesity, and Inflammation-Related Biomarkers in Low-Income Preschoolers within the Healthy Kids Study. J Nutr Educ Behav. 2018: 50(7):S108-9.
• Type: Other Status: Accepted Year Published: 2018 Citation: Townsend MS, Shilts MK & Diaz Rios LK. An Obesity Risk Assessment Tool for Young Children: Validity with BMI and Nutrient Values. J Nutr Educ Behav. National Webinar: Journal Club. November 5, 2018. https://www.sneb.org/journal-club-webinar-series/
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2018 Citation: Diaz Rios LK, Muzaffar H. Health Promotion Research with Latino Children and Parents. Academy of Nutrition and Dietetics Food & Nutrition Conference & Expo". Washington, DC, Oct 2018.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2018 Citation: Diaz Rios LK, Shilts MK, Ontai L, Zavala G, Espinoza M, Townsend MS. Relevance of Motivational Modeling, a pedagogic strategy to improve parental modeling behaviors and feeding practices. University of California Division of Agriculture and Natural Resources Statewide Conference. Ontario, CA, Apr 2018
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2018 Citation: Shilts MK, Sitnick S, Ontai L, & Townsend, MS. A Guided Goal Setting Intervention Improves Child Feeding Practices of Low-Income Parents. J Nutr Behav Educ. 2018: 50(7):S107.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2018 Citation: Lanoue L, Townsend MS, Shilts MK, Drake C, Ontai L, Diaz Rios LK, Keim N, & Styne DM. Using Biomarkers for the Validation of Ni�os Sanos, an Obesity Risk Assessment Tool: Preliminary Results. J Nutr Behav Educ. 2018: 50(7):S109.

Progress 04/01/17 to 03/31/18

Outputs
Target Audience:Typically, the primary caregiver/parent enrolled in our study is a 33 year female (>98%), Hispanic (>99%), born in Mexico (>83%), who is more comfortable speaking Spanish (>95%). A majority has completed grade school (72%), most are unemployed (69%) and live in a household composed of 2 adults (78%) and 2 or 3 children (63%). The children are 56.3% females with an average age of 52 months. More than 30% of the children are overweight (>85th percentile); of these 53% are obese (>95th percentile). The rate of obesity measured in our 3-5 yr old (16.7%) is twice the national average (8.9%) reported in 2-5 year old children (RWJ Foundation, the state of obesity 2017). 70% of mothers are overweight, of these, 50% have a BMI greater than 30 and are obese; however this is a lower obesity rate (35%) than the Latino adults' obesity rates reported nationally (42.6%, RWJ Foundation, 2017). Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?Pediatric and Family Practice Interns and Residents (n=44) at UC Davis Medical Center were trained on childhood obesity determinants and effective intervention strategies plus how to refer patients to the EFENP nutrition intervention offered at their clinics. Trainings were provided by Drs. Styne, Shilts and Ms. Leavens. Undergraduate students were trained to code videotapes of family meals (n=8). Students are trained on the coding system and must achieve reliability with the gold-standard prior to independently coding. This process takes each student approximately 20 hours (8 weeks). The students can then begin coding. In addition to the coding, they are trained on data collection procedures and are asked to accompany the videotaping research assistant on at least one visit each quarter in order to experience the data collection process. Finally, students are required to attend lab meetings once a week and meet with the project manager once every other week to discuss the coding and debrief on any issues that have arisen with the coding or data processing. Finally, all students engage in a journal club as part of the lab meetings whereby selected articles related to the project are presented and discussed. Each student must select an article from the list and present to the group one week of the quarter. This allows the students to understand how the work fits within the larger field of research. How have the results been disseminated to communities of interest?Results have been presented at national and international conferences and locally with collaborators. What do you plan to do during the next reporting period to accomplish the goals?In year four, the focus will be on conducting data cleaning and analyses and disseminating results via manuscripts and presentations at national and international meetings. Biomarker analyses will be completed. Completion of the Healthy Kids for Spanish-speakers Education Package for USDA food assistance programs; and producing a national webinar. In addition, we will also focus efforts on the for NIFA journal supplement (Objective 5 ) and continue to coordinate the NIFA Project Directors' meeting.

Impacts
What was accomplished under these goals? Objective 1: Spanish Obesity Risk Assessment Tools (Healthy Kids-HK and My Child at Meal Time-MCMT) Cross-sectional Validation Using Biomarkers, Anthropometrics, and Dietary Recalls Participant recruitment and data collection continued to be the focus for Year 3 (Y3) to validate the Spanish HK and MCMT tools. In addition, significant effort was devoted to selection of biomarkers, technical planning for the upcoming biomarker analyses and statistical analyses of previously collected biomarkers. One hundred parent-child pairs from 12 Head Start and WIC sites were enrolled (74% completion rate) in Y3 for a total of 210 participants. A child blood sample was collected on ~92% of child participants. Salivary sample collection was administered in children (n=50) to investigate stress and obesity risk. Preliminary analyses were performed on a subset of our participants (n = 167 parents; n=148 children) testing whether the children's metabolic parameters were influenced by their BMI (30.7% overweight or obese) using ANOVA. Children with higher BMI percentiles-for-age have significantly higher plasma cholesterol, LDL-C and nonHDL-C levels compared to children with lower BMI-percentiles. There was a strong significant association between BMI-percentiles-for-age and waist circumference, waist to height ratio and body weight in the children. Thus in our cohort of Spanish speaking low income families, a third of the 3-5yr olds have unhealthy weight and waist measurements, which are associated with higher plasma lipids and glucose levels, putting them at greater risk for compromised health in the future. A subset of participants completed a series of photoshoots to expand our image data bank with photos of Hispanic and American Indian families. These photos will be added to the HK Website http://healthykids.ucdavis.edu/ to customize the HK and MCMT tools. In YR3, we continued analyses of previous data (English speaking cohort) to examine the long term association between children biomarkers (as various indices) HK subscales in a longitudinal model. Results from the preliminary statistical analyses indicate that: 1) Different HK scales are associated with different biomarker indices. 2) Parents with higher HK19 scores (healthier behaviors) have children that have overall healthier metabolic profile. 3) Results show an important time*HK interaction effect for pro-inflammatory indices. We have initiated meetings for the analysis strategy of this study's biomarkers. Data from past and ongoing biomarkers' analyses have revealed certain biomarkers are sensitive to changes in HK scores (IGFBP1, RBP4, etc); other biomarkers are influenced by the children' BMI percentiles-for-age (leptin, adiponectin, insulin, CRP, etc); and there is a limited amount of blood that can be collected from young children so that assays should be prioritized. Efforts to collect and code videotape data of mealtimes continued to assist with the validation of the Spanish MCMT tool.More resources were allocated to videotaping data collection with increased number of data collectors, higher stipends to families, and improved communications with participants. Previously developed English coding procedure was revised to adapt it to be culturally relevant to Spanish-speaking families. A part-time dedicated project manager to oversee recruitment, training, and reliability of the undergraduate coding team was hired. During this project period, 5 new students were trained, 3 students continued from the previous project period, and 21 new videotapes were collected and coding completed on 33 of 47 videos. Objective 3: Diet Quality Tool Development and Validation (My Veggies) MyVeggies, was adapted to be used with Spanish speakers. Content and face validity were achieved after applying a multistep, iterative process that included 4 rounds of cognitive interviews, involving a total of 16 Spanish-speaking parents, and subject-matter experts. Objective 4: Feasibility of Expanded Food and Nutrition Education Program (EFNEP) Intervention with Guided Goal Setting in a Medical Clinic Setting Y3 focus continued to be on recruitment of parents and expansion of medical clinic sites where referrals are obtained and classes are offered. As a result, five new medical clinics are referring parents to nutrition classes. Physicians (n=81) from eight medical clinics have generated 425 patient referrals, of which 227 were generated in Y3. To date, approximately six referrals are needed to get one parent enrolled. Recruitment has been enhanced by offering referred parents to invite a family member or friend to attend. Thirty-one parents (91% female) have been enrolled in the EFNEP intervention in Y3 for a total 69 parents with 83% completing 5 for more classes. Seven series of 8 EFNEP classes each have been conducted in Y3 in both English and Spanish with three new educators trained. Parent and physician feasibility surveys were administered. Parents, reported nutrition topics (95%) and goal setting activities (84%) as "liked very much" and 84% identified physician referral as an important reason for enrolling. Most physicians (n=20) reported the intervention as useful to parent/patients (85%) and physicians (80%). Physicians suggested making the referral box more prominent in their clinic, offering electronic referrals and feedback once patients complete the classes. An additional 29 participant parents (79% Spanish-speaking) have been interviewed upon completing the nutrition classes to assess the relevance and appeal of the behavioral strategy Motivational Modeling. Data has been compiled, transcribed, and organized for content analysis. Interviews confirm recounts from the previous year indicating the story-telling part of the strategy is relevant, for both English- and Spanish-speaking parents; however, the emotion-based messages seem to be less appealing. General impressions on the classes have also been explored during these interviews and will be analyzed. Objectives 3 & 4: Feasibility of a Medical Center Kiosk To stimulate parent interest and physician referrals to the EFNEP nutrition classes, an iPad kiosk for the clinic waiting room was completed in Y3. The kiosk provides parents with tailored family nutrition tips based on 22 items from the HK and MCMT tools. Two rounds of formative evaluation were conducted with parents. Average time to complete the kiosk survey was 3 minutes 16 seconds. All parents (n=6) reported that it was "very easy" or "easy" to complete the survey and they would share the results with the pediatrician. Parents suggested a desire to have results sent via email in addition to the receipt printout, which was subsequently added to the kiosk options. Pilot testing began in August at medical clinics (n=3) targeting low-income English speaking parents. Twelve pilot testing sessions (average 2.54 hrs) were completed by research staff members who set up kiosk and printer, coordinated with the medical clinic front office staff to invite parents at check-in to visit the kiosk and collected data on parent interaction. The first 6 pilot testing sessions, parents interacted with the iPad as part of the kiosk stand (similar to an IV stand). This method resulted in a low number of completions (18%). Another contributing issue to a low completion rate was that the clinic wait time was very brief so most parents interacting with the kiosk could not finish the survey. A new approach was developed where parents were handed the iPad at check-in. We also recruited two new clinics with busier waiting rooms resulting in an 80% completion rate.

Publications

• Type: Conference Papers and Presentations Status: Accepted Year Published: 2017 Citation: Townsend MS, Shilts MK, Ontai L, Drake C, Lanoue L, Styne D, Allen L, Diaz Rios K, Panarella K. Obesity Risk, Parenting & Diet Quality Tools for Hispanic Families with Preschoolers: EFNEP, Head Start, Medical Clinic-Year 2. J Nutr Behav Educ. 2017:49, 7S:S121-122.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2017 Citation: Shilts MK, Reed ML, Leavens L, Ontai L, Lanoue L, Styne D, Townsend MS. Development of a Medical Center Kiosk to Promote Pediatric Obesity Risk Reduction. J Nutr Behav Educ. 2017:49, 7S:S122.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2017 Citation: Ontai L, Diaz Rios K., Shilts MK, Lanoue L, Davidson C, Zavala G, Espinoza M, Townsend MS. Process for Validating My Child at Mealtime: Assessing Parent Mealtime Behavior in Spanish Speaking Families of Preschoolers. J Nutr Behav Educ. 2017:49, 7S:S122-123.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2017 Citation: Diaz Rios LK, Zavala G, Espinoza M, Keim N, Shilts MK, Townsend MS. Spanish adaptation of a pictorial assessment of diet quality. J Nutr Behav Educ. 2017:49, 7S:S123.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2017 Citation: Shilts MK, Panarella K, Leavens LL, Kenyon V, Diaz-Rios K, Davidson C, Lanoue L, Townsend MS. Feasibility of an EFNEP Intervention Delivered in 3 Medical Clinics: Preliminary results. 9th Biennial Childhood Obesity Conference, Abstract book, San Diego, 2017.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2017 Citation: Townsend MS, Keim N, Diaz Rios LK, Shilts MK. Pictorial assessment of Diet Quality: content and face validation. International Society for Behavioral Nutrition and Physical Activity, abstract book 2017: P2.03.15; p413. Victoria, BC, Canada.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2017 Citation: Townsend MS, Healthy Kids: Obesity prevention tools, USDA Highlights session AFRI Obesity Grantees, Society for Nutrition Education and Behavior, July 23, 2017.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2017 Citation: Townsend MS. Moderator for Tools for Assessing Home Obesogenic Environments: From Development to Real World Applications, SNEB Symposium, July 23, 2017.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2017 Citation: D�az Rios K. Speaker. Cultural Adaptation, SNEB Symposium, July 23, 2017.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2017 Citation: Ontai L. Speaker. Validating Parent Responses with Observed Behaviors at Mealtime, SNEB Symposium, July 23, 2017.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2017 Citation: Lanoue L. Speaker. Using Biomarkers to Validate Healthy Kids Obesity Assessment Tools. SNEB Symposium, July 23, 2017.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2017 Citation: Shilts MK. Speaker. Validation and Real World Applications. SNEB Symposium, July 23, 2017.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2017 Citation: D�az Rios K. Speaker. Understanding Nutrition Literacy and Effective Strategies for Communicating Nutrition Information, Pennsylvania Nutrition Education Network Annual Conference, May 2017.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2017 Citation: Ontai LL, Sutter C, Shilts MK, Townsend, MS. Parent Feeding Styles and Their Behavior During Mealtime. Society for Research in Child Development Biennial Meeting, Austin, TX, April 2017.

Progress 04/01/16 to 03/31/17

Outputs
Target Audience:Low-income parent-child (age 3-5) pairs are the target of this study. We have enrolled participants from eight Head Start sites (n=110) and four medical clinics (n=39) focusing on Spanish speaking or bi-lingual parents. Parents (97% women; n=70) completing the cross-sectional validation component were recruited from Head Start are on average 33.9 years old with a BMI of 29.8. Children (n=68) are 4.43 years old with an average BMI-for-age percentile of 67.3. The average BMI-for-age percentile of parent-child pairs from Head Start (n=72) is within normal range. However the data distribution shows that 20 children (28%) have a BMI ≥85th percentile; of these, 65% have a BMI ≥95th percentile and are obese. These data indicate an unusual distribution for these children: a large normal weight group, a small overweight group and a larger than expected obese group. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?Pediatric and Family Practice Residents (n=29) at UC Davis Medical Center were trained on childhood obesity determinants and effective intervention strategies plus how to refer patients to the EFENP nutrition intervention offered at their clinics. Trainings were provided by Drs. Townsend, Styne, Shilts and Mrs. Panarella. Additionally, Dr. Ontai trained atotal of five undergraduate research assistants to reliably code mealtime interaction video recordings to establish Spanish MCMT validation. How have the results been disseminated to communities of interest? Nothing Reported What do you plan to do during the next reporting period to accomplish the goals?In year three, the focus will be on completing enrollment for the Spanish HK and MCMT validation study; conduct data cleaning and analyses; deploy kiosk at a medical clinic site and complete enrollment for EFNEP nutrition education sessions. In addition, executing biomarker analyses, drafting of manuscripts and begin planning for NIFA journal supplement will be priorities.

Impacts
What was accomplished under these goals? Objective 1: Spanish Obesity Risk Assessment Tools (Healthy Kids-HK and My Child at Meal Time-MCMT) Cross-sectional Validation Using Biomarkers, Anthropometrics, and Dietary Recalls Protocol development, recruitment, enrollment and data collection commenced in year 2 to validate the Spanish HK and MCMT tools. The cross sectional study design was selected to test convergent validity using subjective (parental surveys and 24-hour dietary, sleep and activity logs) and objective (anthropometric and biomarkers) measures. Data are collected at 6 time points (T1 to T5, plus videotaping) over a 6-8 week period. Data collection started in April 2016. To date, recruitment has focused on eight Head Start sites with a total of 110 Spanish speaking parent-child pairs recruited of which 84 completed the 5 data collection time points (76% retention). Preliminary analyses of the glucose and lipid profiles of children (28% classified as overweight or obese) show that the children metabolic data are positively associated with BMI percentile: children with high BMI-for-age percentile have higher total plasma cholesterol, LDL-C and NON-HDL cholesterol, higher circulating triglycerides and plasma glucose (P<0.09). The strong significant association between waist circumference and BMI percentile (P<0.008) suggest that these children already accumulate visceral fat which adversely influence their metabolic profile. Clinical biomarkers (grouped into specific index), from existing child blood samples (English speaking cohort) were used for the validation of the HK tool. Results show that blood markers of vitamin A (n =3, pooled as carotenoid index) and inflammation (n = 3, pooled as anti-inflammation index) can be used for convergent validity of specific subscales of HK, while other indices (lipid, metabolic and pro-inflammation index) showed no significant association with HK. Distribution analysis of parameters commonly used (CRP, TNF, IL-6, Cholesterol, LDL-C, glucose, etc) to measure individual differences in adults showed that these markers did not vary among our group of children. Results from these analyses indicate that not all individual metabolic markers in children are sensitive indicators of parental report using HK or strong predictors of obesity risk. The data will be extremely useful in selecting biomarkers for the current study with a Spanish speaking population. Videotape data collection of mealtimes began in year 2 to assist with the validation of the Spanish MCMT tool. This included revising a previously developed protocol and mealtime interaction coding procedure for use with Spanish-speaking families, recruitment and hiring of a bilingual research assistant to recruit families and conduct the videotaping sessions, recruitment of undergraduate student research assistants to help with videotape data collection and train in videotape coding procedures. Families (n=24) have successfully completed the videotaped mealtime portion of the study. A total of five undergraduate research assistants have begun training, with two establishing adequate reliability on implementing the coding procedure. To date, two videotapes have been successfully coded and training is continuing to establish reliability with the remaining coders. Objective 3: Diet Quality Tool Development and Validation (AKA My Veggies) The 22-item diet quality tool in English and Spanish, My Veggies, was finalized and printed. The ARS Western Human Nutrition Research Center based at UC Davis shared some grant funds with our study. This enabled an additional validation study to be conducted with My Veggies. Consequently, the tool was administered to English-speaking (62% female), predominantly middle income population, with an average age of 41.8 years old and a BMI of 28.1 (n=34). The My Veggies tool will be validated against the Block Food Frequency Questionnaire and also the HEI estimated from three 24-hour dietary recalls obtained from the ASA-24. Analyses will commence in year 3. Objective 4: Feasibility of Expanded Food and Nutrition Education Program (EFNEP) Intervention with Guided Goal Setting in a Medical Clinic Setting The intervention protocol was finalized and a bilingual educator was trained. The guided goal setting parent workbook and accompanying education materials were adapted and tested for a Spanish speaking audience. Resident training continued and newly developed recruitment materials (poster, handouts, and prescription referral pads) were deployed. As a result, physicians (n=38) from four pediatric/family practice medical clinics have generated 198 patient referrals. To enroll parents in the intervention, 584 phone calls and 368 texts were made. Thirty-nine parents (89% female) have been enrolled in the EFNEP intervention anchored with guided goal setting and motivational modeling. Six series have been conducted at three separate medical clinics, four of which were conducted in Spanish. Pre and post intervention food behavior checklist survey data show that parents (n=22) completing the intervention more often thought about healthy food choices when feeding their families (45%), used the Nutrition Facts label (50%) and more often reported serving breakfast to their children (45%). Challenges include garnering physician referrals to fill the intervention and getting parents to respond to enrollment phone calls. To date, approximately five referrals and 15 phone calls are needed to get one parent enrolled. Once parents are enrolled, 86% complete 5 or more intervention sessions, invite friends and family members to attend, and report that the nutrition topics (96%) and goal setting activities (88%) were liked very much. Sixty-five percent of parents stated that the physician referral was an important reason for enrolling. New strategies are being tested to increase referrals such as a computer kiosk in the medical clinic site and enhanced advertisement of the start of a new intervention series. Six physicians have completed an online feasibility survey. Eighty-seven percent reported they feel the EFNEP intervention is useful to them and their patients with 100% reporting that they think physicians at other clinics would participate in referring patients to an EFNEP intervention. Motivational Modeling was added to the EFNEP intervention to enhance behavioral change. At the conclusion of the intervention, parents are interviewed about their perception, preference and impact of this behavioral strategy. To date, 6 focus groups have been conducted, for a total of 17 participants interviewed. Four of the 6 focus groups have been audio-recorded and notes have been taken on all of them. Data has been compiled, transcribed, and organized for content analysis. A preliminary assessment shows most participants appreciate the motivational stories, find them useful to "put things into perspective," believe they add value to the classes, and think other parents would like them as well. The emotion-based messages, on the other hand, are showing mixed reviews, with some participants having trouble remembering them. Objective 2 & 4: Medical Center Kiosk The content of the kiosk was determined based on previous HK and MCMT longitudinal validation. The kiosk allows parents of pediatric clinic patients to complete a survey and receive tailored childhood obesity prevention tips. The tailored printout will also encourage the parent to discuss tips with their pediatrician and advertise the free EFNEP intervention offered at the clinic. The computer programmer and graphic designer are in the final stages of kiosk content development and functionality. In consultation with clinic staff and physicians, a kiosk design with attached receipt style printer and clinic location were determined. The kiosk will be pilot tested in 2017. The Healthy Kids Website was translated and redesigned for Spanish speaking parents. Pilot testing of the site will occur in 2017.

Publications

• Type: Journal Articles Status: Published Year Published: 2016 Citation: Townsend MS, Shilts MK, Styne DM, Drake C, Lanoue L, Woodhouse L, Allen LH. Vegetable behavioral tool demonstrates validity with MyPlate vegetable cups and carotenoid and inflammatory biomarkers. Appetite, 2016;107:628-638.
• Type: Journal Articles Status: Published Year Published: 2016 Citation: Sutter C, Ontai LL, Nishina A, Conger KJ, Shilts MK & Townsend MS (2016): Utilizing the desired results developmental profile as a measure of school readiness: evaluating factor structure and predictors of school readiness. Early Child Development and Care. p 1-13, DOI: 10.1080/03004430.2016.1174933
• Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Townsend MS, Shilts MK, Ontai LL, Drake C, Lanoue L, Styne D, Allen L, Diaz Rios K, Panarella K. Obesity Risk, Parenting & Diet Quality Assessment for Spanish-Speaking Families with Preschool Children: EFNEP, Head Start, Medical Clinic-Year 1. J Nutr Educ Behav 2016:48(7): S132.
• Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Ontai L, Sutter C, Shilts MK, Townsend MS. Correspondence Between My Child at Mealtime Responses and Observed Parent Behaviors During Mealtime. J Nutr Educ Behav, 2016;48(7): S127-128.
• Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Diaz Rios K, Ontai L, Zavala G, Espinoza G, Shilts MK, Townsend MS. Spanish Adaptation of My Child at Mealtime: A Feeding Style Self-Assessment Tool for Low-Income Parents of Preschoolers. J Nutr Educ Behav, 2016;48(7): S117.
• Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Sutter, C., Ontai, L.L., Shilts, M.K., Lanoue, L.L., & Townsend, M.S. (2016). Investigating Associations between School Readiness, Biomarkers of Obesity, and Inflammation in Low-Income Preschoolers. Association for Psychological Science Annual Meeting, Chicago, IL.
• Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Townsend MS , Shilts MK, Styne D, Lanoue L, Allen L. Short Pictorial Sweetened Beverage Scale Demonstrates Validity with Anti-inflammatory Index blood values. ISBNPA abstract book 2016: LP2.098: p593.
• Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Townsend MS , Shilts MK, Drake C, Lanoue L, Beatrice F. Focus on Snacks: Reliability and Validity. J Nutr Educ Behav, 2016;48(7): S132-133.
• Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Shilts MK, Drake C, Lanoue L, Beatrice F, Townsend MS. Physical Activity and Screen Time 24-hr Logs Validate a Brief Activity Tool. J Nutr Educ Behav 2016;48(7): S131.

Progress 04/01/15 to 03/31/16

Outputs
Target Audience: Low-income parent-child (age 2-5) pairs are the target of this study. We have recruited participants from four Head Start sites and three medical clinics focusing on Spanish speaking or bi-lingual parents. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided? Nothing Reported How have the results been disseminated to communities of interest? Nothing Reported What do you plan to do during the next reporting period to accomplish the goals?We will begin the cross-sectional validation study of Healthy Kids (HK) and My Child at Meal Time (MCMT) tools with Spanish speaking parents at Head Start. We will select the best biomarkers for validation, based on our previous assessment of the biomarkers' accuracy, stability and sensitivity with respect to the HK tools and target population. We will established standard operating protocols for the collection and laboratory analyses of these biomarkers. The Healthy Kids website will be designed for a Spanish speaking audience. A computer/tablet kiosk displaying HK and MCMT obesity risk assessment results will be developed and pilot tested for a medical clinic setting. We will continue recruitment and delivery of EFNEP lessons at a medical clinic setting. Lastly, we will have the graphic designer photograph vegetable pictures for the diet quality tool and complete the layout and design for two audiences: Spanish speakers and English speakers.

Impacts
What was accomplished under these goals? Hiring of four staff members including a graphic designer, project coordinator and two bi-lingual data collection has been completed. In addition, the Institutional Review Board documents have been submitted and the study has been approved. Selection of the dietary analysis program (ASA24) was completed and staff are currently being trained. Training of new staff is ongoing. Spanish Obesity Risk Assessment Tools (Healthy Kids-HK & My Child at Meal Time-MCMT) The HK and MCMT obesity risk assessment tools were translated. The Spanish versions were cognitively tested with 30 Head Start Spanish-speaking parents. Vocabulary and response options were changed based on parent preferences. Photographs used to assist client understanding of questions were also changed. Parents preferred fresh versus frozen or canned fruit and vegetables and parents indicated that overall pictures should feature Hispanic families but some variety in ethnic groups was preferred. The graphic designer has completed the layout and design of both tools, which are now ready for the validity testing phase of the study. Feasibility of EFENP intervention with Guided Goal Setting in a Medical Clinic To test the feasibility of an EFENP intervention in a Medical Clinic setting, two formal planning meetings with our research staff and medical staff have been conducted. Three meetings with the EFNEP Director, UC Davis Nutrition Specialist, UC Davis Human Development Specialist, EFNEP staff and bi-lingual EFNEP educator were conducted to determine how to tailor the content of the lessons to match the needs of the medical clinic and EFNEP guidelines. To address pediatric obesity prevention, guided goal setting based on the HK & MCMT tools replaced the self-set goal setting in the traditional EFENP curriculum. Parenting topics and motivational modeling were also added to further address determinants of obesity. My Healthy Plate activities were included to address recommended food group proportions and child appropriate portion sizes. To customize the lessons to a Spanish speaking audience with young children, relevant recipes were selected, handouts were translated, assessment tools and promotional materials used photos representing the target audience. A referral process was discussed and referral sheets were developed and printed in pads of 50, simulating the dimensions of drug prescription pads. The doctor completes the referral sheet during the medical visit for the child and the parent adds contact information. Referral sheets were then placed in designated referral boxes [created just for this study] at each clinic. A formal EFNEP presentation describing the project/study was made at a meeting of the resident doctors. To date 16 patient referrals have been made and the first series of EFNEP lessons will begin in February. Diet Quality tool A 22-item diet quality tool focusing on vegetable intake of parents during the past week was developed using web-based photos. The tool was cognitively tested (n=9) with English and bi-lingual speaking parents. Results indicated the necessity of two separate tools for English speaking parents and Spanish speaking parents with different vegetable photographs (i.e, no canned beans for the Hispanic version). Biomarkers During the period in review, we evaluated the biomarker data sets for accuracy, precision and reproducibility as summarized below: Outliers: Boxplots were calculated to determine statistical outliers for each biomarkers. The statistical outliers were evaluated case by case for consistency and metabolic plausibility and kept in the data set if either criteria were met. Accuracy and precision: of the data was evaluated using the percent coefficient of variability (%CV) between duplicate analyses of a child's sample. Biomarkers having duplicates with %CV greater than 25%, indicative of poor precision, were rejected from the data set. Reproducibility of the data measured in different batches or plates was evaluated using an internal standard. When biomarkers were measured as multiplex, reproducibility was poor as indicated by the %CV of the internal standard ranging between 16 to 30%. A global standard curve (GSC) was generated to correct for this plate to plate variability. Stability of the data was assessed by repeating the analyses of a child's blood sample at 2 different times. Overall, some biomarkers (Adiponectin, CRP, RBP-4, IL-10, IL6 and IL-8) show better stability than others (leptin, TNFα and insulin). Indices: Biomarkers were converted to percentiles and summed up into different index: Pro-Inflammatory (sum of IL-6, IL-8, CRP, TNFα, RPB-4; +/- leptin); Anti-Inflammatory (Adiponectin, IGFBP-1, IL-10), Metabolic (glucose; +/- insulin); Lipid (cholesterol, triglycerides, HDL-C, LDL-C); and Carotenes (retinol, α and ß carotene).

Publications

• Type: Conference Papers and Presentations Status: Published Year Published: 2015 Citation: Lanoue L. Healthy Kids Biomarkers Data: Evaluation of Data Quality. Western Human Nutrition Research Center (WHNRC). Oct 30 2015.
• Type: Conference Papers and Presentations Status: Published Year Published: 2015 Citation: Lanoue L. Healthy Kids Biomarker Data: Discussion of data processing, lessons for upcoming study. Western Human Nutrition Research Center (WHNRC). Nov 11 2015.
• Type: Conference Papers and Presentations Status: Published Year Published: 2016 Citation: Lanoue L. Use of Biomarkers in Community Nutrition Studies: Data from the UCD-WHNRC Healthy Kids Project. Western Human Nutrition Research Center (WHNRC). Jan 12 2016.
• Type: Conference Papers and Presentations Status: Published Year Published: 2015 Citation: Townsend MS, Shilts MK, Ontai L. Helping Federal Programs Combat Childhood Obesity with New Valid Evaluation Tools & Education Materials. Institute of Food Safety and Nutrition (IFSN) Seminar Series. September 29, 2015. http://nifa.usda.gov/resource/helping-federal-programs-combat-childhood-obesity-new-valid-evaluation-tools-education
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2016 Citation: Panarella K, Shilts MK, Kenyon V, Leavens L, Davidson C, Townsend MS. EFNEP in a Medical Clinic: Recruitment of Participants. National 2016 EFNEP Coordinators Conference Arlington, VA.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2016 Citation: Panarella K, Shilts MK, Diaz-Rios K, Ontai L, Leavens L, Davidson C, Townsend MS. EFNEP in a Medical Clinic: Customizing 8 lessons. National 2016 EFNEP Coordinators Conference Arlington, VA.
• Type: Journal Articles Status: Published Year Published: 2016 Citation: Ontai L, Sitnick S, Shilts MK, Townsend MS. My Child at Mealtime: A Visually Enhanced Self-Assessment of Feeding Styles for Low-Income Parents of Preschoolers. Appetite. 2016 99:76-81.
• Type: Conference Papers and Presentations Status: Published Year Published: 2015 Citation: Townsend MS, Shilts MK, Allen L, Styne D, Woodhouse L. Serum biomarkers validate a pictorial vegetable behavior tool. J Nutr Behav Educ. 2015:47,4S;S102.
• Type: Conference Papers and Presentations Status: Published Year Published: 2015 Citation: Townsend MS, Shilts MK, Allen L, Styne D, Woodhouse L, Shahab-Ferdows S, Drake C. Biomarkers validate a 3-item sweetened beverage tool. J Nutr Behav Educ. 2015:47,4S;S102.
• Type: Conference Papers and Presentations Status: Published Year Published: 2015 Citation: Townsend MS, Ontai L, Shilts MK, Styne D, Lamp C, Schneider C, Johns M. Efficacy of obesity risk assessment tools integrated with parental guided goal setting to maintain healthy weight among preschool children: year 5. J Nutr Behav Educ. 2015:47,4S;S102.