W2194: Children's Healthy Living Network (CHLN) in the U.S. Affiliated Pacific Region
(Multistate Research Project)
W2194: Children's Healthy Living Network (CHLN) in the U.S. Affiliated Pacific Region
Duration: 10/01/2021 to 09/30/2026
Statement of Issues and Justification
The Children’s Healthy Living Program for Remote Underserved Minority Populations in the Pacific Region Network (CHLN) Multistate is a partnership among remote Pacific states and other jurisdictions of the US: Alaska, Arizona, American Samoa, the Commonwealth of the Northern Mariana Islands (CNMI), Guam, Federated States of Micronesia (FSM), Hawai‘i, Republic of Palau, the Republic of the Marshall Islands (RMI) and West Virginia. All CHLN partners are connected via the US Land Grant College system and an interest in addressing disparities in health that are experienced by ethnic minorities and indigenous populations and those living in rural communities. CHLN partners, inclusive of land grant colleges and public health partners, share a purpose to build capacity to address relevant health issues through research, training and extension. These partnerships aim to affect policies, systems and environments that affect health and are explicitly called for in the 2019 USDA Healthy Food Systems, Healthy People call to action, and the USDA Cooperative Extension Framework for Health and Wellness (Braun et al. 2014). The goal of the CHLN is to develop 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. The Marshall Islands and Guam are in the top ten for diabetes prevalence in the world (30.5% and 18.7%, respectively, International Diabetes Federation 2019). Diabetes, heart diseases, stroke, cancers and other non-communicable diseases 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 common factor: obesity. The number of adults with 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). These populations face a dual burden of food insecurity and obesity, where estimates of nearly half of children sampled by the CHL research program on Guam were living in households who lacked sufficient food or resources to feed the household (Li et al, 2016).
Data are limited on children of the region. Obesity in children is an important determinant of obesity in adulthood. CHL has been successful in collecting data on child growth in the region, where 30% of children in the CHL sample suffered from overweight or obesity (Li et al, 2016). Children with obesity have a higher chance of developing obesity, premature death and disability in adulthood. Children with obesity 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 continues to support and extend the CHL network's training, intervention activities and research programs initiated through CHL, which has demonstrated feasibility of the approach. The land grant institutions held community meetings that resulted in the CHL application. The community engagement process included over 900 community members that included parents, teachers, and community leaders; who identified the need for environmental interventions that address six key behavioral outcomes that became the six CHL target behaviors (Fialkwoski, 2013). The priorities and intervention strategies remain relevant as evidenced by sustained CHL interventions and partner programs. This multistate project has continued to be an important mechanism that maintains the stable partnership and coordinated activities and has facilitated the expansion to include Arizona and West Virginia partners. These partners bring a wealth of new resources and interventions that can be adapted for our region and CHL interventions can be adapted to inform strategies to promote child health in Arizon and West Virginia communities as well. Without this multistate 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
The CHLN team represents US affiliated Pacific jurisdictions, states, and partners across the contiguous U.S., with a base in the land grant colleges and has 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 Healthy Living Center grant (Grant number 69001-27551). 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). Developments as a result of CHL, include a functioning management structure that spans the region, PSE-oriented multi-level intervention research, built capacity and credit and non-credit curriculum in PSE-oriented work to prevent obesity in childhood, collection, analysis, and dissemination of data that filled the gap of missing nutrition surveillance systems in the region, and continued leveraging of these systems to contribute new knowledge through peer reviewed research and publication that informs programs and policies relevant to the underserved population of the Pacific. In addition two training programs, the Child Health Assessment in the Pacific and Children’s Healthy Living Program Dietetic Scholars, have built capacity in the region around child assessment, child health, and dietetics professionals. 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 composition, to guide nutrition guidance and programs in the region.
Since the establishment of the CHLN Multistate (W1194), an additional $2,325,903 in USDA funds has been awarded in the Pacific, over 200 individuals have received formal education on Pacific child nutrition and health through the online Children’s Healthy Living Program Summer Institute courses, four Native Hawaiian students pursuing degrees in Dietetics have been provided partial scholarships, standardized protocols for collecting anthropometric measures (weight, height, waist circumference) have been developed and adopted across the Network partners, data on the nutritional status of individuals and communities in the region has been collected by measuring 1,753 individuals and assessing 548 community environments and CHL data has yielded 12 peer-reviewed publications and been utilized by 30 students in pursuit of higher education. The foundational groundwork for this was accomplished through the CHL CAP grant where 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 CHLN works to disseminate it and continues 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).
Renewal of the CHLN multistate project will extend the continued partnership in the region to adress 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, while expanding to address child health as it relates to issues around food cost, food insecurity, and food systems that have been brought to light by the COVID-19 pandemic and increasingly frequent natural disasters that affect the region and its communities.
Develop 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 and other relevant and available data, findings related to child obesity and its multilevel (policy, system, and environmental) determinants.
The renewal 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 and other multistate partners. 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, intervention studies and follow-up 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, Open Education Resource Human Nutrition Text Book https://pressbooks.oer.hawaii.edu/humannutrition), and CHL intervention materials (Role Model Training Guide, Master Gardening and Food Preservation Materials). CHLN will also seek to aggregate and disseminate data from other related programs available throughout the region such as Expanded Food and Nutrition Education Program (EFNEP) and Supplemental Nutrition Assistance Program Education (SNAP-Ed). Materials not covered by privacy rules (HIPAA and IRB) will be publically available, mostly through the CHL website (www.chl-pacific.org) and through National eXtension networks (chln.extension.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
- Open Education Resources and curriculum for formal and informal training in areas of child obesity policy, monitoring, and intervention will be shared among CHLN institutions and others.
- CHL intervention and other pertinent extension training materials (e.g., Pacific Food Guide) will also be continuously disseminated on the CHL website and other National platforms (i.e., eXtension).
- 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;
- 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).
- Facilitate use of CHL data, findings related to child obesity and its multilevel (policy, system, and environmental) determinants.
- WEBSITE CHL intervention, training resources, community reports, and peer reviewed publications disseminated on the CHL website (chl-pacific.org) and the CHLN eXtension website (https://chln.extension.org/).
Outcomes or Projected Impacts
- Regional and jurisdiction coalitions built to manage shared agenda and advocate for policy changes Capacity building: Improve child food security and human health through collective impact by maintaining or increasing the number of jurisdiction coalitions built to manage shared agenda and advocate for policy changes. Capacity building: Improve child food security and human health through collective impact by maintaining or increasing the number of 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 through extension and other non-credit programs. Capacity building: Increase the number of trained Extension and community health professionals in the areas PSEs, social marketing, health monitoring and surveillance. Capacity building: Increase the number of trained Extension and community health professionals in the areas PSEs, social marketing, health monitoring and surveillance.
- Increased number of Pacific jurisdictions that monitor child health parameters, such as BMI, and other social determinants of health such as food insecurity and food cost. Reduce childhood overweight and obesity prevalence among Pacific communities in jurisdictions that monitor health parameters Reduce childhood overweight and obesity prevalence among Pacific communities in jurisdictions that monitor health parameters
Milestones(2022):Publish 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; dissemination of Pacific BMI monitoring system resources
(2023):Publish longitudinal CHL intervention results; plan for a Pacific food cost and security 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
(2024):Publish longitudinal data utilizing CHL diet data; develop food cost, food security and diet assessment tools for Pacific diet and food security monitoring; 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
(2025):Publish student manuscripts; pilot diet assessment tools for Pacific diet and food security monitoring; 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
(2026):Submit a collaborative grant proposal for further Pacific child health and obesity prevention work around food security monitoring; training child obesity policy, systems and environmentally focused multi-level prevention, child health, nutrition assessment and monitoring through the CHL Summer Institute
Projected ParticipationView Appendix E: Participation
The CHL (http://www.chl-pacific.org/) and CHLN (www.chln.extension.org) websites will be maintained to provide access to publications, intervention material and community reports and scientific reports, and data dashboards. 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. In addition, the content of these courses is readily available for all to view.
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 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 will appoint subcommittees to complete specific objectives and tasks; subcommittees will meet on a monthly basis. 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. Sub-committees will share updates on progress towards meeting specific objectives.
Jurisdiction local advisory committee meetings will be held to ensure cross-sector partnership.
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