CHILDREN`S HEALTHY LIVING CENTER OF EXCELLENCE (CHL CENTER)

• Sponsoring Institution: National Institute of Food and Agriculture
• Project Status: COMPLETE
• Funding Source: AFRI COMPETITIVE GRANT
• Reporting Frequency: Annual
• Accession No.: 1014875
• Grant No.: 2018-69001-27551
• Cumulative Award Amt.: $2,125,903.00
• Proposal No.: 2017-06836
• Project Start Date: Mar 1, 2018
• Project End Date: Feb 29, 2024
• Grant Year: 2018
• Program Code: [A2101]- Childhood Obesity Prevention: Integrated Research, Education, and Extension to Prevent Childhood Obesity

Recipient Organization
UNIV OF HAWAII
3190 MAILE WAY
HONOLULU,HI 96822

Performing Department
Human Nutri, Food & Anim Sci

Non Technical Summary
CHL's goal is to serve as a Center of Excellence to continue to build capacity in a partnership among 11 jurisdictions of the US Affiliated Pacific - to provide training, research and extension/outreach to maintain and extend the CHL network, examine long-term effects of the multilevel CHL intervention and provide access to best practices in policy, systems and environmental approaches for prevention of child obesity. CHL addresses the USDA NIFA priority areas of 1) food safety, nutrition and health 2) agricultural systems and technology and 3) agricultural economics and rural communities. CHL supports long-range improvement in and sustainability of agriculture and food systems in remote underserved (ESPSCOR) US jurisdictions of the Pacific Region that are not represented in National Nutrition and Health Monitoring (NHANES). We aim to :1) Instruction (I): Increase the number of educators, practitioners, and researchers who receive the training and effectively model behaviors necessary to address the complex problem of childhood obesity prevention through further development and enhancement of CHL training programs, including the CHL Summer Institute and Certificate Program in underserved Pacific populations.2) Research (R): Test the long term impact (6 year) of the CHL integrated multilevel policy systems and environmentally focused community intervention on child behaviors, obesity and related functional outcomes in underserved Pacific populations.3) Extension (E): Further build and maintain the CHL Center of Excellence that will continue to monitor Pacific child obesity and related behaviors and environments, to provide information for program and policy guidance to prevent child obesity.

Animal Health Component

100%

Research Effort Categories

Basic

(N/A)

Applied

100%

Developmental

(N/A)

Classification

Knowledge Area (KA)	Subject of Investigation (SOI)	Field of Science (FOS)	Percent
703	6010	1010	50%
704	6050	1170	50%

Knowledge Area
703 - Nutrition Education and Behavior; 704 - Nutrition and Hunger in the Population;

Subject Of Investigation
6010 - Individuals; 6050 - Communities, areas, and regions;

Field Of Science
1010 - Nutrition and metabolism; 1170 - Epidemiology;

Keywords

children

ethnicity

health disparity

nutrition

obesity

Goals / Objectives
The goal of the CHL Center for 2018-2023, among Pacific USDA-defined Experimental Program for Stimulating Competitive Research (EPSCoR) jurisdictions, is to serve as a Center of Excellence to further build capacity and generate new knowledge for regional collective impact on child health. The CHL Center will continue to train and build capacity and health literacy through the CHL Summer Institute; evaluate and develop evidence on the long term and collective impact of the CHL environmentally focused multilevel multicomponent intervention on child behaviors, obesity and acanthosis nigricans in the Pacific through extending our intervention research; and continue to develop, test, maintain, disseminate, train and standardize with a nutrition measurement and monitoring system and workforce for a region that is not served by NHANES, as an extension/outreach activity. With the foundation of partnership and joint effort forged, the CHL Center will maintain and extend the CHL collaborative network. This renewal will:1) Increase the number of diverse educators, practitioners, and researchers who receive the training necessary to address the complex problem of childhood obesity prevention through further development and enhancement of CHL training programs, including the CHL Summer Institute and Certificate Program in underserved Pacific populations, which includes the components of obesity assessment, modification of obesogenic factors and health literacy (Instruction).2) Test the long term impact and evolution (6 year) of the CHL integrated multilevel policy systems and environmentally focused community intervention on child behaviors, obesity and acanthosis nigricans in underserved Pacific populations (Research).3) Further build and maintain the CHL Center of Excellence that will continue to monitor and disseminate Pacific child obesity and related evidence about behaviors and environments, to enhance health literacy and reduce health disparities in program and policy guidance to prevent child obesity and reduction in health disparities (Extension).

Project Methods
CHL Center Objective 1: CHL Center Training Program activities will focus on curriculum development, delivery, and evaluation for both credit and non-credit purposes. Currently, the CHL Center Training Program offers distance courses in Pacific-integrated introductory nutrition; the foundations of childhood obesity in the Pacific; technology and professional skills in childhood obesity prevention; lifespan nutrition; childhood anthropometric and dietary assessment field assessment techniques; childhood health and monitoring for the Pacific; and culture and child health in the Pacific, through the Children's Healthy Living Summer Institute (CHL SI). In order to situate the CHL Center Training Program to offer a Certificate in Child Health, the CHL SI will develop one more distance course, a practicum in child health and the development of a CHL SI online assessment system in year 1. The CHL Center will also be seeking opportunities to articulate course equivalencies at the University of Guam and Northern Marianas College to ensure a Pacific reach of the CHL SI. Through the CHL SI, free CHL curricular tools, such as the Pacific Food Guide, are disseminated to a wider audience. To complement the Pacific Food Guide, the CHL Center Training Program activities will support the adaptation of an Open Education Resource (OER) Textbook for introductory nutrition (https://oer.hawaii.edu/project/human-nutrition/) for the Pacific which will require creating a database of images captured in previous CHL activities. Combined with Pacific examples of basic nutrition concepts, integrating CHL images into a free OER introductory nutrition text will assist with delivering a place-based and Pacific focused introductory nutrition course that is accessible and affordable. The CHL Center Training Program will also develop a non-credit, continuing education training opportunity, appropriate for health extension and other health professionals in the region. Since the series of CHL SI courses were developed in a modular format, the CHL Center grant will support the translation of the courses into individual learning modules offered through UH Outreach College Non-Credit Programs that can be completed for a minimal fee. Once developed, accreditation of the CHL SI by relevant health professional associations (e.g., Commission on Dietetic Registration) will be sought to enhance CHL's service to the region. The CHL SI assessment system will also be adapted to allow for program evaluation data to be collected for the non-credit training.CHL Center Objective 2: We will evaluate the long term intervention effect at 84 months after baseline, which is 5 years after the end of the CHL intervention, by collecting additional data in the original 27 CHL communities. The CHL intervention was implemented in the manner that was intended to be sustainable, by partnering with existing programs and agencies that could continue the activities. The CHL intervention communities were exposed to the intervention for 24 months while the CHL control communities were exposed to an optimized intervention program for 6 months and the CHL temporal communities were not exposed to the program. The hypothesis is that the CHL intervention will have a sustained positive and long term impact on decreasing young children's obesity level and improving related behaviors.A CAT survey of the 27 communities will be conducted and an inventory of community intervention activities of the nine intervention communities will be compiled. The results will be compared against the baseline inventory and the CHL progress reports to document what intervention components have been continued, adopted or dropped. A secondary analysis of the existing CHL intervention data, where we investigate which components of the intervention worked best. The effect of dose of the intervention on the changes in outcomes from baseline to 24 months will be examined, with dose based on the number, reach and type of activities reported in the CHL monthly reports, as shown in the Progress Report section. The results of this analysis will aid in our understanding of the potential impacts of the components of the intervention that are ongoing in the communities. The results of the situation analysis and the secondary analysis will also inform the outreach work in Objective 3 to understand the needs of the communities and the optimal approaches for meeting those needs.We will assess children and parents for relevant outcomes at 84 months after baseline, which is 5 years after the formal end of the CHL intervention. We will measure a cross-sectional sample of 50 children aged 2-8 years in each of the 27 communities, to match the design of the original study. Recruitment will take in the same venues as the baseline and 24 month assessments (HeadStarts, preschools and community events). The selected measurements will mirror those in the original CHL study, with the addition of caregiver reported health literacy. Community level assessments of aspects of the food and physical environment, using the CAT instruments, will also be made at 84 months for all communities to provide repeat measures. The primary outcome measures available over 84 months from intervention, control and temporal communities will be BMI z-score, overweight and obesity status based on the CDC growth data, waist circumference, and acanthosis nigricans. Other primary outcome measures available over 84 months from intervention and control communities will be the behavioral variables of dietary intake of the primary targets, screen time and sleep duration, as well as acanthosis nigricans. The temporal communities will only have these data at 84 months, and will be used to understand the levels in populations not exposed to the intervention, and to inform Objective 3 activities.CHL Center Objective 3: CHL maintains a management structure and set of protocols, including a shared regional server, website and training program-facilitating work and saving cost. Centralized data management will continue to be maintained by the CHL Center. The existing Local Advisory Committees, formed as part of the CHL network, along with coalitions and extension programs will advise on the conduct of the extended CHL intervention trial and dissemination of the results to the communities. CHL staff will work with local partners and coalitions to secure additional funds to extend intervention activities in communities. To increase health literacy, pre-school teachers will be trained on how to understand growth charts, ways to communicate BMI results and obesity prevention information to parents and other caregivers, and be provided with CHL developed culturally and readiness level tailored materials to be distributed to parents and caregivers. The training will be based on the CHL role model guide and will utilize actionable tip sheets focusing on self-care, to improve the health of the community's children. To expand health literacy in the region, the CHL web-site will enlarge the "Resource materials for community supporters" section of the CHL web-site to include policy brief templates, newly developed materials, and links to resources that will assist community partners improve both their own families' health and the collective public health. CHL online asynchronous distance training for both credit (Objective 1) and non-credit (extension, Objective 3) classes at in-state rates through University of Hawai'i Outreach College by the CHL Summer Institute will continue instruction across the enormous distance (7 time zones) in the CHL Pacific region. The CHL Center will continue to provide anthropometric training and standardization training and coordination for the region, maintain a database of standardized measurers, and host a regional monitoring system based on CHL measurements and publicly available data from Department of Education and Health.

Progress 03/01/18 to 01/09/24

Outputs
Target Audience:Communities members and professionals working in child nutrition and health in the Pacific region. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?Open source textbooks were developed in Human Nutrition and Lifespan Nutrition. CHL Summer Institute of courses, related to nutrition and child health in the Pacific, are accessible through University of Hawaii Outreach College. CHL hosts a research group for discussion of research ideas and projects among students, staff and collaborators. How have the results been disseminated to communities of interest?Local advisory committee meetings have continued to meet in each jurisdiction, to share findings and ideas and network on dissemination and implementation. We maintain the chl-pacific.org website as a means of dissemination of data and findings, which includes an interactive data dashboard and data request system. The CHL trial was incorporated into the SNAP-Ed toolkit, as a form of dissemination of the trial tools to other communities. What do you plan to do during the next reporting period to accomplish the goals? Nothing Reported

Impacts
What was accomplished under these goals? We found that 4 years after the conclusion of the active CHL multilevel multicomponent trial (which decreased the prevalence of children with overweight and obesity and acanthosis nigricans in communities), the prevalence continued to decline more in communities that had been in the intervention group, compared to those in the control group, showing the success of the trial. We found that jurisdiction income level was associated with child diet quality, where higher diet quality was found among higher income jurisdictions. Food security was also associated with better blood pressure status in adults. Young children's diets did not meet milk, vegetable, or fruit intake recommendations. Grain intake and monounsaturated fat intake were lower and milk intake was higher in children with better metabolic status. Added sugar in children's diets was predictive of occurrence of acanthosis nigricans in a longitudinal subset of children. Dietary characteristics were worse among older compared to younger children in the Marshall Islands. We have obtained a Sustainable Agricultural Systems grant that allows us to continue to maintain the CHL Center of Excellence and use the CHL data to identify resiliency factors in food systems in the region. We are training 5 new graduate students from the region with this CHL Food Systems project for continued long term impact. We are also maintaining a CHL multistate project and network, which has expanded our reach to the continent, including University of Arizona, University of West Virginia, and Texas A & M University.

Publications

• Type: Journal Articles Status: Published Year Published: 2022 Citation: Novotny R, Yamanaka AB, Dela Cruz R, Strasburger S, Boushey CJ, Butel J, Esquivel M,1 AflagueTF, Fleming T, Coleman P, Deenik J, Shallcross L,Wilkens LR. Food Group, Macronutrient Intake, and Metabolic Status in the US-Affiliated Pacifics Childrens Healthy Living (CHL) Program. Journal of Nutrition, Volume 152, Issue 12, December 2022, Pages 28982912
• Type: Journal Articles Status: Published Year Published: 2023 Citation: Ing CT, Clemens B, Ahn HJ, Kaholokula JK, Hovmand PS, Seto TB, Novotny R, Food Insecurity and Blood Pressure in a Multiethnic Population. Int. J. Environ. Res. Public Health 2023, 20, 6242. https://doi.org/10.3390/ijerph20136242.
• Type: Journal Articles Status: Published Year Published: 2022 Citation: Loo BKG, Okely A, Taylor R, Novotny R, Wickramasinghe P, M�ller-Riemenschneider F, Gade G, Pulungan A, Kusuda S, Tan KH, AsiaPacific 24-Hour Activity Guidelines for the Early Years AsiaPacific consensus statement on integrated 24-hour activity guidelines for the early years Committee https://www.ncbi.nlm.nih.gov/sites/myncbi/rachel.novotny.1/bibliography/5459964/public/?sort=date&direction=ascending The Lancet Regional Health -Western Pacific 2022;100641Published Online https://doi.org/10.1016/j.lanwpc.2022.100641
• Type: Journal Articles Status: Published Year Published: 2022 Citation: Shvetsov YB, Wilkens LR, White KK, Chong M, Buyum A, Badowski G, Leon Guerrero RT, Novotny R. Prediction of breast cancer risk among women of the Mariana Islands: the BRISK retrospective case-control study. BMJ Open. 2022 Dec 9;12(12):e061205. doi: 10.1136/bmjopen-2022-061205. PMID: 36600333; PMCID: PMC9743286
• Type: Journal Articles Status: Published Year Published: 2023 Citation: Hingle M, Short E, Aflague T, Boushey C, Butel B, Coleman P, Deenik J, Fleming T, Olfert M, Shallcross L, Wilkens LR, Novotny R, Food Security is Associated with Higher Diet Quality Among Children of the US Affiliated Pacific Region, The Journal of Nutrition, https://doi.org/10.1016/j.tjnut.2023.01.015
• Type: Journal Articles Status: Published Year Published: 2023 Citation: Smith T, Chong KH, Cross, P, Ipil M, Eliou P, Novotny R, Okely AD. Prevalence and socio-demographic distributions of meeting RMI Guidelines for Healthy Living among elementary school children in Majuro, Republic of Marshall Islands: a cross-sectional population-based survey. The Lancet Regional Health-Western Pacific. https://doi.org/10.1016/j.lanwpc.2023.100783
• Type: Journal Articles Status: Published Year Published: 2023 Citation: Taren D, Alaof� H, Yamanaka AB, Coleman P, Fleming T, Aflague T, Shallcross L,Wilkens L, Novotny R. Diet and Acanthosis Nigricans over a Two-Year Period in Children of the Pacific Region. Nutrients 2023, 15, 2718. https://doi.org/10.3390/nu15122718

Progress 03/01/22 to 02/28/23

Outputs
Target Audience:Professionals and Communities interested in programs and policies for child nutrition and health. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?The following opportunities for training and professional development was seen in all three CHL Center objectives. Objective 1 Eight online summer courses were offered through CHL Summer Institute. The eight courses offered were: FSHN 185 - The Science of Human Nutrition: Integrating basic concepts of science with the study of human nutrition; designed for the person who wants an introduction to nutrition and who may later choose a major in it. FSHN 360 - Applied Professional Skills in Nutrition: Through the use of technology, students will become more familiar with identifying evidence-based information and demonstrating their academic skill sets for future professional success. FSHN 370 - Lifespan Nutrition: Identifying nutrient requirements during pregnancy, infancy, childhood, adolescence and aging; Coupled with an understanding of how basic physiologic and metabolic changes affect nutritional needs across the lifespan; addressing important social and cultural factors influencing nutritional status throughout the lifespan. FSHN 454 - Foundations of Childhood Obesity Prevention in the Pacific: A basic overview of the causes and effects of childhood obesity, evidence-based approaches, community-based research, and policies to prevent childhood obesity as it relates to the Pacific. FSHN 455 - Childhood Anthropometric and Dietary Assessment Field Techniques: Stimulating students' hands on training in the techniques used to measure body composition and collect dietary intake information with a particular emphasis on children. (Offered but did not enrollment minimum) FSHN 456 - Childhood Health and Nutrition Monitoring in the Pacific: Monitoring the health and nutritional status of populations including epidemiology, biostatistics, and health and nutrition surveillance systems. FSHN 457 - Culture and Child Health in the Pacific: Taking a journey through the Pacific region to learn about the People and their culture; Approaches for promoting child health in the Pacific region. FSHN 492 - Field Experience in Childhood Obesity Prevention: This course involves integrating and applying academic knowledge and critical skills, emphasizing professional development, with a field experience approved by a cooperating supervisor or employer. (Offered but did not enrollment minimum) 92 college students completed CHL Summer Institute courses in year 5. Continued childhood obesity research group to present research ideas for discussion and feedback (group consists of three University of Hawaii childhood obesity researchers; three post-doctorate staff; four doctoral students: one from Hawaii; one from Guam, one from American Samoa, and one from CNMI). Objective 2 5 trainings for program staff were conducted for conducting CHL Group Model Building. CHL data used for dissertation for 3 doctoral students from Guam, CNMI and American Samoa. 2 abstracts for manuscripts using CHL data have been approved by project steering committee this year. How have the results been disseminated to communities of interest?The CHL Center of Excellence created CHL statistical analysis framework for food systems and presented at CHL annual meeting and to community members at CHL group model building workshops. CHL staff serves on boards, advisory committees, technical working groups, policy implementation working groups and coalitions throughout the US Affiliated Pacific, nation, and globe, to disseminate CHL results and add to the body of knowledge on childhood obesity prevention. Monthly CHL Center Project Steering Committee meetings were held to update committee members on activities and discuss issues. Held one in-person meeting with CHL Center jurisdiction leads in conjunction with CHLN multistate meeting in August 2022. Analyzing CHL data for simulation modeling for the Food System Resiliency for Children's Healthy Living (CHL Food System grant # 2021-68012-35899). Presented poster on CHL diet data at the Sustainable Agricultural Systems awardee meeting. Other Presentations Douglas Taren, Halimatou Alaof, Ashley B Yamanaka, Patricia Coleman, Travis Fleming, Tanisha Aflague, Leslie Shallcross, Carol Boushey, Lynne Wilkens, Rachel Novotny. A longitudinal analysis of insulin resistance in children, 2- to 8-year olds in the Pacific Region, the Children's Healthy Living Program. IUNS/ICN Tokyo Japan, December. Poster. Rachel Novotny, Tanisha Aflague, Patricia Coleman, Travis Fleming, Leslie Shallcross, Lynne Wilkens. Children's Healthy Living community randomized trial sustainably decreased prevalence of overweight and obesity of young children in the diverse US affiliated Pacific region. IUNS/ICN Tokyo, Japan. December. Oral. Invited. What do you plan to do during the next reporting period to accomplish the goals?Year 6 of the CHL Center of Excellence grant will see further accomplishments to the goals set forth in the grant as we continue to offer courses, conduct follow-up data analysis, and disseminate the results of the long-term CHL intervention effect. For each objective the following are planned for Year 6. Objective 1 Offer eight CHL Summer Institute courses in Summer 2022. Finish development of an open resource textbook on Nutrition throughout the Lifespan. Continue training five CHL Food System graduate students. Continue CHL Research Group to present CHL research. Objective 2 Continue analysis of CHL intervention follow-up data. Continue to provide CHL data for students and researchers. Continue analysis of CHL data for use in CHL Food System Simulation Model. Objective 3 Disseminate CHL findings to communities through advisory councils and coalitions Continue to disseminate findings, trainings and other program information on CHL web site. Present at conferences and continue to publish CHL findings. Present CHL findings at CHL Food System Group Model Building workshop in American Samoa.

Impacts
What was accomplished under these goals? The goal of the CHL Center of Excellence is to further build capacity and generate new knowledge for regional collective impact on child health. To actualize CHL Center's goals the three objectives (listed above) guide the progress of the Center of Excellence. Therefore, the accomplishments of CHL Center are stated by objective. Objective 1 - Training- Accomplishments: CHL Center was able to leverage the CHL related grant, Children's Healthy Living Dietetics (CHLD) Scholarship Program. CHLD provides funding for five Native Hawaiian students in nutrition and health to complete a Bachelor's of Science Dietetics degree at the University of Hawai'i at Manoa. CHLD is supported by the USDA Multicultural Scholars Program, award number 2018-38413-28140. Two students will be completing their dietetics degree this year. The Children's Healthy Living Summer Institute (CHL SI) is an outcome of the CHL Program. CHL SI contributes to CHL's mission through providing access to a training program focused on child health and obesity prevention that is evidence-based. In 2022, CHL Summer Institute offered online offered six summer courses related to childhood obesity. 92 college students completed CHL Summer Institute courses. CHL Research discussion group continued. Group consists of students and junior staff using CHL data for research. 17 research projects were presented. 4 doctorate level students used CHL data for thesis and dissertation work. Development of the Lifespan Nutrition Open Educational Resource textbook, is continuing. As part of the CHL Food Systems grant, award number 2021-68012-35899, five Nutritional Science graduate students from the CHL jurisdictions (Hawaii, Guam, CNMI, American Samoa, and Alaska) have been recruited and have begun either a doctorate or master program. Objective 2 - Research- CHL program sustainability- Accomplishments: Conducted weekly meetings with research staff to oversee data cleaning, data entry, and data analysis. Obtained IRB renewal for CHL study. The CHL food cost survey (FCS) was leveraged to obtain a cooperative agreement with USDA CNPP to conduct a food cost survey in Hawaii and Alaska. The survey was conducted in March 2022. The CHL Center team is continuing to work with the CNPP team to analyze the results. The data has been cleaned and sent to the CNPP team for analysis. Analysis of CHL food data to examine CHL participants HEI 2015 score, DASH score and macro and micro nutrients. Analysis of CHL food data to examine most frequently consumed foods, by food group, among CHL participants. Analysis of CHL food log data to examine time of eating occasions among CHL participants. Analysis of foods predictive of overweight, obesity, acanthosis nigricans and waist-for-height among CHL participants. Descriptive analysis of CHL environmental data collected in CHL intervention communities Identified CHL data as it relates to High Level Panel of Experts (FAO) food system diagram Identified CHL data to analysis as it relates to food security Objective 3 - Extension/Outreach Accomplishments: To disseminate results of the long-term effects of the CHL intervention, the CHL Center team developed community reports. To maintain connection between partners in CHL Center an in person annual meeting was conducted in August 2022 in conjunction with CHL Network Multistate group (W1194). This meeting served to disseminate CHL results and guide the direction of CHL Center. Continued to update the CHL web site (www.chl-pacific.org) to allow for ease of use of CHL data for students, instructors, and researchers. Presented CHL research and process data at 1 conference, the CHL Center Annual meeting and 4 peer-reviewed publications. CHL data was presented at 7 CHL Food System Group Model Building workshops in Hawaii, Guam, CNMI and Alaska. Year Five continued to build on efforts that were established by the CHL program and through these efforts were able to realize meaningful strides towards the goals of the CHL Center of Excellence.

Publications

• Type: Journal Articles Status: Published Year Published: 2022 Citation: A.B. Yamanaka, S. Strasburger, C. Chow, J. Butel, L. Wilkens, J.D. Davis, J. Deenik, L. Shallcross, and R. Novotny. 2022. Food and Physical Activity Environment in the US-Affiliated Pacific Region: The Children's Healthy Living Room. Journal of Nutrition Education and Behavior. doi: 10.1016/j.jneb.2022.08.009
• Type: Journal Articles Status: Published Year Published: 2022 Citation: R. Dela Cruz, E. Wolfe, K.M. Yonemori, M.K. Fialkowski, L.R. Wilkens, P. Coleman, S. Lameko-Mua, E. Johnson, D. Gilmatam, C. Sigrah, M. Shomour, S. Remengesau, J. Alfred, M. Acosta, R. Ettienne, J. Deenik, T. Aflague, K. Abello Salazar, R. Novotny, C.J. Boushey. 2022. Exploring Foods of the Pacific: Cultural Food Identity in the US Affiliated Pacific Region. Hawai'i Journal Of Health & Social Welfare. Vol 18, 9 247-252
• Type: Journal Articles Status: Published Year Published: 2022 Citation: R. Novotny, A.B. Yamanaka, R. Dela Cruz, S. Strasburger, C.J. Boushey, J. Butel, M. Esquivel, T.F. Aflague, T. Fleming, P. Coleman, J. Deenik, L. Shallcross, and L.R. Wilkens. 2022. Food group, macronutrient intake and metabolic status in the US-Affiliated Pacific's Children's Healthy Living (CHL) Program, The Journal of Nutrition, 2022;, nxac173, https://doi.org/10.1093/jn/nxac173
• Type: Journal Articles Status: Published Year Published: 2022 Citation: R. Dela Cruz, E. Wolfe, K.M. Yonemori, M.K. Fialkowski, L.R. Wilkens, P. Coleman, S. Lameko-Mua, E. Johnson, D. Gilmatam, C. Sigrah, M. Shomour, S. Remengesau, J. Alfred, M. Acosta, R. Ettienne, J. Deenik, T.F. Aflague, R. Nelson, K. Abello Salazar, R. Novotny, and C.J. Boushey. 2022. Consumption of Traditional Fruits and Vegetables among Children in the US-Affiliated Pacific Region, Current Developments in Nutrition, Volume 6, Issue 7, July 2022, nzac101, https://doi.org/10.1093/cdn/nzac101
• Type: Journal Articles Status: Published Year Published: 2022 Citation: R. Novotny, A.B.Yamanaka, J. Butel, et al. 2022. Maintenance Outcomes of the Childrens Healthy Living Program on Overweight, Obesity, and Acanthosis Nigricans Among Young Children in the US-Affiliated Pacific Region: A Randomized Clinical Trial. JAMA Netw Open. 2022;5(6):e2214802. doi:10.1001/jamanetworkopen.2022.14802

Progress 03/01/21 to 02/28/22

Outputs
Target Audience:Professionals and Communities interested in programs and policies for child nutrition and health. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?The following opportunities for training and professional development was seen in all three CHL Center objectives. Objective 1: Eight online summer courses were offered through CHL Summer Institute. The eight courses offered were: FSHN 185 - The Science of Human Nutrition: Integrating basic concepts of science with the study of human nutrition; designed for the person who wants an introduction to nutrition and who may later choose a major in it. FSHN 360 - Applied Professional Skills in Nutrition: Through the use of technology, students will become more familiar with identifying evidence-based information and demonstrating their academic skill sets for future professional success. FSHN 370 - Lifespan Nutrition: Identifying nutrient requirements during pregnancy, infancy, childhood, adolescence and aging; Coupled with an understanding of how basic physiologic and metabolic changes affect nutritional needs across the lifespan; addressing important social and cultural factors influencing nutritional status throughout the lifespan. FSHN 454 - Foundations of Childhood Obesity Prevention in the Pacific: A basic overview of the causes and effects of childhood obesity, evidence-based approaches, community-based research, and policies to prevent childhood obesity as it relates to the Pacific. FSHN 455 - Childhood Anthropometric and Dietary Assessment Field Techniques: Stimulating students' hands on training in the techniques used to measure body composition and collect dietary intake information with a particular emphasis on children. (Offered but did not enrollment minimum) FSHN 456 - Childhood Health and Nutrition Monitoring in the Pacific: Monitoring the health and nutritional status of populations including epidemiology, biostatistics, and health and nutrition surveillance systems. FSHN 457 - Culture and Child Health in the Pacific: Taking a journey through the Pacific region to learn about the People and their culture; Approaches for promoting child health in the Pacific region. FSHN 492 - Field Experience in Childhood Obesity Prevention: This course involves integrating and applying academic knowledge and critical skills, emphasizing professional development, with a field experience approved by a cooperating supervisor or employer. (Offered but did not enrollment minimum) 91 college students completed CHL Summer Institute courses in year 4. Continued childhood obesity research group to present research ideas for discussion and feedback (group consists of three University of Hawaii childhood obesity researchers; three post-doctorate staff; four doctoral students: one from Hawaii; one from Guam, one from American Samoa, and one from CNMI). Objective 2: 2 trainings for program staff were conducted for food log data entry and food cost survey data collection. CHL data used for dissertation for 3 doctoral students from Guam, CNMI and American Samoa 12 abstracts for manuscripts using CHL data have been approved by project steering committee this year. 2 students; 8 researchers; and 1 USDA staff. How have the results been disseminated to communities of interest? The CHL Center of Excellence created community reports and placed them on the CHL website. CHL staff serves on boards, advisory committees, technical working groups, policy implementation working groups and coalitions throughout the US Affiliated Pacific, nation, and globe, to disseminate CHL results and add to the body of knowledge on childhood obesity prevention. Three teleconferences were conducted to discuss CHL Center direction. Held one virtual meeting with CHL Center jurisdiction leads in conjunction with CHLN multistate meeting in July 2021. Leveraged CHL data to obtained Sustainable Agricultural Systems grant, Food System Resiliency for Children's Healthy Living (CHL Food System). CHL Food System is a National Institute of Food and Agriculture award (# 2021-68012-35899). Partnered with the Supplemental Nutrition Assistance Education Program (SNAP-Ed) at the University of Guam to deliver Preschool wellness training and marketing materials to 22 Head Start classrooms and 4 Pre-kindergarten classes. What do you plan to do during the next reporting period to accomplish the goals?Year 4 of the CHL Center of Excellence grant will see further accomplishments to the goals set forth in the grant as we continue to offer courses, conduct follow-up data analysis, and disseminate the results of the long-term CHL intervention effect. For each objective the following are planned for Year 5. Objective 1 Offer eight CHL Summer Institute courses in Summer 2022 Select two students for paid internships in Hawaii as part of Western Region Public Health Program Finish development of an open resource textbook on Nutrition throughout the Lifespan Continue training five Native Hawaiian dietetic students for the CHLD program Objective 2 Continue analysis of CHL intervention follow-up data Continue development of anthropometry standardization process for the Pacific Region Continue to provide CHL data for students and researchers Objective 3 Disseminate CHL findings to communities through advisory councils and coalitions Continue to disseminate findings, trainings and other program information on CHL web site Present at conferences and continue to publish CHL findings Partner with Hawaii Department of Health and the Expanded Food and Nutrition Education program at the University of Hawaii to deliver Preschool teacher wellness trainings

Impacts
What was accomplished under these goals? The goal of the CHL Center of Excellence is to further build capacity and generate new knowledge for regional collective impact on child health and in the first year of the grant CHL Center has made strides in achieving these goals. To actualize CHL Center's goals the three objectives (listed above) guide the progress of the Center of Excellence. Therefore, the accomplishments of CHL Center are stated by objective. Objective 1 - Training- Accomplishments: CHL Center was able to leverage the CHL related grant, Children's Healthy Living Dietetics (CHLD) Scholarship Program. CHLD provides funding for five Native Hawaiian students in nutrition and health to complete a Bachelors of Science Dietetics degree at the University of Hawai'i at Manoa. CHLD is supported by the USDA Multicultural Scholars Program, award number 2018-38413-28140. Five students have been selected for the program and three are currently enrolled in the program. The Children's Healthy Living Summer Institute (CHL SI) is an outcome of the CHL Program. CHL SI contributes to CHL's mission through providing access to a training program focused on child health and obesity prevention that is evidence-based. In 2021, CHL Summer Institute offered online offered six summer courses related to childhood obesity. 91 college students completed CHL Summer Institute courses. CHL Research discussion group was formed. Group consists of students and junior staff using CHL data for research. 21 research projects were presented. 4 masters and doctorate level students used CHL data for thesis and dissertation work. An additional accomplishment was a new version of the open source textbook (OER) on the science of human nutrition to improve accessibility and is being used in University of Hawaii and the University of Guam classes. A new OER textbook, titled Lifespan Nutrition is being developed. Objective 2 - Research- CHL program sustainability- Accomplishments: Conducted weekly meetings with research staff to oversee data collection, data entry, and data analysis. Obtained IRB renewal for CHL study. Updated CHL food cost survey (FCS). The CHL FCS is used to determine the cost for a family of four to eat according to the Thrifty Food Plan (TFP). Online training on the collection of the CHL FCS and the supplemental FCS was conducted. *This activity was to be conducted in 2020 but due to COVID 2020 restrictions was postponed until March 2021. Conducted CHL FCS and supplemental FCS in Alaska, American Samoa, CNMI, Guam and Hawaii. All FCS data was cleaned and CHL FCS costs were analyzed for each jurisdiction and communities. The long-term analysis of the CHL intervention was conducted. Examined the change from baseline to long-term data collection, from post-intervention data collection to long-term data collection [insert table of results?] [JB1] Began analysis CHL food data to examine CHL participants HEI 2005 score and macro and micro nutrients. Began analysis of CHL environmental data collected in CHL intervention communities Objective 3 - Extension/Outreach Accomplishments: To disseminate results of the long-term effects of the CHL intervention, the CHL Center team developed a community reports To maintain connection between partners in CHL Center an annual meeting was conducted virtually in July 2021 in conjunction with CHL Network Multistate group (W1194). This meeting served to disseminate CHL results and guide the direction of CHL Center. Continued to update the CHL web site (www.chl-pacific.org) to allow for ease of use of CHL data for students, instructors, and researchers. Continued development of a child anthropometric protocol guide for use in the Pacific region. Presented CHL research and process data at 2 conferences and 3 peer-reviewed publications. CHL data request system process was leveraged to obtain CHL consultant to establish a data request process for the Hawaii Department of Human Services' Supplemental Nutrition Assistance Program (SNAP). Year Four continued to build on efforts that were established by the CHL program and through these efforts were able to realize meaningful strides towards the goals of the CHL Center of Excellence.

Publications

• Type: Journal Articles Status: Published Year Published: 2021 Citation: Butel, J., Braun, K.L., Davis, J., Bersamin, A., Fleming, T., Coleman, P., et al. 2021. Community social network pattern analysis: Development of a novel methodology using a complex, multi-level health intervention. Gateways: International Journal of Community Research and Engagement. 2021;14(1).
• Type: Journal Articles Status: Published Year Published: 2021 Citation: Novotny, R., Earle, M.E., Jung, Y.O., Julian, G.J., Hill, E., LeonGuerrero, R., Coleman, P., Deenik, J., Boushey, C., and Wilkens, L.R. 2021. Pacific Tracker (PacTrac) version 3.1 Diet and Physical Activity Assessment Tool for the Pacific Region. HAWAII JOURNAL OF HEALTH & SOCIAL WELFARE, JULY 2021, VOL 80, NO 7, pgs 21-24.
• Type: Journal Articles Status: Published Year Published: 2021 Citation: Yamanaka, A.B., Davis, J.D., Wilkens, L.R., Hurwitz, E.L., Fialkowski, M.K., Deenik, J., Guerrero, R.T., and Novotny, R. 2021. Peer Reviewed: Determination of Child Waist Circumference Cut Points for Metabolic Risk Based on Acanthosis Nigricans, the Childrens Healthy Living Program. Preventing Chronic Disease. 2021;18.2021;18:210021. DOI:https://doi.org/10.5888/pcd18.210021
• Type: Book Chapters Status: Published Year Published: 2022 Citation: Braun, K., Revilla Fialkowski, M.K., and Novotny, R. 2022. Community-based Participatory Research to Address Indigenous Health, In: Improving Indigenous Public Health Through Community Engaged Interventions. University of Kentucky Press, Lexington.
• Type: Journal Articles Status: Published Year Published: 2021 Citation: Schneeman, B.O., Ard, J.D., Boushey, C.J., Bailey, R.L., Novotny, R., Snetselaar, L.G., de Jesus, J.M., and Stoody, E.E. 2021. Impact of the National Academy of Sciences, Engineering, and Medicine Report on the Process for the 2020 Dietary Guidelines Advisory Committee. Adv Nutr 2021;00:17.
• Type: Journal Articles Status: Published Year Published: 2021 Citation: Dewey, K.G., Pannucci, T., Casavale, K.O., Davis, T.A., Donovan, S.M., Kleinman, R.E., Taveras, E.M., Bailey, R.L., Novotny, R., Schneeman, B.O., Stang, J., de Jesus, J., and Stoody, E.E. 2021. Development of Food Pattern Recommendations for Infants and Toddlers 624 Months of Age to Support the Dietary Guidelines for Americans, 20202025, The Journal of Nutrition, 2021;, nxab201, https://doi.org/10.1093/jn/nxab201
• Type: Journal Articles Status: Published Year Published: 2021 Citation: Nevins, J.E., Donovan, S.M., Snetselaar, L., Dewey, K.G., Novotny, R., Stang, J., Taveras, E.M., Kleinman, R.E., Bailey, R.L., Raghavan, R., and Scinto-Madonich, S.R. 2021. Omega-3 fatty acid dietary supplements consumed during pregnancy and lactation and child neurodevelopment: a systematic review. The Journal of Nutrition. 2021 Nov;151(11):3483-94, https://doi.org/10.1093/jn/nxab238.
• Type: Journal Articles Status: Published Year Published: 2021 Citation: English, L.A., Ard, J.D., Bailey, R.L., Bates, M., Bazzano, L., Boushey, C., Brown, C., Butera, G., Callahan, E.H., de Jesus, J., Mattes, R.D., Mayer-Davis, E.J., Novotny, R., Obbagy, J.E., Rahavi, E.B., Sabate, J., Snetselaar, L., Stoody, E., Van Horn, L., Venkatramanan, S., and Heymsfield, S.B. 2021. Evaluation of Dietary Patterns and All-Cause Mortality: A Systematic Review. JAMA Network Open. 2021 Aug 2;4(8):e2122277-.
• Type: Journal Articles Status: Awaiting Publication Year Published: 2021 Citation: Bailey, R., Ard, J.D., Davis, T.A., Naimi, T.S., Schneeman, B.O., Stang, J.S., Dewey, K., Donovan, S.M., Novotny, R., Snetselaar, L.G., de Jesus, J., Casavale, K., Pannucci, T., and Stoody, E.E. 2021. A Proposed Framework for Identifying Nutrients and Food Components of Public Health Relevance in the Dietary Guidelines for Americans, J Nutr.
• Type: Journal Articles Status: Published Year Published: 2022 Citation: Kai, J., Chen, J.J., Braun, K.L., Kaholokula, J.K., Novotny, R., Boushey, C.J., Fialkowski, M.K.* 2022. Associations between cultural affiliations, household membership and diet quality among Native Hawaiian, Pacific Islander, and Filipino infants in Hawai'i. Children. Children 2022, 9(1), 48; https://doi.org/10.3390/children9010048

Progress 03/01/20 to 02/28/21

Outputs
Target Audience:Students, Professionals and Communities interested in programs and policies for children's food, nutrition and health. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?The following opportunities for training and professional development were seen in all three CHL Center objectives. Objective 1: Eight online summer courses were offered through CHL SI. The courses offered were: FSHN 185 - The Science of Human Nutrition: Integrating basic concepts of science with the study of human nutrition; designed for the person who wants an introduction to nutrition and who may later choose a major in it. FSHN 360 - Applied Professional Skills in Nutrition: Through the use of technology, students will become more familiar with identifying evidence-based information and demonstrating their academic skill sets for future professional success. FSHN 370 - Lifespan Nutrition: Identifying nutrient requirements during pregnancy, infancy, childhood, adolescence and aging; Coupled with an understanding of how basic physiologic and metabolic changes affect nutritional needs across the lifespan; addressing important social and cultural factors influencing nutritional status throughout the lifespan. FSHN 454 - Foundations of Childhood Obesity Prevention in the Pacific: A basic overview of the causes and effects of childhood obesity, evidence-based approaches, community-based research, and policies to prevent childhood obesity as it relates to the Pacific. FSHN 455 - Childhood Anthropometric and Dietary Assessment Field Techniques: Stimulating students' hands on training in the techniques used to measure body composition and collect dietary intake information with a particular emphasis on children. FSHN 456 - Childhood Health and Nutrition Monitoring in the Pacific: Monitoring the health and nutritional status of populations including epidemiology, biostatistics, and health and nutrition surveillance systems. FSHN 457 - Culture and Child Health in the Pacific: Taking a journey through the Pacific region to learn about the People and their culture; Approaches for promoting child health in the Pacific region. FSHN 492 - Field Experience in Childhood Obesity Prevention: This course involves integrating and applying academic knowledge and critical skills, emphasizing professional development, with a field experience approved by a cooperating supervisor or employer. 136 college students completed CHL SI courses in year 2. Continued childhood obesity research group to present research ideas for discussion and feedback (group consists of three University of Hawaii childhood obesity researchers; three post-doctorate staff; four doctoral students: one from Hawaii; one from Guam, one from American Samoa, and one from CNMI). One 2-day adult anthropometry standardization was conducted in Hawaii. 4 staff from independent research projects were trained. One CHL research internship for undergraduate student in Hawaii. CHL SI Foundations of Obesity course material used for the development of a Western Region Public Health Training Center course on "Communicating with parents and caregivers about weight". Selected one student for paid internship in Hawaii as part of Western Region Public Health program. Objective 2: 2 trainings for program staff were conducted for food log data entry, and food cost survey data collection. 15 abstracts for manuscripts using CHL data have been approved by program steering committee this year. 1 doctoral student from Tufts University used CHL data for research study Manuscript published How have the results been disseminated to communities of interest? The CHL Center of Excellence created an interactive data visualization on CHL prevalence data available on the CHL website. CHL staff serves on boards, advisory committees, technical working groups, policy implementation working groups and coalitions throughout the US Affiliated Pacific, nation, and globe, to disseminate CHL results and add to the body of knowledge on childhood obesity prevention. Four teleconferences were conducted to discuss CHL Center direction. Held one virtual meeting with CHL Center jurisdiction leads in conjunction with CHLN multistate meeting in July 2020. cHL Center was part of a symposium on Systems approaches to prevent and reduce obesity through multilevel multicomponent (MLMC) interventions across the globe using CHL data at the International Society of Behavioral Nutrition and Physical Activity conference - June 2020 Other Presentations: Novotny and Boushey were members of the US Dietary Guidelines Advisory Committee for 2020. Other committees: Dr. Novotny is on the Hawaii Public Health Institute Advisory Board. What do you plan to do during the next reporting period to accomplish the goals?Year 3 of the CHL Center of Excellence grant will see further accomplishments to the goals set forth in the grant as we continue to offer courses, collect follow-up data, and disseminate the results of the CHL intervention. For each objective the following are planned for Year 4. Objective 1 Offer eight CHL Summer Institute courses in Summer 2021 Begin to modify the Food and Activity log training for use in Hawaii SNAP-Ed and EFNEP programs. Select two students for paid internships in Hawaii as part of Western Region Public Health Training program. Finish development of an open resource textbook on Nutrition throughout the Lifespan Continue training five Native Hawaiian dietetic students for the CHLD program Objective 2 Conduct Food Cost Survey in American Samoa, Alaska, CNMI, Guam and Hawaii. Continue analysis of CHL intervention follow-up data (Time 3). Continue development of anthropometry standardization process for the Pacific Region. Continue to provide CHL data for students and researchers. Objective 3. Disseminate CHL findings to communities through advisory councils and coalitions Continue to disseminate findings, trainings and other program information on CHL web site Present at conferences and continue to publish CHL findings.

Impacts
What was accomplished under these goals? The goal of the CHL Center of Excellence is to further build capacity and generate new knowledge for regional collective impact on child health and in the first year of the grant CHL Center has made strides in achieving these goals. To actualize CHL Center's goals the three objectives (listed above) guide the progress of the Center of Excellence. Therefore, the accomplishments of CHL Center are stated by objective. Objective 1 - Training- Accomplishments: CHL Center was able to leverage the CHL related grant, Children's Healthy Living Dietetics (CHLD) Scholarship Program. CHLD provides funding for five Native Hawaiian students in nutrition and health to complete a Bachelor of Science Dietetics degree at the University of Hawai'i at Manoa. CHLD is supported by the USDA Multicultural Scholars Program, award number 2018-38413-28140. Five students have been selected for the program and one has completed the first year of studies. The Children's Healthy Living Summer Institute (CHL SI) is an outcome of the CHL Program. CHL SI contributes to CHL's mission through providing access to a training program focused on child health and obesity prevention that is evidence-based. In 2020, CHL SI offered online offered eight summer courses related to childhood obesity. 81 college students completed CHL SI courses. A CHL Research discussion group was formed. The group consists of students and junior staff and other collaborators using CHL data for research. 14 research projects were presented. 5 masters and doctorate level students used CHL data for thesis and dissertation work. An additional accomplishment was the development an open source textbook on the science of human nutrition used in University of Hawaii classes. CHL Center partnered with and been funded by the Western Region Public Health Training Center, and developed a free online version of the CHL Talking to Caregivers about BMI training. Objective 2 - Research- CHL program sustainability- Accomplishments: CHL Center conducted weekly meetings with research staff to oversee data collection, data entry, and data analysis. Obtained IRB renewal for CHL study. Updated CHL food cost survey (FCS). The CHL FCS is used to determine the cost for a family of four to eat according to the Thrifty Food Plan (TFP). Online training on the collection of the CHL FCS and the supplemental FCS was conducted. We conducted the CHL FCS and supplemental FCS in Alaska, American Samoa, CNMI, Guam and Hawaii. We completed enrollment in the CHL follow-up study for data collection. In year 3, 120 additional participants were enrolled (114 in Alaska and 6 in Guam). Total enrollment for the follow-up study is 1516 participants (315 in Hawaii; 324 in American Samoa; 300 in Guam; 339 in CNMI; 238 in Alaska). Community environment assessments were completed in all jurisdictions; Community Readiness Assessment was completed in all jurisdictions. All data with the exception of the FCS data, has been entered and cleaned. Primary follow up (Time 3) analysis has been started. Objective 3 - Extension/Outreach Accomplishments: To disseminate results of the CHL intervention the CHL Center team developed an interactive prevalence data display on the CHL website (https://www.chl-pacific.org/community-connections/chl-prevalence-data/). To maintain connection between partners in CHL Center, an annual meeting was conducted virtually in July 2020 in conjunction with CHL Network Multistate group (W1194). This meeting served to disseminate CHL results and guide the direction of CHL Center. We updated the CHL web site (www.chl-pacific.org) to allow for ease of use of CHL data for students, instructors, and researchers. Wedeveloped a Diet Quality Index based on the Healthy Eating Index using CHL data to further examine the effects of the CHL intervention. We continued development of a child anthropometric protocol guide for use in the Pacific region. We presented CHL research and intervention process data at 2 conferences and in 3 peer-reviewed publications. In Year Three we continued to build on efforts that were established by the CHL program and through these efforts were able to realize meaningful strides towards the goals of the CHL Center of Excellence.

Publications

• Type: Journal Articles Status: Published Year Published: 2020 Citation: Schneeman, B.O., Ard, J.D., Boushey, C.J., Bailey, R.L., Novotny, R., Snetselaar, L.G., de Jesus, J.M., and Stoody, E.E. 2020. Impact of the National Academy of Sciences, Engineering, and Medicine Report on the Process for the 2020 Dietary Guidelines Advisory Committee. Adv Nutr 2021;00:17.
• Type: Journal Articles Status: Published Year Published: 2020 Citation: Korn, A.R., Butel, J., Davis, J., Yamanaka, A.B., Coleman, P., Wilkens, L.R., Economos, C.D., and Novotny, R. 2020. Role of social ecological model level on young Pacific children's sugar-sweetened beverage and water intakes: Children's Healthy Living intervention. Public Health Nutr. 2020 Nov 25:1-6. doi: 10.1017/S1368980020004796. Epub ahead of print. PMID: 33234187.
• Type: Journal Articles Status: Published Year Published: 2020 Citation: Leon Guerrero, R., Barber, L.R., Aflague, T., Paulino, Y., Hattori-Uchima, M., Acosta, M., Wilkens, L., and Novotny, R. 2020. Prevalence and Predictors of Overweight and Obesity Among Young Children in the Childrens Healthy Living Study on Guam. Nutrients 2020, 12, 2527; doi:10.3390/nu12092527. PMCID:PMC7551370
• Type: Journal Articles Status: Published Year Published: 2020 Citation: Badowski, G., Simsiman, B., Bordallo, R., Green, M., Shvetsov, Y.B., Wilkens, L.R., Novotny, R., and Leon Guerrero, R.T. 2020. Cumulative Incidence rates of Breast Cancer by age for Filipinos and Chamorros in Guam. Hawaii Journal of Health & Social Welfare, June 2020:79(6). Supplement 2, pgs 40-44.
• Type: Journal Articles Status: Published Year Published: 2020 Citation: Greenberg, J.A., Luick, B., Alfred, J.M., Barber, L.R., Bersamin, A., Coleman, P., Esquivel, M., Fleming, T., Leon Guerrero, R.T., Hollyer, J., Johnson, E.J., Novotny, R., Remengesau, S.D., and Yamanaka, Y. 2020. The Affordability of a Thrifty Food Plan-based Market Basket in the United States-affiliated Pacific Region. Hawaii Journal of Health and Social Welfare JULY 2020, VOL 79, NO 7;17-23.

Progress 03/01/19 to 02/29/20

Outputs
Target Audience:Professionals and Communities interested in programs and policies for child nutrition and health. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?The following opportunities for training and professional development was seen in all three CHL Center objectives. Objective 1: Eight online summer courses were offered through CHL Summer Institute. The eight courses offered were: FSHN 185 - The Science of Human Nutrition: Integrating basic concepts of science with the study of human nutrition; designed for the person who wants an introduction to nutrition and who may later choose a major in it. FSHN 360 - Applied Professional Skills in Nutrition: Through the use of technology, students will become more familiar with identifying evidence-based information and demonstrating their academic skill sets for future professional success. FSHN 370 - Lifespan Nutrition: Identifying nutrient requirements during pregnancy, infancy, childhood, adolescence and aging; Coupled with an understanding of how basic physiologic and metabolic changes affect nutritional needs across the lifespan; addressing important social and cultural factors influencing nutritional status throughout the lifespan. FSHN 454 - Foundations of Childhood Obesity Prevention in the Pacific: A basic overview of the causes and effects of childhood obesity, evidence-based approaches, community-based research, and policies to prevent childhood obesity as it relates to the Pacific. FSHN 455 - Childhood Anthropometric and Dietary Assessment Field Techniques: Stimulating students' hands on training in the techniques used to measure body composition and collect dietary intake information with a particular emphasis on children. FSHN 456 - Childhood Health and Nutrition Monitoring in the Pacific: Monitoring the health and nutritional status of populations including epidemiology, biostatistics, and health and nutrition surveillance systems. FSHN 457 - Culture and Child Health in the Pacific: Taking a journey through the Pacific region to learn about the People and their culture; Approaches for promoting child health in the Pacific region. FSHN 492 - Field Experience in Childhood Obesity Prevention: This course involves integrating and applying academic knowledge and critical skills, emphasizing professional development, with a field experience approved by a cooperating supervisor or employer. 136 college students completed CHL Summer Institute courses in year 2. Continued childhood obesity research group to present research ideas for discussion and feedback (group consists of three University of Hawaii childhood obesity researchers; two post-doctorate staff; four doctoral students: two from Guam, one from American Samoa, and one from CNMI). One 2-day adult anthropometry standardization conducted in Hawaii. 4 staff from independent research project trained. One CHL community internship for graduate student in Hawaii; one community internship for doctoral student in CNMI. CHL SI Foundations of Obesity course material used for the development of a Western Region Public Health Training Centercourse on "Effective Advocacy in the Context of Childhood Obesity". Objective 2: Two 3-day measurement training/anthropometric standardization workshops FOR PROGRAM STAFF were offered in American Samoa, Alaska, and CNMI. 3 trainings for program staff were conducted for data entry, food log data entry, and food cost survey data collection. Objective 3: CHL data used for dissertation for 5 doctoral students from Hawaii, Guam, CNMI and American Samoa resulting in one completion of PhD in Epidemiology, one all but dissertation and one dissertation proposal 4 abstracts for manuscripts using CHL data have been approved by project steering committee this year. 1 doctoral student from Tufts University used CHL data for research study; manuscript submitted. Hosted one grant workshop by program officer Chester - 42 people attended. How have the results been disseminated to communities of interest? The CHL Center of Excellence created one-page flyers highlighting changes in community child measures and distributed them to parents and caregivers at community measurement events. The flyers were posted on the CHL web site as well. CHL intervention has been included in the SNAP-Ed toolkit CHL staff contacted Head Start, preschool, and school administrators and teachers and provided information on results of CHL study and explained the follow-up process and rationale. CHL staff serves on boards, advisory committees, technical working groups, policy implementation working groups and coalitions throughout the US Affiliated Pacific, nation, and globe, to disseminate CHL results and add to the body of knowledge on childhood obesity prevention. Ten teleconferences were conducted to discuss CHL Center direction. Held one face-to-face meeting with CHL Center jurisdiction leads in conjunction with CHLN multistate meeting in July 2019. Led Symposia on Systems approaches to prevent and reduce obesity through multilevel multicomponent (MLMC) interventions across the globe using CHL data at the International Society of Behavioral Nutrition and Physical Activity conference - June 2019 Symposia on Implementation Science in Nutrition and Physical Activity Large-scale Community-Based Health Interventions - Novel Strategies for Capturing and Monitoring Dissemination using CHL data at the International Society of Behavioral Nutrition and Physical Activity conference - June 2019 Oral presentation by Tufts University student on Deconstructing the effect of the Children's Healthy Living (CHL) multilevel trial on sugar-sweetened beverage and water intakes in early childhood at the International Society of Behavioral Nutrition and Physical Activity conference - June 2019 Poster presentation on "Year 1 of the Children's Healthy Living (CHL) Center of Excellence" at the Society for Nutrition Education and Behavior Conference - July 2019 Participated in World Health Organization work group developing global protocol for childhood obesity surveillance in Geneva, Switzerland in June 2019. Novotny and Boushey are member of the US Dietary Guidelines Advisory Committee for 2020. What do you plan to do during the next reporting period to accomplish the goals?Year 2 of the CHL Center of Excellence grant will see further accomplishments to the goals set forth in the grant as we continue to offer courses, collect follow-up data, and disseminate the results of the CHL intervention. For each objective the following are planned for Year 2. Objective 1 Offer eight CHL Summer Institute courses in Summer 2019 Begin to modify the Talking to Caregivers about BMI workshop for CE credit Select two students for paid internships in Hawaii as part of Western Region Public Health program Begin development of an open resource textbook on Nutrition throughout the Lifespan Continue training five Native Hawaiian dietetic students for the CHLD program Objective 2 Conduct Food Cost Survey in American Samoa, Alaska, CNMI, Guam and Hawaii Gather CHL Center follow-up data in American Samoa, Alaska, and CNMI Complete Community Readiness Surveys Continue follow-up data entry and cleaning Continue development of anthropometry standardization process for the Pacific Region Continue to provide CHL data for students and researchers. Objective 3. Disseminate CHL findings to communities through advisory councils and coalitions Continue to disseminate findings, trainings and other program information on CHL web site Develop data visualization of prevalence data on CHL web site Present at conferences and continue to publish CHL findings

Impacts
What was accomplished under these goals? The goal of the CHL Center of Excellence is to further build capacity and generate new knowledge for regional collective impact on child health and in the first year of the grant CHL Center has made strides in achieving these goals. To actualize CHL Center's goals the three objectives (listed above) guide the progress of the Center of Excellence. Therefore, the accomplishments of CHL Center are stated by objective. Objective 1 - Training- Accomplishments: CHL Center was able to leverage the CHL related grant, Children's Healthy Living Dietetics (CHLD) Scholarship Program. CHLD provides funding for five Native Hawaiian students in nutrition and health to complete a Bachelor's of Science Dietetics degree at the University of Hawai'i at Manoa. CHLD is supported by the USDA Multicultural Scholars Program, award number 2018-38413-28140. Five students have been selected for the program and are in the first year of studies. The Children's Healthy Living Summer Institute (CHL SI) is an outcome of the CHL Program. CHL SI contributes to CHL's mission through providing access to a training program focused on child health and obesity prevention that is evidence-based. In 2019, CHL Summer Institute offered online offered eight summer courses related to childhood obesity. 95 college students completed CHL Summer Institute courses. CHL Research discussion group was formed. Group consists of students and junior staff using CHL data for research. 12 research projects were presented. 7 masters and doctorate level students used CHL data for thesis and dissertation work. Two-day adult standardization was conducted in Hawaii using CHL protocols for an early career investigator mentored by Novotny who was awarded an National Institutes of Health K01 grant (K01HL146930) for CHL Adults, a study further examining CHL household by examining obesity and blood pressure in adult family members of CHL child participants. 4 CHL ADULT study staff were trained. An additional accomplishment was the continued development an open source textbook on the science of human nutrition used in University of Hawaii classes. Partnering with and funded by the Western Region Public Health Training Center, developed a free online version of the CHL Foundations of Obesity course. Objective 2 - Research- CHL program sustainability- Accomplishments: Conducted weekly meetings with research staff to oversee data collection, data entry, and data analysis. Obtained IRB renewal for CHL study. Updated CHL food cost survey (FCS). The CHL FCS is used to determine the cost for a family of four to eat according to the Thrifty Food Plan (TFP). The CHL project steering committee agreed to collect a supplemental FCS to collect costs of frequently consumed or locally sourced food items not included in the CHL FCS. The supplemental FCS was created. Online training on the collection of the CHL FCS and the supplemental FCS was conducted. Two 3-day measurement training/anthropometric standardization workshops were offered in Alaska and the Commonwealth of the Northern Marina Islands (CNMI). 11 people trained and standardized to collect data in Hawaii and Guam (5 in Alaska and 6 in CNMI); One 2-day measurement training workshop was offered in American Samoa. Six people were trained in data collection. 1,413 participants enrolled in study for follow-up data collection (329 in Hawaii; 325 in American Samoa; 294 in Guam; 340 in CNMI; 124 in Alaska). Community Assessments were completed in American Samoa, CNMI, Guam and Hawaii; Community Readiness Assessment was completed in Hawaii, American Samoa and CNMI. First and second data entry have been completed in Hawaii, American Samoa and CNMI. Data cleaning has been completed for Hawaii, American Samoa, and CNMI. Objective 3 - Extension/Outreach Accomplishments: To disseminate results of the CHL intervention the CHL Center team created one-page flyers with anthropometric and behavioral change results from CHL time 1 and time 2 data collection periods for 27 communities. Flyers are disseminated at CHL Center measurement events. To maintain connection between partners in CHL Center an annual meeting was held in July 2019 in conjunction with CHL Network Multistate group (W1194). This meeting served to disseminate CHL results and guide the direction of CHL Center. Updated the CHL web site (www.chl-pacific.org) to reflect CHL Center activities, the CHLD program, and to disseminate CHL results. Developing a Diet Quality Index based on the Healthy Eating Index using CHL data to further examine the effects of the CHL intervention. Developing a child anthropometric protocol guide for use in the Pacific region Year Two continued to build on efforts that were established by the CHL program and through these efforts were able to realize meaningful strides towards the goals of the CHL Center of Excellence.

Publications

• Type: Journal Articles Status: Published Year Published: 2019 Citation: Butel, J., Braun, K., Nigg, C., Leon Guerrero, R., Fleming, T., Bersamin, A., and Novotny, R. 2019. Estimating intervention dose of the multilevel multisite children's healthy living program intervention. Translational Behavioral Medicine, Translational behavioral medicine, 22 May 2019.
• Type: Journal Articles Status: Published Year Published: 2020 Citation: Aflague, T.A., Leon Guerrero, R.T., Delormier, T., Novotny, R., Wilkens, L.R., and Boushey, C.J. 2020. Examining the Influence of Cultural Immersion on Willingness to Try Fruits and Vegetables Among Children in Guam: the Traditions pilot study. Nutrients. 2020, 12, 18; doi:10.3390/nu12010018.

Progress 03/01/18 to 02/28/19

Outputs
Target Audience:Children, Professionals and Communities interested in child health. Changes/Problems:Due to major damage caused by Super Typhoon Yutu to the islands of Saipan and Tinian in the Commonwealth of the Northern Marianas Islands (CNMI), CHL Center activities have been postponed. The typhoon also caused significant damage to the Land Grant institution, Northern Marinas College, were the CNMI CHL Center activities were conducted. The college is currently operating from leased offices and CHL equipment and supplies will need to be replaced. We are hoping to conduct CHL Center follow-up measures in October 2019; however, this is tentative as CNMI is still in the recovery process. What opportunities for training and professional development has the project provided?The following opportunities for training and professional development was seen in all three CHL Center objectives. Objective 1: 10 CHAP fellows from CNMI, Guam and Hawaii successfully completed the CHAP Summer Fellowship. Eight online summer courses were offered through CHL Summer Institute. The eight courses offered were: FSHN 185 - The Science of Human Nutrition: Integrating basic concepts of science with the study of human nutrition; designed for the person who wants an introduction to nutrition and who may later choose a major in it. FSHN 360 - Applied Professional Skills in Nutrition: Through the use of technology, students will become more familiar with identifying evidence-based information and demonstrating their academic skill sets for future professional success. FSHN 370 - Lifespan Nutrition: Identifying nutrient requirements during pregnancy, infancy, childhood, adolescence and aging; Coupled with an understanding of how basic physiologic and metabolic changes affect nutritional needs across the lifespan; addressing important social and cultural factors influencing nutritional status throughout the lifespan. FSHN 454 - Foundations of Childhood Obesity Prevention in the Pacific: A basic overview of the causes and effects of childhood obesity, evidence-based approaches, community-based research, and policies to prevent childhood obesity as it relates to the Pacific. FSHN 455 - Childhood Anthropometric and Dietary Assessment Field Techniques: Stimulating students' hands on training in the techniques used to measure body composition and collect dietary intake information with a particular emphasis on children. FSHN 456 - Childhood Health and Nutrition Monitoring in the Pacific: Monitoring the health and nutritional status of populations including epidemiology, biostatistics, and health and nutrition surveillance systems. FSHN 457 - Culture and Child Health in the Pacific: Taking a journey through the Pacific region to learn about the People and their culture; Approaches for promoting child health in the Pacific region. FSHN 492 - Field Experience in Childhood Obesity Prevention: This course involves integrating and applying academic knowledge and critical skills, emphasizing professional development, with a field experience approved by a cooperating supervisor or employer. 123 college students completed CHL Summer Institute courses. Established childhood obesity research group to present research ideas for discussion and feedback (group consists of three University of Hawaii childhood obesity researchers; two post-doctorate staff; three doctoral students: two from Guam, and one from American Samoa). Established CHL community internship for one graduate student in Hawaii for Spring 2019. Objective 2: Two 3-day measurement training/anthropometric standardization workshops FOR PROGRAM STAFF were offered in Hawaii and Guam. Objective 3: CHL data used for dissertation for 5 doctoral students from Hawaii, Guam, CNMI and American Samoa resulting in one completion of PhD in Public Health, one all but dissertation and one dissertation proposal. How have the results been disseminated to communities of interest?CHL Center has disseminated results through various means in all three objectives. Objective 1: CHLD convened a community advisory council consisting of members from the Native Hawaiian community. The council was consulted on the scholarship application and strategies for recruitment. CHAP fellow project videos were made available on the CHAP YouTube Channel (https://www.youtube.com/channel/UCI5xqH6A-1bmN9DVesc7H8Q/videos) and the link to the videos was posted on the CHL web site. CHAP staff also presented changes to curriculum to include childhood obesity prevention at local Native Hawaiian focused conference. Objective 2: The CHL Center of Excellence created one-page flyers highlighting changes in community child measures and distributed them to parents and caregivers at community measurement events. The flyers were posted on the CHL web site as well. CHL staff contacted Head Start, preschool, and school administrators and teachers and provided information on results of CHL study and explained the follow-up process and rationale. CHL staff identified and contacted people from Head Starts/Early Childhood Education, local indigenous groups, extension personnel, and organizations focusing on policy initiatives to serve on Local Advisory Council. Objective 3: The final CHL community reports were posted on the CHL web site and distributed to key community partners. Nine teleconference were conducted to discuss CHL Center direction. Held one face-to-face meeting with CHL Center jurisdiction leads in conjunction with CHLN multistate meeting in May 2018. Conducted 2 community workshops for parents and caregivers on BMI and weight categories in preschool children. Oral session on CHL intervention outcome presented at the American Society of Nutritionists conference - June 2018. Symposia on Lesson Learned in Multilevel Multicomponent Interventions using CHL data at the International Society of Behavioral Nutrition and Physical Activity conference - June 2018. Poster presentation on "Strategies and Barriers to the CHL Intervention" at the Society for Nutrition Education and Behavior Conference - July 2018. Poster presentation on "Long-Term Impact of the Child Health Assessment in the Pacific (CHAP) Undergraduate Summer Fellowship Program" at the Society for Nutrition Education and Behavior Conference - July 2018. What do you plan to do during the next reporting period to accomplish the goals?Year 2 of the CHL Center of Excellence grant will see further accomplishments to the goals set forth in the grant as we continue to offer courses, collect follow-up data, and disseminate the results of the CHL intervention. For each objective the following are planned for Year 2. Objective 1: Offer eight CHL Summer Institute courses in Summer 2019. Begin to modify the CHL SI Foundations of Obesity Class into modules for CE credit. Select two students for paid internships in Hawaii as part of Western Region Public Health program. Begin development of an open resource textbook on Nutrition throughout the Lifespan. Select and begin training five Native Hawaiian dietetic students for the CHLD program. Objective 2: Conduct measurement and anthropometric standardization trainings in American Samoa, CNMI, and Alaska. Gather CHL Center follow-up data in American Samoa, Alaska, and CNMI. Complete Community Assessments and Community Readiness Surveys. Begin follow-up data entry and cleaning. Begin development of anthropometry standardization process for the Pacific Region. Continue to provide CHL data for students and researchers. Objective 3: Disseminate CHL findings to communities at measurement events and through local advisory councils. Obtain feedback from community members and other researchers on CHL web site. Disseminate CHL intervention to interested communities and practitioners by posting CHL intervention on web sites (such as the SNAP-Ed toolkit). Present at conferences and continue to publish CHL findings.

Impacts
What was accomplished under these goals? The goal of the CHL Center of Excellence is to further build capacity and generate new knowledge for regional collective impact on child health and in the first year of the grant CHL Center has made strides in achieving these goals. To actualize CHL Center's goals the three objectives (listed above) guide the progress of the Center of Excellence. Therefore, the accomplishments of CHL Center are stated by objective. Objective 1 - Accomplishments: CHL Center was able to leveraging two separate CHL related grants, Child Health in the Pacific (CHAP) Summer Fellowship Program and Children's Healthy Living Dietetics (CHLD) Scholarship Program. The CHAP program provided a summer training opportunity for undergraduate students working towards degrees in nutrition, nursing, early childhood education, public health and other related degrees. CHAP is supported by the Agriculture and Food Research Initiative Grant no. 2016-67032-24989 from the USDA National Institute of Food and Agricultural Science. In 2019, ten CHAP fellows (four from Guam, four from CNMI, and two from Hawaii) completed three summer classes, were standardized for child anthropometry and conducted child obesity related community project in their jurisdiction. Ten mentors at University of Hawaii, University of Guam, and Northern Marinas College were trained and mentored CHAP fellows and oversaw community project. CHLD is a new grant that will provide funding for five Native Hawaiian students in nutrition and health to complete a Bachelor's of Science Dietetics degree at the University of Hawai'i at Manoa. CHLD is supported by the USDA Multicultural Scholars Program, award number 2018-38413-28140. Recruitment for students has been started. The Children's Healthy Living Summer Institute (CHL SI) is an outcome of the CHL Program. CHL SI contributes to CHL's mission through providing access to a training program focused on child health and obesity prevention that is evidence-based. In 2019, CHL Summer Institute offered online offered nine summer courses related to childhood obesity. 123 college students completed CHL Summer Institute courses. An additional accomplishment was the development an open source textbook on basic nutrition that is used in University of Hawaii classes. Objective 2 - Accomplishments: To prepare for the follow-up measures to test the long-term effect of the CHL intervention, the CHL Center team completed revisions to data collection surveys, training manuals, and two data entry databases, the CHL data entry application and PacTrac. The CHL data entry application is used to enter CHL form data and was updated to reflect changes to the forms. PacTrac software, developed by our group, will be used to enter food log data. Conducted weekly meetings with research staff to oversee revisions to data collection and data entry process. Obtain IRB approval for modifications to CHL study. Two 3-day measurement training/anthropometric standardization workshops were offered in Hawaii and Guam. 22 people trained and standardized to collect data in Hawaii and Guam (7 in Hawaii and 15 in Guam); 147 participants enrolled in study for follow-up data collection in Hawaii; Community Assessments completed in 4 Hawaii communities and started in 2 Guam communities; Community Readiness Assessment completed in Hawaii. Objective 3 - Accomplishments: To disseminate results of the CHL intervention the CHL Center team completed 18 community reports containing data from CHL time 1 and time 2 data collection periods. These reports contained CHL-wide data, jurisdictional level data, and community level data to inform community members, practitioners, and policy makers. Analysis of the CHL intervention effect was completed and results were published in JAMA online. To maintain connection between partners in CHL Center an annual meeting was held in June 2018 in conjunction with CHL Network Multistate group (W1194). This meeting served to disseminate CHL results and guide the direction of CHL Center. To enhance health literacy in the Region a preschool teacher workshop on "Communicating BMI to parents" was developed. This hands-on workshop increases preschool teacher knowledge of how child BMI is calculated, how to determine a child's weight category (using CDC Growth Charts), and how to communicate these findings to parents/caregivers of young children. Year one built on efforts that were established by the CHL program and through these efforts were able to realize meaningful strides towards the goals of the CHL Center of Excellence.

Publications

• Type: Journal Articles Status: Published Year Published: 2018 Citation: Novotny, R., Davis, J., Butel, J., Boushey, C.J., Fialkowski, M.K., Nigg, C.R., Braun, K.L., Leon Guerrero, R.T., Coleman, P., Bersamin, A., Areta, A.A.R., Barber, L.R., Belyeu-Camacho, T., Greenberg, J., Fleming, T., Dela Cruz-Talbert, E., Yamanaka, A., Wilkens, LR. 2018. Effect of the Childrens Healthy Living Program on Young Child Overweight, Obesity, and Acanthosis Nigricans in the US-Affiliated Pacific Region: A Randomized Clinical Trial. JAMA Network Open, 1(6), e183896-e183896
• Type: Book Chapters Status: Published Year Published: 2018 Citation: Novotny, R., F. Li, L. Wilkens, M. Fialkowski, T. Fleming, P. Coleman, R. Leon Guerrero, A. Bersamin, and J. Deenik. 2018. Chapter 3. Economic Influences on Child Growth Status, from the Childrens Healthy Living Program in the US-Affiliated Pacific Region. In: WEALTHY BUT UNHEALTHY: Overweight and Obesity in Asia and the Pacific:Trends, Costs, and Policies for Better Health. Edited by Matthias Helble and Azusa Sato. 2018 Asian Development Bank Institute.
• Type: Journal Articles Status: Awaiting Publication Year Published: 2019 Citation: Butel, J., Braun, K.L., Nigg, C.R., Davis, J., Boushey, C., Leon Guerrero, R., Bersamin, A., Coleman, P., Fleming, T., and Novotny, R. 2019. Implementation Strategies and Barriers to Native Hawaiian and Other Pacific Islanders Community Interventions: A Cross-Case Study of the Childrens Healthy Living Program. Asian American Journal of Psychology. http://dx.doi.org/10.1037/aap0000135
• Type: Journal Articles Status: Published Year Published: 2018 Citation: Gittelsohn, J., Novotny, R., Trude, A.C.B., Butel, J., and Mikkelsen, B.E. 2018. Challenges and lessons learned from multi-level multi-component interventions to prevent and reduce child obesity. Int J Environ Res Public Health. 2018 Dec 24;16(1). pii: E30. doi: 10.3390/ijerph16010030