Journal of Public Health | Vol. 32, No. 2, pp. 219 –229 | doi:10.

1093/pubmed/fdp105 | Advance Access Publication 15 November 2009

Efficacy of a child-centred and family-based program in

promoting healthy weight and healthy behaviors in Chinese
American children: a randomized controlled study
Jyu-Lin Chen1, Sandra Weiss2, Melvin B. Heyman3, Robert H. Lustig3
1
Department of Family Health Care Nursing, University of California, 2 Koret Way Box 0606, San Francisco, CA, USA
2
Department of Community Health Systems, University of California, San Francisco, CA, USA
3
Department of Pediatrics, University of California, San Francisco, CA, USA

Downloaded from https://academic.oup.com/jpubhealth/article/32/2/219/1609231 by guest on 24 April 2023

Address correspondence to J.-L. Chen, E-mail: [email protected]

A B S T R AC T

Objective To examine the efficacy of an interactive, child-centred and family-based program in promoting healthy weight and healthy lifestyles
in Chinese American children.

Design A randomized controlled study of a culturally sensitive behavioral intervention.

Subjects Sixty-seven Chinese American children (ages, 8–10 years; normal weight and overweight) and their families.

Measurements Anthropometry, blood pressure, measures of dietary intake, physical activity, knowledge and self-efficacy regarding physical
activity and diet at baseline and 2, 6 and 8 months after baseline assessment.

Results Linear mixed modeling indicated a significant effect of the intervention in decreasing body mass index, diastolic blood pressure and
fat intake while increasing vegetable and fruit intake, actual physical activity and knowledge about physical activity.

Conclusion This interactive child-centred and family-based behavioral program appears feasible and effective, leading to reduced body mass
index and improved overweight-related health behaviors in Chinese American children. This type of program can be adapted for other minority
ethnic groups who are at high risk for overweight and obesity and have limited access to programs that promote healthy lifestyles.

Keywords Chinese Americans, family based, healthy lifestyles, overweight prevention, randomized clinical trail

Introduction American adults with a BMI of 23–24.9 and triples for those
with a BMI of 25–26.9;7 – 9 possibly because due to genetic
Obesity is the most critical public health concern facing chil-
differences in the body composition and metabolic
dren of all ethnicities today, including Chinese Americans. One
responses.2,3,10 As obese children tend to be obese adults,
study suggests that 31% of Chinese Americans 6–11 years old
overweight management needs to start in childhood. Given the
are overweight (body mass index (BMI) .85th percentile) or
negative effect of obesity on Chinese American children’s
obese (BMI .95th percentile).1 At the same BMI, Chinese
health, developing a culturally appropriate intervention is
Americans are at higher risk of cardiovascular disease and type
imperative to reduce health disparities in this population.
2 diabetes mellitus than non-Hispanic whites.2,3 Obese chil-
Weight management interventions can be effective when
dren have increased risk for cardiovascular risk factor cluster-
they are designed to simultaneously change dietary behavior,
ing.4 Approximately 56% of the overweight Chinese children
in the mainland China have at least two criteria of metabolic
syndrome (i.e. glucose intolerance, obesity, hypertension and
dyslipidemia).5 A study of Chinese American children also Jyu-Lin Chen, Associate Professor of Nursing
suggests that a higher BMI is associated with higher levels of Sandra Weiss, Professor of Nursing
low-density lipoprotein and total cholesterol.6 Additionally, the Melvin B. Heyman, Professor of Medicine
risk of hypertension and diabetes doubles for Chinese Robert H. Lustig, Professor of Medicine

# The Author 2009, Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. 219
220 J O U RN A L O F P U B L I C H E A LTH

increase physical activity, reduce television viewing time and is a child having a BMI between 5th –84th percentile for
improve coping, and when they are culturally appropriate, his/her age and gender, based on the Centers for Disease
parent-inclusive and tailored to the unique individual charac- Control and Prevention (CDC) growth chart. Data were col-
teristics of each participant.11 – 17 However, multifaceted inter- lected from September 2006 to December 2008.
ventions have not been tested in Chinese American children
and their families. Thus, we developed an individual tailored
Study procedure and intervention
child-centred and family-focused behavioral program (Active
Upon approval from the University of California,
Balance Childhood [ABC] study) that focuses on promoting
San Francisco, Committee on Human Research, 8- to
healthy weight management and healthy lifestyles (adequate
10-year-old children who self-identified as Chinese and their
dietary intake and improved physical activity) in Chinese
mothers were invited to participate in this study. Participants
American children, ages 8–10, and their families.

Downloaded from https://academic.oup.com/jpubhealth/article/32/2/219/1609231 by guest on 24 April 2023

were recruited from Chinese language programs in the
The aim of this study is to examine the efficacy of the
San Francisco Bay area. Research assistants described the
ABC program in promoting healthy weight and healthy life-
study to potential children and gave them an introduction
styles in Chinese American children. Our hypotheses were
letter and research consent form to take home to their
that children in the intervention group will report a decrease
parents. Parents who were interested in the study signed and
in BMI and waist-to-hip ratio, a healthier dietary intake
returned the consent form, providing their names and
(more vegetable and fiber and lower fat and sugar intake),
contact information to the research team. Children and
being more active and improved knowledge and self-efficacy
parents were informed that they could refuse to participate
in physical activity and nutrition than will children in the
or withdraw from the study at any time.
control group measured 2, 6 and 8 months later.
After parents gave informed consent and children pro-
vided verbal assent, baseline data were collected, and chil-
Participants and methods dren and parents were randomly assigned to the
intervention group or the waiting list control group by a
A randomized controlled study design was used to examine
computer-generated random number assignment (Fig. 1).
the efficacy of the ABC study’s program. Children in the
Research assistants went to the study site and administered
study completed questionnaires regarding their levels of
all of the questionnaires for children to complete. Children
physical activity, dietary intake, usual food choices, knowl-
also had their weight, height, waist and hip circumferences
edge of nutrition and physical activity and self-efficacy
and blood pressure measured. Parents completed question-
related to physical activity and healthy food choices at base-
naires at home and mailed them back to the research team
line (T0) and 2 months (T1), 6 months (T2) and 8 months
within 2-weeks of receiving them. Children assigned to the
(T3) after the baseline assessment. The primary caregiver
intervention group participated in small group weekly
completed questionnaires regarding parents’ demographic
session activities for 8 weeks, and parents in the intervention
information and levels of acculturation. Eight to 10-year-old
group participated in two small group workshops in 8
Chinese American children who were normal weight or
weeks.
overweight and their parents were eligible for enrollment if
Waiting-list control group children and families partici-
they met the following criteria: (1) The adult and child self-
pated in the data collection activities at the same time as
identify ethnicity as Chinese or of Chinese origin, and they
those in the intervention group. After completing the final
reside in the same household. A dyad of one adult and one
follow-up assessment, this group received the ABC study
child was the minimum necessary for a household to partici-
intervention.
pate. Two adults per child were encouraged to participate.
(2) The child was able to speak and read English. (3) The
child was in good health, defined as free of an acute or life- ABC study intervention overview
threatening disease and able to attend to activities of daily The intervention is based on the social cognitive theory
living such as going to school. Children with chronic health developed by Bandura.18 – 20 The theory proposes that cog-
problems that included any dietary modifications or activity nitive factors, behavioral factors (including other personal
limitations (e.g. diabetes, exercise-induced asthma) were factors such as preferences and competencies), and environ-
excluded. (4) Parents were able to speak English, Mandarin mental influences are interactive and integrated determi-
or Cantonese and were able to read in English or Chinese nants. The learning and social influences stem both directly
and to complete questionnaires. Overweight is defined as a and vicariously from numerous resources, including parents.
child having BMI 85th percentile whereas normal weight In this model of reciprocal causation, cognitive, behavioral
 H EA LT H Y W EI G H T A N D H EA LTH Y L IF E STY L E P RO G RA M 221

session once each week for 8 weeks, and parents partici-

pated in two sessions that lasted 2 h each session during
that 8 weeks. Children took part in a play-based workshop
facilitated by a bicultural/bilingual research assistant. The
intervention program consisted of educational play-based
activities that increase children’s self-efficacy and facilitate
their understanding and use of critical thinking and
problem-solving skills related to nutrition, physical activity
and coping. The intervention for children was designed to
improve their self-efficacy and self-competence via interac-
tive activities (such as games and play), and to promote

Downloaded from https://academic.oup.com/jpubhealth/article/32/2/219/1609231 by guest on 24 April 2023

internal motivation to change health behaviors and maintain
a healthy weight. For example, children learned how to
select healthy meals and will be involved in role-playing and
practice sessions about options and choices related to high-
sugar and high-fat foods. An interactive dietary preparation
software program tailored to common Chinese foods that
was developed by Joslin Diabetes Center Asian American
Diabetes Initiative was used for this study.21 In each session,
children engaged in lessons related to nutrition, physical
activity and critical thinking (See Table 1 for overview of the
intervention program components).
At the beginning of each session, children spent 15 min
on physical activities. Physical activity sessions were aimed at
increasing children’s energy expenditure by implementing a
15-min activity session each week for 8 weeks. They
engaged in different types of non-competitive activities
(such as dance, brisk walking and jump rope), learned types
of activities that they can do during recess and at home, and
also learned alternatives to watching television. In addition,
children received a pedometer, activity diary and books
related to physical activity. For the remaining 30 min of each
session, we focused on children’s knowledge regarding nutri-
tion and physical activity and reinforced the notion of self-
efficacy regarding food choices and alternatives to high-fat
Fig. 1 Study procedure. and high-sugar foods and television viewing. Children
received a food diary to record their food intake, books
and environmental factors all operate as interrelating deter- related to healthy eating and a packet of materials in both
minants. Several key concepts such as self-efficacy, outcome Chinese and English each week explaining the activities that
expectation, skill mastery and self-regulation capabilities highlight healthy eating and active lifestyles.
included in the social cognitive theory are used to explain A family component (two 2-h sessions) was incorporated
and predict a person’s behavior.18 – 20 This study intervention into this study to provide reinforcement and social support
addressed these concepts by attempting to increase chil- at home for the education received during the study. The
dren’s and parents’ self-efficacy through setting realistic and parents took part in ‘Healthy Eating and Healthy Family: A
achievable goals, providing necessary skills to achieve Hands-on Workshop’, which was led by a bilingual/bicul-
mastery, and improving self-regulation in maintaining tural registered dietitian. The group workshops (8 –10
healthy weight and healthy lifestyles. parents) included sets of exercises to increase parents’
Once four to six families had been randomized to the knowledge and skills regarding healthy food preparation, dis-
intervention group, the parents and children met separately cussion of issues related to dealing with children’s eating
for small-group sessions. Children participated in a 45-min habits and problems and brainstorming about specific
222 J O U RN A L O F P U B L I C H E A LTH

Table 1 Intervention program for children

Week Objective Themes

1 Understand how body work and how to recognize and cope The importance of healthy food and active lifestyle to our health.
with feelings The importance of healthy coping including recognize feeling and adequate
problem-solving skills to your health
2 Ability to utilize adequate problem-solving techniques and Relaxation techniques
coping skills 5 steps problem solving
Coping, stress and health
3 Ability to be utilized adequate relaxation techniques and Relaxation techniques
developed healthy coping Self-monitoring: tracks of my feeling

Downloaded from https://academic.oup.com/jpubhealth/article/32/2/219/1609231 by guest on 24 April 2023

Healthy coping strategies
4 Understand food and health Nutrition information including food pyramid, reading labels and serving size
Understand your current eating habits and setting a realistic goal for healthy
eating
Food and stress: alternative to reducing your stress
5 Ability to be make smart food choice The Family Wok: how to help your family prepare healthy eating
Ways to prepare healthy and easy snacks
Celebrating holidays with healthy/yummy food
Food and stress: alternative to improve your health and mood
6 Ability to be improve activity level How does physical activity help you?
How much should you be active?
Fun activities for anytime and anywhere
7 Understand various fun activities for children and families Fun activities for anytime and anywhere
Activities for the whole family
Alternative to stress: exercise for better health and happy mood
8 Understand key concepts about healthy and happy Active lifestyle for healthy and happy body
childhood Balance nutrition for better health
Coping with stress/unhappiness
Making smart choices for you and your family

family/children activities to improve dietary intake and phys- baseline. Children completed their questionnaires in English,
ical activity. The parent intervention included a workbook, and parents completed questionnaires in either Chinese or
video clips and discussion of techniques. In addition, English.
parents were encouraged to allow children to make their
own choices for agreeable foods and activities. Parents were
Parental measures
also encouraged to involve their children in grocery shop-
Family information
ping and meal preparation.
The 12-item parent questionnaire includes parent(s)’ and
After completion of each of the data collection activities,
children’s ages, parents’ weights and heights, parents’ occu-
parents and children received a $10 gift certificate. Upon
pation(s), family income and parents’ levels of education.
completion of the study, they received a $30 gift certificate.
The questionnaire was written at a third-grade reading level
At the 2 month (T1), 6 month (T2) and 8 month (T3) assess-
and took approximately 5 min to complete. Mothers com-
ments, the children completed questionnaires regarding their
pleted this questionnaire at baseline.
dietary intake, usual food choices, knowledge about nutrition
and physical activity and self-efficacy regarding physical
activity and food choice. The children also wore a Caltrac Suinn-Lew Asian self-identity acculturation scale
personal activity computer to measure their physical activity The Suinn-Lew Asian self-identity acculturation scale
and had their weight, height, blood pressure and waist and (SL-ASIA) is used to examine the levels of maternal accul-
hip circumferences measured at all the assessments. Primary turation.22,23 The SL-ASIA scale is a 21-item multiple-choice
caregivers (all mothers) completed questionnaires regarding questionnaire covering topics such as language (4 items),
their demographic information and acculturation level at identity (4 items), friendships (4 items), behaviors (5 items),
 H EA LT H Y W EI G H T A N D H EA LTH Y L IF E STY L E P RO G RA M 223

general and geographic background (3 items) and attitudes accelerometer), we chose to use Caltrac in our study because
(1 item). Scores could range from a low of 1.00, indicative of its relatively low cost ($70) and ease of use. The Caltrac
of low acculturation or higher Asian identity, to a high of is designed to be placed at the hip and to measure vertical
5.00, indicative of high acculturation or high Western iden- acceleration. Readings from the device have been used to
tity. The scale also permits classification as ‘bicultural’, indi- predict oxygen consumption and net caloric expenditure,
cating that a person has adopted some Asian values, beliefs based on the user’s age, height and weight, during exercise.
and attitudes along with some Western values, beliefs and The Caltrac has a moderate to high validity, ranging from
attitudes. Validity and moderate to good reliability have been 0.35 to 0.97, with heart rate and observation methods.26 A
reported.22,23 The Cronbach alpha for the SL-ASIA was high reliability of the device, ranging from 0.87 to 0.98, was
0.79 – 0.91 for Chinese Americans.22,23 This questionnaire is also reported in children.26 In this study, children were
available in Chinese and English and is written at a instructed to place the Caltrac at the hip for 3 consecutive

Downloaded from https://academic.oup.com/jpubhealth/article/32/2/219/1609231 by guest on 24 April 2023

fifth-grade reading level. It takes about 10 to 15 min to days (two weekdays and one weekend day). Children were
complete the questionnaire. also instructed to wear the Caltrac as soon as getting up
from the bed in the morning and remove it only in shower,
Children’s measures in water-related activities (i.e. swimming) and sleeping.
BMI Average count was used for analysis.
BMI has a well-established association with stature and age
among children and adolescents.24,25 BMI was calculated by Three-day food diary
dividing body mass in kilograms by height in meters This quantitative self-report food diary was used to estimate
squared (kg/m2). BMI has acceptable ranges of sensitivities dietary intake of children. Children received a 3-day food
and specificity. Sensitivity ranged from 29 to 88%, specificity diary containing an instruction sheet, a sample completing
ranged from 94 to 100% and predictive value ranged from day’s food-record sheet and eight blank white dietary record
90 to 100%, in children24,25 In this study, BMI lower than forms. Each form included spaces for the child’s name, day
the 5th percentile was defined as underweight, between the of the week, date of recording and blank lines to record
6th and 84th percentile was defined as normal weight and food and drink grouped into the following categories: break-
BMI above the 85th percentile was defined as overweight fast, snack, lunch, snack, dinner and snack. Children were
and 95th percentile as obese, based on the growth chart asked to record all foods and beverages consumed for 3
developed by CDC. consecutive days. They also recorded serving sizes. Kappa
coefficients and percent of agreement for interobserver
Waist-to-hip ratio reliability ranged from 0.43 to 0.91.27,28 The diary takes
The waist-to-hip ratio was derived from the waist and hip approximately 10 min to complete. Parents were asked to
circumferences. Waist circumference was measured midway complete the diary together with their children to increase
between the lowest rib and the superior border of the iliac the accuracy of dietary report.
crest. Hip circumference was measured at the maximal pro-
trusion of the buttocks. The circumferences were given as
Usual food choices
the mean of two measurements to the nearest 0.1 cm.
This 14-item survey was part of the Health Behavior
Questionnaire developed for the Child and Adolescent Trial
Blood pressure for Cardiovascular Health (CATCH) study. This survey
Systolic and diastolic blood pressure (DBP) were measured asked about usual food choices (behavior) in a forced-choice
by using a mercury sphygmomanometer with specific cuff format that focuses on low-fat and low-sodium foods. It
size appropriate for children (Baumanometer, W.A. Baum measured usual food selections and what types of food a
Co, Copiague, New York) to the nearest 2 mm Hg, twice in child eats most of the time. Children were given a choice
the child’s right arm, with the child seated after 10 min of between two foods and asked which one they eat more
rest. often. Sample questions are ‘Which foods do you eat most
of the time: hot dog or chicken? Frozen yogurt or ice
Caltrac personal activity computer cream?’ A higher score indicated more healthy food choices.
The Caltrac has been widely used in assessing physical Validity was obtained by including expert review and pilot
activity among children and adults.26 Although there are testing with a focus group. The alpha coefficient for internal
other advanced measures of physical activity (i.e. consistency in the original study was 0.76.29
224 J O U RN A L O F P U B L I C H E A LTH

Physical activity knowledge Data analysis

This five-item questionnaire was developed by the researcher Descriptive statistics were calculated initially for demo-
to assess children’s knowledge about physical activity. Items graphic characteristics and all major study variables. We used
were adapted from recommendations from the US t-tests to examine any differences in variables between inter-
Department of Agriculture30 and the American Heart vention and control groups at the baseline. We examined
Association31 regarding dietary guideline, MyPyramid and whether the rate of change across the four data collection
children’s health. Sample questions included the following: time points was different for the children in the intervention
How much aerobic activity is required for a healthy heart? group than for children in the control group by fitting linear
How many hours a day should a child watch television or mixed-effects models that included functions of time and
play video games? The reliability coefficient for internal con- group effects to the repeated child data. With a continuous
sistency with the sample of children in this study was 0.65. outcome, the mixed-model approach to analyze longitudinal

Downloaded from https://academic.oup.com/jpubhealth/article/32/2/219/1609231 by guest on 24 April 2023

Children received one point for every question they data is a method of modeling population parameters as
answered correctly. A higher score indicates more accurate fixed effects while simultaneously modeling individual
knowledge about physical activity needs. The total score was subject parameters as random effects. The modeling of indi-
used for analysis. vidual subjects was obtained as random deviations about
the population model. Follow up t-tests were used to
Dietary knowledge examine the efficacy of the intervention on three follow-up
This 14-item survey also was part of the Health Behavior time (T0 –T1, T0 – T2, T0 – T3). All analyses were performed
Questionnaire developed for the CATCH study. It measured in SPSS 15.0, with 0.05 set as the required level of
children’s knowledge about healthy food choices. Children significance.
were asked to identify which food was ‘better for your
health’. Samples of two choices included ‘whole wheat or
white bread’ and ‘frozen corn or canned corn’. Content val- Power analysis
idity was examined by including expert review and focus A minimum of 30 participants per group provides power of
group pilot testing from the CATCH study. This survey had 0.85 at an alpha of 0.05 to detect a moderate difference in
a reported internal consistency ranging from 0.76 to 0.78.29 BMI between the two groups between baseline and
A higher score indicates more accurate dietary knowledge. 8-month follow-up (mean BMI difference 0.8 between the
groups which reflects a difference of 1 of a standard devi-
Child dietary self-efficacy ation [SD]).
This 15-item self-report questionnaire measured children’s
self-confidence in their ability to choose foods low in fat
and sugar.29 The questionnaire contained 15-item stems
Results
beginning with ‘How sure are you. . . ?’ Items were scored
on a Likert scale, with options of ‘not sure’, ‘a little sure’ or Descriptive data
‘very sure’. Higher scores indicated higher self-efficacy. The Initially, 72 children and families agreed to participate in this
internal consistency ranged from 0.82 to 0.87 in the third study. Of these, 67 children and their parents met the cri-
and fifth graders.29,32 The questionnaire took about five to teria for eligibility and were enrolled in this study. Baseline
10 min for children to complete. characteristics of the complete sample are shown in Table 2.
Thirty-five children and their families were randomized to
Physical activity self-efficacy the intervention group and 32 children and their families
This subscale of the Health Behavior Questionnaire was were randomized to the control group. The mean age of the
used to measure the children’s self-confidence in their ability children was 8.97 (SD, 0.89) years. Twenty-nine of the chil-
to participate in various age-appropriate physical activi- dren were girls and 31 children were overweight or obese
ties.29,32 The subscale included five items in which children with BMI greater than the 85th percentile based on CDC
were asked if they were ‘not sure’, ‘a little sure’ or ‘very sure’ growth chart. Approximately 51% of children in the inter-
that they could do such things as ‘keep up a steady pace vention group and 41% of children in the control group
without stopping for 15 –20 min’. Higher scores indicated were overweight or obese (X 2 ¼ 0.79, P ¼ 0.38).
higher self-efficacy. Internal consistency ranged from 0.67 to Approximately 54% of children in the intervention group
0.69 in the third and fifth graders.29,32 The questionnaire and 59% of children in the control group were boys (X 2 ¼
took about two to 5 min for children to complete. 0.18, P ¼ 0.68). No difference was found in the overweight
 H EA LT H Y W EI G H T A N D H EA LTH Y L IF E STY L E P RO G RA M 225

Table 2 Means and SD for all variables at baseline

All (n ¼ 67) Intervention (n ¼ 35) Control (n ¼ 32)

Children variables
Age, years 8.97 (0.89) 9.14 (0.85) 8.78 (0.91)
Body mass indexa 19.22 (3.18) 19.74 (3.58) 18.65 (2.63)
Waist-to-hip ratio 0.89 (0.05) 0.88 (0.04) 0.89 (0.06)
Systolic blood pressureb 103.41 (8.36) 105.74 (9.01) 99.87 (5.81)
Diastolic blood pressure 61.03 (12.50) 63.23 (12.91) 57.70 (11.31)
Caltrac count 3951.52 (1405.22) 3747.61 (1389.13) 4228.84 (1407.04)
Fat, % 29.32 (3.00) 29.76 (2.83) 28.50 (3.20)

Downloaded from https://academic.oup.com/jpubhealth/article/32/2/219/1609231 by guest on 24 April 2023

Sugar, gb 25.26 (9.32) 28.84 (8.15) 19.08 (8.03)
Vegetables and fruit, number of servings 2.12 (0.73) 2.15 (0.73) 2.08 (0.75)
Food choice 9.01 (2.16) 9.14 (2.21) 8.84 (2.11)
Physical activity knowledge 3.63 (1.07) 3.69 (1.11) 3.56 (1.05)
Nutrition knowledge 9.58 (2.72) 9.47 (2.99) 9.71 (2.40)
Physical activity self-efficacy 2.32 (0.47) 2.31 (0.45) 2.33 (0.50)
Nutrition self-efficacy 2.43 (0.41) 2.44 (0.42) 2.40 (0.42)
Parent variables
Mother’s age, years 41.44 (4.37) 41.53 (4.85) 41.33 (3.76)
Mother’s education, years 14.03 (4.55) 14.03 (4.35) 14.04 (4.87)
Mother’s body mass index 23.06 (3.82) 22.71 (4.05) 23.54 (3.49)
Father’s age, years 44.25 (5.28) 43.60 (5.42) 44.96 (5.11)
Father’s education, years 15.59 (3.69) 15.47 (3.36) 15.71 (4.06)
Father’s body mass index 24.88 (4.59) 24.13 (5.61) 25.69 (3.61)

a
Calculated as weight in kilograms divided by height in meters squared.
b
Significant difference between the intervention and control groups at P , 0.05.

distribution by sex between children in the intervention children who provided follow-up data and those lost to
group and children in the control group. follow-up.
The mean maternal age was 41.4 (SD, 4.37) years, and Data on outcome variables for the intervention and
the mean number of years of education was 14 (SD, 4.55) control groups are presented in Table 3. The mixed-model
years. The mean BMI for mothers was 23.06 (SD, 3.82). analysis indicated that significantly more of the children in
The mean paternal age was 44.25 years (SD, 5.28), and the the intervention group had decreased their BMI, decreased
mean number of years of education was 15.59 years (SD, DBP, increased physical activity as measured by Caltrac,
3.69). Their mean acculturation score was 2.38 (SD, 0.69) decreased fat intake, and increased vegetable and fruit intake
suggesting a low acculturation. The mean BMI for fathers than did the children in the control group (see Table 4 and
was 24.88 (SD, 4.59). Baseline variables did not differ sig- Fig. 2 for summary of mixed-model analysis). All children in
nificantly between the intervention and control groups, the study increased their knowledge about physical activity
except for systolic blood pressure and sugar intake (interven- over time (effect ¼ 2 0.227, P ¼ 0 .008) with more signifi-
tion group had higher level than the control group; see cant increases in the intervention group than in the control
Table 2). group (effect ¼ 0.266, P ¼ 0.02).
Follow-up t-tests on significant outcome variables
Longitudinal analysis revealed that significant differences were found between T0
Fifty-seven children and their families (85%) completed and T1, T0 and T2 and T0 and T3 on BMI, physical activity,
baseline and follow-up measures; 94% of children in the fat consumption and vegetable and fruit intake in the inter-
intervention group and 75% of children in the control vention group (P , 0.05). Significant differences were also
group completed baseline and follow-up measures. No sig- found between T0 and T2 and T0 and T3 on SBP and DBP
nificant differences were found in baseline variables between (P , 0.05). No significant differences were found on
226 J O U RN A L O F P U B L I C H E A LTH

Table 3 Means and SD for all outcome variables in the intervention and control groupsa

Variable Intervention Control

T1 T2 T3 T1 T2 T3

Body mass indexb 19.48 (3.48) 19.29 (3.45) 19.32 (3.38) 18.14 (2.60) 18.42 (2.69) 18.42 (2.56)
Waist-to-hip ratio 0.88 (0.04) 0.88 (0.04) 0.88 (0.04) 0.91 (0.06) 0.90 (0.06) 0.90 (0.06)
Systolic blood pressure 104.97 (9.10) 103.88 (7.84) 102.91 (8.25) 99.65 (6.63) 98.90 (7.01) 99.00 (6.36)
Diastolic blood pressure 61.52 (9.62) 59.94 (9.95) 59.27 (9.62) 57.43 (10.95) 57.60 (11.65) 58.05 (10.81)
Caltrac count 4452.90 (1342.03) 5011.51 (1188.82) 4979.72 (1187.90) 4188.45 (1242.58) 4160.95 (1072.79) 4319.62 (1250.96)
Fat, % 27.87 (2.90) 27.18 (2.92) 27.51 (2.09) 28.24 (2.78) 28.20 (2.47) 28.68 (2.71)

Downloaded from https://academic.oup.com/jpubhealth/article/32/2/219/1609231 by guest on 24 April 2023

Sugar, g 26.45 (8.22) 24.16 (7.91) 24.68 (6.32) 21.81 (8.89) 20.97 (7.34) 21.85 (7.81)
Vegetables and fruit, 2.82 (0.80) 2.87 (0.80) 3.06 (0.82) 1.59 (0.75) 1.92 (0.64) 2.00 (0.79)
number of servings
Food choice 8.86 (2.32) 9.05 (2.50) 8.45 (2.30) 7.98 (1.67) 7.50 (2.11) 7.56 (2.48)
Physical activity knowledge 3.94 (0.81) 3.80 (1.18) 3.82 (0.83) 3.58 (1.18) 2.47 (1.88) 3.52 (0.81)
Nutrition knowledge 9.82 (2.85) 10.30 (2.34) 10.65 (2.04) 8.85 (2.61) 7.86 (2.49) 10.31 (1.91)
Physical activity 2.46 (0.37) 2.44 (0.41) 2.40 (0.42) 2.27 (0.52) 2.38 (0.53) 2.35 (0.63)
self-efficacy
Nutrition self-efficacy 2.63 (0.39) 2.61 (0.39) 2.65 (0.50) 2.31 (0.51) 2.46 (0.42) 2.44 (0.42)

a
T1 was 2 months, T2 was 6 months and T3 was 8 months after the baseline assessment.
b
Calculated as weight in kilograms divided by height in meters squared.

outcome variables between T0 and T1, T0 and T2 and T0 been associated with improvements in their lipid profiles,
and T3 in the control group except for physical activity insulin sensitivities and cardiovascular function.33 – 35
knowledge in which decreased physical activity knowledge Although the benefit of decreased relative weight may not
found in T2 compared with T0). been seen right after the intervention as shown in our study,
our intervention suggests improvement of blood pressure
4-month post-intervention. Thus, maintaining healthy
Discussion
weight in children is critical in improving their health,
Main finding of this study especially in cardiovascular health. Thus, our data suggest
The results suggest that Chinese American children in an that such an intervention is an effective way of promoting
interactive child-centred and family-based behavioral healthy weight and improving blood pressure in Chinese
program (such as the ABC study) decreased their BMI and American children.
DBP, increased their physical activity level, decreased fat In addition to the reductions in BMI and DBP, children
intake, increased vegetable and fruit intake and increased in the intervention group also improved their
their knowledge regarding physical activity significantly more overweight-related health behaviors by reducing fat intake
than children in the control group. Results indicate that a and increasing vegetable and fruit intake and physical activity
culturally appropriate healthy lifestyle program that uses level more so than children in the control group. The
interactive small-group sessions can be effective in promot- improvement of fat and vegetable and fruit intake is seen in
ing healthy weight and healthy lifestyles for Chinese all study follow-up assessments. Improving dietary behaviors
American children. and physical activity level have been suggested to be critical
Children in the intervention group showed decreased factors in reducing overweight in children.36 – 38 Our inter-
BMI and DBP whereas children in the control group kept vention demonstrates an improvement in several
similar levels of BMI and blood pressure throughout the overweight-related behaviors, and these behaviors last for
8-month study. The decreased in BMI in the intervention several months after the intervention ended. Moreover, we
group was found in all follow-up assessments (T1, T2 and found that children in the intervention group also improved
T3) while decreased in both SBP and DBP was found at 6- their knowledge about physical activity more than children
(T2) and 8-month (T3) follow-up but not immediate after in the control group. Improvement of overweight-related
the intervention (T1). Improvements in children’s BMIs have health behaviors in combination with increasing knowledge
 H EA LT H Y W EI G H T A N D H EA LTH Y L IF E STY L E P RO G RA M 227

Table 4 Summary of mixed-model analysis for effects of the ABC led to reductions in BMI in children, with the largest effects
intervention associated with parental involvement at least for several
months after the intervention.13,15,39,40 Thus, intervention
Outcomes Parameter Effect 95% CI P for healthy weight management in Chinese American chil-
estimate dren should incorporate information related to adequate diet
and active lifestyles and should be tailored to the family’s
Body mass Time 0.018 20.035 –0.071 0.51
needs.
index Group 1.080 20.404 –2.565 0.15
Time  groupa 20.150 20.220 –0.080 0.001
Waist-to-hip Time 0.001 20.005 –0.006 0.84 What is already known on this topic
ratio Group 20.012 20.045 –0.020 0.45 Previous studies have suggested that effective interventions
Time  group 20.001 20.008 –0.006 0.79 for overweight in children must target several

Downloaded from https://academic.oup.com/jpubhealth/article/32/2/219/1609231 by guest on 24 April 2023

Systolic Time 20.534 21.203 –0.134 0.12 overweight-related health behaviors (including dietary behav-
blood Groupa 5.961 2.079 –9.844 0.003 ior, physical activity, problem-solving and coping skills). The
pressure Time  group 20.533 21.377 –0.312 0.22
program must include parents and must be culturally appro-
Diastolic Time 20.177 21.123 –0.769 0.71
priate.11 – 15 However, such multifaceted and culturally sensi-
blood Group 5.309 20.101 –10.719 0.05
tive program has not been tested in Chinese Americans.
pressure Time  groupa 21.305 22.499 –0.111 0.03
Caltrac Time 1.341 2148.974 –151.655 0.99
count Group 2228.827 2853.142 –395.488 0.47 What this study adds
Time  groupa 428.685 236.059 –621.310 0.001 Our intervention was based on social cognitive theory, tar-
Fat, mean, Time 20.160 20.487 –0.167 0.34 geted overweight-related behaviors and included parents as
% Group 0.679 20.803 –2.161 0.36 the partners in behavioral changes in their children. This
Time  groupa 20.542 20.938 –0.146 0.008
program was also designed to fit the busy schedules of chil-
Sugar, Time 20.264 21.079 –0.551 0.52
dren and their families by delivering the intervention at the
mean, g Group 0.748 22.692 –4.188 0.67
after-school program and date/time that were convenient
Time  group 20.693 21.681 –0.295 0.17
Vegetable Time 20.032 20.141 –0.077 0.56
for children and their families. To obtain feedbacks regard-
and fruit, Group 0.497 0.051 –0.943 0.06 ing the effect of the program, we interviewed participating
number of Time  groupa 0.306 0.175 –0.438 0.001 parents in the intervention group (n ¼ 22) after they have
servings, completed the program. Comments from participating
mean families suggest that accessibility of the program was a key
Food choice Timea 20.505 20.859 –0.152 0.005 reason why children and their families participated in the
Group 0.337 20.709 –1.383 0.52 intervention program. Given that the health issues related to
Time  group 0.329 20.118 –0.776 0.15 overweight are substantial, accessible and convenient cultu-
Physical Timea 20.227 20.392 –0.061 0.008 rally appropriate child-centred and family-based intervention
activity Group 0.311 20.232 –0.853 0.26
program can be effective in preventing overweight and
knowledge Time  groupa 0.266 0.047 –0.484 0.02
improving cardiovascular health in a high-risk population. In
Nutrition Time 0.125 20.234 –0.484 0.49
conclusion, this interactive child-centred and family-based
knowledge Group 0.244 20.891 –1.379 0.67
Time  group 0.287 20.194 –0.767 0.24
ABC program appears to be both feasible and effective in
Physical Time 0.031 20.024 –0.086 0.27 reducing BMI and promoting overweight-related health
activity Group 0.027 20.195 –0.248 0.81 behaviors in Chinese American children.
self-efficacy Time  group 20.003 20.075 –0.070 0.94
Nutrition Time 0.022 20.032 –0.077 0.42 Limitations of this study
self-efficacy Group 0.104 20.098 –0.306 0.31
Our study also has some limitations including (1) conven-
Time  group 0.042 20.028 –0.113 0.24
ience sampling, (2) parents with high education, (3) only
a
Significant difference between intervention and control groups at
involved Chinese American children and (4) follow-up for
P , 0.05. only 6 months after the intervention. Despite our effort to
retain participants, 25% of children and their families in the
can be related to the reductions in BMI and DBP found in control group withdrew from the study, compared with only
the intervention group. Our results are supported by results 6% of children in the intervention group. However, baseline
of other studies that suggest combined lifestyle interventions characteristics did not differ significantly between children
228 J O U RN A L O F P U B L I C H E A LTH

Downloaded from https://academic.oup.com/jpubhealth/article/32/2/219/1609231 by guest on 24 April 2023

Fig. 2 Significant changes in (A) body mass index, (B) diastolic blood pressure, (C) Caltrac, (D) fat intake, (E) vegetable and fruit intake and (F) physical
activity knowledge.

who completed the follow-up assessments and children who Community Health Care Association community grants and
dropped out of the study. The high retention rate in the in part by NIH grant DK060617 to M.B.H.
intervention group could be attributed to the interactive
design of the program and culturally appropriate infor-
mation taught to children and families, which attracts chil-
dren and parents, as well as to the feasibility of the program References
that made it feasible for both children and their parents to 1 Tarantino R. Addressing childhood and adolescent overweight.
participate in the study. Future research should examine the Paper Presented at the NICOS Meeting of the Chinese Health Coalition.
long-term effects of this program on insulin sensitivity and San Francisco, September 2002.
cardiovascular function as well. 2 Stevens J. Ethnic-specific revisions of body mass index cutoffs to
define overweight and obesity in Asians are not warranted. Int J
Obes Relat Metab Disord 2003;27(11):1297– 9.
Funding 3 Tan CE, Ma S, Wai D et al. Can we apply the National Cholesterol
Education Program Adult Treatment Panel definition of the meta-
This publication was made possible by grant number KL2 bolic syndrome to Asians? Diabetes Care 2004;27(5):1182 – 6.
RR024130 to J.L.C. from the National Center for Research 4 Garnett SP, Baur LA, Srinivasan S et al. Body mass index and waist
Resources, a component of the National Institutes of Health circumference in midchildhood and adverse cardiovascular disease
(NIH) and NIH Roadmap for Medical Research, Chinese risk clustering in adolescence. Am J Clin Nutr 2007;86(3):549 – 55.
 H EA LT H Y W EI G H T A N D H EA LTH Y L IF E STY L E P RO G RA M 229

5 Li YP, Yang XG, Zhai FY et al. Disease risks of childhood obesity 24 Freedman DS, Perry G. Body composition and health status among
in China. Biomed Environ Sci 2005;18(6):401 – 10. children and adolescents. Prev Med 2000;31:34 – 53.
6 Chen JL, Wu Y. Cardiovascular risk factors in Chinese American 25 Goran ML. Measurement issues related to studies of childhood
children: associations between overweight, acculturation, and phys- obesity: assessment of body composition, body fat distribution,
ical activity. J Pediatr Health Care 2008;22(2):103– 10. physical activity, and food intake. Pediatrics 1998;101:505 – 18.
7 Coughlan A, McCarty DJ, Jorgensen LN et al. The epidemic of 26 Noland M, Danner F, DeWalt K et al. The measurement of
NIDDM in Asian and Pacific Island populations: prevalence and physical activity in young children. Res Q Exerc Sport 1990;61(2):
risk factors. Horm Metab Res 1997;29(7):323– 31. 146 – 53.
8 Fisher L, Chesla CA, Chun KM et al. Patient-appraised couple 27 Baxter SD. Accuracy of fourth-graders’ dietary recalls of school
emotion management and disease management among Chinese breakfast and school lunch validated with observations: in-person
American patients with type 2 diabetes. J Fam Psychol versus telephone interviews. J Nutr Educ Behav 2003;35(3):124 – 34.
2004;18(2):302– 10. 28 Weber JL, Lytle L, Gittelsohn J et al. Validity of self-reported dietary

Downloaded from https://academic.oup.com/jpubhealth/article/32/2/219/1609231 by guest on 24 April 2023

9 McNeely MJ, Boyko EJ. Type 2 diabetes prevalence in Asian intake at school meals by American Indian children: the Pathways
Americans: results of a national health survey. Diabetes Care Study. J Am Diet Assoc 2004;104(5):746 – 52.
2004;27(1):66– 9. 29 Edmundson E, Parcel GS, Feldman HA et al. The effects of the
10 Faith MS, Leone MA, Ayers TS et al. Weight criticism during phys- Child and Adolescent Trial for Cardiovascular Health upon psycho-
ical activity, coping skills, and reported physical activity in children. social determinants of diet and physical activity behavior. Prev Med
Pediatrics 2002;110(2 Pt 1):e23. 1996;25(4):442– 54.
11 Golan M, Kaufman V, Shahar DR. Childhood obesity treatment: 30 United States Department of Agriculture (USDA). Steps to a heal-
targeting parents exclusively v. parents and children. Br J Nutr thier you, 2006. http://www.mypyramid.gov/steps/whatshoul-
2006;95(5):1008 – 15. dyoueat.html (15 March 2006, date last accessed).
12 Rugg K. Childhood obesity: its incidence, consequences and pre- 31 Association AH (ed). Children’s Health. Dallas, TX: American Heart
vention. Nurs Times 2004;100(3):28– 30. Association, 2006.
13 Stice E, Shaw H, Marti CN. A meta-analytic review of obesity pre- 32 Matheson DM, Killen JD, Wang Y et al. Children’s food consump-
vention programs for children and adolescents: the skinny on inter- tion during television viewing. Am J Clin Nutr 2004;79(6):1088– 94.
ventions that work. Psychol Bull 2006;132(5):667– 91. 33 Kirk S, Zeller M, Claytor R et al. The relationship of health out-
14 Summerbell CD, Ashton V, Campbell KJ et al. Interventions for comes to improvement in BMI in children and adolescents. Obes
treating obesity in children. Cochrane Database Syst Rev Res 2005;13(5):876– 82.
2003;3:CD001872. 34 Nemet D, Barkan S, Epstein Y et al. Short- and long-term beneficial
15 Young KM, Northern JJ, Lister KM et al. A meta-analysis of family- effects of a combined dietary-behavioral-physical activity interven-
behavioral weight-loss treatments for children. Clin Psychol Rev tion for the treatment of childhood obesity. Pediatrics
2007;27(2):240 –9. 2005;115(4):e443 – 9.
16 Enderlin CA, Richards KC. Research testing of tailored interven- 35 Reinehr T, Andler W. Changes in the atherogenic risk factor profile
tions. Res Theory Nurs Pract 2006;20(4):317– 24. according to degree of weight loss. Arch Dis Child
17 Ryan P, Lauver DR. The efficacy of tailored interventions. J Nurs 2004;89(5):419– 22.
Scholarsh 2002;34(4):331– 7. 36 Chen JL, Kennedy C. Factors associated with obesity in
18 Bandura A. Health promotion by social cognitive means. Health Chinese-American children. Pediatr Nurs 2005;31(2):110– 5.
Educ Behav 2004;31(2):143– 64. 37 Chen JL, Kennedy C, Yeh CH et al. Risk factors for childhood
19 Bandura A. Human agency in social cognitive theory. Am Psycholo obesity in elementary school-age Taiwanese children. Prog Cardiovasc
1989;44:1175 –84. Nurs 2005;20(3):96 – 103.
20 Bandura A. Social Foundations of Thought and Action: A Social Cognitive 38 Nicklas TA, Baranowski T, Cullen KW et al. Eating patterns, dietary
Theory. New Jersey: Prentice Hall, 1986. quality and obesity. J Am Coll Nutr 2001;20(6):599– 608.
21 Joslin Diabetes Center. 2007. http://aadi.joslin.harvard.edu/ (15 39 McGovern L, Johnson JN, Paulo R et al. Treatment of pediatric
March 2006, date last accessed). obesity: a systematic review and meta-analysis of randomized trials.
J Clin Endocrinol Metab 2008;93(12):4600 – 5.
22 Suinn RM, Khoo G, Ahuna C. The Suinn-Lew Asian Self-Identity
acculturation scale: cross-cultural information. J Multicultural 40 McLean N, Griffin S, Toney K et al. Family involvement in weight
Counseling Dev 1995;27:139 – 48. control, weight maintenance and weight-loss interventions: a sys-
tematic review of randomised trials. Int J Obes Relat Metab Disord
23 Suinn RM. Measurement of acculturation of Asian Americans.
2003;27(9):987– 1005.
Asian Am Pac Isl J Health 1998;6(1):7 – 12.