The Impact of the Healthy Children, Healthy Families Curriculum on Maternal Food Parenting Practices

Objective: To assess the impact of the evidence-based Healthy Children, Healthy Families (HCHF) curriculum on changes in positive food parenting practices (FPPs). Design/Setting: Non-experimental pre/post within-subjects design. The study primarily took place at a free healthcare clinic (Clinica Esperanza/Hope Clinic) located in Providence, RI. Participants: Mother-child dyads were recruited from the community (n=40) and completed baseline data measures for an 8-week group-based intervention, with 24 mother-child dyads completing the intervention. Dyads were primarily Hispanic, and of low socio-economic status. Intervention: The 8-week, evidence-based HCHF curriculum/intervention was delivered primarily in Spanish to 4 separate groups of mothers by trained paraprofessional educators, or navegantes. Main Outcome Measures: Mothers completed self-administered surveys pre/post which included demographic questions, seven subscales from the Comprehensive Feeding Practices Questionnaire, and the 16-item HCHF Behavior Checklist. Analysis: Descriptive statistics and paired samples t-tests were used to analyze motherchild dyad data (n=40). Results: There were significant improvements in positive FPPs, including modeling and involvement, (p<0.05). There were also significant improvements in several mother and child diet and activity outcomes. Conclusions and Implications: Positive FFPs, and mother and child health behaviors improved after participating in an 8-week group based intervention. Community-based delivery of the HCHF curriculum is feasible and may be effective in improving food parenting practices as well as behaviors that contribute to childhood obesity.


Introduction
Prevention of childhood obesity continues to be a public health priority. 1 In 2011-2012, 16.9% of children and adolescents in the United States (US) were obese. 1 This is concerning, given that childhood obesity is associated with increased risk for many diseases such as heart disease, hypertension, and type 2 diabetes. 1,2 In addition, obese and overweight children are more likely to be obese adults which puts them as increased risk for adverse health outcomes across the lifespan. 3,4 Despite recent reductions in childhood obesity rates, disparities among race/ethnicity persist nationwide. 1,[5][6][7] For example, using data from 2011-2012, over 22% of Hispanic youth aged 2-19 were obese in the US, as compared to 14.1% of non-Hispanic white youth and 8.6% of non-Hispanic Asian youth. 1 In the state of Rhode Island (RI) these disparities are even greater. In 2011, 25% of Hispanic kindergarteners (5 yrs) in RI were obese, as compared to 14% of non-Hispanic White and 11% of non-Hispanic Black kindergarteners. 6 These rates increase as children reach 7 th grade (12 yrs), as 30% of Hispanic 7 th graders, 23% non-Hispanic black and 17% of non-Hispanic white 7 th graders were obese in 2011. 6 These rates are consistently highest in Hispanic populations, which is concerning given that this population is one of the largest ethnic minority groups not only in Rhode Island but in the US as well, and this population is expected to grow 1,6 . Obesity prevention programs that focus on Hispanic populations are needed to reduce these racial/ethnic disparities and to help continue to reduce national obesity rates 1,6 . Given these disparities and the increased risk for developing obesity later in life, 1,[3][4][5]8 involving parents to aide in childhood obesity prevention is critical. [9][10][11][13][14][15] Parents play an important role in shaping a child's diet and eating behaviors early in life. [9][10][11][13][14][15]18,19,22,28,30,31 Parents serve as an authority figure and role model for their children 9-11,13-15, , and can improve the environments by reducing obesogenic factors and increasing healthy parenting practices. [9][10][11][13][14][15][18][19][20]28 Given that parents play a key role in shaping a child's diet and feeding habits, [18][19][20][21] interventions that include parents as agents of change are often successful in facilitating behavior changes at the family level. [9][10][11][13][14][15] Parents are important gate keepers for the home food environment, and play a role in obesity risk through several parenting behaviors. For example, parents use strategies to maintain or alter a child's food intake, known as food parenting practices 18 . Food parenting practices are goal directed behaviors that influence the amount or type of food a child eats, and include modeling, involvement, and encouragement of balance and variety. 13,16,18,19 These food parenting practices have been identified as important factors in the development of weight gain and obesogenic eating behaviors in young children. 12,13,[16][17][18][19][20][21][22]24,25,28 Food parenting practices influence the diet quality and weight status of young children. 12,13,16,-22,24,25,28 One longitudinal study among Mexican American families found that parental use of food restriction predicted higher weight status at year 1, while pressure to eat was related to a lower weight status. 25 Similarly, another longitudinal study with 323 mother-child dyads (child ages 1.5-2 yrs), found that instrumental feeding, or food as reward, was positively correlated with child BMI-z score at multiple time points. 12 Given these results, childhood obesity interventions should include parent education on the impact of food parenting practices and tools to promote practices that are associated with favorable health outcomes. [9][10][11][13][14][15][16]19,27,28 Most of the literature on food parenting practices has focused primarily on negative food parenting practices such as pressure to eat and restriction. 12 parenting practices and child weight status. 28 Of those studies, a majority focused on negative food parenting practices, and the associations of these types of practices with child weight status. 28 Most studies were focused on practices like pressure to eat, restriction, and instrumental and emotional feeding, and very few studies included positive/supportive food parenting practices in their main findings. 28 The review highlights the need for future interventions to focus on parenting and positive food parenting practices 28 , such as modeling, child involvement, and encouragement. 16 In studies focusing on these positive food parenting practices, modeling, involvement, and encouragement have also shown to be associated with diet quality and BMI. [9][10][11][12]18,20,25 For example, among 699 child-parent dyads, parental encouragement/modeling and overall positive food parenting practices were associated with favorable diet quality and weight status in children aged 6-11 years. 20 Children's BMI z-scores were negatively associated with parent encouragement/modeling, and positively associated with permissive food parenting practices. 20 These associations suggest that along with information about modifying negative food parenting practices, it is important to target positive food parenting practices when designing interventions as a way to improve child diet habits and therefore weight status.
Although there have been multiple interventions to prevent childhood obesity, [28][29][30][31] few have targeted the modification of positive food parenting practices set within a community setting among low-income Hispanic populations. The Healthy Children, Healthy Families (HCHF) is an evidence-based curriculum for parents of 3-11-year-old children that focuses on the importance of developing healthy lifestyle behaviors through parenting style, food parenting practices, and the home environment. [32][33][34][35] HCHF is a family-centered obesity prevention curriculum/intervention that focuses on parenting skills, with the goal of facilitating healthy lifestyle changes within a family system. [31][32][33][34] The HCHF curriculum was designed for community nutrition educators to deliver to lowincome parents throughout an 8-week series of weekly workshops. [32][33][34][35][36] Although previous studies utilizing the HCHF curriculum have found improvements in parent and child health behaviors following the intervention, 34 including reduced soda and fast food intake, higher low-fat dairy, vegetable, and fruit intakes, and less TV watching and more active play for children. 35 In addition, the study found improvements in self-reported parenting behaviors (eating with their child, autonomy) following the intervention. 35 Given the focus of the HCHF curriculum on food parenting practices, it is important to understand the impact of the intervention on these practices. This may shed light on these practices as possible mediators of these outcomes as well as future targets for intervention improvement.
The purpose of the present study was to assess if mothers participating in a childhood obesity intervention utilizing the HCHF curriculum would improve their selfreported positive food parenting practices pre/post intervention. In addition, the study aimed to assess changes in parent and child behaviors related to dietary intake and activity.

Study Design
The study utilized a non-experimental, within-subjects pre/post design. The primary hypothesis was that parents would improve their scores on the supportive food parenting practice of modeling. The secondary hypothesis was that parents would improve their scores on supportive food parenting practices of encouragement of balance and variety and involvement. Additional exploratory hypotheses were that there would be improvements in parent and child diet and activity outcomes such as increases in intake of fruits, vegetables, and low-fat dairy, increased physical activity, and decreased consumption of energy dense snacks, fast food, and soda.

Study Setting
The study involved a community partnership with Clínica Esperanza/Hope Clinic (CEHC), a free healthcare clinic located in the Olneyville area of Providence, RI. The clinic provides free healthcare services to the uninsured, and also provides community health programs delivered by trained paraprofessional educators. As an existing community platform for health interventions, CEHC was chosen as the community partner for this study, and was the primary setting for the delivery of the intervention. All protocols of the proposed study were approved by the University of Rhode Island Institutional Review Board.

Participants and Recruitment
Eligible participants were parents or primary caregivers of children between the ages of 3-11 years, and willing to attend the weekly workshop sessions for 8 weeks.
Although recruitment included both male and female participants, only one male participated. This male participant was removed from the analytic study sample in order to assess changes in mothers only. The target population was parents living in the Providence, Rhode Island area. In addition, we intended to reach a large percentage of at risk parents, specifically low-income Hispanic parents, given the demographics of this area. The median household income in Olneyville is $17,538, and 61% of the population is Hispanic. 37 Recruitment fliers (Appendix C) including study information were placed throughout the Olneyville area and distributed to organizations including community centers, local businesses, parks, libraries, and churches. In addition, the navegantes and community partners including healthcare clinics and current health-related programs helped do in person recruitment in the community. Interested parents were screened inperson or via telephone to determine eligibility. Recruitment efforts continued on a rolling basis by continuously recruiting eligible parents to participate in the next available group.

Intervention
The HCHF curriculum was taught by navegantes (paraprofessional educators) employed through CEHC. Navegantes participated in a formal 2-day training on the HCHF curriculum, conducted by representatives from Cornell University. The training reviewed the foundations of the curriculum, answered frequently asked questions, addressed common barriers, and allowed for the practice of activities and lessons in the curriculum. The training also provided the navegantes with valuable background knowledge of the overall goals of the curriculum as well as tools and techniques surrounding curriculum flow, delivery, and evaluation.
The HCHF curriculum highlights 'paths to success' and 'keys to success' to facilitate healthy changes in families (Appendix D). 32,33 These paths and keys to success, which serve as the backbone of the HCHF curriculum, highlight several positive food parenting practices, and encourage parents to use these practices with their families at home. Examples include setting a good example for their child (modeling), and offering healthy choices within limits (guiding). 32,33 By integrating health education with parental support and tools to promote firm and responsive parenting, HCHF is a curriculum tailored to the specific needs of parents of 3 to 11-year old children.
The HCHF curriculum addresses health education topics surrounding diet, activity, and the home environment. Topics include consuming water or milk instead of sugar sweetened beverages, reducing high-fat and high-sugar foods, eating more fruits and vegetables, playing actively, reducing screen time, and having family meals. 32,33 The curriculum includes problem-solving strategies for health-related behavior change, and utilizes parenting scenarios and role-play to address barriers to behavior change. 32,33 Specifically, the curriculum focuses on strategies that parents can use to improve their food parenting practices, including emphasizing their child's role in food preparation, encouraging their children to eat a balanced and varied diet, and modeling healthy eating behaviors to their children (Appendix E). In addition, each session also included an active play break, featuring a family-friendly activity that parents can do with their families at home (Appendix F). 32,33 Every session includes a healthy recipe for parents to taste (Appendix G), and a weekly prize/incentive, such as pedometers or cooking utensils (Appendix H). For weekly goal-setting, at the end of each session parents identified a 'healthy step' or goal for the week ahead (Appendix I). 32,33 To assess parent participation, attendance was recorded at each session. Study completers were considered for data analysis if they attended at least five out of the eight class sessions. To assess fidelity of the intervention, a portion of the HCHF sessions were observed. Out of the 32 sessions (8 sessions/group, 4 groups total), 19 sessions, or 59% were observed. At least 2 sessions/group were observed. Fidelity assessment was conducted by a trained research assistant using previously developed observation checklists corresponding with each lesson/session of the HCHF intervention 32 (Appendix J). Using the completed observation checklist, intervention fidelity was high (97%), indicating that the navegantes delivered the intervention as it was intended based on the protocol of the HCHF curriculum.

Procedures
Prior to the first session, baseline measures for each group of participants were collected. On the day of the first session, each mother-child dyad arrived at CEHC before the proposed session start time to complete baseline measures. All study materials were available in both English and Spanish. Mothers completed a consent form for themselves

Measures Anthropometrics
Standing height and weight measurements of each parent-child dyad were taken using standardized procedures. 38 Measurements were taken in a private area to assure confidentiality of measurements and to increase the comfort of participants. Each parentchild dyad was instructed to wear light clothing and remove footwear, and if applicable, asked to take down their hair to ensure measurement accuracy. Each parent and child had measurements (height and weight) taken twice to confirm measurement precision. Height was measured using a portable stadiometer (Seca 213). Weight was measured using a calibrated digital scale (Seca 813). To assess parent BMI, the mean calculation for weight and height for each data collection point was used to calculate a BMI score (pre and post). Pre and post-intervention BMI z-scores and percentiles were calculated for children, using the means for height and weight, in addition to date of birth and sex. 39,40

Survey Protocol
The survey was designed to be self-administered and consisted of 84 questions.
Although it was designed to be self-administered, each participant was asked if they needed assistance completing the survey. If the participant needed assistance, a bilingual research assistant or navegante read questions aloud to ensure the participant understood each question and answer option. Parents answered each question as it pertains to their child involved in the study. If a parent has more than one child between ages 3-11, they were instructed to answer questions about the youngest child within the 3-11 age range.
The survey took participants approximately 20-30 minutes to complete.

Demographic Questionnaire
The first section of the baseline survey consisted of 19 demographic questions.

Comprehensive Feeding Practices Questionnaire (CFPQ)
Self-reported food parenting practices were assessed using 29 questions from the Comprehensive Feeding Practices Questionnaire (CFPQ). 42 Prior testing of the CFPQ with parents of 2-to-8-year-old children showed reasonable validity and reliability. For the purpose of this study only seven of the 12 subscales were used, including modeling (4 items), involvement (3 items), encouraging balance and variety (4 items), and teaching about nutrition. 42 Examples for the 'encouraging balance and variety' subscale are "I encourage my child to eat a variety of foods," for the 'environment' subscale, "I keep a lot of snack food (potato chips, Doritos, cheese puffs) in my house" and for the 'involvement' subscale "I involve my child in planning family meals." 42 Each question from the CFPQ has 5 answer options, ranging on a scale from disagree (1), disagree slightly (2), neutral (3), slightly agree (4), to agree (5). 42 Thus, a higher score on each subscale indicates a higher frequency of the corresponding practice. One item indicates lower frequency of the feeding practice, and this item was reverse coded prior to scoring. Subscale means were calculated for seven subscales, and changes in subscale means pre/post will be assessed. The CFPQ subscales and corresponding items for the primary and secondary outcomes of this study are listed in Appendix O.
Each item on the CFPQ is loaded onto a specific subscale, and Cronbach's alphas were calculated from the baseline CFPQ outcomes for our primary and secondary outcomes (modeling, involvement, encouragement of balance and variety). The results for Cronbach's alphas were as follows: modeling (alpha = 0.878), involvement (alpha = 0.927), and encouragement of balance and variety (alpha = 0.629).

Healthy Children, Healthy Families Behavior Checklist (HCHF-BC)
Measures of self-reported parent and child diet, physical activity, and screen time behaviors were assessed using the previously used HCHF behavior checklist. 35,36 The 16item behavior checklist assessed frequency of parent and child health behaviors, including diet habits (11 items) and physical activity/screen time behaviors (3 items). 35,36 For example, "How often do your children play actively for at least 60 minutes a day?" and "How many days a week do you usually eat vegetables?" 35,36 Each item was assessed using a 5-point scale with answers ranging on frequency specific to each question, starting with the least frequent answer option to the most frequent. For example, for the question "How often do your children play actively for at least 60 minutes a day?" the answer options range from (1) once in a while, (2) 1-2 days each week, (3) 3-4 days each week, (4) 5-6 days each week, to (5) every day. Items were scored 1-5 with a higher total score indicating higher frequency of the corresponding behavior. The HCHF-BC items organized by construct are listed in Appendix P.

Statistical Analysis
Statistical analysis was performed using SPSS version 23 Tables 2-4. Corrections for multiple comparisons was not executed given that the variables of interest were correlated. Paired samples t-tests were performed to assess for statistically significant changes pre/post intervention. Cronbach's alphas were calculated for the CFPQ subscales, modeling, encouragement of balance and variety and involvement. Significance level was set at p<0.05.

Study Sample
A total of 41 participants were recruited and completed baseline measurements.
Of those, twenty-five participants completed the intervention and post-intervention measures. One male participant who completed the intervention was removed for data analysis to assess changes in mothers only. After multiple imputation (described above) for missing follow up data for 16 participants, the final sample for data analysis was 40 mothers.
Baseline descriptive statistics on the characteristics of the study sample are reported in Table 1 for the study sample (n=40), study completers (n=24), and study noncompleters (n=16). Overall, mothers were approximately 38.3±11.3 years of age, and 98% were Hispanic/Latino. Almost half of the mothers had less than a high school degree, and a majority of the mothers were not born in the United States. The sample was primarily low-income, with a majority of the mothers reporting an annual household income of $15,000 or less. Over three quarters of the mothers were either overweight or obese (81%). For the children, over half were either overweight or obese (57%), and the mean BMI z-scores was 1.2±1.5.
There were several differences in demographic variables between study completers and non-completers. For example, greater than 50% of non-completers had less than a high school education, as compared to only one-third of completers. There were also differences in employment status between study completers and noncompleters, with 46.7% of non-completers employed full time, as compared to 16.7% of completers.

Primary & Secondary Outcomes
Pre/post intervention outcomes from the Comprehensive Feeding Practices Questionnaire (CFPQ) are summarized in Table 2. From individual subscales on the CFPQ, there was a significant increase in mother's use of modeling (p<0.01). There was an increase in the use of encouragement of balance and variety, however this was not a significant change (p>0.05). There was a significant increase in maternal use of involvement (p<0.05).

Exploratory Outcomes
For outcomes related to other food parenting practices, there were several nonsignificant changes (p>0.05). These non-significant changes include an increase in teaching about nutrition, a decrease in the use of food as a reward, and increases in both restriction for health and restriction for weight control.
Results on pre/post outcomes from the self-reported 16-item HCHF-BC are displayed in Table 3 (Parent and Child Diet & Activity) and Table 4 (Parenting & Home Environment). For diet and activity behaviors of mothers, mothers significantly increased their frequency of both fruit and vegetable intake. Mothers also increased their reported intake of low-fat dairy products, however this was not a significant increase (p>0.05).
There was a significant decrease in soda consumption for mothers (p<0.05). Mothers increased their frequency of physical activity, however this was not a significant increase (p>0.05).
For children, there were no significant changes in fruit or vegetable intake (p>0.05). There was a significant increase in child consumption of low-fat dairy products (p<0.01). There were non-significant changes in child soda consumption or child screen time (p>0.05). There was a significant increase in frequency of physical activity for children (p<0.05).
The remaining five items of the HCHF-BC related to parenting practices and the home food environment. There was a significant increase in parental use of autonomy (p<0.05), defined as parents letting their child decide how much food to eat during mealtime. For food availability, there were non-significant decreases in energy dense snack availability, and fast/convenience food availability (p>0.05). There was also an increase in fruit availability, but this was not significant (p>0.05). Unexpectedly, there was a significant decrease in the frequency of family meals (p<0.001).
The mean attendance rate for all mothers who completed baseline data measures (n=40) was 4.6±2.6 sessions. Of all mothers that completed the 8-week intervention and completed post-intervention measures (n=24), 100% attended at least 5 out of the 8 sessions and were considered 'study completers'. Of the study completers, the mean attendance rate was 6.5±1.2 sessions. Overall, the participant dropout rate was 40%, with 60% of the original sample consisting of study completers.
Out of the 24 mothers who completed the intervention, 96% completed a postintervention evaluation survey, designed to assess participant opinions on the program.
Results from the evaluation survey indicate overall positive attitudes of the program. Of those who completed the survey, 100% agreed that they "enjoyed coming to the HCHF sessions," "learned a lot of new things during the program," "what they learned was useful for them and their families," and that they "learned new parenting skills that helped them get along better with their children." Ninety-five percent of mothers agreed that the time of the sessions was convenient for them, and 88% agreed the location was convenient. Similar to other studies, this study found that food parenting practices are modifiable, and are effective targets for behavior change to improve family health 25,26 One longitudinal study examined several food parenting practices 6, 12, and 24 months post participation in a parent-centered childhood obesity treatment program. 26 The study found that parental restriction, pressure to eat, and monitoring significantly decreased at 24 months post intervention, indicating that improvements in these food parenting practices can be sustained in the long term. 26 This study however was a longer treatment intervention compared to the study reported in this paper and also focused on more of the "negative" food parenting practices; it is possible that parents may be more amenable to changing more positive feeding practices within a shorter period of time. 43 These improvements in food parenting practices support development of healthy eating, favorable diet quality and weight outcomes over time. [16][17][18][19][20][21][24][25][26] Similar to the findings in this paper, another study found that the children of parents participating in an intervention which focused on improving role modeling of healthy behaviors, significantly increased their fruit and vegetable consumption, and parents also significantly influenced a decrease in children's fast/convenience food consumption, which was not observed in the control group. 43 However, the intervention was delivered over the course of one school

Discussion
year, whereas the intervention in the current study was eight weeks. While our study did not find significant changes in child intake of fruit and vegetables, we found nonsignificant increases in these areas. The results of this intervention suggest that parent modeling of healthy eating behaviors, or acting as a role model, is a feasible target for behavior change in childhood obesity prevention efforts, and long term interventions to promote these behaviors may be more effective.
The improvements seen in mother and child diet and activity behaviors are similar to previous studies utilizing the HCHF intervention, 34,35 whereby significant improvements in parent and child diet behaviors, including significant increases for fruit, vegetable, and low-fat dairy intake, and significant reductions in parent soda intake were found. 35 These findings make sense in light of the topics covered during the curriculum where the importance of fruit and vegetable intake, drinking water or milk instead of sweetened beverages are thoroughly covered. 32,33,35 Although the population type and size slightly varied, we found very similar results which adds to the possible efficacy of this intervention in improving health behavior outcomes for parents and children. Despite in the current study having a smaller sample size, there were significant outcomes similar to these findings.
The current study has some limitations. Sample size was relatively small in this study, as participant recruitment, enrollment, and retention was a challenge. However, researchers attempted to reduce barriers to study participation by providing child care, healthy meals, and in some cases transportation to the intervention. In addition, the use of multiple imputation allowed for missing data for participants who dropped out of the intervention to be imputed using a state of the art approach, which was utilized to support the analysis of study completers. [43][44][45] Although the study did not utilize an experimental design, it utilized an evidence-based curriculum in a community-based setting, and was able to reach an at-risk population. [1][2][3][4][5][6][7][8] By targeting a population that was primarily Hispanic and low-income, the intervention was able to reach parents of children who are disproportionately at risk for obesity. 1,[5][6][7] However, successful implementation of this intervention was resource intensive, requiring joint efforts from researchers, educators, and community partners. Participant recruitment and retention remains a challenge, specifically in research studies and community programs that aim to reach parents. [46][47][48] Common barriers to parent participation include transport, parents' work schedules and competing demands on family time. [47][48][49] Limiting barriers to participation in research studies and community programs may help to enroll and retain more participants. 48,49 Ultimately, the success of the program as evidenced by the health outcomes suggest parent participation in the HCHF intervention is a feasible approach to improve behaviors linked to obesity risk.

Conclusions & Implications
The current study found that after participation in the HCHF intervention, mothers significantly increased their use of positive food parenting practices, which are associated with favorable weight status and diet habits in children. [9][10][11][12]18,20,25 Future research should test the efficacy of this intervention utilizing an experimental design and explore food parenting practices as a mediator to weight gain. Although there are several obesity prevention studies, few have specifically targeted or measured food parenting practices and few have taken a family-based approach. 14,15,30,31,34,35 Interventions to prevent childhood obesity may include some information on modifying food parenting practices, but few have had a comprehensive focus and/or have not measured changes in these practices pre/post intervention. 26,27,[34][35][36] Future interventions should include information on how to improve food parenting practices, [11][12][13]16,18 and should adequately measure these changes pre/post intervention, 16,23 given the influence of food parenting practices on a child's diet and weight status. 9

Prevalence of Childhood Obesity and Its Consequences
Childhood obesity is a significant public health issue in the United States (US), as childhood obesity rates have tripled over the past three decades. 1 Increased recognition of childhood obesity as an important public health issue, and efforts of prevention programs nationwide likely contribute to these declining rates.
However, rates of childhood obesity remain high, and further research and interventions are important to combat this public health issue. Therefore, the development of evidencebased childhood obesity interventions, and the continued evaluation of these interventions are critical to continue these efforts.

Hispanic Populations
Despite recent reductions in childhood obesity rates, disparities among race/ethnicity persist nationwide. 1  were obese in 2011 4 . These rates are consistently highest in Hispanic populations, which is concerning given that this population is one of the largest ethnic minority groups not only in Rhode Island but in the U.S. as well, and this population is expected to grow. 1,4 Obesity prevention programs that focus on Hispanic populations are needed to reduce these racial/ethnic disparities and to help continue to reduce national obesity rates.

Low-Income Populations
Childhood obesity prevalence is also disproportionally higher in low-income populations. 1,5-8 For example, obesity prevalence in children ages 2-4 are highest in families living at or below the federal poverty level. 5 Built environments surrounding low-income areas likely contribute to "obesogenic" characteristics that may increase risk factors of obesity. 6 The built environment surrounding low-income neighborhoods often lack access to safe areas and facilities for physical activity and play, and often have a greater amount of fast-food/convenience food outlets and less access to supermarkets. 6 Targeting behavioral and environmental factors that contribute to increased obesity prevalence in low-income populations is an important target for future prevention strategies. 6,9

Influences of the Development of Obesogenic Behaviors
The contribute to obesogenicity include parents, homes, neighborhoods, schools, communities, and government systems. 11,12 Although there are multiple interacting factors that contribute to obesogenicity, this review will focus on parental factors and factors within the home environment, including diet quality, food availability, home food environment, physical activity and screen time behaviors, and maternal food parenting practices.

Diet Quality
Diet quality is an important factor contributing to childhood obesity risk.
Evidence shows that positive eating patterns, and high diet quality is associated with favorable health outcomes. 13 These healthy dietary patterns include those highlighted in the 2015-2020 Dietary Guidelines for Americans, which promote the consumption of fruits, vegetables, whole grain, legumes, nuts/seeds, lean proteins, seafood, and low-fat dairy products. 13 These dietary components contribute to decreased risk for multiple diseases including diabetes, heart disease, cancer, and hypertension. 13 However, the diet quality of Americans of all ages is not reflective of these dietary guidelines. Moreover, in children between the ages of 4 and 13, average daily consumption of vegetables was between 0.8 and 1.1 cups, while the recommended amount is between 1.5-3.0 cups/day. 13 Additionally, children are consuming added calories from added sugars and energy-dense snacks. 13 For example, for children ages 4 to 13, daily percentage of kcals contributed by added sugars range from 15-17%, while the recommended limit is 10% or less. 13 For children, this is particularly concerning as proper nutrition during childhood is imperative for development of healthy weight status and diet habits into adulthood. 13 The home environment is a target for improving diet quality, 14 as two thirds of the foods children consume is from home. 15

Home Food Environment
Parents and family members play an important role in a variety of factors contributing to childhood obesity by acting as the gate-keepers of the home food environment. [16][17][18] The home food environment model described by Rosenkranz & Dzewaltowski is defined as overlapping interactive domains composed of built and natural, sociocultural, political and economic, micro-level and macro-level environments, and depicts the contextual environment where a child develops eating behaviors. 14 In addition to providing food in the home, or the physical environment, parents are also responsible for providing a positive sociocultural environment. 19 A cross-sectional study conducted by Couch et al. explored the home food environments relation to child diet quality and weight status, using DASH score and BMI z score, respectively. 20 The study defined the home food environment as including the physical environment (e.g. food availability), and the sociocultural environment (e.g. parenting behaviors and feeding practices). 20 The study found that the home food environment explained 28% of the variance in child BMI and 9-21% of the variance in various measures of child dietary quality. 20 Several aspects of the sociocultural environment are based around food parenting practices, such as parental modeling/encouragement, indicating that these parenting behaviors are possible areas to target in childhood obesity prevention.

Physical Activity & Screen Time
Another component of the home environment that contributes to childhood obesity risk is the physical activity (PA) and screen time behaviors of families. One study consisting of 421 parent-child dyads (child ages 5-10 yrs) and examined the relationships between parenting styles and practices and child physical activity and screen time. 21 Child PA was assessed using accelerometers and parent questionnaires, and child screen time was assessed using surveys and screen time logs. 21 Parenting styles and practices were assessed via questionnaires (Langer), and child BMI percentile was calculated. 21 There was an inverse association between BMI and physical activity, with each unit increase in BMI, activity decreased by 8 minutes per day. 21 Parental support for PA, which was observed across parenting styles, was positively associated with child PA. 21 Regression models found associations of child BMI and parenting styles in relation to screen time. 21 Child BMI was positively related to screen time, with each unit increase in BMI was associated with a 20-23% increase in the likelihood that the child had more than 2 hours of screen time per day. 21 Parenting styles and practices were also associated with screen time. Both authoritarian and permissive parenting styles were associated with a 133% and 113% respective increase in the likelihood of a child having more than 2 hours of daily screen time. 21 Parenting styles and practices are predictors of screen time and PA behaviors, in addition to food parenting practices, suggesting the importance of parenting style as a target of behavior change in childhood obesity prevention efforts.

Parenting Styles
Parenting style is defined by a set of attributes, attitudes, and ways of interacting with children that can influence child outcomes. 22 Four general types of parenting have been identified. [22][23][24] These parenting styles are categorized based on parental levels of demandingness/firmness and responsiveness. Authoritative parenting is characterized by high levels of both firmness and responsiveness, while the authoritarian style is categorized by high levels of firmness, and low levels of responsiveness. 22,24 In indulgent parenting style, parents are high in responsiveness but low in firmness, while neglectful parenting style is categorized by low levels of firmness and responsiveness. 18,22,24 Longitudinal studies have found associations between parenting style and child BMI.
Specifically, the authoritative parenting style has been found to be protective against child overweight over time. 19,[24][25][26] These general parenting styles can be applied to the style in which parents approach child feeding, known as parent feeding styles. 18,24,27 Similar to general parenting style, parent feeding styles have been linked to both positive and negative outcomes related to obesity. For example, in a cross-sectional study of 231 primary caregivers, authoritative feeding was positively associated with the availability of fruits and vegetables. 28 Authoritative feeding was also positively associated with child consumption of dairy and vegetables, while authoritarian feeding was negatively associated with availability of fruit and vegetables, and child consumption of vegetables. 28 Given the connection between parenting style, feeding style, and obesity risk, interventions should address parenting behaviors and feeding styles as a target of behavior change to improve outcomes related to obesity.
Research studies involving parenting behaviors and styles may help to clarify the relationships between parenting and behaviors linked to childhood obesity. One study by Hubbs-Tait et al. aimed to identify the relationship between parental feeding styles and practices and general parenting styles, in order to understand how to target parenting practices to increase intervention efficacy. 27 For instance, parental use of responsibility, restricting, monitoring, and modeling all significantly predicted authoritative parenting style in a sample of 239 parents. 27 Additionally, restricting, pressuring, and monitoring all significantly predicted authoritarian parenting style. 27 The researchers concluded that general parenting styles are associated with parental feeding practices, and that interventions/programs should include approaches to behavior change that take into account parenting styles and family dynamics. 27

Food Parenting Practices
Parental feeding practices, more recently defined as food parenting practices, have been identified as important factors in the development of weight gain and obesogenic eating behaviors in young children. [29][30][31][32] Food parenting practices are defined as goal directed behaviors that influence the amount or type of food a child eats [29][30][31][32] . Examples of food parenting practices include modeling, restriction, involvement, and encouragement. [29][30][31][32] These food parenting practices, have been identified as important factors in the development of weight gain and obesogenic eating behaviors in young children. 29,[32][33][34][35][36][37][38] Food parenting practices influence the diet quality and weight status of young children. 29,[32][33][34][35][36][37][38] One longitudinal study among Mexican American families found that parental use of food restriction predicted higher weight status at year 1, while pressure to eat was related to a lower weight status. 36 Similarly, another longitudinal study with 323 mother-child dyads (child ages 1.5-2 yrs), found that instrumental feeding, or food as reward, was positively correlated with child BMI z score at multiple time points. 29 Given these results, it makes sense for childhood obesity interventions to include parent education on the impact of food parenting practices and tools to promote positive practices. 15,16,18,32,33,[38][39][40][41][42] Most of the literature on food parenting practices has focused primarily on negative food parenting practices such as pressure to eat and restriction. [29][30][31]33,35,36,38,42,43 A recent systematic review by Shloim et al. reviewed studies investigating parenting styles and practices, and feeding practices in relation to weight status in children ages 4-12 years. The review identified 22 previous studies that examined the relationship between food parenting practices and child weight status. 38 Of those studies, a majority focused on negative food parenting practices, and the associations of these types of practices with child weight status. 38 Most studies were focused on practices like pressure to eat, restriction, and instrumental and emotional feeding, and very few studies included positive/supportive food parenting practices in their main findings. 38 Therefore, the review discusses the need for future interventions to focus on authoritative parenting and positive food parenting practices 38 , such as autonomy support or promotion and structure, which include modeling, child involvement, and encouragement. 32 In studies focusing on these positive/supportive food parenting practices, encouragement, modeling, and involvement have also shown to be associated with diet quality and BMI. 20,29,31,36,[39][40][41] For example, among 699 child-parent dyads, parental encouragement/modeling and overall authoritative food parenting practices were associated with favorable diet quality and weight status in children aged 6-11 years. 20 Children's BMI z-scores were negatively associated with parent encouragement/modeling, and positively associated with permissive food parenting practices. 20 These associations suggest that along with information about modifying negative food parenting practices, it is also of importance for interventions to target positive or supportive food parenting practices as a way to improve child diet quality and therefore weight status.
In a sample of 394 parent-child dyads (children ages 18 mo. -5 yrs), parental food involvement -an authoritative feeding practice-was strongly correlated with consumption of fruits and vegetables. 44 In another study of 316 mother-child dyads (child ages 2-5 yrs), maternal feeding practices were assessed using the Comprehensive Feeding Practices Questionnaire (CFPQ), and child dietary intake was assessed by parent completion of an eating habits questionnaire. 45 In this study, supportive feeding practices, including modeling, building a healthy home food environment, involvement, encouraging balance and variety, and teaching about nutrition, were all significantly correlated with fruit and vegetable intake. 45 These positive feeding practices are potential targets for interventions as behaviors parents can use to decrease development of obesogenic behaviors.

Family-Centered Interventions
Given the important influence of parent feeding practices on childhood obesity risk, it is important for interventions to be family-centered. Interventions that are tailored to the needs of the family and include as many members of the family are more successful than individual-focused interventions. 16

Culturally Tailored Interventions
Another characteristic of successful family-based interventions are that they are culturally tailored. A randomized controlled trial by Barkin et al. explored the effectiveness of a family-centered, culturally tailored intervention on BMI in Latino-American families. 46 Seventy-five parent-child dyads participated in the study (children ages 2-6). 46 The intervention group participated in Salud con Familia (Health with the Family) program, which consisted of 12 weekly skill-building sessions at a community recreation center. 46 The program was designed to improve family nutrition, while increasing physical activity and reducing sedentary behaviors of the family, and took into account several cultural factors of the study sample. 46 BMI of the parents and children were assessed and the children who participated in the intervention experienced an average reduction in BMI of 0.51 over a period of 3 months. 46 The results of this study indicate that community-engaged, culturally-tailored interventions can successfully change children's early growth patterns such as BMI, and may be an effective approach for childhood obesity interventions. Information that is useful for parents involves skillbuilding techniques surrounding parenting practices, which equip parents with the tools they need to facilitate behavior changes in their family. By providing more useful and applicable information, parents will be more likely to benefit from interventions tailored to their learning needs.

HCHF Curriculum
One intervention that emphasizes the importance of positive feeding practices, and allows for community-based tailoring is the evidence-based Healthy Children, Healthy Families (HCHF) intervention. The HCHF intervention is an evidence-based curriculum for parents of 3-11-year-old children that focuses on the importance of developing healthy lifestyle behaviors through parenting style, food parenting practices, and the home environment. [47][48][49][50] HCHF is a family-centered obesity prevention curriculum/intervention that focuses on parenting skills, with the goal of facilitating healthy lifestyle changes within a family system. [47][48][49][50] The HCHF curriculum was designed for community nutrition educators to deliver to low-income parents throughout an 8-week series of weekly workshops. [47][48][49] By focusing on family lifestyles and parenting, HCHF is a curriculum tailored to participants by meeting the needs of lowincome parents with young children. [47][48][49] The HCHF curriculum was designed for use in the Expanded Food Nutrition Education Program (EFNEP) by Cornell University through the Collaboration for Health, Activity, and Nutrition in Children's Environments (CHANCE). [47][48][49][50] Upon development of the HCHF curriculum, interventions began throughout New York to evaluate the success of the program. [47][48][49][50] By 2012, over 500 low-income parents and caregivers of children 3-11 years of age completed the HCHF curriculum. Participating parents reported significant improvements in their child's diet and physical activity behaviors in addition to improvements in self-reported parenting behaviors. [47][48][49][50] Although the program has collected self-reported measures on diet and physical activity, researchers have not collected comprehensive data on outcomes related to specific feeding practices. 50,51 The validated behavior checklist tool used to measure pre/post intervention behavior changes includes only two items assessing parenting practices; one question assessing family meals, and another assessing how often parents allow their child to decide how much to eat, two different parameters related to feeding. 50,51 In addition to the validated behavior checklist, using validated tools such as the Comprehensive Feeding Practices Questionnaire (CFPQ) to assess changes in parent feeding practices pre/post intervention will allow researchers to determine how the HCHF curriculum influences changes in specific feeding practices.

Study Design
The study utilized a non-experimental, within-subjects pre/post design. Parents The current study involved a community partnership with Clínica Esperanza/Hope Clinic (CEHC), a free healthcare clinic located in the Olneyville area of Providence, RI. The clinic provides free healthcare services to the uninsured, and also provides community health programs delivered by trained paraprofessional educators, or navegantes. As an existing community platform for health interventions, CEHC was chosen as the community partner for this study, and was the primary setting for the delivery of the intervention. All protocols of the proposed study were approved by the University of Rhode Island Institutional Review Board.

Participants and Recruitment
Eligible participants were parents or primary caregivers of children between the ages of 3-11 years, and willing to attend the weekly workshop sessions for 8 weeks. The target population was parents living in the Providence, Rhode Island area. In addition, we intended to reach a large percentage of at risk Hispanic parents given the demographics of this area.
Recruitment fliers (Appendix C) including study information were placed throughout the Olneyville area and distributed to organizations including community centers, local businesses, parks, libraries, and churches. In addition, the navegantes and community partners including healthcare clinics and current health-related programs helped do in person recruitment in the community. Interested parents were screened inperson or via telephone to determine eligibility. Navegantes would explain the program to parents, and answer questions about the study, in order to enroll participants.
Recruitment efforts continued on a rolling basis by continuously recruiting eligible parents to participate in the next available group.

Intervention
The HCHF curriculum was taught by the navegantes (paraprofessional educators)

Anthropometrics
Standing height and weight measurements of each parent-child dyad were taken using standardized procedures. 3 Measurements were taken in a private area to assure confidentiality of measurements and to increase the comfort of participants. Each parent-child dyad was instructed to wear light clothing and remove footwear, and if applicable, asked to take down their hair to ensure measurement accuracy. Each parent and child had measurements (height and weight) taken twice to confirm measurement precision. Height measurements were rounded to the nearest 0.5 cm, with a requirement of two measurements within 0.5 cm of one another. If the difference between the first two measurements was greater than 0.5 cm, additional measurements were taken until an accurate measurement is reached, that is, two values within 0.5 cm of each other. For weight, the two measurements were required to be within 0.5 lb. of one another. If the difference between the first two measurements was greater than 0.5 lb., additional measurements were taken until there were two values within 0.5 lb. of one another.
Height was measured using a portable stadiometer (Seca 213). Weight was measured using a calibrated digital scale (Seca 813). To assess parent BMI, the mean calculation for weight and height for each data collection point was used to calculate a BMI score (pre and post). For children, using the means for height and weight for both pre and post assessment, in addition to their date of birth and sex, a BMI z-score and BMI-percentile was calculated to assess changes in BMI. 4,5 Survey Protocol The survey was designed to be self-administered and consisted of 84 questions.
Although it was designed to be self-administered, each participant was asked if they needed assistance completing the survey. If the participant needed assistance, a bilingual research assistant or navegante read questions aloud to ensure the participant understood each question and answer option. Parents answered each question as it pertains to their child involved in the study. If a parent has more than one child between ages 3-11, they were instructed to answer questions about the youngest child within the 3-11 age range.
The survey took participants approximately 20-30 minutes to complete.

Demographic Questionnaire
The first section of the baseline survey consisted of 19 demographic questions. to agree (5). 7 Thus, a higher score on each subscale indicates a higher frequency of the corresponding practice. One item indicates lower frequency of the feeding practice, and this item was reverse coded prior to scoring. Subscale means were calculated for seven subscales, and changes in subscale means pre/post will be assessed. The CFPQ subscales and corresponding items for the primary and secondary outcomes of this study are listed in Appendix O.

Healthy Children, Healthy Families Behavior Checklist (HCHF-BC)
Measures of self-reported parent and child diet, physical activity, and screen time behaviors were assessed using the previously used HCHF behavior checklist. 8 The 16item behavior checklist assessed frequency of parent and child health behaviors, including diet habits (11 items) and physical activity/screen time behaviors (3 items). 8 For example, "How often do your children play actively for at least 60 minutes a day?" and "How many days a week do you usually eat vegetables?" 8 Each item was assessed using a 5-point scale with answers ranging on frequency specific to each question, starting with the least frequent answer option to the most frequent. For example, for the question "How often do your children play actively for at least 60 minutes a day?" the answer options range from (1) once in a while, (2) 1-2 days each week, (3) 3-4 days each week, (4) 5-6 days each week, to (5) every day. Items were scored 1-5 with a higher total score indicating higher frequency of the corresponding behavior. The HCHF-BC items organized by construct are listed in Appendix P.

Statistical Analysis
Statistical analysis was performed using SPSS version 23