Towards a Healthier Future in the Northern Mariana Islands: Understanding Influences of Diet and Physical Activity on Overweight and Obesity of Young Children
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2024
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Abstract
Childhood overweight or obesity (OWOB) has many adverse health consequences throughout the life course. A group of islands where childhood OWOB is of great concern is the U.S. Commonwealth of the Northern Mariana Islands (CNMI), an archipelago located in the northwestern region of the Pacific. Various sociocultural and environmental influences have been found to affect childhood OWOB and related health behaviors, including diet and physical activity. Determinants of childhood OWOB found in the Pacific can be seen across the socioecological levels (i.e. individual, interpersonal, organizational, community, and policy). Very little research has been conducted to understand the sociocultural and environmental determinants of childhood OWOB specific to the CNMI. The objective of this dissertation is to fill this gap in the literature by describing the dietary patterns and physical activity behaviors of children in the CNMI and assess the sociocultural and environmental factors contributing to health behaviors, which ultimately determine weight status. Three study aims were examined to answer the central hypothesis developed from the Institute of Medicine’s framework on childhood obesity prevention – availability and/or quality of health-promoting foods and spaces for children’s activity in communities influences childhood diet and physical activity in remote Pacific islands such as the CNMI, which in turn determine childhood weight status. Aim 1 examined differences in dietary patterns and physical activity behaviors among CNMI children ages 2 to 8 years old of varying weight status and demographics using baseline data collected from the Children’s Healthy Living (CHL) program. Diet and physical activity data were assessed in terms of U.S. health indices using the 2005 Healthy Eating Index (HEI-2005), screen time, and metabolic equivalents (METs). Weight status was assessed using body mass index (BMI) category and BMI z score, with cut points as defined by the U.S. Centers for Disease Control and Prevention (CDC), removing underweight. This study found 1 in 3 CNMI children were OWOB, with the older age group of 6 to 8 years old having higher OWOB than 2- to 5-year-olds. Diet quality of CNMI children needs improvement, with a HEI-2005 total score of 60.9 out of 100. Eighty percent of children exceeded the recommended amount of screen time, averaging about 5 hours of screen time per day. Almost 60% of children had the recommended amount of physical activity (1 hour or more of daily moderate to vigorous activity), averaging 1.3 hours of moderate activity per day, but only 0.07 hours of vigorous activity per day. Significant differences in HEI-2005, screen time, MET hours, and BMI weight status were found by age group (2-5 years old and 6-8 years old), race and ethnicity [Northern Marianas Descent (NMD), Other Pacific Islander, Filipino, and Other race and ethnicity], and CNMI village residence (Kagman, Koblerville/San Antonio, Oleai, and Tanapag/San Roque). Children who ate any fruits or vegetables classified as traditional in the CNMI also had higher HEI-2005 total scores than those who ate none. In statistical models, no association was found between HEI-2005 and MET hours with BMI z score or OWOB in the total sample of children. However, in subgroup analysis stratifying age groups, an inverse association was found between HEI-2005 and BMI z score among the 6- to 8-year-old children only, showing higher quality diet among 6- to 8-year-olds with lower BMI z score.
Aim 2 assessed how the food and physical activity environments in CNMI communities affect diet, physical activity behaviors, and weight status of children using data collected from CHL’s Community Assessment Toolkit (CAT) surveys, which assessed food and physical activity environments using separate scoring systems. No significant associations were found between the food and physical activity environments and health behaviors (diet and physical activity) or weight status. Despite this, differences in environmental components were found by community, store type, and physical activity space facility setting, demonstrating how these environments can be improved.
Aim 3 identified perceived facilitators and barriers that allow or inhibit parents/caregivers to promote healthy behaviors for children in the CNMI using a qualitative method and community-based participatory research approach called Photovoice. Parents/caregivers of children ages 2 to 8 years old were asked to take photos in their communities and homes of what they believed to be facilitators or barriers of healthy living for their children. Photos were discussed through focus groups that generated ideas for action to improve the food and physical activity environments in the CNMI. Seven (7) overarching themes of facilitators and barriers were found – Availability & Access to Food, Physical Activity Spaces, Activity Choices, Environmental Resources, Norms, Affordability of Food & Activities, and Family Influences.
These results did not provide enough concrete evidence to support this dissertation’s central hypothesis that availability and quality of health-promoting foods and activity spaces in CNMI communities influence childhood diet and physical activity, which in turn would influence childhood weight status. Descriptive findings from Aims 1 and 2 and qualitative findings from Aim 3 suggest that there are some differences in the availability and quality of health-promoting foods and activity spaces in addition to differences in child dietary patterns and physical activity behaviors between CNMI communities. This dissertation also revealed the significant influence of individual level factors, such as age and race and ethnicity, on health behaviors and weight status. These findings suggest the need to expand data collection in the CNMI and for more robust methods to assess the association between environmental factors and individual level health behaviors and outcomes, particularly in smaller, more homogenous populations.
From these findings, implications for public health practice include increasing interventions that focus on the transition into elementary school, supporting and expanding local sustainable agriculture, and creating policies and programs to improve food store outlets and physical activity spaces in the CNMI. Future research is needed to improve and expand methods for studying the food and physical activity environments, further examine traditional food intake of children, and continue surveillance on child diet, physical activity, and weight status.
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Public health, Diet, Northern Mariana Islands, Nutrition, Pacific, Pediatric Obesity, Physical Activity
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219 pages
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