Progress 04/15/11 to 04/14/17

Outputs
Target Audience:Hispanic pregnant women and mothers of young children (ages newborn to 3 years old) receiving obstetrical and pediatric care in a primary care setting. The goal of the project was to promote healthy habits and prevent the development of childhood obesity. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?Opportunities for training and professional developmentinclude Dietetic interns: training 3 dietetic interns in community nutrition and obesity prevention. (1) Debbie Blue completed her MS/dietetic program from Queens College, obtained her RD and CLC certification, and focuses on diabetes management. (2) Ana Leibovici completed her MS/dietetic program from Columbia University and obtained her RD. (3) Ingris Garcia completed the Dominican University Distance Program and is pursuing public health/community nutrition. Janneth Bancayan, a research assistant on the StEP-RCT, finished her MS/dietetic program at NYU and is currently a StEP dietitian. Undergraduate/graduate students: include training 9 NYU undergraduate/graduate students (Ashley Beck, Shin Yi Chong, Sara Rose Fetter, Shannon Herbert, Erica Hsia, Grace Kim, Colleen McConnell, Daniela Ochoa, and Lauren Thomas) on pediatric dietary assessment methodology through a structured research internship. These students have assisted with the StEP:P-3 10 month infant dietary intakes. NYU nutrition doctoral student Thomas is studying methods to assess energy and nutrient intake in breast and combination fed infants in the StEP cohort for her dissertation Post doctoral fellows: Our original USDA funding successfully trained a post-doctoral pediatric fellow Dr. Candice Taylor-Lucas, who performed mentored research of StEP:P-3. She is now an Assistant Professor at the University of California, Irvine, where she is implementing the StEP prevention principles. We are currently training another post-doctoral pediatric fellow, Michelle Katzow, in the development and evaluation of early child obesity prevention Dr. Rachel Gross also trained as a post-doctoral pediatric fellow in this program, launching her research career. As a StEP-RCT co-project director, she successfully obtained a NIH/NICHD K23 career development award to address barriers to intervention success within low-income populations by tailoring StEP to address poverty-related risks, such as depression or food insecurity. Dr. Gross will accomplish this by combining the StEP program with Healthy Steps, a primary care-based parenting program that incorporates mental health specialists into pediatric care during the first 3 years of life How have the results been disseminated to communities of interest?Results have been disseminated through presentation at pediatric, public health and nutrtion scientific meetings and published in scientific journals What do you plan to do during the next reporting period to accomplish the goals? Nothing Reported

Impacts
What was accomplished under these goals? Data collected: Over the course of the study, intervention and control families were evaluated according to the schedule below. A research assistant performed these assessments by telephone or in person. Assessments were timed to cover crucial periods when important feeding and family activity patterns become established. Baseline: Assessment of socio-demographic data, maternal diet consumption and lifestyle behaviors were performed after completing enrollment.Subject enrollment was complete by December 31, 2014, with a total N of 566. There were 266 dyads randomized to receive the Starting Early intervention. 533 infants were born. 3 months: This was timed to occur before most infants have begun solid foods and to assess short-term breastfeeding duration. All 3 month assessments are completed for a final n of 456 10 months: This was timed to coincide with the increase in foods and other liquids and increasing regularity of infant patterns such as regular feeding and sleep times. It was also timed to assess longer-term breastfeeding. All 10 month assessments are completed and are currently being analyzed fro a final n of 412. 19 months: This was timed to occur when children may begin using words to describe feeding and when increased negativism associated with feeding may lead to parenting difficulties. There are 390 complete 19 month assessments and the remainder are ongoing. 2 and 3 years: These assessments focused on a period of increasing child independence, feeding struggles and increased exposure to an obesogenic environment. There are 358 two year assessments and 248 three year assessments completed; the remainder are ongoing. Final results: 3 month assessment:. The mothers receiving our intervention had higher maternal infant feeding knowledge scores than mothers in the control group, leading to higher rates of exclusive breastfeeding and higher percentage of breast milk given in those who also fed their infants formula. Mothers in the intervention group were less likely than controls to have introduced complementary foods and liquids at the time of the 3 month assessment. 10 month assessment: Mother-infant pairs in the intervention group were more likely to give breast milk as the only milk source and have daily family meals, and less likely to give juice or cereal in the bottle compared to controls. Intervention mothers were more likely to exhibit lower pressuring, indulgent and laissez-faire feeding styles; and to have higher nutrtition knowledge. These findings demonstrate that a primary-care based family-centered obesity prevention program can implement feasible and effective infrastructure for promoting breastfeeding and physical activity in families at high risk for obesity. Major activities completed Individual Nutrition Counseling: During the third trimester of pregnancy and the postpartum period, intervention families received brief individual counseling from a registered dietician/certified lactation consultant (RD/CLC) and included discussion of plans for infant feeding, breastfeeding promotion, and overcoming obstacles to breastfeeding Family Groups: nutrition and parenting support group (NPSG) sessions led by an RD/CLC with other program staff began at the one month well child visit, and occurred at every subsequent well child visit. These sessions focused on feeding and parenting issues related to the babies' specific ages using a variety of participant led adult education strategies, including discussions, activities, games and demonstrations. Appointments were made to cohort dyads into 40 separate groups, allowing for each dyad to participate in NPSGs with the same set of 4-8 family peers. To date, 30 cohorts have completed the program and 10 cohorts, (approximately 40 mother-infant pairs) are still participating in the final 3 sessions. These will all be completed by December. Groups were conducted in English and Spanish. Nutrition DVD: Families received a bilingual nutrition DVD with culturally specific content designed to teach optimal feeding methods during the first 2 years of life. This video entitled "It's Never Too Early: Feeding Your Baby Well"/ "Empezando Temprano: La Buena Alimentación de Tu Bebé" has four age-appropriate chapters on infant feeding and one chapter on food and behavior. Relevant chapters of the video served as the starting point for the interactive groups. The DVD was developed based on recommended feeding guidelines for optimal infant/toddler feeding and early obesity prevention with input from focus groups of Latina mothers and community advocates. The impact of this video has been evaluated for acceptance by families and its effects on parent feeding knowledge and behaviors and has been shown to improve both parent nutrition knowledge and feeding behaviors. Plain Language Handouts: Intervention families received plain language handouts to reinforce the curriculum presented in the family groups and DVD. The handouts were written for low literacy readers, with a positive message and were designed for families with low literacy and numeracy skills. Handout content was reviewed during the family group. In the process of developing the curriculum and implementing the program, we developed systems for tracking mother/infant dyads, scheduling infant appointments and assessments, collecting data, and spreading awareness about our program throughout the obstetric and pediatric clinics. In addition, we developed systems to monitor both the quality and fidelity of the intervention.Starting Early program staff attended meetings with health care providers and staff from the obstetric and pediatric clinics at both program sites in order to build relationships of mutual support. Regular meetings with clinical providers ensured support, reinforced the Starting Early preventive nutrition message, and allowed time for feedback from clinicians. The Project Coordinator and staff met regularly with the Principal Investigators and co- Investigators.

Publications

• Type: Journal Articles Status: Published Year Published: 2017 Citation: Gross RS, Mendelsohn AL, Yin HS, Tomopoulos S, Gross MB, Scheinmann R, Messito MJ. Randomized controlled trial of an early child obesity prevention intervention: Impacts on infant tummy time. Obesity (Silver Spring). 2017 May;25(5):920-927. doi: 10.1002/oby.21779. Epub 2017 Mar 22.
• Type: Journal Articles Status: Published Year Published: 2016 Citation: Gross RS, Mendelsohn AL, Gross MB, Scheinmann R, Messito MJ. Randomized Controlled Trial of a Primary Care-Based Child Obesity Prevention Intervention on Infant Feeding Practices. J Pediatr. 2016 Jul;174:171-177.e2. doi: 10.1016/j.jpeds.2016.03.060. Epub 2016 Apr 21.
• Type: Journal Articles Status: Published Year Published: 2016 Citation: Gross RS, Mendelsohn AL, Gross MB, Scheinmann R, Messito MJ. Material Hardship and Internal Locus of Control Over the Prevention of Child Obesity in Low-Income Hispanic Pregnant Women. Acad Pediatr. 2016 Jul;16(5):468-74. doi: 10.1016/j.acap.2016.02.003. Epub 2016 Feb 6.
• Type: Conference Papers and Presentations Status: Published Year Published: 2017 Citation: Randomized Control Trial of a Primary Care-Based Child Obesity Prevention Intervention Beginning in Pregnancy: Impact on Infant Feeding at Age 10 Months Mary Jo Messito, Alan Mendelsohn, and Rachel Gross, Abstract #2706787 Pediatric Academic Society Meeting San Francisco May 2017
• Type: Conference Papers and Presentations Status: Published Year Published: 2017 Citation: Food Insecurity during Pregnancy and Infancy and Obesity-Promoting Maternal Infant Feeding Styles in Low-Income Hispanic Families Rachel Gross, Alan Mendelsohn, and Mary Jo Messito Abstract Pediatric Academic Society Meeting San Francisco May 2017
• Type: Conference Papers and Presentations Status: Published Year Published: 2017 Citation: Womens Physical Activity in Pregnancy and Infant Activity at Age 3 Months. Marissa Cardillo, Alan Mendelsohn, Rachel Gross,and Mary Jo Messito, Abstract #2706437 Pediatric Academic Society Meeting San Francisco May 2017
• Type: Conference Papers and Presentations Status: Published Year Published: 2017 Citation: Prenatal Material Hardship and Infant Temperament at 10 Months Old in Low-Income Hispanic Mother-Infant Dyads. Anne Fuller, Mary Jo Messito, Alan L. Mendelsohn, Suzette O. Oyeku, Rachel Gross. Abstract Pediatric Academic Society Meeting San Francisco May 2017

Progress 04/15/15 to 04/14/16

Outputs
Target Audience:Hispanic pregnant women and mothers of young children (ages newborn to 3 years old) receiving obstetrical and pediatric care in a primary care setting. The goal of the project is to promote healthy habits and prevent the development of childhood obesity. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?The Starting Early program has served as the community/research rotation for one dietetic intern and two medical student research fellow. How have the results been disseminated to communities of interest?Preliminary results have been disseminated to communities of interest through abstracts and presentations at meetings. Two manuscripts are currently in press. What do you plan to do during the next reporting period to accomplish the goals?We plan to continue running the intervention and following the participants to age 3.

Impacts
What was accomplished under these goals? Outputs: In Year 5 of the grant, we completed 3 month and 10 month follow up surveys on the entire cohort and published final results on breastfeeding and feeding styles at 3 months. We continued using the 19 and 28 month survey tools, and created and began using the final assessment at 36 months. We continued the Starting Early intervention consisting of lunchtime family groups. Assessments: In addition to the two baseline, 3 month, 10 month and 19 month surveys, we also conduct a comprehensive survey at child age 28 and 36 months which assesses the following: child diet using the ASA24 computerized 24-hour diet recall system, nutrition and feeding knowledge, diet beliefs and behaviors, feeding styles, perception of weight, parental responsiveness, health and physical activity of the child, media use, sleeping habits, child temperament, working and childcare, basic socio-demographics and maternal diet. At 36 months we are also collecting height, weight and waist circumference of the mother and child, as well as blood pressure from the child. Subject enrollment: Subject enrollment was completed with an N of 566 on December 31, 2014. Starting Early Intervention: The Starting Early intervention included individual and group counseling by a nutritionist. Individual counseling occurred prenatally and perinatally during the mother's postpartum hospital stay. Immediately after randomization, the nutritionist provided prenatal counseling which included discussion of plans for infant feeding, breastfeeding promotion, and overcoming obstacles to breastfeeding. When the baby was born, the nutritionist saw the intervention mother and newborn in the nursery in the first few days after birth to provide breastfeeding support. Groups began at the baby's 1 month well child visit, and occur at every scheduled well child visit after that. On the day of the well child visits, mother/infant dyads from the intervention group participate in lunchtime family groups led by a nutritionist where they discuss feeding and parenting issues related to the babies' specific ages using a variety of participant led adult education strategies, including discussions, activities, games and demonstrations. Appointments are made to cohort the mothers so the same families are coming together during the groups as the children grow and develop. Systems development: We developed systems for tracking mother/infant dyads, scheduling baby appointments and assessments, collecting data, and spreading awareness about our program throughout the obstetric and pediatric clinics. In addition, we developed systems to monitor both the quality and fidelity of the intervention. Relationship building: Starting Early program staff continued to attend meetings with health care providers and staff from the obstetric and pediatric clinics at both program sites in order to build relationships of mutual support. Regular meetings with clinical providers ensured support and reinforced the Starting Early preventive nutrition message, and allowed time for feedback from the clinicians. The Project Coordinator and staff met regularly with the Principal Investigators and co-Investigators. Completed 3 and 10 month surveys: Table 1: Baseline Characteristics for Both the Enrollment Sample and the 3-Month Analytic Sample Characteristics Enrollment Sample (n=533) 3-Month Analytic Sample (n=456) Expectant Mother (Prenatal) Control (n=267) Intervention (n=266) p-value Control (n=235) Intervention (n=221) p-value Age (mean (SD)) 27.9 (5.8) 28.5 (6) .18 28.1 (5.8) 29.0 (6.1) .14 Primiparous 107 (40.1) 92 (34.6) .21 91 (38.7) 68 (30.8) .08 WIC participant 228 (85.4) 237 (89.1) .24 202 (86.0) 199 (90.0) .20 SNAP participant 95 (35.6) 98 (36.8) .79 87 (37.0) 88 (39.8) .56 Education (less than high school) 77 (28.8) 100 (37.6) .04 73 (31.1) 87 (39.4) .08 Married or living as married 191 (71.5) 188 (70.7) .85 167 (71.1) 161 (72.9) .68 Working 67 (25.1) 67 (25.2) 1.00 36 (15.6) 40 (18.1) .53 US born 51 (19.1) 56 (21) .56 43 (18.3) 40 (18.1) 1.00 Pre-pregnancy obese status 79 (29.6) 76 (28.5) .85 69 (29.4) 62 (28.5) .92 Prenatal depressive symptoms 90 (33.7) 91 (34.3) .93 76 (32.5) 70 (31.8) .92 Household food insecurity 87 (33.5) 74 (28.2) .22 81 (35.5) 62 (28.6) .13 Birth Sample (n= 529)a 3-Month Analytic Sample (n=456)b Child (Birth) Control (n=266) Intervention (n=263) p-value Control (n=235) Intervention (n=221) p-value Male gender 127 (47.7) 132 (50.2) .60 114 (48.5) 114 (51.6) .57 C-section 64 (24.6) 60 (23.4) .76 58 (24.7) 48 (21.7) .51 Premature < 37 weeks GA 5 (1.9) 10 (3.8) .20 5 (2.2) 7 (3.3) .37 Birth weight (mean (SD)) 3.39 (.49) 3.35 (.45) .28 3.40 (.49) 3.38 (.45) .57 LGA 32 (12.4) 21 (8.3) .15 29 (12.4) 19 (8.8) .23 Table 2: Effects of the Starting Early Intervention on Infant Feeding Practices at 3 Months Infant Feeding Practices Group (n=456) p-value Odds Ratio or Mean Difference 95% CI Control (n=235) Intervention (n=221) Breastfeeding in newborn period Ever breastfed in the hospital (%) 95.3 % 95.9 % .82 1.16a .47 - 2.85 Exclusive BM in the hospital (%) 31.1 % 37.1 % .20 1.31a .89 - 1.93 Exclusive BM leaving the hospital (%) 37.9 % 45.7 % .11 1.38a .95 - 2.01 Breastfeeding at 3 months old Any BM at 3 months (%) 80.4% 83.3% .47 1.21 .75 - 1.95 Exclusive BM at 3 months (%) 24.7 % 34.8 % .02 1.63a 1.09 - 2.45 100% BM on 24 hour diet recall (%)c 34.3 % 45.9 % .01 1.62a 1.11 - 2.37 Breastfeeding intensity continuous score (Mean (SD))c,d 59.7 (39.7) 67.7 (39.3) .03 -8.0b -15.3 - -0.75 Breastfeeding intensity categoriesc .006 Low intensity (< 20% BM) 23.9% 20.5% .63a .39 - 1.02 Medium intensity (20-80% BM) 34.6% 23.6% .51a .33 - .78 High intensity (> 80% BM) 41.5% 55.9% REF Ever gave BM and formula at the same feeding (%) 31.1 % 22.4 % .15 .64a .36 - 1.15 BM and formula at same feed per day (Mean (SD))c 4.3 (14.1) 2.0 (7.2) .03 2.30b .22 - 4.38 Other feeding at 3 months old Introduced tea, water, juice or cereal in the bottle (%) 16.7 % 6.3 % .001 .34a .18 - .64 Table 3: Effects of the Starting Early Intervention on Maternal Infant Feeding Knowledge at 3 Months Group n (%) (n=454) p-value Odds Ratio 95% CI Individual Questions Control (n=233) Intervention (n=221) Infant formula is as good as breast milk 162 (69.5) 140 (63.3) .17 .76 .51 - 1.12 If a baby is breastfed, he or she will be less likely to get ear infections 201 (86.3) 200 (90.5) .19 1.52 .85 - 2.72 If a baby is breastfed, he or she will be less likely to get to get a cough or a cold 207 (88.8) 206 (93.2) .14 1.73 .89 - 3.35 If a baby is breastfed, he or she will be less likely to get diarrhea 189 (81.1) 197 (89.1) .02 1.91 1.12 - 3.27 If a baby is breastfed, he or she will be less likely to become overweight 199 (85.4) 200 (90.5) .11 1.63 .91 - 2.90 Babies should be fed only breast milk for the first 6 months 212 (91.0) 204 (92.3) .74 1.19 .61 - 2.32 Formula is easier to digest than breast milk 204 (87.6) 202 (91.4) .22 1.51 .82 - 2.78 Breastfeeding helps mothers lose weight fastera 191 (82.7) 206 (93.6) <.001 3.08 1.63 - 5.84 Most women make enough breast milk for their babies to grow healthy. 197 (84.5) 198 (89.6) .13 1.57 .90 - 2.75 Feeding both breast milk and formula at the same feeding may cause you to feed your baby too much b 156 (67.2) 174 (78.7) .006 1.80 1.18 - 2.75 Feeding both breast milk and formula increases the amount of your breast milk. 181 (77.7) 160 (72.4) .23 .75 .49 - 1.16 You should not add anything to a bottle besides breast milk or formula. 189 (81.1) 197 (89.1) .02 1.91 1.12 - 3.27 Mean (SD) p-value Mean Difference 95% CI Total Knowledge Score c 9.8 (1.90) 10.3 (1.56) .002 .51 .19 to .83 Table 4: 10 month results Behavior at 10 months Intervention Control P value Exclusive breastfeeding 43% 33% p=.04 Tummy time 41% 29% p=.01 Not giving juice 39% 24% p=.003 Family meals 83% 70% p=.006 Less early introduction of complimentary foods 6% 17% p=.001

Publications

• Type: Journal Articles Status: Awaiting Publication Year Published: 2016 Citation: Gross RS, Mendelsohn AL, Gross MB, Scheinmann R, Messito MJ. Material Hardship and Internal Locus of Control over the Prevention of Child Obesity in Low-Income Hispanic Pregnant Women. Academic Pediatrics. In press.
• Type: Journal Articles Status: Awaiting Publication Year Published: 2016 Citation: Gross RS, Mendelsohn AL, Gross MB, Scheinmann R, Messito MJ. Randomized Controlled Trial of a Primary Care-Based Child Obesity Prevention Intervention on Infant Feeding Practices. The Journal of Pediatrics. In press.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2015 Citation: Gross RS, Mendelsohn AL, Gross MB, Scheinmann R, Messito MJ. Large Infant Appetite and Maternal Feeding Styles in Low-Income Hispanic Families. Platform presentation at Pediatric Academic Societies meeting in San Diego, CA 2015.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2015 Citation: Messito MJ, Mendelsohn AL, Gross MB, Scheinmann R, Gross RS. Characteristics Related To Infant Appetite in Low-Income Hispanic Families. Platform presentation at Pediatric Academic Societies meeting in San Diego, CA 2015.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2015 Citation: Scheinmann R, Gross RS, Gross MB, Chiasson MA, Bermudez D, Messito MJ. Maternal depression and breastfeeding duration in Hispanic mothers. Platform presentation at the American Public Health Association (APHA) meeting in Chicago, IL 2015.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2015 Citation: Messito MJ, Mendelsohn AL, Scheinmann R, Gross MB, Gross RS. Starting Early (SE): A Primary Care-Based Family-Centered Intervention to Prevent Child Obesity Beginning during Pregnancy. Platform presentation at the American Academy of Pediatrics (AAP) National Conference & Exhibition in Washington, DC 2015.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2016 Citation: Gross RS, Mendelsohn AL, Gross MB, Scheinmann R, Messito MJ. Randomized Control Trial of a Primary Care-Based Child Obesity Prevention Intervention Beginning in Pregnancy: Impact on Infant Feeding at Age 3 Months. Platform presentation at AAP Presidential Plenary & Annual Silverman Lecture 2016 at the Pediatric Academic Societies meeting in Baltimore, MD, 2016.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2016 Citation: Trinidad N, Mendelsohn AL, Blanco A, Lanza L, Rivera J, Messito MJ, Gross RS. Household Food Insecurity in Low-Income Hispanic Mothers: A Qualitative Study from the Starting Early Trial. Platform presentation at Pediatric Academic Societies meeting in Baltimore, MD, 2016.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2016 Citation: Farkas JS, Gross RS, Tomopoulos S, Gross MB, Diaz K, Messito MJ. Prenatal Stressors and Postpartum Infant Outcomes. Platform presentation at Pediatric Academic Societies meeting in Baltimore, MD, 2016. Poster presentation at the Annual Academic Pediatric Association Regions 2 and 3 meeting, Manhattan, NY, 2016.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2015 Citation: Lee DK, Majumder OL, Jimenez-Robbins C, Cole WG, Hasan S, Messito MJ, Gross RS, Mendelsohn AL, Adolph KE. The Effects of SES and Overweight Status on Infants Motor Milestones. Poster presentation at Society for Research in Child Development (SRCD) meeting in Philadelphia, Pennsylvania 2015.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2015 Citation: Ramirez C, Messito MJ, Scheinmann R, Mendelsohn AL, Gross MB, Gross RS. Exclusive Breastfeeding and Maternal-Infant Feeding Styles in Low-Income Hispanic Mothers. Poster presentation at Academic Pediatric Association Region 2&3 conference in New York, New York 2015; Poster presentation at Pediatric Academic Societies meeting in Washington, DC 2015.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2015 Citation: Lee DK, Majumder OL, Jimenez-Robbins C, Cole WG, Hasan S, Messito MJ, Gross RS, Mendelsohn AL, Adolph KE. The Effects of SES and Overweight Status on Infants Motor Milestones. Poster presentation at National American Society for the Psychology of Sport and Physical Activity (NASPSPA) meeting in Portland, Oregon 2015.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2015 Citation: Messito MJ, Mendelsohn AL, Gross MB, Diaz KN, Scheinmann R, Chiasson MA, Gross RS. Starting Early/Empezando Temprano: Randomized Control Trial (RCT) to Test the Effectiveness of an Early Obesity Prevention Program. Poster presentation at the Society for Nutrition Education and Behavior, Pittsburg, Pennsylvania 2015.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2015 Citation: Blanco AE, Messito MJ, Gross MB, Scheinmann R, Gross RS. Starting Early/Empezando Temprano: A Primary Care-Based Family-Centered Nutrition Program to Prevent Early Childhood Obesity Beginning in Pregnancy. Poster presentation at the Food & Nutrition Conference & Expo" for the Academy of Nutrition and Dietetics in Nashville, Tennessee 2015.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2015 Citation: Messito MJ, Mendelsohn AL, Scheinmann R, Gross MB, Gross RS. Starting Early (SE): A Primary Care-Based Family-Centered Intervention to Prevent Child Obesity Beginning during Pregnancy. Invited poster presentation at the American Academy of Pediatrics (AAP) National Conference & Exhibition in Washington, DC 2015.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2016 Citation: Lee DK, Jimenez-Robbins C, Hasan S, Messito MJ, Gross RS, Mendelsohn AL, Adolph KE. Access to Resources affects Infant Motor Milestones. Poster presentation at International Conference on Infant Studies in New Orleans, LA 2016.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2016 Citation: Edson K, Diaz K, Gross RS, Messito MJ. Maternal Verbal Responsivity and Infant Feeding Behaviors in Low-Income Hispanic Families. Poster presentation at Pediatric Academic Societies meeting in Baltimore, MD, 2016. Poster presentation at the Annual Academic Pediatric Association Regions 2 and 3 meeting, Manhattan, NY, 2016.

Progress 04/15/14 to 04/14/15

Outputs
Target Audience: Hispanic pregnant women and mothers of young children (ages newborn to 3 years old) receiving obstetrical and pediatric care in a primary care setting. The goal of the project is to promote healthy habits and prevent the development of childhood obesity. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided? The Starting Early program has served as the community/research rotation for three dietetic interns and currently a medical student research fellow. How have the results been disseminated to communities of interest? Preliminary results have been disseminated to communities of interest through abstracts and presentations at meetings. What do you plan to do during the next reporting period to accomplish the goals? We plan to continue running the intervention and follow the participants to age 3.

Impacts
What was accomplished under these goals? Outputs: In Year 4 of the grant, we completed subject enrollment and our last babies in the program were born. We completed our three year curriculum and create and began using the 28 month survey tool. We continued the Starting Early intervention, including prenatal and postpartum individual sessions with the nutritionist providing the intervention, and lunchtime family groups. Curriculum development: Working with a multi-disciplinary team of experts in general pediatrics, developmental-behavioral pediatrics, obesity prevention and treatment, nutrition, health literacy and public health, we continued to adapt and improve a 3-year curriculum for the family group intervention. We constantly refine the curriculum based on feedback from the family groups. Assessments: In addition to the two baseline, 3 month and 10 month surveys, we also conduct a comprehensive survey at baby age 19 months which assesses the following: feeding behaviors at 19 months using the ASA24 computerized 24-hour diet recall system, nutrition and feeding knowledge, diet beliefs and behaviors, feeding styles, perception of weight, parental responsiveness, health and physical activity of the baby, media use, sleeping habits, child temperament, working and childcare, basic socio-demographics and parenting stress, anxiety and depression. We also completed and began using the 28 month survey which focuses on the assessment ofchildhood andfeeding behavior, feeding practices, nutrition knowledge, perception of weight, media use, child's physical activity and sleep. It alsoincludesthe use of the ASA24 computerized 24-hour recall system. Subject enrollment: Enrollment continued out of the obstetric clinic at Bellevue Hospital Center and was complete with an N of 567 on December 31, 2014. Program staff participated in the enrollment process by meeting eligible women in the clinic, confirming their eligibility, inviting them to participate and obtaining consent if they agreed. The comprehensive baseline survey was completed at that initial enrollment visit and women were met at a following obstetric appointment to complete a comprehensive Food Frequency Questionnaire which is a detailed assessment of dietary intake over the previous year. Randomization into either control, or Starting Early intervention groups took place at a third meeting after the subject was at least 32 weeks gestation; randomization was performed by a nutritionist. For women randomized into the Starting Early intervention group, the intervention was initiated at that time. Randomization was completed in February 2015 with a total N of 534 participants, half of them being intervention. Starting Early Intervention: The Starting Early intervention includes individual and group counseling by a nutritionist. Individual counseling occurs prenatally and perinatally during the mother's postpartum hospital stay. Immediately after randomization, the nutritionist provides prenatal counseling which includes discussion of plans for infant feeding, breastfeeding promotion, and overcoming obstacles to breastfeeding. When the baby is born, the nutritionist sees the intervention mother and newborn in the nursery or in the first few days after birth to provide breastfeeding support. Groups begin at the baby's 1 month well child visit, and occur at every scheduled well child visit after that. On the day of the well child visits, mother/infant dyads from the intervention group participate in lunchtime family groups led by a nutritionist where they discuss feeding and parenting issues related to the babies' specific ages using a variety of participant led adult education strategies, including discussions, activities, games and demonstrations. Appointments are made to cohort the mothers so the same families are coming together during the groups as the children grow and develop. Systems development: We developed systems for tracking mother/infant dyads, scheduling baby appointments and assessments, collecting data, and spreading awareness about our program throughout the obstetric and pediatric clinics. In addition, we developed systems to monitor both the quality and fidelity of the intervention. Relationship building: Starting Early program staff continued to attend meetings with health care providers and staff from the obstetric and pediatric clinics at both program sites in order to build relationships of mutual support. Regular meetings with clinical providers ensured support and reinforced the Starting Early preventive nutrition message, and allowed time for feedback from the clinicians. The Project Coordinator and staff met regularly with the Principal Investigators and co-Investigators. Maternal Demographics at Baseline: N= 559 Total Percent (%) or mean Pre pregnancy BMI > 30 130 (28.1%) Age 28 (7.6) Primparious 213 (38.1%) US born 116 (21%) Less than high school education 185 (33.1%) Married/Living with partner 393 (70%) SNAP participant 203 (36.3%) WIC participant 487 (87.1%) Food Insecure 104 (30.9%) Depressive symptoms (5 or more on PHQ9) 195 (35%) Daily Servings Fruit 1.88 (1.1) Daily Servings Vegetables 2.36 (1.7) Daily Ounces Sugar-Sweetened Beverages 9.85 (12) Daily TV Time, hours 2.6 hrs (1.9) No daily physical activity 166 (29.7%) 3 month Data - infant age 3 month Total Percent (%) or mean Birth weight 3.35 (0.48) Large for gestational age (bwt > 4kg) 43 (10.7) Infant gender (male) 184 (50.8) Any breastfeeding 290 (80.2) Exclusive breastfeeding 103 (28.5) Resetrain time 148 (1.89) Tummy time y/n 297 (82.3) Infant mealtime TV exposure, any 66 (82) Infant TV exposure 0.35 (0.69) IFSQ scores: Responsive Satiety 4.44 (0.66) / Attention 3.92 (1.54) Laissez faire Attention 1.87 (0.73) / Diet Quality 1.52 (1.10) Pressuring Finishing 2.16 (0.95) / Cereal 1.87 (0.88) / Soothing 2.84 (1.19) Restrictive Amount 3.78 (1.20) / Diet Quality 2.70 (1.65) Indulgent Permissive 1.29 (0.79) / Soothing 1.38 (0.97) / Pampering 1.40 (0.96) Infant night sleep 8.75 (2.25) Infant total sleep 14.3 (3.17)

Publications

• Type: Conference Papers and Presentations Status: Accepted Year Published: 2014 Citation: Mary Jo Messito, MD, mary.messito@nyumc.org, NYU School of Medicine, Bellevue Hospital Center, Bellevue Hospital Center, 562 First Avenue, New York, NY, 10025; A. L. Mendelsohn, MD; M. Gross, MS, RD; K. Diaz, BS; R. Scheinmann, MPH, Public Health Solutions; C. Taylor Lucas, MD, MPH, NYU School of Medicine, Bellevue Hospital Center; M. A. Chiasson, DrPH, Public Health Solutions; R. Gross, MD, MS, Albert Einstein College of Medicine, Childrens Hospital at Montefiore. Starting Early/Empezando Temprano: Randomized Control Trial (RCT) to Test the Effectiveness of an Early Obesity Prevention Program. Society for Nutrition Education and Behavior Annual Meeting, Minneapolis, MN. July 2014.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2014 Citation: Mary Jo Messito, MD, mary.messito@nyumc.org, NYU School of Medicine, Bellevue Hospital Center, Bellevue Hospital Center, 562 First Avenue, New York, NY, 10025; R. Gross, MD, MS, Albert Einstein College of Medicine, Childrens Hospital at Montefiore; A. L. Mendelsohn, MD, NYU School of Medicine, Bellevue Hospital Center; S. Tomopoulos, MD; M. Gross, MS, RD; R. Scheinmann, MPH, Public Health Solutions. Starting Early/Empezando Temprano: Randomized Control Trial (RCT) to Test the Efficacy of an Early Obesity Prevention Program. American Academy of Pediatrics Annual Meeting, San Diego, CA. October 2014
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2014 Citation: Roberta Scheinmann, MPH, RScheinmann@healthsolutions.org, Public Health Solutions, 40 Worth St. New York, NY, 10013; M. A. Chiasson, DrPH, Public Health Solutions; R. Gross, MD, MS, Albert Einstein College of Medicine, Childrens Hospital at Montefiore; M. Gross, MS, RD; J. Bancayan, BS; Mary Jo Messito, MD. Maternal Consumption of Sweets During Pregnancy & its with Infant Feeding. The Obesity Society Annual Meeting, Boston, MA. October 2014.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2015 Citation: Chris Ramirez, BA1, Mary Jo Messito, MD1, Roberta Scheinmann, MPH2, Alan Mendelsohn, MD1, Michelle Gross, MS RD1 and Rachel Gross, MD MS3. 1Pediatrics, New York University School of Medicine, New York, New York 10016, United States; 2Research and Evaluation Unit, Public Health Solutions, New York, New York 10013, United States and 3Pediatrics, Albert Einstein College of Medicine / Children's Hospital at Montefiore, Bronx, New York 10467, United States. Exclusive Breastfeeding and Maternal-Infant Feeding Styles in Low-Income Hispanic Mothers. Poster Presentation at Pediatric Academic Society Annual Meeting, San Diego, CA. April 2015.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2015 Citation: Rachel Gross, MD MS1, Alan Mendelsohn, MD2, Michelle Gross, MS RD2, Roberta Scheinmann, MPH3 and Mary Jo Messito, MD2. 1Pediatrics, Albert Einstein College of Medicine / Children's Hospital at Montefiore, Bronx, New York, United States; 2Pediatrics, New York University School of Medicine, New York, New York, United States and 3Research and Evaluation, Public Health Solutions, NY, United States. Infant Food Responsiveness and Maternal Feeding Styles in Low-Income Hispanic Families. Platform Presentation at Pediatric Academic Society Annual Meeting, San Diego, CA. April 2015.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2015 Citation: Mary Jo Messito, MD1, Alan Mendelsohn, MD1, Michelle Gross, MS, RD1, Roberta Scheinmann, MPH2 and Rachel Gross, MD,MS3. 1Dept of Pediatrics, New York University School of Medicine, New York, NY 10016, United States; 2Research and Evaluation Unit, Public Health Solutions, New York, NY, United States and 3Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, United States. Characteristics Related to Infant Appetite in Low-Income Hispanic Families. Platform Presentation at Pediatric Academic Society Annual Meeting, San Diego, CA. April 2015.

Progress 04/15/13 to 04/14/14

Outputs
Target Audience: Hispanic pregnant women and mothers of young children (ages newborn to 3 years old) receiving obstetrical and pediatric care in a primary care setting. The goal of the project is to promote healthy habits and prevent the development of childhood obesity. Changes/Problems: This year we engaged in two significant collaborations. The first is a collaboration with Dr. Leonardo Trasande to assess the relationship between urine phthalate (Di-2-ethylhexylphthalate (DEHP)) metabolites and maternal and infant dietary behaviors, weight status and other health outcomes. There are three proposed hypotheses. Hypothesis 1: DEHP metabolites are positively associated with maternal and infant diets, including milk source, poultry consumption, and inversely associated with fruit and vegetable consumption. Hypothesis 2: DEHP metabolites in women are associated with their weight status and in infants are associated with increased weight-for-length z-scores at 10 and 19 months. Hypothesis 3: The Starting Early intervention will produce reductions in infant DEHP metabolites at 10 and 19 months. We are introducing urine analyses at 4, 9 and 18 months as part of this proposed ancillary study to the parent RCT. We have collected over 30 urine samples from babies aged 3 to 4 months for both intervention and control infants at well child visits. The second collaboration is the collection and analysis of videotaped infant movement, activity and feeding in the NYU Infant Action Lab (NYU IAL) at the Psychology Department at New York University. We have begun observing infant movement, activity and feeding for a subset of 250 enrolled mother-infant dyads at 3 developmental time points: infant age 9-10 months, 12-13 months and 18-19 months as part of an ancillary study to the parent Starting Early RCT. A subset of mother infant dyads consecutively sampled from both intervention and control groups to include a range of infant weight for length percentiles will be offered participation in this ancillary study. We will collect approximately 10 trials of the infant crawling or walking over a pressure sensitive “gait mat” that records the timing and placement of infants? steps, 15-60 minutes of spontaneous motor play activity, and 15-60 minutes of an ad lib feeding, and several measures of body dimensions, in total, requiring approximately 90 minutes in the (NYU IAL) for each time point. Mothers who elect to participate will be asked to sign a separate additional consent and will receive a stipend of $40 plus public transportation fees for their time spent in the lab. Age appropriate foods will be provided. Over fifteen mother infant dyads have participated in the analysis thus far. What opportunities for training and professional development has the project provided? The Starting Early program has served as the community/research rotation for two dietetic interns. In addition, a graduate student in Nutrition Education conducted a formal evaluation of the Starting Early curriculum as her masters thesis. How have the results been disseminated to communities of interest? Preliminary results have been disseminated to communities of interest through abstracts and presentations at meetings. What do you plan to do during the next reporting period to accomplish the goals? We plan to complete enrolling the planned number of subjects, continue running the intervention, and follow the participants to age 3.

Impacts
What was accomplished under these goals? Outputs: In Year 3 of the grant, our oldest Starting Early babies celebrated their first birthdays and we developed and began using the second year of family group curriculum. We also started using the 10 month survey and developed a 19 month survey. We continued subject enrollment and the Starting Early intervention, including prenatal and postpartum individual sessions with the nutritionist providing the intervention, and lunchtime family groups. Curriculum development: Working with a multi-disciplinary team of experts in general pediatrics, developmental-behavioral pediatrics, obesity prevention and treatment, nutrition, health literacy and public health, we continued to adapt and improve a 3-year curriculum for the family group intervention. In addition to constantly refining the curriculum based on feedback from the family groups, we began working with a team of nutrition education experts to verify the fidelity of the curriculum. Assessments: In addition to the two baseline and 3 month surveys, we also conduct a comprehensive survey at baby age 10 months which assesses the following: feeding behaviors at 10 months using a 24-hour recall, nutrition and feeding knowledge, feeding styles, perception of weight, locus of control, parental responsiveness, health and physical activity of the baby, media use, sleeping habits, working and childcare, basic socio-demographics and psychosocial stressors like food insecurity. We also have a near final draft of the 19-month assessment. Subject enrollment: Enrollment continued out of the obstetric clinic at Bellevue Hospital Center. Program staff participated in the enrollment process by meeting eligible women in the clinic, confirming their eligibility, inviting them to participate and obtaining consent if they agreed. The comprehensive baseline survey was completed at that initial enrollment visit and women were met at a following obstetric appointment to complete a comprehensive Food Frequency Questionnaire which is a detailed assessment of dietary intake over the previous year. Randomization into either control, or Starting Early intervention groups took place at a third meeting after the subject was at least 32 weeks gestation; randomization was performed by a nutritionist. For women randomized into the Starting Early intervention group, the intervention was initiated at that time. We anticipate enrollment to continue through the end of 2014 in order to reach an N of 500. Starting Early Intervention: The Starting Early intervention includes individual and group counseling by a nutritionist. Individual counseling occurs prenatally and perinatally during the mother’s postpartum hospital stay. Immediately after randomization, the nutritionist provides prenatal counseling which includes discussion of plans for infant feeding, breastfeeding promotion, and overcoming obstacles to breastfeeding. When the baby is born, the nutritionist sees the intervention mother and newborn in the nursery or in the first few days after birth to provide breastfeeding support. Groups begin at the baby’s 1 month well child visit, and occur at every scheduled well child visit after that. On the day of the well child visits, mother/infant dyads from the intervention group participate in lunchtime family groups led by a nutritionist where they discuss feeding and parenting issues related to the babies’ specific ages using a variety of participant led adult education strategies, including discussions, activities, games and demonstrations. Appointments are made to cohort the mothers so the same families are coming together during the groups as the children grow and develop. Systems development: We developed systems for tracking mother/infant dyads, scheduling baby appointments and assessments, collecting data, and spreading awareness about our program throughout the obstetric and pediatric clinics. In addition, we developed systems to monitor both the quality and fidelity of the intervention. Relationship building: Starting Early program staff continued to attend meetings with health care providers and staff from the obstetric and pediatric clinics at both program sites in order to build relationships of mutual support. Regular meetings with clinical providers ensured support and reinforced the Starting Early preventive nutrition message, and allowed time for feedback from the clinicians. The Project Coordinator and staff met regularly with the Principal Investigators and co-Investigators. Baseline: Pregnant women 26-34 weeks gestation (n=357) Mean (SD) or n (%) Pre pregnancy BMI >30 40 (35%) Age (years) 28 (7) First child 160 (40%) US Born 73 (18%) Education < High School 133 (33%) Married / Living with partner 279 (70%) SNAP Participant 142 (36%) WIC Participant 350 (88%) Food Insecure 128 (33%) Depressive Symptoms 74 (35%) Daily Servings Fruit 1.9 (1.1) Daily Servings Vegetables 2.4 (1.7) Daily Ounces Sugar-Sweetened Beverages 9.8 (12) Daily TV Time, hours 2.7 (2) No Daily Physical Activity 117 (29%) 3 month Data: Infant Age 3 Months n = 226 Mean(sd) or %(n) Birth weight 3.3 (.45) Large for gestational age (bwt >4 kg) 8.5 (18) Infant gender (male) 52.3 (115) 3 month wt/lt z score .18 (1.15) 3 m wt/lt %ile>97 5.3 (10) Any breastfeedinng 72.9 (164) Exclusive Breastfeeding 25.7 (57) Restrain time 191 (141) Tummy time y/n 80.1 (177) Infant mealtime TV exposure, any 82.8 (183) Infant TV exposure .35 (.99) IFSQ scores: Responsive 4.1 (1.1) Laissez faire 1.7 (1) Pressuring 2.3 (1) Restrictive 3.2 (1.4) Indulgent 1.3 (.9) Infant night sleep 8.75 (2.1) Infant total sleep 14 (3.2)

Publications

• Type: Conference Papers and Presentations Status: Accepted Year Published: 2013 Citation: Mary Jo Messito, MD, mary.messito@nyumc.org, New York University School of Medicine-Bellevue Hospital Center, Department of Pediatrics, 562 1st Avenue, New York, NY 10025; M. Gross, MS, RD; A. Mendelsohn, MD; R. Gross, MD, Montefiore Children's Hospital. Belief that Exclusive Breast Milk is Best: Breastfeeding Knowledge and Country of Origin in Low-Income Latina Pregnant Women. Society for Nutrition Education and Behavior Annual Meeting, Portland, OR. August 2013.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2013 Citation: Mary Jo Messito, MD, mary.messito@nyumc.org, NYU School of Medicine, Bellevue Hospital Center, Bellevue Hospital Center, 562 First Avenue, New York, NY, 10025; A. L. Mendelsohn, MD; M. Gross, MS, RD; K. Diaz, BS; R. Scheinmann, MPH, Public Health Solutions; C. Taylor Lucas, MD, MPH, NYU School of Medicine, Bellevue Hospital Center; M. A. Chiasson, DrPH, Public Health Solutions; R. Gross, MD, MS, Albert Einstein College of Medicine, Childrens Hospital at Montefiore. Starting Early/Empezando Temprano: Randomized Control Trial (RCT) to Test the Effectiveness of an Early Obesity Prevention Program. Society for Nutrition Education and Behavior Annual Meeting, Portland, OR. August 2013.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2013 Citation: Mary Jo Messito. NIH WORKSHOP ON PREVENTION OF OBESITY IN INFANCY AND EARLY CHILDHOOD. Bethesda, MD. October 2013.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2013 Citation: R.S. Gross, Pediatrics, Albert Einstein College of Medicine / Children's Hospital at Montefiore, Bronx, New York, UNITED STATES; R. Scheinmann, Research and Evaluation, Public Health Solutions, New York, New York, UNITED STATES; M. Gross, K. Diaz, C. Taylor-Lucas, A.L. Mendelsohn, S. Tomopoulos, M. Messito, Pediatrics, NYU School of Medicine, New York, New York, UNITED STATES; Relationships between Infant Tummy Time, Restrained Time and TV time in Low-Income Hispanic Families at Highest Risk of Early Child Obesity. Poster Presentation at Obesity Society Annual Meeting, Boston, MA. November 2013.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2014 Citation: Kenny Diaz, BA1, Rachel Gross, MD MS2, Roberta Scheinmann, MPH3, Michelle Gross, MS RD1, Alan Mendelsohn, MD1, Soultana Tomopoulos, MD1 and Mary Jo Messito, MD1. 1Pediatrics, New York University School of Medicine, New York, NY, United States;2Pediatrics, Children's Hospital at Montefiore / Albert Einstein College of Medicine, Bronx, United States and 3Research and Evaluation, Public Health Solutions, New York, NY, United States. Relationship between Prenatal TV Watching During Meals and Infant TV Exposure During Feeding. Pediatric Academic Society Annual Meeting, Vancouver, BC. To be presented May 2014.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2014 Citation: Rachel Gross, MD MS1, Alan Mendelsohn, MD2, Roberta Scheinmann, MPH3, Michelle Gross, MS RD2, Kenny Diaz, BA2 and Mary Jo Messito, MD2. 1Pediatrics, Albert Einstein College of Medicine / Children's Hospital at Montefiore, Bronx, New York, United States; 2Pediatrics, New York University School of Medicine, New York, New York, United States and 3Research and Evaluation, Public Health Solutions, New York, New York, United States. Prenatal Material Hardship and Infant Nighttime Sleep Duration in Low-Income Hispanic Families. Pediatric Academic Society Annual Meeting, Vancouver, BC. To be presented May 2014.

Progress 04/15/12 to 04/14/13

Outputs
Target Audience: Hispanic pregnant women and mothers of young children (ages newborn to 3-years-old) receiving obstetrical and pediatric care in a primary care setting. The goal of the project is to promote healthy habits and prevent the development of childhood obesity. Changes/Problems: Our study is based in downtown New York City at NYU School of Medicine/BHC and two affiliated out-patient clinics, BHC and GHS. Our sites were significantly impacted by Hurricane Sandy which hit the East Coast at the end of October 2012. As a result of damage sustained from the storm, the 2 outpatient clinics were closed for 3 weeks and BHC in-patient services were closed for 3 months. Women who received prenatal care in the affiliated clinics, and would have delivered their infants at BHC were obligated to receive care and deliver their infants at other facilities. Approximately 100 women had enrolled in the study and were anticipated to deliver during the time that BHC was closed. Those women delivered at several different area hospitals, and had initial well child care visits at the sites where they delivered. Since the Starting Early intervention is tied to both the peri-natal hospital stay and pre-natal and well child visits none of the initial 100 women enrolled could receive the complete intervention as planned. We continue to be in contact with these ‘Pre-Sandy’ participants, and many have returned to primary care at GHS and BHC and to the Starting Early program. Tracking these participants, minimizing loss to follow-up and understanding how much of the program the intervention group mothers have received is an on-going effort for the project. We will have to consider the impact of storm related loss to follow-up and partial intervention exposure when we perform our long term analyses of program effects. In addition, we suspended enrollment in the immediate aftermath of the storm when GHS and BHC were not operational. Enrollment was suspended for 2 weeks at GHS and approximately 3 months at BHC. Although we are currently enrolling participants faster than our expected rate, the hiatus in enrollment will extend the overall duration of the project. What opportunities for training and professional development has the project provided? 2 of our staff nutritionists have completed certfiied lactation counselor training. All program staff are learning about data collection and analysis, through group and individual sessions with the PI's How have the results been disseminated to communities of interest? Abstracts accepted and presented at the Pediatric Academic Society. What do you plan to do during the next reporting period to accomplish the goals? We plan to coninue refinement of the intervention materials and enrolling new participants. We will also continue providing the intervention to enrolled participants, and collecting data on them

Impacts
What was accomplished under these goals? Outputs: In Year 2 of the grant, we completed staff recruitment, continued curriculum and assessment development and began utilizing both, and continued systems development and relationship building. We also initiated subject enrollment and the Starting Early intervention, including prenatal and postpartum individual sessions with the nutritionist providing the intervention, and lunchtime family groups, Staff recruitment: We successfully recruited our third bilingual research assistant. Curriculum development: Working with a multi-disciplinary team of experts in general pediatrics, developmental-behavioral pediatrics, obesity prevention and treatment, nutrition, health literacy and public health, we continued to adapt and improve a 3-year curriculum for the family group intervention. We continued to refine the curriculum based on feedback from piloting the family groups. Assessments: We developed and initiated a comprehensive survey for women with babies age 3 months to assess the following: early feeding, breastfeeding and pumping behaviors, formula feeding behaviors, feeding behaviors at 3 months using a 24-hour recall, nutrition and feeding knowledge, feeding styles, perception of weight, mother’s physical activity, health and physical activity of the baby, media use, sleeping habits, working and childcare, basic demographics and depression. We also have a near final draft of the 10-month assessment. Subject enrollment: In July and August of 2012 we began enrolling eligible women in their third trimester of pregnancy during their prenatal visits to the obstetric clinics of Bellevue Hospital Center (BHC) and Gouverneur Healthcare Services (GHS). Program staff participated in the enrollment process by meeting eligible women in the clinic, confirming their eligibility, inviting them to participate and obtaining consent if they agreed. The comprehensive baseline survey was completed at that initial enrollment visit and women were met at a following obstetric appointment to complete a comprehensive Food Frequency Questionnaire which is a detailed assessment of dietary intake over the previous year. Randomization into either control, or Starting Early intervention groups took place at a third meeting after the subject was at least 32 weeks gestation; randomization was performed by a nutritionist. For women randomized into the Starting Early intervention group, the intervention was initiated at that time. Starting Early Intervention: The Starting Early intervention includes individual and group counseling by a nutritionist. Individual counseling occurs prenatally and perinatally during the mother’s postpartum hospital stay. Immediately after randomization, the nutritionist provides prenatal counseling which includes discussion of plans for infant feeding, breastfeeding promotion, and overcoming obstacles to breastfeeding. When the baby is born, the nutritionist sees the intervention mother and newborn in the nursery or in the first few days after birth to provide breastfeeding support. Groups begin at the baby’s 1 month well child visit, and occur at every scheduled well child visit after that. On the day of the well child visits, mother/infant dyads from the intervention group participate in lunchtime family groups led by a nutritionist where they discuss feeding and parenting issues related to the babies’ specific ages using a variety of participant led adult education strategies, including discussions, activities, games and demonstrations. Appointments are made to cohort the mothers so the same families are coming together during the groups as the children grow and develop. Systems development: We developed systems for tracking mother/infant dyads, scheduling baby appointments and assessments, collecting data, and spreading awareness about our program throughout the obstetric and pediatric clinics. In addition, we developed systems to monitor both the quality and fidelity of the intervention. Relationship building: Starting Early program staff continued to attend meetings with health care providers and staff from the obstetric and pediatric clinics at both program sites in order to build relationships of mutual support. Regular meetings with clinical providers ensured support and reinforced the Starting Early preventive nutrition message, and allowed time for feedback from the clinicians. The Project Coordinator and staff met regularly with the Principal Investigators and co-Investigators. Outcomes / Impacts: 164 pregnant women signed consent 120 pregnant women randomized – 60 control, 60 intervention 107 infants born Maternal Demographics at Baseline: N=164 Total Percent (%) or mean Non-US born 80.1 Less than high school education 33.8 Mean age 27 BMI 30 or greater (obese) 34.5 Married 70.2 Primiparous 42.6 WIC 81.5 Depressive symptoms (5 or more on PHQ9) 25.3

Publications

• Type: Conference Papers and Presentations Status: Accepted Year Published: 2013 Citation: Rachel Gross, MD MS, Alan Mendelsohn, MD, Michelle Gross, MS RD and Mary Jo Messito, MD. Household Food Insecurity and Internal Locus of Control Related to Child Weight Status in Low-Income Latina Pregnant Women. Platform Presentation at Pediatric Academic Society Meeting, Washington D.C. May 2013.
• Type: Conference Papers and Presentations Status: Accepted Year Published: 2013 Citation: Candice T Lucas, MD, MPH, Rachel Gross, MD, MS, Suzy Tomopoulos, MD, MS, Arthur Fierman, MD, Alan Mendelsohn, MD and Mary Jo Messito, MD. Association of Media Exposure and Maternal Perception of Healthy Toddler Weight in Low SES, Latina Pregnant Women. Poster Presentation at Pediatric Academic Society Meeting, Washington D.C. May 2013.

Progress 04/15/11 to 04/14/12

Outputs
OUTPUTS: In Year 1 of the grant, we focused on staff recruitment, curriculum design and pilot testing, assessment development, staff training and systems development. Staff recruitment: We successfully recruited a team of three bilingual English-Spanish speaking nutritionists, one of whom is the Project Coordinator, and two bilingual research assistants. All aspects of developing this program are being tracked in a manual for future dissemination. Curriculum development: Working with a multi-disciplinary team of experts in general pediatrics, developmental pediatrics, obesity prevention and treatment, nutrition, health literacy and public health, we developed a 3-year curriculum for the family group intervention. In addition, we designed a curriculum for the individual prenatal and neonatal nutritional counseling. Intervention staff completed training as Certified Lactation Counselors (CLC). Bilingual plain language handouts were developed to accompany the curriculum. Each nutritionist piloted the family group curriculum for the first year of the intervention (baby ages 1 month, 2 months, 4 months, 6 months and 9 months). Refinements were made to the curriculum based on feedback from the pilot groups. Assessments: We developed a comprehensive baseline survey for women in their third trimester of pregnancy, assessing breastfeeding knowledge and attitudes, plans for infant feeding, general nutrition knowledge and behaviors, perception of weight, physical activity, media use, literacy, household food security, neighborhood stress, social support, depressive symptoms and general demographic information. In addition, we purchased a widely used Food Frequency Questionnaire in order to evaluate nutritional intake over the previous year. Staff training and systems development: All members of the staff were trained by research experts in the process of consenting and interviewing potential study participants, and trained by pediatricians on using the Electronic Medical Record system to track enrolled participants. The Project Coordinator and research assistants were also trained in the appointment scheduling system. Relationship building: Starting Early program staff attended several meetings with health care providers and staff from the obstetric and pediatric clinics at both program sites in order to build relationships of mutual support. Staff also met with clinic Social Workers to create a referral plan for mother with depressive symptoms. The Project Coordinator and staff meet regularly with the Principal Investigators and co-Investigators. PARTICIPANTS: This project has brought together multi-disciplinary team of experts in general pediatrics, developmental and behavioral pediatrics, child obesity prevention and treatment, nutrition, health literacy, media, epidemiology and public health. TARGET AUDIENCES: Hispanic pregnant women and mothers of young children (ages newborn to 3-years-old) receiving obstetrical and pediatric care in a primary care setting. The goal of the project is to promote healthy habits and prevent the development of childhood obesity. PROJECT MODIFICATIONS: Nothing significant to report during this reporting period.

Impacts
We have not measured outcomes or impacts during this study period since recruitment had not started.

Publications

• No publications reported this period