W1194: Children's Healthy Living Network (CHLN) in the U.S. Affiliated Pacific Region
(Multistate Research Project)
W1194: Children's Healthy Living Network (CHLN) in the U.S. Affiliated Pacific Region
Duration: 10/01/2016 to 09/30/2021
Statement of Issues and Justification
The Children’s Healthy Living Program for Remote Underserved Minority Populations in the Pacific Region (CHL) is a partnership among remote Pacific states and other jurisdictions of the US: Alaska, American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI), Guam, Federated States of Micronesia (FSM), Hawai‘i, Republic of Palau, and the Republic of the Marshall Islands (RMI). All jurisdictions have US Land Grant Colleges. CHL is a partnership among land grant colleges and public health partners that share a purpose to build capacity to address health issues through research, training and outreach. Partnership among land grants, components of land grants, and public health and other partners that affect policies, systems and environments that affect health is explicitly called for in the recent USDA Healthy Food Systems, Healthy People (2016) call to action, and the USDA Cooperative Extension Framework for Health and Wellness (Braun et al. 2014). Partnership is also called for in the new Interagency Committee on Human Nutrition Research (2016). The goal of the CHL Program collaboration among Pacific Region states/jurisdictions was to build social/cultural, physical/built, and political/economic environments that will promote active play and intake of healthy food to prevent young child obesity in the Pacific Region. To do this, CHL engages the community, and focuses on capacity building and sustainable environmental change.
The Pacific region has some of the highest rates of non-communicable disease in the world. FSM and RMI are in the top three of rates of diabetes in the world (35%, International Diabetes Federation 2013). Diabetes, heart diseases, strokes, cancer and other NCDs are affecting Pacific peoples at a disproportionate rate compared to other populations, placing a significant burden on their daily functionality, and threatening the national security of these island countries and territories (PIHOA 2010). All of these conditions have a primary causal factor: obesity. Adult obesity is among the highest in the world in these countries, especially among women (FSM 58%, RMI 48%, Ng et al 2013). Pacific lifestyles continue to transition from native crops to imported foods, and from active forms of work and play to sedentary ones, as in most of the world (World Health Organization, 2015, http://www.who.int/mediacentre/factsheets/fs311/en).
Data are limited on children of the region. Childhood obesity is an important determinant of adult obesity. Obese children have a higher chance of obesity, premature death and disability in adulthood. Obese children have breathing difficulties, increased risk of fractures, hypertension, early markers of cardiovascular disease, insulin resistance and psychological effects. Contributors to obesity occur across the life course and include both early undernutrition and nutrition excess. Obesity is associated with social and health problems. Prevention is the best long term solution.
This multistate project will support and extend the CHL network, training, intervention activities and research programs initiated through CHL, which has demonstrate feasability of the approach. The land grant institutions held stakeholder meetings that resulted in the CHL application. Land grant colleges in the Pacific have been an organizing mechanism for CHL. This multistate project will continue to be an important mechanism to maintain a stable partnership and coordinated activity. Without this tool the group will need to rely on grant opportunities that are now smaller and will likely result in smaller less coordinated subsets of the partners working together. This project has the potential to model multistates as platforms for coordinated health extension coalitions to facilitate and support broad sector partnership for health.
Related, Current and Previous Work
CHL is composed of a team that represents all US affiliated Pacific jurisdictions, with a base in the land grant colleges. CHL evolved from past collaborations among its participants. The largest collaboration was from a USDA NIFA CAP grant (Grant number 2011-68001-30335), and most recent was the Child Health Assessment of the Pacific (CHAP) USDA NIFA ELI fellowship grant (Grant number 2016-67032-24989). CHL evolved from 20 years developing land grant partnership through the Agricultural Development of the American Pacific Program, and its outgrowth, Healthy Living in Pacific Islands (Novotny et al 2013). The resulting CHL grant solidified a management structure, developed PSE-oriented multi-level intervention research, built capacity and course work in PSE-oriented work to prevent child obesity, gathered data that filled the gap of missing nutrition surveillance systems in the region, and continues to use those systems to develop understanding through peer reviewed research and publication and to inform programs and policies relevant to the underserved population of the Pacific, not served by NHANES. Since NHANES does not sample the Pacific region, nor present data on Native Hawaiian, Native Alaskan or Pacific Islander race/ethnic groups, measured data on obesity, dietary intake and physical activity are not available without CHL, and are critical to guide programs and policies. Further, since Pacific foods are not identified in these surveys, they will not be analyzed by national labs for nutritional properties, to guide nutrition guidance and programs in the region.
CHL conducted a meta-analysis of available research and agency data of the child obesity problem in the Pacific and showed the overweight plus obesity level to be 21% at 2y to 39% at 8y (Novotny et al. 2015). Obesity prevalence went from 10% and age 2y to 23% at 8y.
CHL gathered data on 51 communities in 11 jurisdictions on over 5,000 children, their households, and their communities. 27 of these communities in 5 jurisdictions were involved in a multilevel community randomized controlled trial (Wilkens et al 2014) and the other 25 communities collected the same data in a one-time prevalence survey. Data include acanthosis nigricans screening, weight, height and waist circumference assessment, 2 randomly selected days of 6,453 food and activity logs (food records and physical activity logs) from 2-8yo children throughout the region, community environment assessments (store, park, church, walkability and food and utility cost assessments), data which will be evaluated to help fill the void in data for policy and program planning, and which will provide a foundation from which ongoing monitoring systems will be developed and sustained.
Further, CHL has developed a community based intervention program (Braun et al. 2014, Fialkowski et al. 2013, Wilken et al 2013) and is disseminating it and continuing to serve as a data hub and a facilitator of coalition building and training in the community (Fialkowski et al 2015).
The CHL work was conducted through a community engaged process (Fialkowski et al 2013) that involved development of Local Advisory Committees (LAC’s) in each jurisdiction, that included all sectors and provide groups identified that might influence child health. These LAC’s meet at least annually and evolved into community and jurisdiction level coalitions that organized and sustained key efforts. CHL was recognized as a backbone organization that facilitates the work and provides a key evaluation and training role that we aim to sustain with this multistate project; this role suited to the land grant mission of facilitation of community work (extension), evaluation (research) and training (instruction).
The CHLN multistate project will extend the work of two other multistate projects (W2005 and W2003) that are related to child obesity by focusing on the Pacific Region and the policy, systems and environmental approaches to obesity prevention and support of child health and wellness.
Adapt and disseminate CHL child obesity policy, systems and environmentally focused multi-level prevention training and social marketing materials for the Pacific region.
Facilitate use of CHL data, findings related to child obesity and its multilevel (policy, system, and environmental) determinants.
Promote partnership and coalition building and strengthening in and among Pacific communities and the region around child health.
Build and sustain a child health and nutrition monitoring system in the Pacific.
The multistate project will use existing core CHL infrastructure (Coordinating Center, Data Center, Training Center) and guidelines (Data Use, Publication, Core Values) to share data, tools, training and intervention materials among Pacific jurisdictions. The CHL infrastructure includes data coordination, training in child obesity prevention, and leadership on obesity measurement and standardization (Li et al 2015, Fialkowski et al. 2015, Novotny et al. 2013).
The CHLN will have available data from the CHL prevalence and intervention studies, tools used to collect those data (accelerometers, stadiometers, scales, measuring tapes, Pacific Tracker diet and activity software), training material developed (Pacific Food Guide, CHL Summer Institute), and CHL intervention materials (Role Model Training Guide, Master Gardening and Food Preservation Materials). Materials not covered by privacy rules (HIPAA and IRB) will be publically available, mostly through the CHL website (www.chl-pacific.org).
These resources, data, and collaborations will form the basis of new grant proposals, training programs, extension and outreach activities and capacity building within each jurisdiction.
Measurement of Progress and Results
- Objective 1. Adapt and disseminate CHL child obesity policy, systems and environmentally focused multi-level prevention training and social marketing materials for the Pacific region (Hawai‘i, Guam CNMI). CHL Summer Institute classes in child obesity policy, systems and environmentally focused multi-level prevention, child health, nutrition assessment and monitoring will be offered through the University of Hawai‘i Outreach College starting in summer 2016. These courses will be taken and evaluated (IRB exemption received). Two of these courses are also included in the CHAP Summer Undergraduate Fellowship Program (Hawai‘i lead). The CHL Summer Institute classes will be packaged into a University of Hawai‘i approved Certificate in Child Health. The CHL Summer Institute will use tuition dollar revenue to sustain the program (e.g., costs for instructors, curriculum development, and infrastructure). Trainings delivered through CHL Summer Institute will include credit and non-credit (continuing education) opportunities (Hawai‘i lead). Develop communications and share with Extension and others. The strategies and lessons learned through the implementation of the CHL Program can be incorporated into existing programs such as Head Start and EFNEP that promote prevention of child obesity and chronic disease and can be used in messaging and programs supported by Extension and other governmental agencies for health care and public health professionals. Currently, in the USAP, there is growing support from local health departments for NCD Coalitions. Extension and the local NCD coalitions can also be used to disseminate findings, shape policies and train local clinicians, health professionals, and the general public. CHL intervention and other pertinent extension training materials (e.g., Pacific Food Guide) will also be continuously disseminated on the CHL website.
- Objective 2. Facilitate and use CHL data, findings related to child obesity and its multilevel (policy, system, and environmental) determinants (Hawai‘i, Guam, CNMI, Alaska). a. MANUSCRIPTS (all participating CHL jurisdictions will be represented on each manuscript) Jurisdiction, Community, Household, and Child Data (Multilevel): Manuscripts on child outcomes: sugar sweetened beverage intake, child water intake, child fruit and vegetable intake, obesity and acanthosis nigricans; Manuscripts on Pacific food security and food assistance programs; The effect of the CHL multilevel intervention on child outcomes; Jurisdiction and Community Levels: Description of the thrifty food plan costs in the US affiliated Pacific; Students projects at participating academic institutions; b. GRANT PROPOSALS Grant proposals leverage CHL collaborations and data to further understanding of child obesity, nutrition transition and the Pacific environment such as the NIH U24 on Research Capacity Building for the US affiliated Pacific (Hawai‘i, CNMI, Guam). c. WEBSITE CHL intervention and community reports, and peer reviewed publications disseminated on the CHL website (chl-pacific.org).
- Objective 3. Promote partnership and coalition building and strengthening in and among Pacific communities and the region (Hawai‘i, Guam, CNMI). Jurisdiction CHL Local Advisory Committees maintained and partnerships maintained with related coalitions (NCD) through annual meetings. Annual CHLN meetings to continually maintain a collaborative regional work plan and to share findings. Quarterly virtual or teleconference meetings.
- Objective 4. Build and sustain a child health and nutrition monitoring system in the Pacific (Hawai‘i, Guam, CNMI). Regional and jurisdiction partnerships (Head Start, Early Head Start, Department of Education [DOE] Pre-Kindergarden) developed and measurement events conducted and analyzed. Training, facilitation, and data system support for Pacific child health monitoring system development.
Outcomes or Projected Impacts
- Increase by 10% the number of Pacific children that receive nutrition and activity programming to prevent child obesity and promote child health – EFNEP, Head Start, DOE.
- Regional and jurisdiction coalitions built to manage shared agenda and advocate for policy changes
- Knowledge and skill transfer for obesity prevention and child health among participants in training programs such as CHL Summer Institute and CHAP through extension and other non-credit programs.
- Certificate in Child Health offered through the University of Hawai‘i Outreach College. Anyone will be able to take the courses in in child obesity policy, systems and environmentally focused multi-level prevention, child health, nutrition assessment and monitoring through the online platform, including individuals from remote Pacific islands.
- Increased number of Pacific jurisdictions that monitor child obesity and health parameters, such as BMI.
Milestones(2017):Publish baseline/prevalence data related to child obesity prevention; training in child obesity policy, systems and environmentally focused multi-level prevention, child health, nutrition assessment and monitoring through the CHL Summer Institute/CHAP; Pacific BMI monitoring system training
(2018):Publish CHL intervention result; plan for a Pacific BMI monitoring system; training in child obesity policy, systems and environmentally focused multi-level prevention, child health, nutrition assessment and monitoring through the CHL Summer Institute/CHAP
(2019):Publish CHL diet related papers; implement Pacific BMI monitoring system; training in child obesity policy, systems and environmentally focused multi-level prevention, child health, nutrition assessment and monitoring through the CHL Summer Institute
(2020):Publish student manuscripts; report on Pacific BMI through CHLN monitoring system; training child obesity policy, systems and environmentally focused multi-level prevention, child health, nutrition assessment and monitoring through the CHL Summer Institute
(2021):Submit a collaborative grant proposal for further Pacific child health and obesity prevention work; training child obesity policy, systems and environmentally focused multi-level prevention, child health, nutrition assessment and monitoring through the CHL Summer Institute; Certificate on Child Health offered
Projected ParticipationView Appendix E: Participation
The CHL website (http://www.chl-pacific.org/) will be maintained to provide access to publications, intervention material and community reports and scientific reports. Peer-reviewed publications will be accessible to the scientific community through national research databases and the CHL website.
Classes will be offered through an online platform (CHL Summer Institute) through Outreach College at the University of Hawai‘i in child obesity policy, systems and environmentally focused multi-level prevention, child health, nutrition assessment and monitoring. This method allows anyone to take these courses at the in-state tuition rate for credit. Non-credit classes for continuing education will also be offered.
Training and partnership in child health assessment and monitoring will be available through the CHLN.
The proposed multi-state group (CHLN) has a history of using a collaborative approach in implementing their research projects. This relationship started with the the Agricultural Development of the American Pacific Program and Healthy Living in Pacific Islands, and was fortified further with our largest collaboration (CHL) and now the CHAP. The research team has established common procedures, protocols, and organizational structure. The CHL Coordinating Center will be maintained with guidance provided by the CHL Program Steering Committee (PSC) composed of a representative from each jurisdiction that participated in CHL (Hawai‘i, Alaska, American Samoa, Guam, Commonwealth of the Northern Mariana Islands, Palau, RMI, FSM). CHL data and publication guidelines will be followed and will provide opportunity for submission and review of manuscript proposals from any interested party.
An annual meeting will take place to evaluate progress and to plan for the upcoming year. The attendees at the supporting CHLN annual meeting will nominate and elect a chair, a vice chair and a secretary to oversee the annual plan of work. The chair may appoint subcommittees to complete specific objectives and tasks. The vice-chair will succeed the chair and support the chair in performing his/her duties and serve for a one-year term. The secretary will distribute documents prior to meetings, provide minutes describing the discussion and actions suggested during the meetings maintain an updated members roster, and help the chair/vice-chair prepare the accomplishments report. The secretary will succeed the vice-chair.
Conference calls for multistate representatives will be held, at minimum, quarterly.
Jurisdiction local advisory committee meetings will be held to ensure cross-sector partnership.
Braun B, Bruns K, Cronk L, Fox LK, Koukel S, Le Menestrel S, Lord LM, Reeves C, Rennekamp R, Rice C, Rodgers M, Samuel J, Vail A, Warren T. Cooperative Extension’s National Framework for Health and Wellness, March 2014.
Fialkowski MK, DeBaryshe B, Bersamin A, Nigg C, LeonGuerrero RT, et al. A community engagement process identifies environmental priorities to prevent early childhood obesity: the Children’s Healthy Living Program for Remote Underserved Populations in the Pacific Region (CHL). Maternal Child Health J, 2013;18:2261-2274. DOI 10.1007/s10995-013-1353-3. (PMID: 24043557)
Fialkowski MK, Delormier T, Hattori-Uchima M, Leslie JH, Greenberg J, Kim J, Deenik JL, Dunn MA, Areta A, Novotny R. Indigenous Workforce Training by the Children’s Healthy Living Program (CHL) to Prevent Childhood Obesity in the Underserved US Affiliated Pacific Region. J Health Care Poor Underserved. 2015; 26(2 Supplement): 83-95.
Interagency Committee on Human Nutrition Research. National Nutrition Research Roadmap 2016‒2021: Advancing Nutrition Research to Improve and Sustain Health. Washington, DC: Interagency Committee on Human Nutrition Research; 2016.
International Diabetes Federation. Diabetes Atlas. Sixth edition: IDF; 2013. http://www.idf.org/sites/default/files/EN_6E_Atlas_Full_0.pdf. Accessed 15 Oct 2015.
Li, F., Wilkens, L. R., Novotny, R., Fialkowski, M. K., Paulino, Y. C., Nelson, R., Boushey, C. J. Anthropometric measurement standardization in the US-affiliated pacific: Report from the Children's Healthy Living Program. American Journal of Human Biology, 2015. doi: 10.1002/ajhb.22796
Ng M, Fleming T, Robinson M, Thomson B, Graetz N, Margono C, et al. Global, regional and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. The Lancet. 2014;384(9945).
Novotny R, Fialkowski MK, Areta AA, Bersamin A, Braun K, DeBaryshe B, Deenik J, Dunn M, Hollyer J, Kim J, Leon Guerrero RT, Nigg CR, Takahashi R, Wilkens LR. University of Hawai'i Cancer Center Connection: The Pacific Way to Child Wellness: The Children's Healthy Living Program for Remote Underserved Minority Populations of the Pacific Region (CHL). Hawaii J Med Public Health, 2013; Nov;72(11):406-8. (PMCID: PMC3831571)
Novotny R, Fialkowski MK, Li F, Paulino YSN, Vargo D, Jim R, Coleman P, Bersamin A, Nigg CR, Leon Guerrero RT, Deenik, J, Kim JH, Wilkens LR. Systematic review of prevalence of young child overweight and obesity in the United States Affiliated Pacific region compared to the 48 contiguous states: a the Children’s Health Living Program. Am J Pub Health, 2014;DOI:10.2105/AJPH2014.302283. (PMID: 25393168)
Pacific Island Health Officer's Association (PIHOA) 2010. State of Emergency due to Non communicable Disease. http://www.pihoa.org/initiatives/policy/ncds.php
USDA Healthy Food Systems, Healthy People, 2016.
Wilkens LR, Novotny R, Fialkowski MK, Boushey CJ, Nigg C, Paulino YSN, LeonGuerrero RT, Bersamin A, Vargo D, Kim J, Deenik J. Children’s Healthy Living (CHL) Program for Remote Underserved Populations in the Pacific Region: rationale and design of a community randomized trial to prevent early childhood obesity. BMC Public Health, 2013;13(1):944. (PMCID: PMC3851862)
World Health Organization, 2015, Obesity. Available at:http://www.who.int/mediacentre/factsheets/fs311/en.