ACCESSION NO: 0224871  SUBFILE: CRIS 

PROJ NO: HAW01210-G AGENCY: NIFA HAW 

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

INVESTIGATOR: Novotny, R.; DeBaryshe, B.; Edmonds, C.; Deenik, J.; Dunn, M.; Stokes, A.;
Wilkens, L.; Nigg, C.; Vargo, D.; Kim, J.; Luick, B.; LeonGuerrero, R.

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

CHILDREN`S HEALTHY LIVING PROGRAM FOR REMOTE UNDERSERVED MINORITY

POPULATIONS OF THE PACIFIC REGION (CHL)

NON-TECHNICAL SUMMARY: The program emphasizes child obesity prevention through

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

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

APPROACH: Program and data inventories will be completed in Year One. In each jurisdiction
we will inventory available relevant trade, economic, food, nutrition, physical activity, obesity,
and health data for children ages 2 through 8 years old. Data will be used to finalize the
research design and content, identify needed policy changes, determine training/education
priorities, and provide baseline data for the intervention program monitoring and evaluation
system. Based on the needs assessment during Year One, the training needs of each
jurisdiction will be determined. Candidates for training will be identified, and applications will be
submitted for selected training programs in grant Year Two. Trainees will be active contributors
to the program intervention, dissemination and policy development in their home jurisdiction.
The program intervention will be a group randomized trial of young children from selected
daycare/schools that will target change in the social/cultural, physical/built and
political/economic environment of the neighboring community for active play and healthy eating
to prevent obesity and its functional outcomes in the Pacific Region. Intervention findings will be
presented in community and professional venues. Advocacy for at least one local policy change
to support a healthy children's environment will occur at each site. A local advisory committee in
each jurisdiction will be formed to guide and sustain the program work.

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

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

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

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