Diet and Physical Activity
Hip-Hop to Health Jr. for Latino Preschool
Children
Marian L. Fitzgibbon,*† Melinda R. Stolley,*† Linda Schiffer,* Linda Van Horn,‡
Katherine KauferChristoffel,‡§ and Alan Dyer‡
Abstract
FITZGIBBON, MARIAN L., MELINDA R. STOLLEY,
LINDA SCHIFFER, LINDA VAN HORN, KATHERINE
KAUFERCHRISTOFFEL, AND ALAN DYER. Hip-Hop
to Health Jr. for Latino preschool children. Obesity. 2006;
14:1616 –1625.
Objective: Hip-Hop to Health Jr. was a diet/physical activity
intervention designed to reduce gains in BMI (kilograms per
meter squared) in preschool minority children.
Research Methods and Procedures: Twelve predominantly
Latino Head Start centers participated in a group-random-
ized trial conducted between Fall 2001 and Winter 2003.
Six centers were randomized to a culturally proficient 14-
week (three times weekly) diet/physical activity interven-
tion. Parents participated by completing weekly homework
assignments. The children in the other six centers received
a general health intervention that did not address either diet
or physical activity. The primary outcome was change in
BMI, and secondary outcomes were changes in dietary
intake and physical activity. Measures were collected at
baseline, post-intervention, and at Years 1 and 2 follow-up.
Results: There were no significant differences between in-
tervention and control schools in either primary or second-
ary outcomes at post-intervention, Year 1, or Year 2 follow-
ups.
Received for review October 26, 2005.
Accepted in final form June 28, 2006.
The costs of publication of this article were defrayed, in part, by the payment of page
charges. This article must, therefore, be hereby marked “advertisement” in accordance with
18 U.S.C. Section 1734 solely to indicate this fact.
*Department of Medicine, Institute for Health Research and Policy, University of Illinois,
Chicago, Illinois; †Veterans Administration Midwest Center for Health Services and Policy
Research and the Jesse Brown Veterans Administration Medical Center, Chicago, Illinois;
‡Department of Preventive Medicine, Feinberg School of Medicine, Northwestern Univer-
sity, Chicago, Illinois; and §Children’s Memorial Hospital, Chicago, Illinois.
Address correspondence to Marian L. Fitzgibbon, Institute for Health Research and Policy,
University of Illinois at Chicago, 1747 West Roosevelt Road, Room 558, Chicago, IL
60608.
E-mail: mlf@uic.edu
Copyright © 2006 NAASO
1616 OBESITY Vol. 14 No. 9 September 2006
Discussion: When Hip-Hop to Health Jr. was conducted in
predominantly black Head Start centers, it was effective in
reducing subsequent increases in BMI in preschool chil-
dren. In contrast, when the program was conducted in
Latino centers, it was not effective. Although the interven-
tion did not prevent excessive weight gain in Latino chil-
dren, it was very well received. Future interventions with
this population may require further cultural tailoring and a
more robust parent intervention.
Key words: overweight, prevention, Latino, minority
children, intervention
Introduction
Obesity is epidemic in the U.S. (1) and is associated with
increased risk for numerous medical problems (2–5). Many
obesity-related risk factors and diseases are strikingly ap-
parent in minority populations (6 –9). The most recent
National Health and Nutrition Examination Survey data
indicate that among 2- to 5-year-old children, 11.5% of
non-Hispanic Whites, 13.0% of non-Hispanic blacks, and
19.2% of Mexican Americans are overweight (1). These
data also suggest that rates continue to shift as children
age. For example, for children 6 to 11 years of age, 17.7%
of non–Hispanic Whites, 22.0% of non-Hispanic blacks,
and 22.5% of Mexican Americans are overweight. Thus,
the preschool years are a crucial time to alter the trajectory
toward overweight among high-risk children if we are to
effectively address this public health crisis.
The school is an excellent setting for the promotion of
healthy eating and activity among children (10). Most U.S.
children are enrolled in school, and, unlike most other
settings, schools provide continuous contact. Importantly,
research suggests that exercise has a positive effect on
cognitive development, which is critical if schools are to
support this type of initiative (11). A review of published
school-based interventions conducted since 1983 found 11
that were conducted in the U.S. (12–22) and nine outside the
U.S. (23–31). Of the 11 conducted in the U.S., three focused
specifically on minority children (12,19,21), others had
Overweight Prevention in Minority Children, Fitzgibbon et al.
ethnically diverse samples (13,16,20), and one was con-
ducted with a primarily white sample (14). Eighteen of the
interventions were conducted with grade school (12,14 –
18,20,21,23,24,28 –31) or middle school (13,19,26,27) chil-
dren, one was conducted with high school students (22), and
one spanned preschool and grade school (25). None of the
studies focused exclusively on high-risk minority preschool
children. However, more research is needed to determine
why Latino children have high rates of obesity and what
preventive interventions are effective (32).
The primary aim of Hip-Hop to Health Jr. was to compare
changes in BMI (kilograms per meter squared) in 3- to
5-year-old minority children from schools randomized to
a weight control intervention or to a control group that
received a general health intervention. Two cohorts of
children participated in the trial; the first group of chil-
dren attended 12 predominantly black preschools, where-
as the second cohort attended 12 predominantly Latino
preschools. Results for the children attending predomi-
nantly black centers at the Year 1 and Year 2 follow-ups
showed that children in the intervention group had sig-
nificantly smaller relative changes in BMI than children
in the control group (33). This paper reports follow-up
results for the children attending the predominantly Latino
centers.
Research Methods and Procedures
Study Design
Twelve Head Start sites that were administered through
the Archdiocese of Chicago and that served primarily
Latino children were recruited to participate. The 12 schools
were then randomly assigned to the intervention group or
the control group. All children were eligible to participate in
the intervention, but data were only collected on children
whose parents provided informed consent. The primary
outcome was the difference in change in BMI between the
children in intervention schools and children in control
schools from baseline (Fall 2001) to Year 1 post-interven-
tion (Winter to Spring, 2002) and Year 2 post-intervention
(Fall 2002 to Winter 2003). We focused on the Years 1 and
2 follow-ups because we did not anticipate any substantial
change in BMI immediately post-intervention. Behavior
change outcomes, including dietary intake, physical activ-
ity, and television viewing, were secondary outcome mea-
sures. Specifically, fat and saturated fat intake as a percent-
age of total calories and grams of fiber per 1000 kcal were
calculated from a single dietary recall completed by each
parent for their child. Parents also reported their child’s
television viewing (average hours per day) and the fre-
quency and intensity of their child’s physical activity in the
last week. Approval for the study was given by the Institu-
tional Review Board on Human Subjects at the Northwest-
ern University Feinberg School of Medicine and by the
University of Illinois at Chicago.
Interventions
The rationale and development of the intervention will be
briefly described here and is described in detail elsewhere
(34). Based on prior interventions conducted by our group
and other researchers (35,36) and with input and review
from early childhood educators, nutritionists, exercise phys-
iologists, community health promoters, and Head Start ad-
ministrators, we developed a culturally proficient interven-
tion tailored to this population (34). The weight control
intervention consisted of 14 weeks (three times weekly) of
a diet/physical activity curriculum delivered by trained early
childhood educators. Each session included 20 minutes of a
nutrition activity based on hand puppets that reflected the
food pyramid (e.g., Miss Dairy, Mr. Fat, Miss Grain, etc.).
This was followed by 20 minutes of aerobic activity that
was not based on skill building but on overall moderate to
vigorous movement. Target behaviors for the intervention
included increased fruit and vegetable consumption, de-
creased fat intake, decreased sedentary behavior, and in-
creased physical activity. The intervention did not target
overweight children specifically because our goal was not
weight loss. Instead, our goal was to take these young
children off the trajectory toward obesity as they grew,
without excessive weight gain. Also, we were mindful of
not creating any stigmatization in this young age group. The
curriculum was linguistically, culturally, and developmen-
tally appropriate (34). It was delivered in both Spanish and
English. This dual language format is how the standard
curriculum is delivered in predominantly Latino Head Start
sites administered through the Archdiocese of Chicago.
Nutrition and physical activity interventions may be
more successful when based on an understanding of factors
that influence choice related to health behavior change. It
is critical when working with preschool children that be-
havior change principles fit the developmental needs of
the children. We developed our intervention in accordance
with social cognitive theory (37,38) as the primary frame-
work, with concepts from self-determination theory (39).
The parent intervention included receiving weekly news-
letters that mirrored the children’s curriculum and accom-
panying homework assignments that were designed to be an
interactive activity between parents and children. Parents
received 12 homework assignments during the 14-week
intervention. If parents completed and returned the home-
work, they received a small monetary incentive.
The control sites were provided with a 14-week (one time
weekly for 20 minutes) curriculum that taught general
health concepts such as seat belt safety, immunization, and
dental health. The parent component for the control group
consisted of weekly newsletters that mirrored the curricu-
lum, but there were no homework assignments.
OBESITY Vol. 14 No. 9 September 2006 1617
Overweight Prevention in Minority Children, Fitzgibbon et al.
Measures
The measures used are described in detail elsewhere (40)
and are described briefly below.
Demographics. At baseline, parents reported their child’s
date of birth, gender, and ethnicity and their own date of
birth, education, and marital status.
Parent Acculturation. Parents completed the Short Ac-
culturation Scale at baseline (41). The Short Acculturation
Scale is a four-item questionnaire that measures accultura-
tion as a preference for English or Spanish in spoken lan-
guage, written material, and social networks. A mean score
of 2.99 or less on the five-point scale is considered low-
acculturated.
BMI. Height and weight were measured at baseline, post-
intervention, and Years 1 and 2 follow-up. Height was
measured by trained research assistants using a stadiometer.
Weight was assessed using a digital scale (Seca, Hanover,
MD), with participants wearing light clothes and no shoes.
BMI was calculated as weight (kilograms)/height (meters)2.
BMI z scores and BMI percentiles for age and sex were
calculated for each child based on the 2000 Centers for
Disease Control and Prevention growth charts using the
NutStat module of Epi Info 2000 (42,43).
Dietary Intake. Dietary intake data were collected at
baseline, post-intervention, and Year 2 follow-up. For pre-
literate children, direct observations by parents or other
caregivers are required and are often the gold standard used
in dietary assessment validation studies (44). Dietary intake
was reported by the parent for the child for a 24-hour period.
However, the parent reported only the meals she observed,
so that we often obtained partial recalls rather than full
24-hour recalls. The recalls were initially documented by
hand and then entered into the most recent version of the
Nutrition Data System for Research (45). At baseline, 79%
of the recalls were collected by telephone; 100% of the
recalls were collected by telephone at post-intervention and
Year 2 follow-up. For quality control purposes, duplicate
entry was performed on a randomly selected 10% sample of
recalls by a different dietitian.
Physical Activity. Parents were asked to report how fre-
quently their child engaged in an activity designed to im-
prove his or her physical fitness during the last week and
how hard the child worked during most of the activity.
Parents also reported the number of hours per day their child
watched television. The television viewing question did not
cover a specific time period. Physical activity data were
collected at baseline, post-intervention, and Year 2 follow-
up.
The baseline and post-intervention interviews were done
at the school the child attended. However, because many of
the students were no longer at the school at the Years 1 and
2 follow-ups, the majority of the assessments were done at
the participants’ homes.
1618 OBESITY Vol. 14 No. 9 September 2006
Statistical Analyses
The primary analytic approach was intention to treat,
with all participants completing follow-ups included in the
condition to which they were assigned. Baseline compara-
bility of intervention and control schools was assessed using
two-sample Student’s t tests for continuous variables and ␹2
tests for categorical variables. To test the primary hypoth-
esis, SAS (SAS Institute Inc., Cary, NC) Proc Mixed was
used, with the individual school as the unit of randomiza-
tion, yielding a test statistic with 10 df for 12 schools (46).
Changes in BMI and BMI z score at follow-up were the
dependent variables. Because the average time from the
baseline visit to the Year 2 follow-up visit was significantly
longer for the control children (772 days) than for the
intervention children (744 days), all analyses included ad-
justment for months from baseline. Analyses were con-
ducted with and without adjustment for baseline age quartile
and baseline BMI or BMI z score. We adjusted for age
quartile rather than age as a continuous variable because of
non-linear associations between baseline age and change in
BMI at post-intervention and Years 1 and 2. For dietary,
physical activity, and television viewing measures, we used
SAS Proc Mixed and the absolute values at follow-up,
adjusted for the baseline value, rather than change scores.
For BMI and BMI z score, differences between groups
were considered significant if the two-tailed p value was
⬍0.05. For secondary outcome measures and height and
weight, differences between groups are reported along with
their corresponding 95% confidence intervals.
Sample Size
The original study design called for the recruitment of 35
children per Head Start site (420 total). This number, along
with the number of Head Start sites, i.e., 12, was selected to
provide at least 80% power to detect a difference between
groups of 0.35 standard deviations (SDs)1 (within-site) of
the change in BMI, assuming one-sided tests at the 5%
level, an intraschool correlation no more than 0.015, and a
retention rate of 80% at each follow-up assessment, i.e., that
at least 336 children would complete the final follow-up
assessment. Four hundred one children were recruited. The
retention rate was somewhat higher than expected, with 336
children providing anthropometric data at Year 1 and 331 at
Year 2. However, the number of children varied by school
and results reported here are based on two-sided tests, so we
recalculated power to detect a difference of 0.35 SDs. In
these calculations, we used the standard error of the differ-
ence in BMI from SAS Proc Mixed and the estimate of the
within-school component of variance from Proc Mixed to
obtain estimates of power of 42% at Year 1 and 44% at
Year 2. The lower power in these calculations reflects larger
1
Nonstandard abbreviation: SD, standard deviation.
Overweight Prevention in Minority Children, Fitzgibbon et al.
Figure 1: Hip-Hop to Health Jr. study design and participant flow.
than expected values for the intraschool correlation at both
Years 1 and 2, i.e., 0.048 at Year 1 and 0.043 at Year 2.
Results
There were no adverse events reported during the trial for
any participants as a function of the intervention. Retention
was high, and there were no significant differences in re-
tention between the intervention and control groups. The
retention rates were 97%, 86%, and 85%, at post-interven-
tion (14 weeks), Year 1, and Year 2 follow-up, respectively
(see Figure 1). Approximately 54% of intervention parents
completed at least one homework assignment, and the me-
dian number of assignments completed was 1 (interquartile
range ⫽ 8).
Baseline Comparability
At baseline, intervention children were comparable with
control children in age, gender, height, weight, BMI, dietary
intake, and physical activity (see Table 1). However, fewer
children in the intervention group were Latino (73% vs.
89%, p ⬍ 0.001). Mean BMI z score was higher for the
control group (p ⫽ 0.023), and there were more children in
the control group who were at or above the 85th (p ⫽ 0.019)
and 95th (p ⫽ 0.033) percentiles. Female parents of children
in the intervention and control groups were comparable in
age, education, marital status, and level of acculturation, but
control mothers/caretakers had a higher mean BMI than
intervention women (30.3 vs. 28.5 kg/m2, p ⫽ 0.018).
Primary Outcome
As shown in Table 2, post-intervention changes in BMI
and BMI z score were not significantly different between
children in schools randomized to the intervention and
control groups (0.11 vs. 0.13 kg/m2, p ⫽ 0.89 for BMI; and
0.07 vs. 0.05, p ⫽ 0.85 for BMI z score). At Year 1
OBESITY Vol. 14 No. 9 September 2006 1619
Overweight Prevention in Minority Children, Fitzgibbon et al.

Table 1. Child and parent measures at baseline, by treatment group; Hip-Hop to Health Jr.
Intervention Control
N Mean (SD) N Mean (SD) p*
Children
Age (months) 202 50.8 (7.3) 199 51.0 (7.0) 0.71
Gender (% female) 202 47.5 199 51.3 0.45
Race (%) 202 199 ⬍0.001
Black 15.8 6.5
Latino 73.3 89.4
Multi-racial/Other 10.9 4.0
Height (cm) 202 104.0 (5.9) 199 103.3 (6.1) 0.21
Weight (kg) 202 18.6 (4.1) 199 18.8 (3.8) 0.59
BMI (kg/m2) 202 17.0 (2.8) 199 17.5 (2.2) 0.10
BMI z score for age and sex† 202 0.87 (1.24) 199 1.13 (1.06) 0.023
BMI ⱖ85th percentile (%)‡ 202 39.6 199 51.3 0.019
BMI ⱖ95th percentile (%)‡ 202 21.8 199 31.2 0.033
Total fat (% kcal)§ 188 30.0 (8.7) 174 30.5 (8.8) 0.59
SFA (% kcal)§ 188 11.3 (3.8) 174 11.7 (4.1) 0.37
Dietary fiber (g/1000 kcal)§ 188 8.5 (4.6) 174 8.5 (4.4) 0.96
TV viewing (h/d) 180 2.8 (1.6) 170 2.6 (1.5) 0.46
Exercise frequency (% ⱖ7⫻/wk) 180 26.7 170 22.4 0.35
Exercise intensity (Borg scale) 180 3.7 (2.9) 169 3.4 (2.5) 0.30
Parents¶
Age (years) 155 31.5 (8.6) 155 30.7 (7.2) 0.38
BMI (kg/m2) 136 28.5 (5.9) 136 30.3 (6.3) 0.018
Education (years) 140 11.3 (3.6) 138 10.6 (3.7) 0.10
Married/living as married (%) 140 67.9 138 65.9 0.73
Acculturation score储 107 2.0 (1.2) 121 2.0 (1.3) 0.80

SD, standard deviation.

* From ␹2 tests for categorical variables and two-sample Student’s t tests for continuous variables.
† Deviation from the mean BMI for age and sex for the reference population divided by the age and sex-specific SD for the reference
population (42).
‡ Overweight or at-risk-for-overweight is defined as BMI ⱖ85th percentile for age and sex. Overweight is defined as BMI ⱖ95th percentile
for age and sex.
§ If the child was in school the previous day, the parent completed a recall for the child’s time at home; otherwise, the parent completed
a 24-hour recall for the child.
¶ Female parents with some baseline data only.
储 Mean score for four questions about language used in thinking, reading, and speaking at home and with friends. Possible scores for each
question range from 1 (uses only Spanish) to 5 (uses only English). Latina parents only.

follow-up, the increase in BMI for children in intervention
schools was 0.33 kg/m2, and the mean increase for children
in control schools was 0.48 kg/m2 (p ⫽ 0.46). The change
in BMI z score was also not significantly different between
the intervention and control groups at Year 1 follow-up,
0.00 and 0.07, respectively (p ⫽ 0.56).
At Year 2 follow-up, the mean increase in BMI was
0.46 kg/m2 in intervention children and 0.70 kg/m2 in
control children (p ⫽ 0.34), and the BMI z score change was
⫺0.13 and 0.00 for intervention and control children, respec-
tively (p ⫽ 0.34). Adjusting for baseline age and baseline BMI
or BMI z score did not substantially change these results.

1620 OBESITY Vol. 14 No. 9 September 2006

Overweight Prevention in Minority Children, Fitzgibbon et al.

Table 2. Adjusted* change in child weight, height, BMI, and BMI z score at post-intervention and 1- and 2-year
follow-up; Hip-Hop to Health Jr.

Intervention Control Difference

(intervention ⴚ control)
Follow-up N Mean change (SE) N Mean change (SE) (95% CI) p
Post-intervention
Height (cm) 196 2.69 (0.13) 187 2.79 (0.13) ⫺0.10 (⫺0.51 to 0.31)
Weight (kg) 196 1.13 (0.12) 187 1.20 (0.12) ⫺0.07 (⫺0.46 to 0.31)
BMI (kg/m2)† 196 0.11 (0.11) 187 0.13 (0.11) ⫺0.02 (⫺0.37 to 0.33) 0.89
Adjusted BMI (kg/m2)‡ 196 0.12 (0.11) 187 0.12 (0.11) 0.00 (⫺0.36 to 0.36) 1.0
BMI z score§ 196 0.07 (0.07) 187 0.05 (0.07) 0.02 (⫺0.21 to 0.25) 0.85
Adjusted BMI z score‡§ 196 0.07 (0.06) 187 0.07 (0.06) 0.01 (⫺0.19 to 0.20) 0.94
Year 1
Height (cm) 176 8.97 (0.16) 160 8.77 (0.16) 0.20 (⫺0.30 to 0.70)
Weight (kg) 176 3.84 (0.19) 160 3.98 (0.20) ⫺0.14 (⫺0.76 to 0.48)
BMI (kg/m2)¶ 176 0.33 (0.14) 160 0.48 (0.14) ⫺0.15 (⫺0.60 to 0.29) 0.46
Adjusted BMI (kg/m2)‡ 176 0.31 (0.16) 160 0.44 (0.17) ⫺0.13 (⫺0.65 to 0.39) 0.60
BMI z score§ 176 0.00 (0.09) 160 0.07 (0.09) ⫺0.08 (⫺0.36 to 0.21) 0.56
Adjusted BMI z score‡§ 176 ⫺0.01 (0.07) 160 0.11 (0.07) ⫺0.11 (⫺0.34 to 0.11) 0.29
Year 2
Height (cm) 171 13.49 (0.20) 160 13.34 (0.20) 0.14 (⫺0.50 to 0.78)
Weight (kg) 171 5.91 (0.31) 160 6.18 (0.32) ⫺0.27 (⫺1.26 to 0.72)
BMI (kg/m2)储 171 0.46 (0.17) 160 0.70 (0.18) ⫺0.25 (⫺0.80 to 0.31) 0.34
Adjusted BMI (kg/m2)‡ 171 0.46 (0.19) 160 0.66 (0.20) ⫺0.20 (⫺0.82 to 0.42) 0.49
BMI z score§ 171 ⫺0.13 (0.09) 160 0.00 (0.09) ⫺0.13 (⫺0.41 to 0.15) 0.34
Adjusted BMI z score‡§ 171 ⫺0.13 (0.07) 160 0.02 (0.07) ⫺0.15 (⫺0.38 to 0.09) 0.19

SE, standard error; CI, confidence interval.

* Adjusted for group randomization by Head Start site and months from baseline using SAS Proc Mixed (SAS Institute Inc., Cary, NC).
† For children with post-intervention anthropometric data, the unadjusted mean (SD) for BMI at baseline was 17.1 (2.8) kg/m2 for children
in the intervention group and 17.4 (2.2) kg/m2 for children in the control group. At post-intervention, the unadjusted mean (SD) for BMI
was 17.2 (2.9) kg/m2 for children in the intervention group and 17.5 (2.3) kg/m2 for children in the control group.
‡ Adjusted for baseline age quartile, baseline value, months from baseline, and Head Start site. The baseline age quartiles were ⬍3.759,
3.759 to ⬍4.293, 4.293 to 4.753, and ⱖ4.753 years. Quartiles were coded as indicator variables.
§ Deviation from the mean BMI for age and sex for the reference population divided by the age- and sex-specific SD for the reference
population (42).
¶ For children with Year 1 anthropometric data, the unadjusted mean (SD) for BMI at baseline was 17.1 (2.9) kg/m2 for children in the
intervention group and 17.4 (2.1) kg/m2 for children in the control group. At Year 1, the unadjusted mean (SD) for BMI was 17.5 (3.5) kg/m2
for children in the intervention group and 17.9 (2.6) kg/m2 for children in the control group.
储 For children with Year 2 anthropometric data, the unadjusted mean (SD) for BMI at baseline was 17.1 (2.9) kg/m2 for children in the
intervention group and 17.4 (2.1) kg/m2 for children in the control group. At Year 2, the unadjusted mean (SD) for BMI was 17.6 (3.6) kg/m2
for children in the intervention group and 18.1 (3.0) kg/m2 for children in the control group.

Secondary Outcomes recalls. At post-intervention, 56% of the 334 recalls were

Reported intake of total and saturated fat and dietary fiber partial recalls. At Year 2 follow-up, 63% of the 280 recalls
was similar between children in the intervention and con- were partial recalls. There were also no significant differ-
trol groups at post-intervention and Year 2 follow-up (see ences between groups in reported frequency and intensity of
Table 3). At baseline, 66% of the 362 recalls were partial exercise or in TV viewing at any assessment point.

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Overweight Prevention in Minority Children, Fitzgibbon et al.

Table 3. Adjusted* child diet† and physical activity at postintervention and 2-year follow-up; Hip-Hop to Health Jr.

Intervention Control Difference

(intervention ⴚ control)
Follow-up N Mean (SE) N Mean (SE) (95% CI)
Post-intervention
Total fat (% kcal) 178 30.24 (0.60) 156 30.22 (0.64) 0.02 (⫺1.95 to 1.99)
SFA (% kcal) 178 11.37 (0.25) 156 11.30 (0.27) 0.07 (⫺0.75 to 0.89)
Fiber (g/1000 kcal) 178 8.96 (0.32) 156 8.16 (0.34) 0.80 (⫺0.26 to 1.85)
TV viewing (h/d) 171 2.57 (0.13) 153 2.54 (0.13) 0.03 (⫺0.38 to 0.44)
Exercise frequency (% ⱖ7 times/wk) 171 29.58 (3.55) 152 29.30 (3.76) 0.28 (⫺11.24 to 11.80)
Exercise intensity (Borg scale) 171 4.49 (0.29) 151 4.67 (0.30) ⫺0.18 (⫺1.12 to 0.76)
Year 2
Total fat (% kcal) 156 28.82 (0.61) 124 29.06 (0.70) ⫺0.25 (⫺2.32 to 1.83)
SFA (% kcal) 156 10.89 (0.17) 124 11.03 (0.22) ⫺0.14 (⫺0.76 to 0.49)
Fiber (g/1000 kcal) 156 8.14 (0.49) 124 8.61 (0.53) ⫺0.47 (⫺2.07 to 1.13)
TV viewing (h/d) 154 2.34 (0.12) 139 2.34 (0.12) 0.00 (⫺0.38 to 0.38)
Exercise frequency (% ⱖ7 times/wk) 154 28.60 (4.13) 139 17.82 (4.32) 10.8 (⫺2.56 to 24.12)
Exercise intensity (Borg scale) 154 4.32 (0.15) 139 4.62 (0.16) ⫺0.30 (⫺0.79 to 0.19)

SE, standard error; CI, confidence interval; SFA, saturated fat.

* Adjusted for baseline value and Head Start site using SAS Proc Mixed (SAS Institute Inc., Cary, NC).
† If the child was in school the previous day, the parent completed a recall for the child’s time at home; otherwise, the parent completed
a 24-hour recall for the child.

Discussion fect family eating and exercise patterns. A recent study

In contrast to our follow-up results for children attending
primarily black Head Start centers (33), there were no
significant group differences in BMI change at follow-up,
the main outcome of this randomized controlled trial. There
were also no differences between the two groups on the
secondary outcomes of dietary intake and physical activity.
Several factors may have led to these null findings. First,
the parental component of the intervention may not have
been intensive enough for this sample of low-acculturated
Latinos. Studies that have specifically considered familial
factors related to overweight in Latino children have under-
scored the importance of including parents and addressing
the family environment in pediatric obesity intervention
efforts. Sallis et al. (47) examined the correlates of physical
activity among Mexican-American and Anglo-American
preschoolers and found that Mexican-American children
made fewer requests for activity, received fewer prompts
from parents, and spent less time outdoors than Anglo-
American children. Furthermore, Mexican-American fami-
lies had lower scores on family recreation than Anglo-
American families (47), and research suggests that children
are more active when their parents are active (48,49). An-
other study highlighted the use of food as bribes in less
acculturated Latino mothers (50). Additionally, parents’
perceptions of their children’s weight status potentially af-
among parents of 5- and 6-year-old children reported that
fewer than one-half of Latino mothers with an overweight
child correctly assessed the child as overweight (51). We
did not assess whether parents perceived their child as
overweight, but 19% of the children were at risk for over-
weight, and 26% were overweight.
Second, although we piloted the intervention with both
African Americans and Latinos to assess acceptability be-
fore starting the trial, the intervention may not have targeted
ethnic foods and the cultural aspects of eating and physical
activity in a way most appropriate for low-acculturated
Latinos. For example, several studies have documented the
excessive consumption of juice among Latino children (52–
54), and dietary observations of Mexican-American boys
suggest a higher consumption of saturated fat than in chil-
dren of other ethnicities (55), although this was not evident
in our study. Overall, cultural differences may affect the
efficacy of health risk reduction programs (19,56,57).
Third, children who attended the predominantly Latino
centers had higher BMIs at baseline than children from the
predominantly black centers [mean (SD) ⫽ 17.2 (2.5) vs.
16.6 (1.8) kg/m2, p ⬍ 0.001]. BMI z scores were also higher
at baseline in children from the predominantly Latino cen-
ters [mean (SD) ⫽ 1.00 (1.16) vs. 0.65 (1.01)]. Children
with larger body fat stores seem to have greater difficulty

1622 OBESITY Vol. 14 No. 9 September 2006

Overweight Prevention in Minority Children, Fitzgibbon et al.
regulating their energy intake than their normal-weight or
underweight counterparts (58). The intervention, therefore,
may not have been intensive enough to alter the trajectory
toward overweight for these high-risk Latino children.
However, in our predominantly black centers, the weight
control intervention was effective both for children who
were at risk or overweight and for normal-weight children
(33).
Although not without controversy (59,60), adiposity re-
bound has been suggested as a critical period for the devel-
opment of obesity (61). Typically, BMI increases during the
1st year of life before decreasing and then increasing again
later in childhood (62). The timing of the occurrence of the
minimum value of BMI has been termed “adiposity re-
bound” (63). A number of studies have shown an associa-
tion between the timing of the adiposity rebound and an
increased risk of obesity (64 – 66). It is not clear whether
factors such as physical activity or sedentary behavior have
an impact on the timing of the adiposity rebound (62,67).
However, it is important to note that the measurement of
adiposity rebound requires at least three serial BMI mea-
surements, so the timing of the rebound can only be ascer-
tained after it has occurred (62).
The significant difference in BMI z score at baseline
between the intervention and control groups could poten-
tially complicate the interpretation of the results of this trial.
Because we were testing a school-based intervention, we
were unable to randomize by individual child and chose to
use a cluster randomized design. We realized that random-
izing by site rather than by individual could increase the
chances for differences between the intervention and control
groups, and such differences, in fact, occurred. However,
adjusting for the baseline value of BMI or BMI z score did
not substantially change the estimates of the differences
between groups at follow-up. Therefore, it is unlikely that
the baseline differences had a major effect on the outcome
of the study.
We should also note that the intraschool correlation was
larger than anticipated for the predominantly Latino centers
and that correlation was larger than the intraschool correla-
tion for the predominantly black centers. Thus, in this study,
the power to detect differences was dramatically reduced
from the 80% used in the original sample size calculations.
However, change in BMI was smaller in the intervention
group, as originally hypothesized, both with and without
adjustment for baseline differences between groups. This
and the results in black children encourage us to plan an
improved intervention and try again.
The continuing rise in childhood obesity is a serious
public health concern. In our sample of low-acculturated
Latina parents, the mean BMI was close to the obese range
(i.e., 29.4 kg/m2). Children under 10 years old who have
obese mothers are ⬎3 times more likely to be obese in
adulthood than children with normal-weight mothers (68).
Currently, many children live in environments that promote
inactivity and the consumption of highly caloric and palat-
able foods (69). The school environment provides an ideal
setting to promote healthy eating behaviors and the reduc-
tion of sedentary behaviors. The preschool years are also
ideal for educating parents about the benefits of a healthy
lifestyle.
Despite the null findings in our primary analyses, the
program was very well-received by children, parents, and
school personnel. We also documented high retention rates
with a relatively mobile low-acculturated population at 2
years post-intervention. We speculate that more effort is
needed to include parents as models of change in the adop-
tion of healthy eating and physical activity. However, as
part of that effort, considerably more attention should be
given to how differences in rates of obesity between under-
served and non-underserved populations are affected by
culturally based decisions related to food choice, leisure
time physical activity, role of parents as models for chil-
dren, and expectations for weight control and health.
Acknowledgments
This work was supported by the National Heart, Lung,
and Blood Institute (Grant HL 58871). We gratefully ac-
knowledge the administrators, staff, teachers, food service
personnel, parents, and children in the Head Start sites who
participated in this project. We would also like to thank the
Hip-Hop to Health Jr. staff, who worked with the utmost
professionalism to conduct this study in this underserved
population, and Allison Thompson for technical assistance.
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