Discussion
obesity, weight gain
OBESITY, DENTAL CARIES, INSULIN RESISTANCE
Unexpectedly, we observed a small, statistically significant relative increase in child BMIz and modified BMIz among those enrolled in the intervention (vs. control). However, aligned with a priori hypotheses, we also observed significantly higher odds of children meeting three health behavior recommendations at follow-up, specifically in relation to SSB intake, water intake, and screen time; no significant differences in vegetable, fruit, and juice intake, nor time spent in physical activity and night sleep were observed. Additionally, parents enrolled in the high-intensity PConnect program exhibited significant increases in parental empowerment, relative to those who did not participate in PConnect, though no difference was observed for those exposed to CHL overall (vs. control). These results align well with results form a systematic review of obesity interventions in ECE settings [Although the relative differences in BMIz and modified BMIz are statistically significant (respectively: Though unexpected, there are a few possible reasons we observed a small significant increase in BMIz and modified BMIz among the intervention vs. control group. First, the control and intervention groups demonstrated limited exchangeability because randomization was conducted at the program- (vs. child-) level. With the number of programs being relatively small (At follow-up, the positive impacts observed on relative odds of meeting some child health behavior recommendations (i.e., SSB intake, water intake, and screen time), but not others (i.e., fruit, vegetable, or juice intake; physical activity; and night sleep duration), align with findings from similar lifestyle-based intervention programs in early childhood [Children in the intervention exhibited 40-60% higher odds of meeting recommendations for SSB, water and screen time. This relative increase in odds (~ 50%) may be meaningful, as any reduction in sugary beverage consumption may help alleviate risk of, for example, unhealthy weight gain, insulin resistance, and dental caries [Finally, we observed a significant, relative increase in parental empowerment among parents in the intervention condition who enrolled in PConnect versus those who did not. The observed relative increase of 0.17 empowerment units (scale: 1-4) translates to a caregiver with PConnect (vs. without) rating higher agreement with roughly two to three empowerment questions at follow-up. For example, a caregiver may report higher agreement with statements, related to the prompt “If I have concerns about my child’s health …” : I know I can get my family to help”, “I ask friends and family for health or advice”, and “I use the programs, services, and other resources in my community to help my child.” Though an abundance of literature cites empowerment as the foundation for intervention development, the measurement literature on empowerment as an outcome in health promotion studies remains limited [Several limitations should be taken into consideration when considering this study’s results. First, it is possible that the intervention dose was too low for the majority of families, particularly those who did not participate in PConnect. While our process evaluation suggests that intervention activities were implemented as planned and that parents in the intervention were more likely to report the receipt of nutrition support and educational materials likely to be exposed to nutrition support, CHL was only implemented for half of the intended time across all programs as a result of the premature conclusion of the study. Coupled with this, rapid turnover of Head Start families precluded our ability to examine change over multiple years for the five programs that implemented CHL over 2 years. An academic school year may not be long enough to observe the translation of parent-level changes (in behavior, cognition, and beliefs) into meaningful changes in child anthropometries.The use of self-report behavior measures could also be considered a limitation, as self-report methods may introduce measurement error or conscious bias [In terms of strengths, our use of data compiled by Head Start to operationalize the child outcomes allowed both the diversity and size of our sample to exceed those of most other school-based studies in the field [