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ACCESSION NO: 0224871 SUBFILE: CRIS
PROJ NO: HAW01210-G AGENCY: NIFA HAW
PROJ TYPE: AFRI COMPETITIVE GRANT PROJ STATUS: TERMINATED
CONTRACT/GRANT/AGREEMENT NO: 2011-68001-30335 PROPOSAL
NO: 2010-04888
START: 01 APR 2011 TERM: 31 MAR 2017 FY: 2017
GRANT AMT: $4,967,049 GRANT YR: 2014
AWARD TOTAL: $24,727,396
INITIAL AWARD YEAR: 2011

INVESTIGATOR: Novotny, R.; DeBaryshe, B.; Edmonds, C.; Deenik, J.;

Dunn, M.; Stokes, A.; Wilkens, L.; Nigg, C.; Vargo, D.; Kim, J.; Luick, B.;
LeonGuerrero, R.

PERFORMING INSTITUTION:
UNIV OF HAWAII
3190 MAILE WAY
HONOLULU, HAWAII 96822

CHILDREN`S HEALTHY LIVING PROGRAM FOR REMOTE

UNDERSERVED MINORITY POPULATIONS OF THE PACIFIC REGION
(CHL)

NON-TECHNICAL SUMMARY: The program emphasizes child obesity

prevention through training, community based participatory intervention
research, dissemination/outreach, policy change and use of a local advisory
committee, to assure integration of program activity into local and regional
plans and policies, and assure sustainability of effort.

OBJECTIVES: The goal of this program is to build social or cultural, political

or economic, and physical or built environments that will promote active play
and intake of healthy food to prevent young child obesity in the Pacific Region
including Alaska, American Samoa, Commonwealth of the Northern Mariana
Islands, Freely Associated States of Micronesia, Guam and Hawaii. The
program will engage the community, and focus on capacity building and
sustainable environmental change. Specific objectives are 1. Conduct local
program inventories and needs assessments using community based
participatory approaches in order to identify culturally and economically
sustainable approaches to affect community, family, and child healthy food
intake and active play or physical activity behavior. 2. Train 22 professionals
and paraprofessionals in food, nutrition and public health, and in research and
evaluation methods at various levels of need in the region, in order to maintain
healthy weight and prevent young child obesity. 3. Develop a Pacific food,
nutrition and physical activity data management, monitoring and evaluation
system using assessment data, and aggregate, display and communicate
available data, pertinent to young child obesity. 4. Decrease the prevalence of
young child overweight and obesity by 8 percent; and its functional outcomes
(decrease acanthosis nigricans by 5 percent, and increase sleep by 15
minutes per day); increase moderate to vigorous physical activity by 10
minutes per day & decrease sedentary behavior (screen time) by 10 minutes
per day; increase healthy eating (fruit and vegetable intake by 1 serving per
day, water intake by one half cup per day; decrease sweetened beverage
intake by one half cup/day and decrease fatty meat intake by 1 serving per
day), through community-based primary prevention environmental
interventions. 5. Use Pacific food and nutrition, and physical activity data and
intervention information to incur at least one "environmental" policy change
per jurisdiction.

APPROACH: Program and data inventories will be completed in Year One. In

each jurisdiction we will inventory available relevant trade, economic, food,
nutrition, physical activity, obesity, and health data for children ages 2 through
8 years old. Data will be used to finalize the research design and content,
identify needed policy changes, determine training/education priorities, and
provide baseline data for the intervention program monitoring and evaluation
system. Based on the needs assessment during Year One, the training needs
of each jurisdiction will be determined. Candidates for training will be
identified, and applications will be submitted for selected training programs in
grant Year Two. Trainees will be active contributors to the program
intervention, dissemination and policy development in their home jurisdiction.
The program intervention will be a group randomized trial of young children
from selected daycare/schools that will target change in the social/cultural,
physical/built and political/economic environment of the neighboring
community for active play and healthy eating to prevent obesity and its
functional outcomes in the Pacific Region. Intervention findings will be
presented in community and professional venues. Advocacy for at least one
local policy change to support a healthy children's environment will occur at
each site. A local advisory committee in each jurisdiction will be formed to
guide and sustain the program work.
PROGRESS: 2011/04 TO 2017/03
Target Audience:The US affiliated Pacific jurisdictions of Alaska, American
Samoa, Commonwealth of the Northern Mariana Islands, Palua, Marshall
Islands, each of the Federated States of Micronesia (Chuuk, Kosrae, Yap and
Pohnpei), Guam, and Hawaii were targets of the CHL program. The target
age group for the program was children 2-8 years old, in the context of their
families, communities and jurisdiction. There were 27 communities involved in
the CHL cluster randomized intervention trial. Changes/Problems: Nothing
Reported What opportunities for training and professional development has
the project provided?CHL Training Students by site, institution and degree
program: Alaska Ron Standlee-Strom, University of Alaska Fairbanks, MS in
Natural Resources Management GRADUATED Tara Stiller, University of
Alaska Anchorage, MPH GRADUATED American Samoa Marietta Lafaele,
University of Hawai`i, BA in Public Health (Spring 2017) Aifili Tufa, University
of Hawai`i, PhD in Public Health- Epidemiology (Spring 2017) Commonwealth
of the Northern Mariana Islands (CNMI) Rose Castro, University of Alaska
Anchorage, Master of Public Health (MPH) online (Spring 2017) Patricia
Coleman, University of Alaska Anchorage, Master of Public Health (MPH)
online (Spring 2017) Freely Associated States of Micronesia (FAS) Ivenglynn
Andon, University of Guam, BS in Health Sciences (Spring 2018) Kimberly
Areieta Guam Community College, Certificate in Early Childhood
Development (estimated graduation unknown) Lilian Billimon, University of
Guam, BS in Health Sciences (estimated graduation unknown) Joachim
Castro, University of Hawai`i, BA in Public Health (Spring 2017) Samuel
Foulchag, University of Hawai`i, BS in Food Science and Human Nutrition (2
semesters remaining), working as WIC nutritionist at Kokua Kalihi Valley
Clinic in Honolulu Trisha Johnson, University of Hawai`i, BS in Food Science
and Human Nutrition GRADUATED Shra Kedi, University of Hawai`i, BA in
Public Health GRADUATED Evigan Sengebau University of Guam, BS in
Health Sciences (Spring 2018) Neelma Skilling, University of Hawai`i, BS in
Food Science and Human Nutrition (Spring 2017) Srue Wakuk University of
Hawaii, BA in Public Health GRADUATED Guam Tanisha Aflague, University
of Hawai`i, PhD in Nutrition GRADUATED Lenora Matanane, University of
Hawai`i, MS in Nutritional Sciences GRADUATED Hawaii Monica Esquivel,
University of Hawai`i, PhD in Nutrition GRADUATED Ashley Morisako,
University of Hawai`i, Master of Public Health (MPH)- Indigenous Health
GRADUATED Two students dropped out of the CHL Training Program
(Rachel Garcia, Alaska, Fall 2013; Caleb Scanlan, American Samoa, Spring
2013) for personal reasons. Newstudents (Tara Stiller, AK; Aifili Tufa, AS)
filled those positions. Two students were released from CHL Training Program
(Edumyle Otobed, FAS, Spring 2014 and Renni Taiugmai, FAS, Fall 2015)
due to failure to meet the academic goals required by the CHL Training
Program and the academic institution. Their positions were not filled by
another student due to the timeframe of the grant cycle. In addition to CHL
trainees opportunities for CHL staff has resulted in staff professional
development and training. Four CHL staff have obtained tenture-track
positions at Universities; three obtained promotions; eight staff are pursuing
advanced degrees; and two have obtained professional positions. Summer
Institute The CHL Summer Institute will provide an opportunity to sustainably
deliver CHL developed curriculum. The CHL is working with the UHM College
of Education Distance Course Design and Consulting (DCDC) to optimize the
curriculum into an online deliverable platform. Focus will also include
alignment with the Pacific curricula, degree programs and job opportunities.
The SI will be delivered through the University of Hawaii Outreach College
which will allow for non-UH students to enroll. Long term development of a
certificate program is planned along with alignment with various accreditation
agencies. The CHL SI will benefit health professionals across the region in
various careers including nursing, nutrition, public health, medical and early
childhood education. Courses have been developed for the CHL SI including
1. Foundations of Childhood Obesity Prevention in the Pacific, 2. Culture and
Child Health in the Pacific, 3. Childhood Anthropometric and Dietary
Assessment Field Techniques, 4. Childhood Health and Monitoring in the
Pacific, 5. Applied Professional Skills in Nutrition, 6. the Science of Human
Nutrition (adapted for the Pacific), and 7. Lifespan Nutrition. One more course,
Practicum in Childhood Obesity Prevention, is planned to be developed in
2017 for delivery in summer 2018. In summer 2016 the following courses
were offered: Culture and Child Health in the Pacific, Childhood
Anthropometric and Dietary Assessment Field Techniques, and the Science of
Human Nutrition (adapted for the Pacific). A total of 102 students enrolled in
these courses. In summer 2017 the following courses are planned to be
delivered: 1. Foundations of Childhood Obesity Prevention in the Pacific, 2.
Culture and Child Health in the Pacific, 3. Childhood Anthropometric and
Dietary Assessment Field Techniques, 4. Childhood Health and Monitoring in
the Pacific, 5. Applied Professional Skills in Nutrition, 6. the Science of Human
Nutrition (adapted for the Pacific), and 7. Lifespan Nutrition. Child Health in
the Pacific Undergraduate Summer Fellowship Program (CHAP) A new
training program funded through USDA's ELI grant program was awarded to
the CHL Team which started in spring 2016, providing scholarships for
undergraduate summer training (CHAP). In summer 2016 10 students
enrolled in CHAP from a new partner Chaminade University (Honolulu [2] and
Chuuk [2]), and from Northern Marianas College (2), University of Guam (2),
and the University of Hawai'i at Manoa (2). These students took 2 of the CHL
SI courses (Childhood Anthropometric and Dietary Assessment Field
Techniques and the Science of Human Nutrition (adapted for the Pacific)) in
addition to completing standardization training in anthropometry and a
mentored field experience. Ten students are expected to enroll in summer
2017 from Chaminade University (Honolulu campus only [1]), Northern
Marianas College (3), University of Guam (4), and the University of Hawai'i at
Manoa. In addition, CHL has obtained applied to be a USDA Hatch multistate
project - CHL Network (CHLN) and has been recently approved. This project
will assist us to maintain our landgrant base and collaboration to support the
CHL coalition. How have the results been disseminated to communities of
interest?The CHL final community reports are a comprehensive compilation of
all data collected by CHL. Report one has been completed and provides all
baseline results to all 11 jurisdictions, while report 2 will focus primarily on the
intervention results and changes which occurred in the Intervention
jurisdictions' communities only. Report one provides frequencies and
percentages of all data collected from our communities at baseline; including
information on breast feeding, food security, and culture to name a few. The
Community Assessment Toolkit (CAT), Food Cost Survey as well as
information on the CHL Trainees is included. Information is community
specific for the Intervention jurisdictions and State Specific for the FAS. The
reports have been presented to community partners. In addition, the reports
are available to download from the CHL web site. Report 2 will contain
information on CHL intervention effects and community level information on
changes in the environment (CAT data), anthropometric measures, and target
behaviors. This data will be made available on the CHL web site can be used
to make relevant policy and program changes throughout the region. What do
you plan to do during the next reporting period to accomplish the goals?While
this is the final reporting period, we will continue to maintain the CHL website
as a place of communication.

IMPACT: 2011/04 TO 2017/03
What was accomplished under these goals? This year the CHL Program
focused on data entry and analysis and writing. A web based manuscript and
data request/proposal submission system has been implemented allowing
information sharing and approval of CHL related publications, presentation,
and data use. The CHL Training program is working to further develop
curriculum into a sustainable CHL summer institute academic program to be
delivered virtually. Continued updates have been made to the CHL computer
server, which is used to maintain communication and store data across all
CHL jurisdictions. The CHL prevalence study was conducted among children
in 51 communities in United States Affiliated Pacific (USAP) jurisdictions of:
Hawai'i, Alaska, Commonwealth of the Northern Mariana Islands, Guam,
American Samoa, Palau, Republic of the Marshall Islands (RMI), and 4
Federated States of Micronesia (Pohnpei, Yap, Kosrae, Chuuk) between 2012
and 2015. Cross-sectional measurements of weight, height, and Acanthosis
Nigricans (AN) in 5775, 2 to 8 years old found the prevalence of obesity to be
14.0%, overweight 14.4%, healthy weight 68.9%, and underweight 2.6%. The
prevalence of obesity washigher in males (16.3%) than females (11.6%),
higher among 6 to 8 years old (16.3%) than 2 to 5 years old (12.9%), highest
in American Samoa (21.7%), and absent in RMI. In total, 4.7% of children had
AN, with no sex difference, higher in 6 to 8 years old (6.8%) than 2 to 5 years
old (3.5%) and highest in Pohnpei (11.9%), and absent in Alaska. Obesity was
highly associated with AN (odds ratio=9.25, 95% confidence interval=6.69-
12.80), with the strongest relationships among Asians, followed by Native
Hawaiians and Pacific Islanders (NHPI). Obesity, age, and Asian and NHPI
race were positively associated with AN (Novotny R et al. 2016). Twenty
students completed the CHL-delivered training program consisting of the
following CHL seminar courses: 1. Foundations of Obesity in the Pacific
(a.k.a. Obesity 101); 2.Evidence-Based Approaches and Practices in
Childhood Obesity Prevention; 3. Childhood Obesity Prevention: Community
Engagement and Capacity Building in the Pacific; and, 4. Using Policy and
Advocacy in Preventing Childhood Obesity. Nine students have graduated
with another six expected to graduate in Spring 2017. Two are on track to
graduate in Spring 2018, two have an unknown graduation date, and one has
two semesters to completion and is currently working. Students' focal areas
included public health, nutrition, food science, and agricultural systems. Of the
students that graduated: two have taken instructor/faculty positions at the
University of Guam; one student from Guam passed the Registration
Examination for Dietitians; one is the Health Education Manager at a
community health center in Hawaii; one is working at the University of Hawaii
Cancer Center; one is working for the Ministry of Health in Republic Of
Marshall Islands; one student from Alaska is working at the Center for Alaska
Native Health Research and the other one is looking for a position; and two
are continuing their education (medical school, from Hawaii, and International
Sports Certificate program, from Pohnpei). The medical school student was
awarded a Native Hawaiian Health Scholarship for her second year. For
objective 3, a data entry system has been developed with the Cancer Center
to enter food and activity logs (FAL) and the community assessment tools
(CAT). All FAL and CAT data entry has been completed for all of CHL.
Preliminary analysis on 24 month data related to diet, and built environment
resources for food and physical activity has been completed. We are in the
process of compiling final community reports, which include the CHL program
intervention effects and comparison of baseline and 24 month measures for
the CHL target behaviors and obesity related outcomes in the five intervention
jurisdictions. These data systems will inform future data management,
monitoring and evaluation. A program sustainability activity has been the
continuation of Anthropometric Standardization Training across the CHL
regions, at the request of Health departments, Headstart programs and other
grant programs, in partnership with CHL Team members and the Pacific
Island Health Officers Association (PIHOA). Through these trainings we are
increasing the capacity of the region to locally measure and monitor obesity
and other anthropometric measurements. For objective 4, a total of 1,130
activities were implemented during the CHL intervention. Of those activities 86
addressed "Reviewing Assessment Data on Policy and the Physical
Environment related to the 6 CHL behaviors"; 405 activities focused on
"Partnering and Advocating for Environmental Change"; 372 activities
"Promoted the CHL Message"; and 264 activities related to "Training
Trainers". Jurisdictions submitted intervention six months post-intervention
reports to indicate which activities were sustained by the communities. Of the
20 intervention activities, 19 were sustained in at least one community. Eight
of the 20 activities were sustained by five or more intervention communities
with all communities sustaining at least three activities. The optimized
communities' plan consisted of eight most successful activities that were
implemented in the delayed optimized communities from June through
December 2015 with the exception of communities in CNMI. CNMI postponed
conducting community activities for four months due to Super Typhoon
Souledor which affected 90% of Saipan in August 2015. Seven of the nine
optimized communities implemented six or more of the activities with two
communities implementing three of the activities. Activities are still continuing
in many of the CHL communities. For example: Training for childcare
providers is continuing in Alaska, CNMI, Guam, and Hawaii and the promotion
of CHL messages and materials are being incorporated into web sites in
Alaska and on buses in American Samoa. These are in addition to the
changes to the environment which have ongoing impacts in the communities
such as: improvements made to playgrounds in CNMI, Gaum, and Hawaii;
purchases of play equipment for classes in Alaska; and the establishment of
school gardens in American Samoa, CNMI, Guam, and Hawaii. The
continuation of these activities is mainly due to the partnerships established in
communities during the CHL intervention. Working with coalitions, pre-
schools, departments of education, non-profits, other government agencies,
other college/university departments, extension services, elected officials,
businesses, and key community leaders tell of the broad reach the CHL
program had into the communities. For objective 5, controlling for age and sex
of 2-10 year old children and accounting for the randomization units and
clustering, the CHL intervention communities had significant changes in the
following variables compared to control communities: prevalence of
acanthosis nigricans (change of -0.1% vs +0.2%), child overweight plus
obesity (-3.0% vs +1.7%), child waist circumference (+0.2cm vs +9cm), and
daily screen time (-2.4min vs +3.0mins). Accelerometry and food related
variables (fruit and vegetable intake, sugar sweetened beverage intake, water
intake) are still being analyzed. For objective 6, in Guam, in partnership with
the Department of Education and Non Communicable Disease Coalition the
CHL teamsupports efforts for the Early Start, Fit for Life Initiative with the goal
of establishing a policy to provide students with the minimum of 25 minutes of
instructional PE and Health each day. CNMI is in the process of incorporating
childcare wellness policies in childcare facility regulations. Hawaii is
continuing to work on establishing nutrition guidelines in childcare regulations
and CHL data is being used to support legislation for a one cent per ounce fee
on sugar-sweetened beverages. An adolescent health screening legislation
was successfully passed in Hawaii.

PUBLICATIONS (not previously reported): 2011/04 TO 2017/03

1. Type: Journal Articles Status: Published Year Published: 2016 Citation:
Esquivel, M.K., Fialkowski, M.K., Aflague, T., and Novotny, R. 2016. Engaging
Head Start Teachers on Wellness Policy Implementation to Improve the
Nutrition and Physical Activity Environment in Head Start Classrooms: A
Qualitative Study of the Children?s Healthy Living Program (CHL) in Hawai?i.
J Family Med Community Health 3(5): 1094
2. Type: Journal Articles Status: Published Year Published: 2016 Citation:
Nigg, C.R., Ul Anwar, M.M., Braun, K.L., Mercado, J., Fialkowski, M.K., Areta,
A., Belyeu Camacho, T., Bersamin, A., Leon Guerrero, R., Castro, R.,
DeBaryshe, B., Vargo, A.M., Braden, K.W., Novotny, R. 2016. A review of
promising multicomponent environmental child obesity prevention intervention
strategies by the children?s healthy living program. Journal of Environmental
Health. 2016; 79(3): 18-26
3. Type: Journal Articles Status: Published Year Published: 2016 Citation:
Mikkelsen, B.E., Novotny, R., and Gittelsohn, J. 2016. Multi-Level, Multi-
Component Approaches to Community Based Interventions for Healthy
Living?A Three Case Comparison. Int. J. Environ. Res. Public Health. 2016;
13:1023. doi:10.3390/ijerph13101023
4. Type: Journal Articles Status: Published Year Published: 2016 Citation:
Novotny, R., Li, F., Fialkowski, M.K., Bersamin, A., Tufa, A., Deenik, J.,
Coleman, P., Leon Guerrero, and R., Wilkens, L.R. 2016. Prevalence of
obesity and acanthosis nigricans among young children in the children?s
healthy living program in the United States Affiliated Pacific. Medicine (2016)
95:37(e4711). http://dx.doi.org/10.1097/MD.0000000000004711
5. Type: Journal Articles Status: Published Year Published: 2016 Citation:
Yamanaka, A., Fialkowski, M., Wilkens, L., Li, F., Ettiene, R., Fleming, T.,
Power, J., Deenik, J., Coleman, P., Leon Guerrero, R., and Novotny, R. 2016.
Quality assurance on data collection in the multi-site community randomized
trial and prevalence survey of the children?s healthy living program. BMC
Research Notes. 2016; 9:432. doi:10.1186/s13104-016-2212-2
6. Type: Journal Articles Status: Published Year Published: 2016 Citation:
Esquivel, M.K., Nigg, C., Fialkowski, J.K., Braun, K., Li, F., and Novotny, R.
2016. Influence of teachers? personal health behaviors on operationalizing
obesity prevention policy in Head Start preschools: A project of the Children?s
Healthy Living Program (CHL). Journal for Nutrition Education and Behavior.
2016; 48 (5)
7. Type: Conference Papers and Presentations Status: Published Year
Published: 2016 Citation: Novotny, R., Bersamin, A., Leon Guerrero, R.,
Coleman, P., Fleming, T. CHL multilevel multicomponent intervention for child
health in native communities in the US affiliated Pacific. He Huliau, October
13,2016
8. Type: Conference Papers and Presentations Status: Published Year
Published: 2016 Citation: Fialkowski, M.K., Leon Guerrero, R., Bersamin, A.,
Deenik, J., Flemming, T., Coleman, P., 2016. Novotny, R. 2016. Unanticipated
Capacity Building in the Children?s Healthy Living Multi-level and Multi-site
Integrated Coordinated Agricultural Program in the Pacific. He Huliau. October
13, 2016.
9. Type: Conference Papers and Presentations Status: Published Year
Published: 2016 Citation: Novotny, R., Bersamin, A., Leon Guerrero, R.,
Coleman, P., and Fleming, T. 2016. Year 5 of the Children?s Healthy Living
Program for Remote Underserved Minority Populations of the Pacific Region
(CHL) Society for Nutrition Education and Behavior 2016.
10. Type: Conference Papers and Presentations Status: Published Year
Published: 2016 Citation: Fialkowski, M.K. 2016. The Childrens Healthy Living
Summer Institute: An Opportunity for Sustained Pacific Workforce Capacity
Development, North American College and Teachers of Agriculture National
Association of College Teachers Association 2016.
11. Type: Conference Papers and Presentations Status: Published Year
Published: 2016 Citation: Butel, J., Wilkens, L., Nigg, C., Braun, K., Li, F.,
Bersamin, A., Leon Guerrero, R., Coleman, P., Fleming, T., Cagasan, M., and
Novotny, R. 2016. Does dose mediate the Effect of Multilevel, Multisite
Intervention Activities on Childhood Obesity Outcomes in The Childrens
Healthy Living (CHL) Program. Hawaii Public Health Association October 13,
2016.
12. Type: Conference Papers and Presentations Status: Published Year
Published: 2016 Citation: Yonemori, K., Boushey, C. Novotny, R., Fialkowski,
M., Wilkens,L., Bersamin, A., Leon Guerrero, R., Coleman, P., and Ennis, T.
2016. Collecting wrappers, labels, and packages to enhance dietary
information from food records among children 2-8 years participating in the
Childrens Healthy Living Program (CHL) for remote underserved minority
populations in the Pacific region. National Nutrient Data Bank Conference.
13. Type: Conference Papers and Presentations Status: Published Year
Published: 2016 Citation: Fialkowski, M.K., Yamanaka, A., Fleming, T.,
Coleman, P., Leon Guerrero, R., and Novotny, R. 2016. Changes in
Community Readiness in the Children?s Healthy Living (CHL) Program in
Remote Underserved Minority Populations of the Pacific. San Diego, CA.
Society for Nutrition Education and Behavior. 7/30-8/2/2016.
14. Type: Conference Papers and Presentations Status: Published Year
Published: 2016 Citation: Fialkowski, M.K., Sandlin, M., Hattori-Uchima, M.,
Turner, H., Coleman, P., and Novotny, R. 2016. Child Health Assessment in
the Pacific (CHAP) Summer Fellowship Program. San Diego, CA. Society for
Nutrition Education and Behavior Conference. 7/30-8/2/2016.
15. Type: Conference Papers and Presentations Status: Published Year
Published: 2016 Citation: Novotny, R., Li, F., Bersamin, A., Leon Guerrero, R.,
Coleman, P., Fleming, T., Deenik, J., and Wilkens, L. 2016. Prevalence of
Stunting and relationship to Obesity in the US affiliated Pacific- Childrens
Healthy Living study. Experimental Biology 2016. April 2, 2016.
16. Type: Conference Papers and Presentations Status: Published Year
Published: 2016 Citation: Bersamin, A. Power, J., Uliassi, D., and Philip, J.
2016. The Prevalence of Obesity in Alaska Native Children: Results from the
Children?s Healthy Living Program. Experimental Biology 2016.