Research

Original Investigation

Healthy Habits, Happy Homes

Randomized Trial to Improve Household Routines for Obesity
Prevention Among Preschool-Aged Children
Jess Haines, PhD, MHSc, RD; Julia McDonald, MS, MPH; Ashley O’Brien, LCSW, MPH; Bettylou Sherry, PhD, RD;
Clement J. Bottino, MD; Marie Evans Schmidt, PhD; Elsie M. Taveras, MD, MPH

Editorial page 1002

IMPORTANCE Racial/ethnic and socioeconomic disparities exist across risk factors for Supplemental content and
childhood obesity. Journal Club Slides at
jamapediatrics.com
OBJECTIVE To examine the effectiveness of a home-based intervention to improve
CME Quiz at
household routines known to be associated with childhood obesity among a sample of jamanetworkcme.com and
low-income, racial/ethnic minority families with young children. CME Questions page 1087

DESIGN Randomized trial.

SETTING The intervention was delivered in the families’ homes.

PARTICIPANTS The study involved 121 families with children aged 2 to 5 years who had a
television (TV) in the room where he or she slept; 111 (92%) had 6-month outcome data (55
intervention and 56 control). The mean (SD) age of the children was 4.0 (1.1) years; 45% were
overweight/obese. Fifty-two percent of the children were Hispanic, 34% were black, and 14%
were white/other. Nearly 60% of the families had household incomes of $20 000 or less.

INTERVENTIONS The 6-month intervention promoted 4 household routines, family meals,

adequate sleep, limiting TV time, and removing the TV from the child’s bedroom, using (1)
motivational coaching at home and by phone, (2) mailed educational materials, and (3) text
messages. Control subjects were mailed materials focused on child development.

MAIN OUTCOMES AND MEASURES Change in parent report of frequency of family meals
(times/wk), child sleep duration (hours/d), child weekday and weekend day TV viewing
(hours/d), and the presence of a TV in the room where the child slept from baseline to 6
months. A secondary outcome was change in age- and sex-adjusted body mass index
(calculated as weight in kilograms divided by height in meters squared).

RESULTS Compared with control subjects, intervention participants had increased sleep
duration (0.75 hours/d; 95% CI, 0.06 to 1.44; P = .03), greater decreases in TV viewing on
weekend days (−1.06 hours/d; 95% CI, −1.97 to −0.15; P = .02), and decreased body mass
index (−0.40; 95% CI, −0.79 to 0.00; P = .05). No significant intervention effect was found
for the presence of a TV in the room where the child slept or family meal frequency.

CONCLUSIONS AND RELEVANCE Our results suggest that promoting household routines,
particularly increasing sleep duration and reducing TV viewing, may be an effective approach
to reduce body mass index among low-income, racial/ethnic minority children. Longer-term
Author Affiliations: Author
studies are needed to determine maintenance of behavior change. affiliations are listed at the end of this
article.
TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01565161 Corresponding Author: Elsie M.
Taveras, MD, MPH, Division of
General Pediatrics, Department of
Pediatrics, Pediatric Population
Health Management, Massachusetts
General Hospital for Children, 100
Cambridge Street, 15th Fl, Mail Code
JAMA Pediatr. 2013;167(11):1072-1079. doi:10.1001/jamapediatrics.2013.2356 M100C1570, Boston, MA 02114
Published online September 9, 2013. (etaveras@partners.org).

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 Healthy Habits, Happy Homes
T
he prevalence of overweight and obesity among young
children in the United States is high.1 Racial/ethnic mi-
nority children and those living in low-income house-
holds bear a disproportionate share of the burden of over-
weight status,1,2 making development of effective intervention
strategies for these high-risk populations particularly urgent.
Racial/ethnic and socioeconomic disparities also exist across
many known risk factors for childhood overweight and
obesity.3-8 Interventions that are able to address the dispari-
ties in obesity-related risk factors may help curb the increase
in overweight and obesity among racial/ethnic minority chil-
dren and those living in low-income households.
Among a national sample of preschool-aged children, An-
derson and Whitaker9 found that children who were exposed
to 3 household routines (ie, regularly eating dinner as a fam-
ily, adequate nighttime sleep, and limiting screen time) had
substantially lower obesity rates than children who were not
exposed to those routines. The findings were similar across ra-
cial/ethnic groups and across socioeconomic status. Ander-
son and Whitaker’s findings suggest that promotion of these
household routines may be an effective way to prevent child-
hood obesity among racial/ethnic minority and low-income
families. While a number of home-based obesity prevention
interventions have been implemented in very early infancy,10-14
to our knowledge, few obesity interventions for older chil-
dren have been delivered in the home where household rou-
tines occur. 15-17 No home-based interventions have ad-
dressed all of these household routines.
The purpose of this study was to assess the extent to which
a home-based intervention, compared with a mailed control
condition focused on healthful development, resulted in im-
provements in household routines that may be preventive of
childhood overweight and obesity among racial/ethnic minor-
ity and low-income families with children aged 2 to 5 years.
We also examined the impact of the intervention on change
in child body mass index (BMI, calculated as weight in kilo-
grams divided by height in meters squared).
Methods
Study Design and Participants
Healthy Habits, Happy Homes is a randomized trial.18 In
Supplement, eFigure 1 provides a schematic of the study de-
sign. Between June 1, 2011, and February 1, 2012, we recruited
families from 4 community health centers that serve primar-
ily low-income and racial/ethnic minority families in the greater
Boston area. Participants were families with children aged 2
to 5 years who had a television (TV) in the room where the child
slept (verified by staff at home visit). We excluded (1) parents
who were unable to respond to interviews in English or Span-
ish; (2) families who planned to move from the area; (3) par-
ents who were younger than 18 years of age; and (4) children
who had a chronic health condition such as severe cerebral
palsy.
Using patient records from individual health centers, we
identified 1467 potentially eligible families. We mailed a let-
ter to each parent introducing the study and inviting them to
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Original Investigation Research
participate and included an opt-out telephone number should
the family choose not to participate. We telephoned families
who did not refuse additional contact beginning 7 days after
mailing the letter. Of the 1467 potentially eligible families, re-
search assistants attempted telephone contact with 1148, dur-
ing which time they described the study, screened for eligi-
bility, collected contact information, and scheduled a home
visit to collect baseline data and obtain written consent. Fami-
lies were enrolled once we obtained their baseline data and
written consent. Of the 500 parents who could be contacted
and were eligible for the study, 121 enrolled in the study (re-
sponse rate = 24%).
For simplicity, we determined our required sample size
using one of our targeted routines—TV viewing. To detect a 1.2-
hour reduction in TV viewing per day19 with a 2-sided 5% sig-
nificance level and a power of 80%, we determined that a
sample size of 60 participants per condition was necessary,
based on an anticipated dropout rate of 10%.
To assign enrolled families to the intervention or control
condition, we used a stratified block randomization scheme.
Stratum was recruitment site blocked by child sex; condition
was assigned by blocks of 4 in each strata. Our statistical pro-
grammer used a computerized routine to randomly assign the
stratified blocks to the intervention and control condition. As-
signments were implemented through sealed sequentially
numbered individual envelopes that the research assistant
opened following the completion of baseline assessments.
All baseline and 6-month follow-up data were obtained
during a home visit. Participants received $40 for completing
the baseline visit and $50 for completing the 6-month fol-
low-up visit. All study activities were approved by the Har-
vard Pilgrim Health Care human subjects committee.
Treatment Groups
Families randomized to the control condition received 4
monthly mailed packages that included educational materi-
als on reaching developmental milestones during early child-
hood and low-cost incentives (eg, coloring books). The edu-
cational materials were adapted from the Centers for Disease
Control and Prevention’s “Developmental milestones” (http:
//www.cdc.gov/ncbddd/actearly/milestones/index.html). Ma-
terials focused on milestones for each age group organized by
developmental domain (social/emotional, language, cogni-
tive, and motor).
Intervention
The Healthy Habits, Happy Homes intervention is a home-
based intervention that uses individually tailored counseling
by health educators to encourage behavior change. The inter-
vention was informed by findings from focus groups with 74
racial/ethnic minority parents of young children.20 Major com-
ponents of the intervention included (1) motivational coach-
ing by a health educator during 4 home visits and 4 health
coaching telephone calls, (2) mailed educational materials
(eFigure 2 in Supplement) and incentives, and (3) weekly text
messages on adoption of household routines.
We trained 4 bilingual health educators to use motiva-
tional interviewing21-23 during the home visits and coaching
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 Research Original Investigation Healthy Habits, Happy Homes

Table 1. Overview of the Home Visit, Mailed Educational Materials, and Text Messages for the Healthy Habits, Happy Homes Intervention

Unit Home Visit Content Mailed Education Materials Sample Text Message
Creating rou- Introduction and goal setting; Incentives: coloring book, stickers; How could you add more family meals to your week? (Think about
tines in your activity: creating a daily sched- newsletter: Sleep for Better Health breakfast, lunch, or dinner. Sit at a table, turn the TV off, and enjoy
home ule; handouts: overview of your meal together.); Try the 3 Bs: bath, book, and bed! Routines make
goals, implementing routines bedtime easier for parents and children.
Sleep for bet- Check-in; activity: bedtime rou- Incentives: Good Night Moon book, Well-rested children make for happier parents (2-5 y olds need 11+
ter health tine clock; handout: sleep tips art kit); newsletter: Limiting Your TV hours of sleep, and enough sleep can make for better moods and better
Time learning); Mommy, I can’t sleep... TV at bedtime makes it harder for
kids to relax and go to sleep. For quiet time at the end of the day, read a
book or sing softly.
Limiting your Check-in; activity: “fitness Incentives: mitt and ball set, Beren- Think about this: children with a TV in their bedroom watch an average
child’s inac- dice”; handout: limiting TV stain bears, too much TV, water of almost 1.5 h more/d than those without a TV in the bedroom; play-
tive time bottle; newsletter: Get Active time for your child can be cooking or clean-up time for you (encourage
her to do puzzles, look at books, or build with blocks instead of watch-
ing TV)
Eating better Check-in; activity: sometimes Incentives: laminated placemat, cup, Healthy drinks, such as water and low-fat milk, in the fridge will help
together anytime food cards; handouts: and plate set; newsletter: Sugar- your child make healthy choices, fruit slices in a pitcher of water make
healthy snacking, cooking with Sweetened Beverages it pretty and fun; use a calendar and fun stickers to keep track of how
your child many fruits and vegetables your child eats. And remember, your kids
learn from you, so start crunching!

Abbreviation: TV, television.

calls. Each home visit included (1) a check-in to review prog-
ress and setbacks to behavior change, (2) discussion of behav-
ior change goals and collaborative goal setting, and (3) a con-
crete activity or tool the parent could use to support behavior
change. Table 1 provides an overview of the home visit, mailed
educational materials and incentives, and sample text mes-
sages for each unit. The monthly coaching calls were de-
signed to assess participants’ progress on making changes, pro-
vide support for challenges that arose, and reinforce study
messages. The intervention focused on promotion of 4 house-
hold behaviors: eating meals together as a family, obtaining
adequate sleep, limiting TV time, and removing the TV from
the child’s bedroom. Although the intervention was de-
signed to change behaviors related to excess weight gain, child’s
weight was not discussed in the intervention; instead, the in-
tervention focused on promotion of the key household behav-
iors with particular attention to achieving the goals in low-
resource home environments.
In addition to the coaching home visits and calls, parents
received text messages twice weekly for 16 weeks and then
weekly for the last 8 weeks of the program (Table 1). Those par-
ticipants without a cell phone that could accept texts (n = 11)
received mailed postcards with the same information.
Outcome Measures
Our main outcomes were change, from baseline to follow-up,
in 4 behaviors: eating meals together as a family, child’s sleep
duration, child’s TV viewing time, and presence of a TV in the
room where the child slept. Using surveys at baseline and fol-
low-up, we asked parents to report the number of days at least
some of the family ate a meal together in the past 7 days.24 To
measure sleep duration, we asked parents to quantify the av-
erage amount of daily sleep their child obtained including naps,
and separately asked about bedtime and wake time in the past
month.25-27 To measure TV viewing time, we asked parents to
report separately the number of hours their child watched TV
on an average weekday and weekend day in the past month.28
We also asked whether the child had a TV in the room where
he or she slept.29
As a secondary outcome, we assessed change in child BMI.
Trained research assistants measured child height using a
Schorr board and child weight using a calibrated electronic
scale. We then calculated child BMI and age-specific and sex-
specific percentiles using the Centers for Disease Control and
Prevention references.30 We chose BMI itself as the anthropo-
metric outcome rather than BMI z score because published
studies have indicated that while the BMI z score is optimal
for assessing adiposity on a single occasion, BMI is preferable
for measuring change in adiposity.31
We kept detailed records of completed home visits and
calls. To assess parents’ satisfaction with the intervention, we
asked parents in the intervention group during the follow-up
survey to rate how satisfied they were with the program com-
ponents and how helpful each component was in guiding their
approach to their child’s behaviors. We also asked parents
whether they would recommend the program to their family
and friends.
Statistical Methods
We first performed univariate analyses of variables of inter-
est to examine baseline distributions of characteristics by in-
tervention status and to examine distributional assump-
tions. In intent-to-treat complete case analyses, we used
regression models to examine differences from baseline to
6-month follow-up between the intervention and control
groups. For continuous measures, we used linear regression,
and for dichotomous outcomes, we used logistic regression
models. We performed all analyses using SAS version 9.2 (SAS
Institute).
Results
The Figure details the participant flow in the Healthy Habits,
Happy Homes study. We randomized 121 parent-child dyads
to the intervention (n = 62) or the control condition (n = 59).
Two participants withdrew from the study and 8 were lost to
follow-up. A total of 111 (92% of those enrolled at baseline) com-

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 Healthy Habits, Happy Homes Original Investigation Research

pleted the 6-month follow-up assessments. Table 2 shows base-

Figure. Participant Flow for the Healthy Habits, Happy Homes Study
line characteristics of our study sample overall and by inter-
vention assignment. The mean (SD) age of the children was 4.0 1467 Were pre-eligible
(1.1) years; 45% were overweight or obese at baseline. Nearly
60% of the study sample had annual household incomes at or 4 Opted out
below $20 000. Children in the study were predominantly His-
panic (52%) or black (34%), and 80% co-slept with their par- 315 Missed contact
window
ents. There were no substantive group differences at baseline
in health behaviors or BMI.
1148 Attempted contacts during
Table 3 shows baseline and 6-month follow-up levels of our recruitment window
behavioral and BMI outcomes by intervention arm. Fre-
quency of eating family dinners remained relatively un- 190 With disconnected/
wrong numbers
changed in both the intervention and control families with no
intervention effect. We observed an intervention effect for child
458 Were ineligible
sleep duration; at 6 months, child sleep duration increased by 298 With no TV in bedroom
0.56 hours/d in the intervention group and decreased by 0.19 60 Planning to move
49 Because of language
hours/d in the control group, yielding a difference of 0.75 17 Because of age
hours/d (95% CI, 0.06 to 1.44; P = .03). We observed larger de- 34 For other reasons

creases in weekend TV viewing among children in the inter-

174 Declined to participate
vention group compared with the control group (−1.06 hours/d;
95% CI, −1.97 to −0.15; P = .02). Weekday TV viewing also de-
163 Did not get in contact
creased more among children in the intervention, but this dif-
ference was not statistically significant. Families in both the 163 Pre-enrolled
intervention (20%) and control (12%) conditions reported re-
moving the TV from the room where their child slept, with no 39 Did not complete
significant intervention effect (P = .29). baseline assessment

At 6 months, child BMI had decreased by a mean of 0.18

in the intervention group and increased by 0.21 in the control
group, yielding a difference of −0.40 (95% CI, −0.79 to 0.00;
P = .05).
We aimed for participants to complete 4 home visits and
4 phone calls with a health educator by 6 months. Among the
62 families randomized to intervention, 48 (77%) completed
all 4 home visits. Fewer families completed the phone calls;
23 (37%) completed all 4 phone calls. Among the 55 interven-
tion families who completed the process survey at follow-up,
89% reported being “satisfied” or “very satisfied” with the pro-
gram as a whole; 98% were “satisfied” or “very satisfied” with
the counseling received during home visits; and 98% were “sat-
isfied” or “very satisfied” with the counseling received dur-
ing coaching calls. Nearly all parents (98%) reported they would
recommend the program to friends and family.
Discussion
In this 6-month follow-up of a home-based randomized trial,
we found that a multicomponent intervention that uses indi-
vidually tailored counseling focused on improving house-
hold routines increased children’s sleep duration and re-
duced children’s TV viewing on weekends. We found that,
compared with control subjects, children who participated in
the intervention decreased their BMI.
To our knowledge, the Healthy Habits, Happy Homes study
is the first home-based randomized trial to address key house-
hold routines related to obesity risk among young children. Re-
cent reviews of obesity prevention interventions among young
children have identified the paucity of home-based interven-
3 Were ineligible at baseline
visit (no TV in bedroom)
121 Families in total enrolled
62 In intervention group 59 In control group
1 Withdrew 1 Withdrew
6 Lost to follow-up 2 Lost to follow-up
55 Completed follow-up 56 Completed follow-up
TV indicates television.
tions and have called for interventions that are appropriately
tailored for families.32,33 Our use of motivational interview-
ing by trained health educators allowed families to identify and
work on the challenges and barriers of key relevance to them.
We also designed our intervention based on findings from our
formative research with racially/ethnically diverse, low-
income parents of young children to ensure our intervention
was contextually appropriate for these high-risk popula-
tions. Our use of mobile technology to encourage behavior
change is also novel; to our knowledge, few studies have ex-
amined the use of mobile technology to encourage the adop-
tion of healthful weight-related behaviors.34,35 Our results sug-
gest such an approach is feasible among ethnically/racially
diverse, low-income families. Future studies should be de-
signed to specifically examine the effectiveness of text mes-
sages in supporting healthful weight-related behavior change
among families with young children.

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 Research Original Investigation Healthy Habits, Happy Homes

Table 2. Baseline Characteristics and Behaviors of Participants in the Healthy Habits, Happy Homes Study
Overall and by Intervention Assignment
Overall Intervention Control
(n = 111) (n = 55) (n = 56)
Child characteristics, mean (SD)
Age, y 4.1 (1.1) 4.1 (1.1) 4 (1.1)
BMI 17.4 (2.4) 17.3 (2.1) 17.4 (2.7)
BMI z score 0.91 (1.18) 0.95 (1.12) 0.88 (1.24)
Behaviors/Routines, mean (SD)
Sleep, h/d 10.4 (1.5) 10.4 (1.6) 10.5 (1.4)
TV, h/d 2.5 (1.5) 2.5 (1.6) 2.5 (1.5)
Family meals, times/wk 6.3 (2.0) 6.5 (1.8) 6.1 (2.2)
Sex, No (%)
Female 53 (47.7) 24 (43.6) 29 (51.8)
Male 58 (52.3) 31 (56.4) 27 (48.2)
Race/ethnicity, No. (%)
Black 37 (33.3) 16 (29.1) 21 (37.5)
Hispanic 57 (51.4) 33 (60.0) 24 (42.9)
Other 17 (15.3) 6 (10.9) 11 (19.6)
BMI category, No. (%)
<85th percentile 58 (53.7) 27 (51.9) 31 (55.4)
85th-<95th percentile 29 (26.9) 13 (25.0) 16 (28.6)
>95th percentile 21 (19.4) 12 (23.1) 9 (16.1)
Parent and household characteristics, mean (SD)
Maternal BMI 27.9 (6.1) 27 (5.8) 28.7 (6.4)
Highest parent education, No. (%)
<High school 18 (16.8) 11 (20.4) 7 (13.2)
High school graduate 40 (37.4) 17 (31.5) 23 (43.4)
≥Some college 49 (45.8) 26 (48.1) 23 (43.4)
Married or cohabitating, No. (%)
Married/cohabiting 54 (48.6) 28 (50.9) 26 (46.4)
Not married 57 (51.4) 27 (49.1) 30 (53.6)
Household income, No. (%), $
≤20 000 54 (55.1) 28 (62.2) 26 (49.1)
20 001 to 50 000 34 (34.7) 14 (31.1) 20 (37.7) Abbreviations: BMI, body mass index
>50 000 10 (10.2) 3 (6.7) 7 (13.2) (calculated as weight in kilograms
divided by height in meters squared);
Children co-sleep with parents 80 (72) 43 (78) 37 (66) TV, television.

We found that our intervention had a significant effect on
child sleep duration. Despite strong evidence that sleep du-
ration and quality are associated with obesity risk in young
children,25,27 few published intervention studies have fo-
cused on increasing preschool-aged children’s sleep.36,37 Our
results suggest that a home-based intervention that uses mo-
tivational interviewing to elicit change in household routines
can be used to increase child sleep duration. Empirical evi-
dence of the inverse association between TV viewing and
sleep38,39 suggests that household routines related to both sleep
and TV viewing may be needed to achieve a change in child
sleep duration.
In our intervention, the mean difference (intervention vs
control) in TV viewing on weekend days was −1.06 hours at 6
months. This magnitude of effect is higher than 2 of the 3 in-
tervention studies that have successfully decreased TV view-
ing/screen time among preschool-aged children40,41; the third
intervention measured total screen time only, making a di-
rect comparison of the effect for TV viewing difficult.42 We did
find a smaller, nonsignificant difference (−0.31) in TV view-
ing on weekdays. It is possible that parents have more free time
on the weekends and therefore are better able to implement
limits on children’s TV viewing. Further investigation into how
barriers to limiting TV viewing may differ on weekends and
weekdays is warranted.
Our intervention did not have a significant intervention
effect on the presence of a TV in the room where the child slept.
There are 2 factors that could have contributed to these non-
significant findings. First, it is possible that our intervention,
which focused on household routines, was not intensive or spe-
cific enough to change this behavior. It is possible that a more
intensive and targeted approach, such as financial incen-
tives, may be needed to motivate families to give up a TV. Sec-
ond, in our sample, most parents (80%) reported that their chil-
dren sleep with them. It is possible that parents are not willing
to remove the TV from their own room. Future research should

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 Healthy Habits, Happy Homes Original Investigation Research

Table 3. Change in Behavioral and BMI Outcomes From Baseline to 6 Months by Intervention Assignment

Mean (SD)
Baseline 6 Months Change Difference β (95% CI) P Value
Behavioral outcomes
Family meals, times/wk
Intervention 6.1 (2.16) 5.87 (2.29) −0.23 (2.66)
0.29 (−0.69 to 1.27) .56
Control 6.54 (1.84) 6.03 (2.12) −0.52 (2.53)
Sleep, h/d
Intervention 10.52 (1.42) 11.07 (1.45) 0.56 (1.6)
0.75 (0.06 to 1.44) .03
Control 10.38 (1.63) 10.16 (1.6) −0.19 (2)
TV, h/d
Intervention 2.45 (1.46) 1.64 (1.04) −0.82 (1.46)
−0.54 (−1.22 to 0.15) .12
Control 2.46 (1.64) 2.2 (1.85) −0.28 (2.09)
TV on weekdays, h/d
Intervention 2.4 (1.48) 1.59 (1.04) −0.81 (1.52)
−0.31 (−0.98 to 0.37) .37
Control 2.45 (1.85) 1.95 (1.88) −0.5 (2.03)
TV on weekends, h/d
Intervention 2.56 (1.96) 1.77 (1.5) −0.79 (1.93)
−1.06 (−1.97 to −0.15) .02
Control 2.48 (2.01) 2.77 (2.37) 0.26 (2.79)
TV in bedroom, No. (%)
Intervention 55 (100.0) 44 (80.0) 11 (20.0)
1.75 (0.62 to 4.91)a .29
Control 56 (100.0) 49 (87.5) 7 (12.5)
BMI outcomes
Child BMIb
Intervention 17.34 (2.11) 17.16 (1.99) −0.18 (0.98) Abbreviations: BMI, body mass index
−0.40 (−0.79 to 0.00) .05
Control 17.36 (2.73) 17.57 (3.22) 0.21 (1.07) (calculated as weight in kilograms
divided by height in meters squared);
Child BMI z score
TV, television.
Intervention 0.95 (1.12) 0.89 (1.05) −0.06 (0.63) a
−0.17 (−0.40 to 0.07) .17 Odds ratio (95% CI).
Control 0.88 (1.24) 0.98 (1.07) 0.11 (0.61) b
Adjusted for child age and sex.

explore strategies to motivate parents to remove the TV from
a room where they sleep with their child.
Our intervention had no effect on the frequency of family
meals. The frequency of family meals was fairly high among
our sample, approximately 6 times per week, which may have
resulted in our participants having little “room to move” with
regards to this behavior. The wording of our question, which
defined family meals as “at least some of the family ate to-
gether” may have contributed to this ceiling effect. Because
our intervention had an effect on child BMI despite not chang-
ing family meal frequency, our results suggest that changing
the frequency of family meals may not be a necessary strat-
egy for reducing obesity risk among low-income, racially/
ethnically diverse families. Rollins et al43 explored the asso-
ciation between family meal frequency and obesity levels
among a national sample of children aged 6 to 11 years and
found that the influence of family meals on weight status may
differ by race/ethnicity and income; they found no associa-
tion between the frequency of family meals and obesity preva-
lence among Hispanic and black girls and found a positive as-
sociation between the frequency of family meals and obesity
rates among Hispanic boys from low-education households.
Similar results have been found among adolescents.44 Fur-
ther research on how the association between obesity risk and
family meal frequency and quality may differ by race/
ethnicity and/or income is needed.
At 6 months, the mean difference in BMI for the interven-
tion vs control groups was −0.40. This magnitude of effect was
similar to a recent community-based obesity prevention in-
tervention for Latino American families with preschool-aged
children (Salud Con La Familia) in which the adjusted mean
difference was −0.59 (95% CI, −0.94 to −0.25) at 3 months.45
Like our intervention, the Salud Con La Familia intervention
was culturally tailored and addressed family meals and TV
viewing. It is unclear as to the intervention effect of Salud Con
La Familia on these household routines as these data were not
provided. Our findings suggest that a home-based interven-
tion that uses motivational interviewing to elicit change in
household routines, in particular around TV viewing and sleep
duration, is effective in reducing child’s BMI.
When interpreting our results, several limitations
should be considered. First, our intervention targeted low-
income and racial/ethnic minority parents. Thus, our inter-
vention may not generalize to more socioeconomically
advantaged populations. Second, of the 500 families we
contacted, only 121 (24%) enrolled in the study. Thus, it is
unclear how these results would generalize to those who
did not take up the intervention. Third, although, where
possible, we used validated measures to assess our behav-
ioral outcomes, we used parental report rather than objec-
tive measures. Thus, it is possible that parents could exag-
gerate improvements in behaviors. However, our effect on

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 Research Original Investigation
BMI, an objective measure, and the fact that parents in the
intervention arm did not report an increase in family meals,
a key intervention target, argues against exaggerated
reports of behavior change. Fourth, the follow-up period
was only 6 months, therefore, it is unknown whether these
changes in behavior and BMI were sustained.
ARTICLE INFORMATION
Accepted for Publication: March 13, 2013.
Published Online: September 9, 2013.
doi:10.1001/jamapediatrics.2013.2356.
Author Affiliations: Obesity Prevention Program,
Department of Population Medicine, Harvard
Medical School and Harvard Pilgrim Health Care
Institute, Boston, Massachusetts (McDonald,
O’Brien, Taveras); Department of Pediatrics,
Massachusetts General Hospital, Boston,
Massachusetts (Taveras); Department of Family
Relations and Applied Nutrition, University of
Guelph, Guelph, Ontario, Canada (Haines); Division
of Nutrition, Physical Activity, and Obesity, National
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control and
Prevention, Atlanta, Georgia (Sherry); Division of
General Pediatrics, Children’s Hospital Boston,
Boston, Massachusetts (Bottino, Schmidt); Center
on Media and Child Health, Children’s Hospital
Boston, Boston, Massachusetts (Schmidt).
Author Contributions: Dr Taveras had full access to
the study data and takes responsibility for the
integrity of the data and accuracy of data analysis.
Study concept and design: All authors.
Acquisition of data: McDonald, O’Brien.
Analysis and interpretation of data: Haines,
McDonald, O’Brien, Sherry, Schmidt, Taveras.
Drafting of the manuscript: Haines, McDonald,
Bottino, Taveras.
Critical revision of the manuscript for important
intellectual content: McDonald, O’Brien, Sherry,
Bottino, Schmidt.
Statistical analysis: McDonald
Obtained funding: Haines, Schmidt, Taveras.
Administrative, technical, or material support:
McDonald, O’Brien, Bottino.
Study supervision: Haines, McDonald, Sherry,
Taveras.
Conflict of Interest Disclosures: None reported.
Funding/Support: This work was supported by the
Centers for Disease Control and Prevention and the
National Center for Chronic Disease Prevention and
Health Promotion (Prevention Research Centers
grant 1U48DP00194).
Role of the Sponsors: The sponsors had no role in
the design and conduct of the study; collection,
management, analysis, and interpretation of the
data; and preparation, review, or approval of the
manuscript; and decision to submit the manuscript
for publication.
Disclaimer: The findings and conclusions in this
article are those of the authors and do not
necessarily represent the official position of the
Centers for Disease Control and Prevention.
Additional Contributions: We thank the
participants of the Healthy Habits, Happy Homes
study and the 4 health centers that supported the
study: Dimock Community Health Center, Roxbury
Comprehensive Community Health Centers, and
the Cambridge and Somerville offices of Cambridge
1078 JAMA Pediatrics November 2013 Volume 167, Number 11
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In summary, after 6 months, we found that the Healthy
Habits, Happy Homes intervention improved sleep duration
and TV viewing behaviors, as well as decreased BMI among ra-
cially/ethnically diverse children from low-income house-
holds. Future studies with a longer follow-up are needed to de-
termine maintenance of these behavior changes.
Health Alliance. We also thank the research staff
who helped make the study happen including Karen
Troncoso, BA, BSc, Amy Louer, BA, Stephanie
Ferisin, MHP, Elizabeth Cespedes, MPH, Jhoana
Yactayo, BSc, and Katherine Calderon. Additionally,
we thank Jan Jernigan, PhD, of the Centers for
Disease Control and Prevention for her ongoing
contribution to the development of the Healthy
Habits, Happy Homes program materials and
intervention structure.
Correction: This article was corrected on
September 26, 2013, to add a missing author
affiliation.
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