By Melinda Young

In an obesity prevention program targeted to Native American mothers and infants, participants reduced consumption of sugar-sweetened beverages and improved responsive feeding habits, both of which can contribute to healthier infant weights.1

The authors of the Family Spirit Nurture program compared mothers who received a home-based, six-lesson curriculum targeting infant feeding practices with a control group of mothers who received an injury prevention education program. All participants were part of the Navajo community.1

Family Spirit Nurture is a home visiting intervention aimed at reducing early childhood obesity in Native American children. It is based on the Family Spirit program, which sought to improve the mental and physical well-being of mothers and young children, says Summer Rosenstock, PhD, assistant scientist at the Center for American Indian Health at Johns Hopkins Bloomberg School of Public Health in Baltimore.

The early intervention was distributed to 130 communities across 21 states, Rosenstock adds.

“The original Family Spirit intervention had been rigorously tested through randomized clinical trials and had been widely disseminated,” she says.

Native American children record some of the highest obesity rates in the United States. Research suggests this problem can begin before birth, especially if the mother is obese or gains too much weight in pregnancy, she adds.

“We started to think about intergenerational cycle of obesity and where it was the right place to intervene,” Rosenstock says. “Then, a lot of literature came out about the first 1,000 days and how this was an important point for intervention.”

Early intervention is very important, especially for infants born to mothers who are obese or who have gestational diabetes. The interventions included educational sessions presented by family health coaches.

The clinical trial was developed based on these ideas, as well as the priorities of the Navajo community.

“The key to the study’s success is this is an issue we identified as a priority by the community, and everything is developed in partnership with the community,” Rosenstock says. “One example is that the family coaches incorporate cultural practices into the lessons.”

Every part of the educational sessions was developed in partnership with the community, she adds.

“Given the evidence that was already there for a Family Spirit intervention and how well it was received, this seemed like a platform for an intervention,” Rosenstock says. “Evidence is that pregnancy through the first 24 months of life is a critical time for an intervention to put children on a healthier growth trajectory to prevent obesity.”

The Family Spirit Nurture intervention starts when the infant is 3 months of age and continues through the first six months of the baby’s life. The researchers follow up with families through the first year.

“It’s a relatively short intervention for that critical time,” Rosenstock says. “The reason that time is so critical is because babies are changing really rapidly and growing rapidly.”

The 45-minute educational sessions appeared to significantly affect sugar-sweetened beverage consumption, the mother’s response to feeding, and the infant’s growth trajectory.

The intervention group reported the infants consumed an average of 0.56 cups of sugar-sweetened beverages each week, compared to an average of 1.78 cups per week in the control group.

“The educational topics included the importance of healthy eating for the whole family and the parents’ roles in feeding in early infancy,” Rosenstock says. “The lessons also featured infancy personality traits related to responsive feeding, avoiding sugary drinks, and eating healthy foods.”

For example, the lessons defined sugary drinks and helped mothers visualize the amount of sugar in the drinks they might give their babies.

“Drinks like juice or Gatorade that might be perceived to be good for hydration also fall into that the category of sugary beverages,” Rosenstock says. “The recommendation is to just give water and milk to infants, and mostly it’s just milk until they’re a bit older. That’s what we promote through Family Spirit Nurture and programs.”

Family health coaches helped the mothers problem-solve barriers to success and build on their personal strengths. “I believe the family health coaches were the secret sauce to this intervention’s success,” Rosenstock says.

For example, some families lived in areas where it can be difficult to access a grocery store that sells fresh fruits and vegetables. Safe water also could be challenging for some families. As a result, following the healthy advice of the educational sessions could be challenging for some mothers.

When family coaches identified a problem, such as food insecurity, they would connect the mother to community resources, including transportation, she adds.

“About 35% of the mothers enrolled in this study reported they were water-insecure when they enrolled,” Rosenstock says. “This is definitely an issue they are dealing with, and one of the things you worry about when water is not available is whether you substitute something for water.”

Problems arise when parents substitute sugary drinks for water.

When the babies were between ages 6 and 9 months, all families in the intervention and control groups received water through the program, Rosenstock says.

“We did not analyze the data yet; it’s the next piece we’ll look at,” she explains. “The idea was to try to see how much of an impact water insecurity has on sugary beverage consumption and infant growth.”

Responsive feeding information was a big part of the educational piece of the intervention.

“It’s the practice of responding to the baby’s cues for hunger, but you don’t use food to soothe the baby,” Rosenstock says.

Family health coaches taught mothers how to find out whether the infant was fussing for a non-hunger reason, such as needing a diaper change.

“We found the intervention group had better responsive feeding practices through 9 months of age,” Rosenstock says.

The infants in the intervention group recorded lower rates of standardized body mass index (zBMI) scores than infants in the control group, starting at six months postpartum.

“By 12 months of age, the infant zBMI score for the intervention was at the 73rd percentile,” Rosenstock adds. “For the control group, the average was a zBMI score in the 86th percentile, which is above the 85th percentile — the threshold for categorizing children as overweight.”

Ideally, researchers would follow up on the infants to see if there is a long-term effect of this intervention on obesity.

“We’re hoping to submit for traditional funding to do that, and we’re dependent on getting funding,” Rosenstock says. “We’re hoping to continue the research.”


  1. Rosenstock S, Ingalls A, Cuddy RF, et al. Effect of a home-visiting intervention to reduce early childhood obesity among Native American children: A randomized clinical trial. JAMA Pediatr 2020; Nov 9;e203557. doi: 10.1001/jamapediatrics.2020.3557. [Online ahead of print].