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Summer and Follow-Up Interventions to Affect Adiposity with Mothers and Daughters

      Background

      The development of effective obesity interventions to reduce adiposity indicators in Latina girls is a public health priority because of their increased risk for becoming overweight. Research indicates that the summer season may be a critical time to intervene because summer exacerbates children's risk for excessive weight gain and increased body fat development.

      Purpose

      The purpose of this study was twofold: (1) to determine if summer and follow-up interventions reduce adiposity in Latina girls; (2) to assess if such interventions reduce adiposity in Latina girls after controlling for their mothers' adiposity measures.

      Design

      This study had a non-experimental (one-group pre- and multiple post-intervention assessment) design. Following a 4-week healthy-lifestyle summer program, each mother–daughter pair participated in 12 weekly follow-up sessions.

      Setting/participants

      The sample consisted of 61 pairs of Latina girls and their mothers (N=122). Daughters' average age was 10.9 years (±1.6 years) and mothers' average age was 38.0 years (±1.6 years). All daughters and 92% of the mothers were categorized as overweight/obese.

      Main outcome measures

      Percent body fat (%BF), abdominal fat, and height and weight measurements to calculate BMI were conducted at pre-intervention (M1 [baseline]) and three post-intervention time points (M2 [Month 2]; M3 [Month 3]; and M4 [Month 6]). Paired sample t-tests were used to assess the differences in adiposity among the daughters from M1 to M4. Repeated-measures ANCOVA tests were used to control for mother's adiposity.

      Results

      Reductions of %BF (p<0.001); abdominal fat (p<0.05); and BMI (p<0.001) at M2 were found for the summer intervention, but no effects were found at M4. Maternal %BF, abdominal fat, and BMI did not have an impact on the daughters' adiposity indicators.

      Conclusions

      Results from this study revealed that a summer intervention appears to be effective in reducing adiposity in Latina girls, but the follow-up sessions did not result in sustaining continued reductions. Maternal measures did not influence their daughters' adiposity measures.

      Introduction

      Childhood obesity is a major health problem in the U.S.
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      The development of interventions to combat childhood obesity has become a public health priority. Recent studies indicate that physical activity interventions may be effective in reducing body fat (percent body fat and abdominal fat) among children.
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      particularly those targeting the reduction of adiposity in Latino children.
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      Increasing the physical activity of Latino children is a public health priority, given that they are at increased risk for inactivity. Several studies report that Hispanic and non-Hispanic black children are less active than non-Hispanic white youth.
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      Complicating Latino children's inactivity is their high rate of becoming overweight.
      • Ogden C.L.
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      • Lamb M.M.
      • Flegal K.M.
      Prevalence of high body mass index in U.S. children and adolescents, 2007–2008.
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      • Kit B.K.
      • Flegal K.M.
      Prevalence of obesity in the U.S., 2009–2010 NCHS data brief, no 82.
      The lowest levels of moderate- to vigorous-intensity physical activity (MVPA) have been observed among overweight Hispanic girls.
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      Despite extensive evidence indicating parental influence on children's physical activity
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      few family-based physical activity and obesity interventions have been conducted among children and adolescents.
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      have suggested a novel approach to family-based intervention that targets natural interactions that occur across generations of women within a family, such as mother–daughter pairs who share similar habits and beliefs. These kinds of interventions may be synergistic and cost effective in the prevention and treatment of obesity.
      Research also indicates that the summer season may be a critical time to intervene because summer exacerbates children's risk for excessive weight gain and increased body fat development.
      • Gillis L.
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      • Bar-Or O.
      Relationship between summer vacation weight gain and lack of success in a pediatric weight control program.
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      Childhood body mass index gain during the summer versus during the school year.
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      • et al.
      The effect of school on overweight in childhood: gain in body mass index during the school year and during summer vacation.
      Non-Hispanic black and Hispanic children, as well as overweight children, seem to be particularly vulnerable to increases in weight gain and body fat during this time.
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      • et al.
      The effect of school on overweight in childhood: gain in body mass index during the school year and during summer vacation.

      Rodriguez AX, Olvera N, Leung P, et al. Association between the summer season and body fatness and aerobic fitness among Hispanic children. J Sch Health. Accepted.

      • Carrel A.L.
      • Clark R.R.
      • Peterson S.
      • Eickoff J.
      • Allen D.B.
      School-based fitness changes are lost during the summer vacation.
      Despite evidence indicating that summer is a critical period for increased adiposity in minority children, a paucity of obesity interventions targeting minority children have been conducted during this time period.
      Only two pilot studies have been identified. A study by Baranowski et al.
      • Baranowski T.
      • Baranowski J.
      • Cullen K.
      • et al.
      The Fun, Food, and Fitness Project (FFFP): the Baylor GEMS pilot study.
      revealed a nonsignificant trend in reduction of BMI and body fat in African-American girls (aged 8–10 years) who participated in an 8-week summer obesity intervention followed by 12 weekly follow-up sessions. Olvera et al.
      • Olvera N.
      • Scherer R.
      • McLeod J.
      • et al.
      BOUNCE: an exploratory healthy lifestyle summer intervention for girls.
      reported reductions in BMI, waist circumference, MVPA, and fitness in minority girls (aged 9–14 years) who participated in an intense 3-week intervention named BOUNCE (Behavior Opportunities Uniting Nutrition Counseling and Exercise). The BOUNCE intervention included primarily a group-structured exercise component followed by behavioral counseling and nutrition education with limited parental involvement. Overall, findings from these two studies suggest that the summer season offers a promising time for reducing adiposity in minority children.
      Building on prior work, the purpose of the present study was twofold. The first goal was to determine if there is a reduction in adiposity indicators in Latina girls after their participation in an intense, 4-week BOUNCE summer intervention followed by 12 weekly ReBOUNCE follow-up sessions. The rationale for a 4-week BOUNCE summer intervention is supported by a study by Kellam et al.,

      Kellam SF, Olvera N, Liu J, Smith DW, Leung P. Effect of exercise dosages on adiposity indices in overweight girls. Salud Publica de Mexico. Accepted.

      which compared a 3-week versus 4-week BOUNCE intervention and found that the latter intervention was more effective in eliciting minutes of MVPA than a 3-week BOUNCE intervention. The effectiveness of 12 weekly follow-up sessions was also assessed, because research has shown that booster sessions after an intervention are beneficial to sustain behavior change.
      • Stice E.
      • Shaw H.
      • Marti C.N.
      A meta-analytic review of obesity prevention programs for children and adolescents: the skinny on interventions that work.
      The second goal was to assess if the BOUNCE intervention reduces adiposity in Latina girls, after controlling for their mothers' adiposity measures.
      In the current study, the following research questions were asked: (1) What changes in adiposity indicators (percent body fat, abdominal fat, and BMI) are observed in Latina girls participating in the BOUNCE intervention across four time points conducted at pre-intervention baseline (M1) and three post-intervention time points (M2 [Month 2]; M3 [Month 3]; and M4 [Month 6]); (2) Will the BOUNCE intervention reduce adiposity indicators in Latina girls after controlling for their mothers' adiposity measures?

      Methods

      Study Design

      This is a non-experimental single-group study with data collected at baseline and later again at 2, 3, and 6 months.

      Setting and Participants

      The sample consisted of 61 pairs of Latina girls and their mothers (N=122) recruited across two different cohorts (2009 and 2010; Figure 1). The daughters' mean age was 10.9 years ± 1.6 years and the mothers' mean age was 38.0 years ± 6.5 years. Study inclusion criteria consisted of girls being (1) aged 9–14 years; (2) self-described as Hispanic/Latina; (3) overweight (BMI ≥85th percentile) or obese (BMI ≥95th percentile); and (4) free from physical activity restrictions that would limit active participation in the current study as certified by a medical professional.
      Figure thumbnail gr1
      Figure 1Timeline of intervention and data collection
      BOUNCE, Behavior Opportunities Uniting Nutrition Counseling and Exercise; ReBOUNCE, 12 weekly follow-up sessions to BOUNCE
      Participants were recruited primarily through referrals by school nurses, teachers, and community outreach coordinators. Before baseline measurements, daughters were asked to sign assent forms and mothers were asked to sign a consent form. The University of Houston Committee for the Protection of Human Subjects approved the research protocols and assent/consent forms.

      Intervention

      Summer intervention

      The 2009 and 2010 BOUNCE summer interventions were delivered to daughters from 9am to 5pm, Monday through Friday, during the entire month of July. Each BOUNCE day commonly consisted of three to four exercise sessions, one nutrition education session, one behavioral counseling session, as well as two healthy snacks (100 calories each) and a healthy lunch (500 calories). A typical BOUNCE day started with a flexibility session followed by a sports skills session or games session. Lunch and a nutrition lesson were then followed by a traditional fitness session. Following a counseling session, the day would end with a dance session.
      • Olvera N.
      • Scherer R.
      • McLeod J.
      • et al.
      BOUNCE: an exploratory healthy lifestyle summer intervention for girls.
      • Olvera N.
      • Graham M.
      • McLeod J.
      • Kellam S.F.
      • Butte N.
      Promoting moderate-vigorous physical activity in overweight minority girls.
      For a list of BOUNCE summer topics, see Table 1.
      Table 1Description of the BOUNCE summer intervention topics
      ExerciseCounselingNutrition
      Week 1
       Know Your Body: Muscle ManiaSelf-Esteem: All About Me!Introduction to the BOUNCE Nutrition
       Benefits of ExerciseBody Image: How Do I Look!Basic Terms and Food Function
       Importance of StretchingBody Image: I Am Special?Food Label I
       Rate of Perceived ExertionTreating Yourself Like a QueenHealthy Snacking
       Enjoyment of Physical ActivityGoal Setting IGrocery Shopping
      Week 2
       Tips to Get Moving at Commercial BreaksMy FamilyPortion Sizes
       Goal SettingFamily Health SupportSources of Calories—Fat
       Excuses for ExercisingMedia AdvertisementFood Label II
       Reward YourselfGoal Setting IIFood Demo—Fruit Yogurt Parfait
       Heart Rate MonitoringFamily CommunicationHealthy Breakfast
      Week 3
       Tips to Get Moving at HomeMapping Out FeelingsEnergy Balance
       Energy BalancePositive FocusDining Out
       Components of Physical FitnessBullyingAll About Sugar
       Get F.I.TLife Skills: MoneyFood Demo—Fruit Snacks
       Enlisting Social SupportWinning Attitude/Fear of FailureLet's Add Color to Meals
      Week 4
       Identification of Resources to Increase Physical ActivityI Am a LeaderFruits and Veggies Challenge
       Eating for ExerciseEnlisting Social SupportHidden Fats
       Walking MapsMy Healthy Plan IEnlisting Social Support
       My Exercise PlanMy Healthy Plan IIMenu Planning
       My Exercise PlanTalent ShowFood Demo—Wrap
      BOUNCE, Behavior Opportunities Uniting Nutrition Counseling and Exercise
      Because the BOUNCE summer intervention is primarily an exercise intervention, the next section expands on the BOUNCE exercise component. The BOUNCE exercise program consisted of group physical activity sessions of varied intensity based on Ridley's compendium for energy expenditure in youth (light=2 METs; moderate=3–5 METs; vigorous=≥6 METs; Table 2).
      • Ridley K.
      • Ainsworth B.E.
      • Olds T.S.
      Development of a compendium of energy expenditure for youth.
      Each of the BOUNCE cohorts received 3600 minutes (60 hours) of facilitated group exercise over the 4 weeks. This total equals 900 minutes (15 hours) per week or 180 minutes (3 hours) per day. The BOUNCE exercise program was standardized and included approximately a 5-minute warm-up, 20–50 minutes of light- to vigorous-intensity physical activity, and a 5-minute cool-down. In addition to engaging in various physical activities, participants received handouts on the exercise benefits, components of a healthy lifestyle, and strategies to overcoming barriers to being physically active.
      Table 2Four-week BOUNCE summer exercise sessions
      CategoryCohort 1, 2009Cohort 2, 2010Total exposure
      Flexibility
       Ballet0120120
       Budokon1200120
       Pilates180120300
       Yoga240330570
      Sports skills
       Kickball6060120
       Basketball300300600
       Soccer300300600
       Self-defense240240480
       Track and field0300300
       Tennis1200120
       Volleyball60120180
      Games
       Survivor7575150
       Amazing race7575150
       Relays30030
      Traditional Fitness
       Step aerobics180240420
       Spinning420420840
       Boot camp6060120
       Circuit training240240480
       Core training000
       Latin aerobics1200120
       Kickboxing240240480
      Dancing
       Rumba Zumba180180360
       Hip-hop180180360
       Cheerleading1800180
       Modern dance000
      All activities total360036007200
      Note: Values are minutes.
      BOUNCE, Behavior Opportunities Uniting Nutrition Counseling and Exercise
      During the BOUNCE summer intervention, mothers participated in 2-hour weekly sessions where they received nutrition education, exercise training, and parenting strategies on how to support their daughters' healthy lifestyle program at home. A dietitian, an exercise physiologist, and a developmental psychologist led maternal sessions in English or Spanish. A detailed description of the BOUNCE intervention theoretic foundation has been previously published.
      • Olvera N.
      • Knox B.
      • Scherer R.
      • et al.
      A healthy lifestyle program for Latino daughters and mothers: the BOUNCE overview and process evaluation.
      Bandura's social cognitive theory (SCT)
      • Bandura A.
      Social foundations of thought and action: a social cognifitive theory.
      served as the foundation for the intervention design and included the interplay of personal, behavioral, and social and environmental factors. The personal factors included (1) skills-based sessions to develop ability to perform the behavior when desired (e.g., learning a new motor skill or yoga pose); (2) self-efficacy to perform a specific behavior; (3) expectations of positive outcomes (e.g., having more energy and enjoyment after exercise); and (4) attitudes toward exercise and eating. The behavioral factors included (1) self-control by setting behavioral goals; (2) monitoring one's own behavior; and (3) rewarding one's self when goals are achieved. The social and environmental factors consisted of (1) positive role modeling that provides a supportive environment at home and (2) identification of environmental barriers to exercise.

      Follow-up sessions

      After the 4-week BOUNCE summer program, the Mother–daughter dyads participated in 12 weekly ReBOUNCE afterschool aerobic intervention sessions in the fall (Figure 1). The weekly sessions were 1.5 hours in duration and included physical activity and supplemental information as requested by mothers. The physical activity component was 60 minutes in duration and consisted of a 5-minute warm-up, a 50-minute fitness class, and a 5-minute cool-down. The supplemental information included 30 minutes of nutrition education or parenting training, or sometimes both depending on the topic. Follow-up topics are described in Table 3.
      Table 3Weekly ReBOUNCE follow-up sessions
      WeekExerciseCounselingNutrition
      1Step aerobicsWelcome Back

      Review Progress
      2Salsa dancingGoal Setting: ExerciseGoal Setting: Nutrition
      3Boot campSavvy Grocery Shopping
      4Dodgeball or kickballRaising Children Within Two CulturesFood Demo with BOUNCE Chef
      5Spinning/walkingShall We Dance: Communication Part I
      6SwimmingShall We Dance: Communication Part II
      7Step aerobicsDealing with Halloween

      Food Demo with BOUNCE Chef
      8Salsa dancingParenting Strategies to Promote Healthy Eating and Exercise
      9TriathlonTriathlonTriathlon
      10Dodgeball or kickballParenting Strategies to Raise Confident ChildrenFood Demo with BOUNCE Chef

      Holidays Tips
      11Spinning/walkingHealthy Plan
      12SwimmingBOUNCE PartyBOUNCE Party
      BOUNCE, Behavior Opportunities Uniting Nutrition Counseling and Exercise; ReBOUNCE, 12 weekly follow-up sessions to BOUNCE
      Instructors certified by the nationally recognized Cooper Institute led the BOUNCE and ReBOUNCE exercise sessions, which were held at a gymnasium and dance studio located on a university campus and at a community park. Incentives were provided at each BOUNCE and ReBOUNCE session for participants who achieved their weekly goals. These incentives consisted of small low-cost items such as pencils, pens, journals, stickers, and bracelets. At the end of the summer and follow-up sessions, $20 gift cards and exercise equipment (e.g., soccer balls and basketballs, jump-ropes, and yoga mats) were provided to the top three participants who met their goals.

      Measures

      Data were collected in two cohorts during 2009 and 2010 and four measurement time periods (M1–M4; Figure 1).

      Demographic survey

      Mother and daughter participants answered a short survey consisting of questions about age, educational status, date and place of birth, and self-described ethnicity.

      Attendance

      Daily attendance for each participant was used to calculate the average percentage attendance based on the number of days participants attended per week divided by the number of days that the BOUNCE interventions were offered and multiplied by 100. Participants who came late or left early were recorded as having attended that day. In addition, girls were asked about their participation in other structured summer programs aside from BOUNCE.

      Adiposity indicators

      Percent body fat (%BF) was obtained from a foot-to-foot bioelectric impedance assessment using a Tanita TBF 310 series scale. Measurements of %BF were conducted at the time of the participants' morning arrival during the testing days. A research assistant asked each participant to place her bare feet on the silver foot pads and to stand still while the scale determined the %BF.
      The research assistant first entered participant's height, age, gender, and body type (athletic/non-athletic) into the remote display. The Tanita's definition of an “athletic” person was used: one who is involved in intense physical activity of approximately 10 hours per week. Tanita's athletic definition does not include “enthusiastic beginners” who are making a real commitment to exercising at least 10 hours per week, but whose bodies have not yet changed to require the athletic mode. Thus, “athletic” classification was determined by asking participants if they engage in physical activity of approximately 10 hours per week, or by visually determining if they have an athletic body type. All the BOUNCE participants were classified as non-athletic.
      The Tanita TBF-310 has been found to be a convenient method to assess %BF in groups of children. Children's %BF generated by this scale has been associated with anthropometric measurements (e.g., sum of skinfolds and waist circumference), with intraclass correlation coefficients between 0.90 and 0.95.
      • Kettaneh A.
      • Heude B.
      • Lommez A.
      • Borys J.
      • Ducimetière P.
      • Charles M.
      Reliability of bioimpedance analysis compared with other adiposity measurements in children: the FLVS II Study 2005.
      Other researchers, such as Radley et al.,
      • Radley D.
      • Cooke C.B.
      • Fuller N.J.
      • et al.
      Validity of foot-to-foot bio-electrical impedence analysis body composition estimates in overweight and obese children.
      have suggested using the Tanita TBF-310 to obtain group mean values rather individual values in children. The Tanita TBF-310 has also been validated in women against dual energy radiograph absorptiometry with a correlation coefficient of 0.94.
      • Rubiano F.
      • Nuñez C.
      • Heymsfield S.
      A comparison of body composition techniques.
      Abdominal fat was assessed through waist circumference measurements following guidelines by National Health and Nutrition Examination Survey procedures.
      CDC
      National Health and Nutrition Examination Survey (NHANES): Anthropometry Procedures Manual.
      For this measurement, a spring-gauge, non-elastic flexible measuring tape was placed at a point midway between the participant's lowest rib to the top of the iliac crest at the end of a normal expiration. A research assistant made sure that the tape was comfortable without compressing clothing and was parallel to the floor. Measurements were taken twice, to the nearest 0.5 cm, and the average of the two measurements was recorded as the final value.
      Body weight and height were measured to the nearest 0.1 kg and 0.1 cm, respectively, using a scale (Tanita TBF 310) and a stadiometer (Seca 213). Each participant was told to remove her shoes and socks or any heavy garments before stepping onto the scale. Barefoot height was measured with participants' heels together and toes pointed slightly outward at ∼60 degrees. While participants' arms were at their sides, their shoulders level, and their heels, buttocks, and back of the head touching the vertical backboard, the headpiece was lowered until it firmly touched the crown of the head.
      • Olvera N.
      • Scherer R.
      • McLeod J.
      • et al.
      BOUNCE: an exploratory healthy lifestyle summer intervention for girls.
      • Olvera N.
      • Graham M.
      • McLeod J.
      • Kellam S.F.
      • Butte N.
      Promoting moderate-vigorous physical activity in overweight minority girls.
      BMI was calculated by using standard formula, and values were then used to identify the age- and gender-specific percentile for each child using CDC growth charts. Based on these percentiles, each child was classified as overweight (85th–94th percentile) or obese (≥95th percentile). Using the WHO obesity classification, mothers with a BMI ≤24.9 were considered to be normal weight; overweight with a BMI ≥25.0≤29.9; and obese with a BMI ≥30.

      Data Analysis

      Descriptive statistics including means and SDs were calculated to identify basic characteristics of the data and sample population. Variables were assessed for normality by evaluating skewness and kurtosis. Data were combined across the two cohorts who participated in the 4-week BOUNCE intervention and the 12-week ReBOUNCE follow-up sessions. To detect if the interventions reduced adiposity indicators in Latina girls, changes in %BF, waist circumference, and BMI at M1 (baseline) and post-interventions (M2–M4) were analyzed using paired-sample t-tests. Alpha was set at 0.05. A repeated-measures ANCOVA was used to address the second research question about whether maternal %BF, waist circumference, and BMI (covariates) at M2 have an impact on the daughters' adiposity measures at M2, M3, and M4. All analyses were conducted using SPSS, version 20.0.

      Results

      Baseline Demographic Characteristics of Study Sample

      At baseline (M1), the sample consisted of 61 mother–daughter pairs. Daughters were predominately born in the U.S., whereas a majority of their mothers were from Mexico (Table 4). More than half of the mothers had a high school education. The majority of the mothers reported an annual family income of ≤$30,000. Mothers and daughters had high baseline levels of %BF and abdominal fat, and most of them were classified as obese.
      Table 4Baseline characteristics of study sample (N=61)
      %M (SD)
      DAUGHTERS
      Age (years)10.97 (1.60)
      Country of birth
       U.S.92
       Mexico7
       Central America1
      Body fat
       Percent body fat42.19 (5.76)
       Waist circumference (cm)93.53 (14.58)
       BMI28.87 (6.70)
       BMI ≥85th percentile15
       BMI ≥95th percentile85
      MOTHERS
      Age (years)38.05 (6.52)
      Country of birth
       U.S.31
       Mexico56
       Central America13
      Education
       Elementary/middle school14
       High school42
       Some college30
       College graduate or higher14
      Annual family income ($)
       <10,00018
       10,000–20,00028
       20,001–30,00030
       >30,00024
      Body fat
       Percent body fat40.59 (7.10)
       Waist circumference100.35 (14.64)
       BMI32.63 (7.79)

      Attendance

      Daughters' participation during the 4 weeks of the BOUNCE summer intervention was on average 90% (SD±16%). Conversely, daughters attended the ReBOUNCE sessions less frequently with an average participation of 24% (SD±30%). Reasons for missing ReBOUNCE sessions included competing demands (e.g., tutoring siblings, religious education, school activities); conflicting parent work schedules; and transportation problems. Aside from BOUNCE, the majority of the girls (92%) reported that they did not participate in any other type of program during the summer. Those who reported being involved in an additional summer program participated in YMCA or sport programs sponsored by their church.

      Impact of Interventions on Daughters' Adiposity Indicators

      The change in combined cohorts from M1 to M4 for %BF was a 2.87% point decrease; for waist circumference, a 9.10 cm decrease; and for BMI, a 2.30 decrease (Table 5). Paired-sample t-tests were conducted to evaluate the impact of intervention on lowering %BF, waist circumference, and BMI in Latina girls. Results of the paired-sample t-tests showed decreases in %BF from M1 to M2 (p<0.001) and from M1 to M3 (p=0.019). Also, there were reductions in waist circumference from M1 to M2 (p=0.026), and in BMI from M1 to M2 (p<0.001; Table 6).
      Table 5Mean and SD of daughters' adiposity indicators at M1–M4
      M1 (n=60)M2 (n=56)M3 (n=26)M4 (n=11)
      % body fat42.19 (5.76)38.37 (7.07)39.65
      n=18
       (6.53)
      39.32 (4.17)
      Waist circumference93.53 (14.58)89.38 (15.28)89.71
      n=19
       (16.88)
      84.43 (8.80)
      Height (cm)152.30 (10.38)152.33 (10.30)153.11 (8.09)153.42 (9.46)
      Weight (lb)152.38 (43.15)149.83 (43.27)148.07 (34.79)139.45 (31.83)
      BMI28.87 (6.70)28.76 (5.70)28.80 (5.40)26.57 (3.68)
      Note: M1 = Pre-BOUNCE summer intervention (baseline; June); M2 = Post-1 BOUNCE summer intervention (August; 2 months post-baseline); M3 = Post-2 BOUNCE summer intervention (September; 3 months post-baseline); M4 = Post-3 BOUNCE summer intervention (December; 6 months post-baseline)
      a n=18
      b n=19
      Table 6Daughters' paired sample t-test comparison of body fatness indicators
      VariableM1 vs M2M1 vs M3M1 vs M4
      M differencetdfSig.M differencetdfSig.M differencetdfSig.
      % body fat3.768.59540.0012.252.59170.0191.932.00100.072
      Waist circumference3.582.28540.0263.190.98180.3392.852.0190.074
      Height (cm)0.291.48540.1422.392.69250.0121.490.43100.011
      Weight (lb)1.313.33540.0021.970.76250.4522.901.83100.096
      BMI0.383.69540.0011.280.95180.3540.160.76100.462
      Sig., significance
      A repeated-measures ANCOVA was utilized to address research question (2) and to examine differential change in the daughters' %BF, waist circumference, and BMI over time after controlling for the maternal adiposity at M2. The results indicated that there were no differences in these three measures for the daughters after controlling for maternal %BF, waist circumference, and BMI.

      Discussion

      The primary finding of this exploratory study revealed reductions in %BF, waist circumference, and BMI after participation in the summer BOUNCE intervention. In terms of %BF, the findings are consistent with previous research (using a longer intervention and more-complex research design with inclusion of a control group) that indicated an approximately 2.5%–3.0% reduction in body fat as a result of physical activity intervention compared with 0.6% body fat change in the control group.
      • Howe C.A.
      • Harris R.A.
      • Gutin B.
      A 10-month physical activity intervention improves body composition in young black boys.
      • Gutin B.
      • Yin Z.
      • Johnson M.
      • Barbeau P.
      Preliminary findings of the effect of a 3-year after-school physical activity intervention on fitness and body fat: the Medical College of Georgia Fitkid Project.
      • Gutin B.
      • Barbeau P.
      • Litaker M.
      • et al.
      Effects of exercise intensity on cardiovascular fitness, total body composition, and visceral adiposity of obese adolescents.
      Results from the present study also showed that the BOUNCE summer intervention lowered waist circumference. This is particularly encouraging because recent studies have reported that this measure is a better determinant of cardiovascular disease than BMI.
      • Yusuf S.
      • Hawken S.
      • Ounpuu S.
      • et al.
      Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): a case-control study.
      • Weiss R.
      • Dziura J.
      • Burget T.S.
      • et al.
      Obesity and the metabolic syndrome in children and adolescents.
      • Janssen I.
      • Katzmarzyk P.T.
      • Ross R.
      Body mass index, waist circumference and health risk.
      In addition, reduction was observed from M1 to M2 in daughters' BMI (0.381). Although this reduction is modest, it is congruent with the published expert committee recommendations for obesity treatment, which suggest a gradual weight loss of 1 pound per month for overweight children aged 6–11 years.
      • Barlow S.E.
      Expert Committee
      Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.
      Overall, these results indicate that BMI might not be the only valid measure for obesity status in children. As proposed by Gutin and colleagues,
      • Gutin B.
      • Yin Z.
      • Johnson M.
      • Barbeau P.
      Preliminary findings of the effect of a 3-year after-school physical activity intervention on fitness and body fat: the Medical College of Georgia Fitkid Project.
      • Gutin B.
      The role of nutrient partitioning and stem cell differentiation in pediatric obesity: a new theory.
      body fatness may be a better measure to assess efficacy of physical activity interventions because physical activity can increase lean mass, which in turn may increase BMI. The current data show that the variable %BF changed from M1 to M2 (p<0.001); M1 to M3 (p=0.019); and M1 to M4 (p=0.072). However, BMI changed only from M1 to M2 (p<0.001), not in the other comparisons.
      All three measures showed nonsignificant declines during the ReBOUNCE follow-up sessions. Low retention rate for the ReBOUNCE sessions influenced the internal reliability of these results. Although participation during the ReBOUNCE was low, participation during the day-long BOUNCE summer was high. It is possible that limited opportunities for the girls to participate in summer programs aside from BOUNCE may make them and their parents more willing to participate in this kind of interventions. Further, the high attendance rate of BOUNCE participants during the summer is consistent with that reported by Baranowski et al.
      • Baranowski T.
      • Baranowski J.
      • Cullen K.
      • et al.
      The Fun, Food, and Fitness Project (FFFP): the Baylor GEMS pilot study.
      who found a 95.5% attendance rate in a sample of African-American girls who participated in a summer intervention. Thus, these finding suggest that future research target summer season as an optimal period for intervention.
      Of particular interest is identification of strategies that may be offered to promote sustained participation during ReBOUNCE follow-up sessions amid access barriers (e.g., competing family demands, conflicting parental schedules, and transportation issues). Some of these strategies may include providing transportation and establishing partnerships with fitness programs in the area to maintain focus and support for an active lifestyle. Future studies should employ larger sample sizes and an RCT design, which would strengthen the scientific design of replicating efforts.
      The secondary findings indicated that mothers' %BF, waist circumference, and BMI did not have an impact on the same measures for their daughters as a result of the present intervention. This finding was not totally unexpected given the greater participation of the daughters compared to mothers. Further, the focus of the maternal intervention was to provide them with knowledge and skills to support their daughter's healthy habits. The daughters still made gains in adiposity measures independent of their mothers' status.
      The evidence about the health risks of fatness and obesity continues to mount. More research is needed to identify what other factors, including environmental and sociocultural ones, might contribute to the effects of the BOUNCE interventions and the risk of obesity among Latina girls. For example, understanding the mental and emotional aspects of obesity may be as important as documenting physiologic effects. Future studies should include ecologic approaches to better assess these complex phenomena.

      Conclusion

      In addressing the quandary of childhood obesity among Latino girls, this exploratory study provides an innovative approach to address childhood obesity in an underserved population at a critical period of time. Although the proposed research design reflects a “real-world” approach, it also limited the external generalizability of the results. Therefore, the current conclusions should be viewed cautiously. Future studies should expand on this line of research and refine design weaknesses.
      The current findings indicate that an intensive summer intervention known as BOUNCE may be effective in reducing adiposity indicators in Latina girls, but sustained effects could not be demonstrated at additional follow-up measurement periods, because of high attrition. More research needs to be conducted regarding physical activity maintenance and innovations within the population. Mothers' adiposity did not have an effect on their daughters' %BF, abdominal fat, or BMI.
      This was the first study of its kind designed to examine adiposity indicators among Latina girls and their mothers. The intense intervention and booster sessions were designed to improve adiposity indicators specifically among minority children. Mothers were included as a unique support component, but the authors had hoped to find residual effects on their adiposity measures. However, the value of booster sessions after the summer, as well as mother–daughter dyads remains unclear.
      Research design issues such as participant mortality and a Type III error (incorrectly assuming an intervention was delivered to participants) may have compromised findings related to booster effectiveness and mothers' adiposity measures.
      • Basch C.E.
      • Sliepcevich E.M.
      • Robert S.
      • Gold R.S.
      • Duncan D.F.
      • Kolbe L.J.
      Avoiding type III errors in health education program evaluations: a case study.
      In contrast to the current findings, however, it seems intuitive to continue to argue that follow-up sessions and the inclusion of mothers are important components of overall ecologic strategies to improve Latina girls' adiposity measures. Overall, results from this study address a gap in knowledge regarding the impact of interventions and follow-up sessions for reducing relevant body fatness in Latina girls who are at increased risk for obesity.
      Publication of this article was supported by the Robert Wood Johnson Foundation.
      This study was funded by the Robert Wood Johnson Foundation through its national program, Salud America! The RWJF Research Network to Prevent Obesity Among Latino Children (www.salud-america.org). Salud America!, led by the Institute for Health Promotion Research at The University of Texas Health Science Center at San Antonio, Texas, unites Latino researchers and advocates seeking environmental and policy solutions to the epidemic.
      The authors thank the families who participated in this study. The authors' deepest appreciation is intended to all interns, volunteers, instructors, and coordinators who spent countless hours in the preparation, implementation, and data collection of this study. This work also was supported by the St. Luke's Episcopal Health Charities Foundation and Neighborhood Centers, Inc.
      No financial disclosures were reported by the authors of this paper.

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