Multi-level Approaches to Nutrition Promotion for Low-income Households with Young Children

Abstract

Nearly two out of every three US adults has overweight or obesity; as of 2018 the age-adjusted prevalence of obesity among U.S. adults has risen above 40%. Over the past twenty years, the US has observed a nearly 30% increase in age-adjusted prevalence of obesity and the prevalence of severe obesity has nearly doubled in that time. While the increases in prevalence over the past two years have not been shown to be statistically significant, there is still reason for concern, as it provides evidence that we are digressing from our Healthy People 2020 goal of reaching a national prevalence of 30.5%. Further, estimations predict that by 2030 approximately one out of every two adults will have obesity, with a prevalence of over 50% in 29 states and no less than 35% in any given state.

These shifting trends have predominantly affected women and people of color, thereby highlighting the social injustice of this epidemic. In comparison to men, women experience a twofold higher prevalence of severe obesity, after adjusting for age. In comparison to non-Hispanic Asians and whites, non-Hispanic Black and Hispanic children and adults account for a disproportionate fraction of morbidity and mortality related to overweight and obesity. Based on our current trajectories, these disparities are predicted to continue widening; by 2030, predictive modeling suggests that disparities will widen and severe obesity will serve as the most predominant BMI category among traditionally underrepresented demographic subgroups of women, non-Hispanic black adults, and low-income individuals. Immediate intervention is necessary.

High rates of obesity and disparities therein are not limited to adults; they have been observed in early childhood as well. While obesity rates remain fairly stable from age 10 to age 18, rates are on the rise from infancy throughout early childhood. BMI increases from birth to third year of life predict obesity development later in life. Ultimately, those who develop obesity in childhood and carry it into adulthood are significantly more likely to exhibit related morbidity and mortality. With a nearly threefold increase in childhood obesity prevalence over the past 40 years (i.e., five percent in 1978 to 18.5 percent in 2016), there is reason for concern. One glimmer of hope is that while the prevalence of obesity has increased, the rate of increase has declined over the past 15 years. This may be attributed to the emergence of successful, targeted childhood obesity interventions.

To date, most randomized control trials focusing on healthy diet habits and weight in children have taken place in schools, to sustainably reach kids where they are. However, those that are unsuccessful in also engaging parents often fail to observe an impact. This is largely attributed to parents serving as key stakeholders in the development and maintenance of healthy dietary habits in their children. Parents usually serve as a child’s first and main point of contact, exposure, and imitation. Therefore, they have the potential to serve as essential change-makers in this critical period of early childhood. For this reason, previous studies have suggested that interventions targeting parent behavior, without engagement of the children, are just as effective as those that engage both simultaneously. However, intervention leaders face numerous challenges when attempting to reach parents, including: (1) scheduling and enrollment barriers, (2) cultural differences, and (3) appropriately addressing the stigma associated with obesity and weight management.

In response to these notable gaps in the literature, this dissertation offers a multilevel evaluation of family-based nutrition promotion efforts for ethnically and racially diverse, low-income households with young children in the state of Massachusetts. Specifically, Chapter 1 explores caregiver perceptions regarding the facilitators and barriers to full utilization of benefits and services offered by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Chapter 2 evaluates a theory of change; in particular, it examines whether increases in parental empowerment associated with healthier weight-related parenting practices. Finally, Chapter 3 reports on the evaluation of family-centered obesity prevention program for Head Start parents and children. Together, these chapters are designed to address important questions that will shape design and implementation of interventions to support the development and adoption of healthy lifestyle behaviors early in life.