DECREASING WEIGHT GAIN IN AFRICAN-AMERICAN PREADOLESCENT GIRLS - FIELD AND COORDINATING CENTERS Release Date: April 17, 1998 RFA: HL-98-010 P.T. National Heart, Lung, and Blood Institute Letter of Intent Receipt Date: May 18, 1998 Application Receipt Date: July 30, 1998 PURPOSE The Division of Epidemiology and Clinical Applications (DECA) invites cooperative agreement applications for an estimated four Field Centers and one Coordinating Center to participate, with the assistance of the National Heart, Lung, and Blood Institute (NHLBI), in a collaborative multicenter project on decreasing weight gain during adolescence in high-risk African-American preadolescent girls. The proposed 3-phase research project is designed to address the problem of increasing obesity in the United States, a major cardiovascular disease risk factor that is not showing secular improvement. Although numerous public health organizations strongly recommend that obesity be prevented, few interventions have been tested to implement these recommendations. Because the higher prevalence of obesity in African-American women has been hypothesized to account, in part, for excess cardiovascular disease morbidity and mortality in this population group, this research project will be directed at high-risk African-American girls. The purpose is to develop and test interventions to prevent obesity by decreasing weight gain during the high-risk transitional period from pre- puberty to puberty in African-American girls who are at high risk for developing obesity. Phase 1 will provide support over 2-3 years for the development of interventions through needs assessment and formative research and the pilot-testing of the interventions and the measurement instruments. Phase 2 will support single-center randomized controlled trials for a period of 4-5 years to test the efficacy of the interventions developed in Phase 1. Phases 1 and 2 will total no more than 7 years for the Field Centers and 8 years for the Coordinating Center and be funded by the same mechanism. A Protocol Review Committee will review the results of Phase 1 and the Phase 2 protocols before Phase 2 recruitment begins. About four Field Centers will be supported; two targeting African-American girls with low socioeconomic status (SES) and two targeting African-American girls with higher SES. Although the interventions developed by each Field Center will be unique, the centers will collaborate to define and standardize participant eligibility criteria and key measurements across all centers. A Coordinating Center will be funded to support the standardization and to analyze results of Phase 2. A Phase 3 for dissemination research may be initiated after review of Phase 2 results; open competition for new awards would be conducted for Phase 3. This Request for Applications (RFA) is for Phases 1 and 2 only. HEALTHY PEOPLE 2000 The Public Health Service (PHS) is committed to achieving the health promotion and disease prevention objectives of "Healthy People 2000," a PHS-led national activity for setting priority areas. This RFA, Decreasing Weight Gain During Adolescence in African-American Girls, is related to the priority areas of nutrition, physical activity and fitness, educational and community-based programs, heart disease and stroke, and diabetes. Potential applicants may obtain a copy of "Healthy People 2000" (Full Report: Stock No.017-001-00474-0 or Summary Report: Stock No. 017-001-00473-1) through the Superintendent of Documents, Government Printing Office, Washington, DC 20402-9325 (telephone 202-512-1800). ELIGIBILITY REQUIREMENTS Among the disciplines and expertise that may be appropriate for this research project are health promotion and health education, obesity and weight management, body composition measurement, physical activity measurement and intervention, exercise physiology, nutrition, behavioral and social science, pediatric medicine, preventive medicine, cardiovascular epidemiology, educational technology, and instructional design. Field Center applicants are expected to propose multi disciplinary teams. Applications may be submitted by domestic and foreign, for-profit and non-profit organizations, public and private, such as universities, colleges, hospitals, laboratories, units of State or local governments, and eligible agencies of the Federal government. Racial/ethnic minority individuals, women, and persons with disabilities are encouraged to apply as Principal Investigators. All current policies and requirements that govern the research grant programs of the National Institutes of Health (NIH) will apply to grants awarded under this RFA. Awards for Field Centers and a Coordinating Center will be made under this RFA. The same institution may apply for both a Field Center and a Coordinating Center award, but the applications for each must be separate, and there must be a different Principal Investigator and staff for each to ensure that data analysis is done independently of data acquisition and to ensure blinding of Field Center staff. MECHANISM OF SUPPORT The administrative and funding mechanism to be used to undertake this project will be a cooperative agreement (U01), an assistance mechanism. Under the cooperative agreement, the NIH assists, supports, and/or stimulates and is substantially involved with recipients in conducting a study by facilitating performance of the effort in a "partner" role. Details of the responsibilities, relationships, and governance of a study funded under a cooperative agreement are discussed later in this document under the section entitled TERMS AND CONDITIONS OF AWARD. While multi disciplinary approaches are encouraged, it is not the intent of this announcement to solicit applications for large studies encompassing a variety individual subprojects, i.e., program projects. If collaborative arrangements through subcontracts with other institutions are planned, consult the program staff listed under INQUIRIES. FUNDS AVAILABLE An estimated four awards for Field Centers and one award for a Coordinating Center will be made under this RFA. A maximum of $24.4 million (including Direct costs and Facilities and Administrative costs) will be awarded for Field Centers and the Coordinating Center with about 80% apportioned to the Field Centers. Approximately $1.2 million will be available for the first year, $2.2 million for the second year, $2.7 million for the third year, $4.2 million for the fourth year, $4.6 million for the fifth year, $4.7 million for the sixth year, $4.3 million for the seventh year (final year for Field Centers), and $0.44 million for the last year (Coordinating Center only). Field Center applicants may request up to 7 years of support. Coordinating Center applicants may request up to 8 years of support. Applicants are expected to furnish their own estimates of time required to achieve the objectives of the proposed research project. Since a variety of approaches would represent valid responses to this RFA, it is anticipated that there will be a range of costs among individual grants awarded. Awards and level of support are dependent on the receipt of a sufficient number of applications of high scientific merit. Although this project is provided for in the financial plans of the NHLBI, awards pursuant to this RFA are contingent upon the availability of funds for this purpose. This RFA is a one-time solicitation. Future unsolicited competing continuation applications will compete with all investigator-initiated applications and be submitted and reviewed according to the customary peer review procedures. It is anticipated that support for this project will begin on April 1, 1999. Administrative adjustments in project period and/or amount may be required at the time of the award. RESEARCH OBJECTIVES Background The high prevalence of obesity in Black women may be a contributing factor to their higher mortality from cardiovascular disease and higher prevalence of diabetes and hypertension compared with White and Hispanic women (Fingerhut and Warner, 1997). Although Hispanic women also exhibit high prevalence of obesity, mortality from heart disease is less than for Black or White women and mortality from diabetes is less than for Black women (Fingerhut and Warner, 1997). The increased prevalence of obesity in Black females is present during childhood, and the prevalence of obesity is increasing faster in Black girls than in White girls. Recent data from the third National Health and Nutrition Examination Survey (NHANES III) showed that during preadolescence, age 6-11 years, 30.7 % of Black girls, compared with 22.0% of White girls, were overweight (Troiano et al, 1995). Furthermore, over the past 30 years the prevalence of obesity in this preadolescent age group has increased 150% in Black girls, compared with 40% in White girls (Troiano et al, 1995). The prevalence of obesity in the adolescent age of 12-17 years is similarly high, at 29.9% in Black girls compared with 20.7% in White girls. The 35% increase in obesity over the past 30 years is similar in the preadolescent and adolescent age groups for White girls, but for Black girls the increase is greater in the younger age group (150% more prevalent) than in the older age group (80% increase). Obese children are at high risk of becoming obese adults. Risk ratios of 2.0 to 6.5 have been estimated from several studies, indicating the risk of an obese child becoming an obese adult is up to 6.5 times higher than that of a non-obese child becoming an obese adult (Serdula et al, 1993). During puberty fat accumulation accelerates in girls (Malina and Bouchard, 1991; Foster et al, 1977), and at age 12, the average age of menarche, greater increases in adiposity as measured by sum of three skinfolds are observable in Black girls compared with White girls (Kimm et al, 1994). As in adults (Liu et al, 1996, Denke et al, 1993), cardiovascular disease risk factors such as blood cholesterol and blood pressure are associated with increased weight in children (Smoak et al, 1987; Williams et al, 1992), and unfavorable changes in cardiovascular disease risk factors have been associated with increases in weight in children (Clarke et al, 1986; Freedman et al, 1985). Because Black women have a high prevalence of obesity and other conditions that are ameliorated by weight loss, such as hypertension and diabetes, obesity prevention efforts directed at Black girls have potential long-term health benefits. It is generally agreed that the etiology of obesity is multifactorial. Excess energy intake and/or insufficient energy expenditure contribute to energy imbalance which results in obesity. Eating and physical activity behaviors, psychosocial factors, socioeconomic status, and family and environmental influences are associated with obesity and behaviors related to obesity. In addition, data have been accumulating that genetic factors strongly influence adiposity (Bouchard and Perusse, 1993). Research on mouse and rat genes and their mutations as well as on the leptin receptor has propelled the search for human obesity genes. Determining the effect of genetic polymorphisms on the response of weight to intervention is important to help explain individual variation in responsiveness and to help target future intervention efforts to individuals at risk for obesity. Treatment Programs: Achieving long-term weight loss has long been a difficult and elusive goal in adults (Kramer et al, 1989), and there is evidence that adult Black women are less successful in achieving weight loss than White women (Kumanyika et al, 1991). Weight loss in children also is difficult to achieve, and there are potential safety concerns in promoting weight loss in growing children. Weight loss efforts may compromise children's nutritional status, and dieting has been linked to eating disorders, especially in girls (French et al, 1995). It was recently reported that by age 9-10 years, 40% of Black and White girls are trying to lose weight (Schreiber et al, 1996). Although successful long-term weight loss in children has been reported in clinic-based studies (Epstein et al, 1984; 1990; Davis and Christoffel, 1994), and in shorter term school-based studies of obese children (Resnicow, 1993), most studies were successful at best in the short term and much of the weight lost was subsequently regained in the longer term. Many weight loss studies have had large drop-out rates, where approximately only half of the original sample returns for follow-up visits. Prevention of Obesity: The possibility that healthful behaviors learned in childhood may be sustained through adulthood makes prevention activities targeted at children especially appealing and potentially cost-effective. Promoting optimal weight and preventing obesity by promotion of healthful eating and physical activity habits in children has been recommended by several public health organizations and investigators (USDA, 1995; American Academy of Pediatrics, 1992; Troiano et al, 1995). However, few studies have tested obesity prevention efforts. Prevention-oriented interventions have been tried in school-based studies (Donnelly et al, 1996) and have not focused specifically on obesity prevention but rather have promoted healthful eating behaviors, primarily reducing dietary fat intake, and/or increasing physical activity. In general no effects on weight have been observed (Resnicow, 1993; Leupker et al, 1996). Few non-school-based studies aimed at obesity prevention in children have been conducted. A 6-week obesity prevention pilot study tested a community-based tutoring program based on social learning theory in 24 low-income Black girls, age 8-12 years, and their mothers. Although favorable effects were found in fat intake in the girls and their mothers compared to the control group, assessment of the effectiveness of decreasing weight gain was precluded because of the short time frame of 6 weeks (Fitzgibbon et al, 1995). Subsequently, a 12-week program conducted by the same research group reported favorable changes in total dietary fat and saturated fat in the mothers and saturated fat in the daughters, but no differences in weight were reported between the intervention and control groups at 12 weeks (Stolley and Fitzgibbon, 1997). Interventions to improve diet and physical activity behaviors in children have been successful, although they have not focused on obesity prevention. For example, the Dietary Intervention Study in Children (DISC) successfully decreased dietary fat consumption over 3 years in adolescents (DISC, 1995). The most extensive and promising research on interventions for promoting physical activity among young people has been conducted with students in schools, primarily at the elementary school level (Resnicow, 1997). There is limited evidence concerning the effectiveness of community programs, interventions in health care settings, family programs, and programs for special populations (USDHHS, 1996). The NIH convened a Special Emphasis Panel (SEP), "Intervention Studies in Children and Adolescents to Prevent Cardiovascular Disease," in September 1997. The SEP reviewed the efficacy and effectiveness of interventions to prevent and improve known cardiovascular disease risk factors in children and adolescents and developed recommendations for future research directions for preventive intervention studies. This RFA was developed in response to the SEP's favorable and supportive review of an initiative concept. Minutes from the SEP can be found at www.nhlbi.nih.gov/nhlbi/ under "Meetings and Other Information." Because very few prevention-oriented interventions for obesity have been developed, research to support the early phases of intervention development is urgently needed. Phase 1 of this program is envisioned to address this need. The formative research in Phase 1 will enable centers to develop interventions and measurement instruments for low- and higher SES African-American girls that will be tested subsequently in Phase 2. Finally, Phase 3 (not addressed by this RFA) is envisioned to study the dissemination of the efficacious interventions to other populations of African-American girls, as well as to other ethnic/racial groups after adaptation, and in various settings. Objectives and Research Scope The purpose of Phase 1 is to provide each Field Center with the opportunity to develop its interventions. Coincident with this, and with the assistance of the Coordinating Center, will be the identification, development, and assessment of standardized measurement methodology. Phase 2 is for the purpose of implementing four trials, one at each of the four Field Centers, with the Coordinating Center assuming major responsibility for the collaborative sections of the protocols and measurement procedures, measurement training, quality control, data management, and analyses for the key variables selected for standardization across all Field Centers. The Field Centers and/or Coordinating Center are expected to carry out the following activities during Phases 1 and 2: Phase 1: Development and Pilot Testing Each Field Center - independently of the other Field Centers: 1. Conduct needs assessment and formative research including, for example, focus groups, interviews or surveys, to design an intervention for decreasing weight gain during puberty in African-American girls. This phase can also include behavioral theory refinement. 2. Demonstrate the feasibility of recruitment and retention of the target population over the short term (e.g., 12 weeks). 3. Demonstrate the feasibility of delivery of the intervention over the short term (e.g., 12 weeks). 4. Demonstrate the ability to take quality measurements for center-specific and collaborative data that allow for process, adherence, impact, and outcome evaluations. 5. Demonstrate the ability of the intervention to modify knowledge, attitudes, and other factors that affect diet and physical activity behaviors. Each Field Center and the Coordinating Center: 6. Work collaboratively with other awardees and the Project Office to agree on criteria for participant eligibility and key measurement areas (e.g., at a minimum impact and outcome evaluations and giving consideration to evaluation of adherence and process evaluation), ways to pilot measurements, and criteria for assessment of their reliability and/or validity. 7. Work collaboratively with other awardees and the Project Office to agree on the content of the collaborative database (which at a minimum contains the key variables standardized across all sites), rights to access regarding the collaborative data, and procedures for data analysis, reporting and publication. The Coordinating Center: 8. Assist the Field Centers with standardization of measurement methodology for the key variables (including data forms, procedures manuals, and training), quality control of both measurement and intervention, and data analysis. 9. Provide administrative support to the project by coordinating meetings, conference calls, and communications throughout Phases 1 and 2. Phase 2: Randomized Controlled Trials Each Field Center: 1. Finalize the full-scale study intervention procedures. 2. Conduct a single-center randomized clinical trial, including recruitment, randomization, measurement of center-specific variables (e.g., adherence and process evaluation), and intervention delivery. 3. Work collaboratively with other awardees, the Coordinating Center, and the NHLBI Project Office to measure and assure quality control of the key variables. Each Field Center and the Coordinating Center - collaboratively with the Project Office: 4. Finalize the full-scale study protocols and measurement procedures. 5. Test the efficacy of a medium-term (2-year) intervention to prevent obesity by decreasing weight gain in high-risk African-American preadolescent girls in a randomized clinical trial. 6. Determine whether and to what extent medium-term reduction in weight gain in high-risk African-American preadolescent girls results in more favorable cardiovascular risk factors (e.g., lipids, blood pressure, fasting insulin). 7. Determine the factors associated with successful decreased weight gain in high-risk African-American preadolescent girls, including diet, physical activity, and psychosocial and familial influences. Genetic influences on response to intervention should be assessed. 8. Determine other effects of the intervention on biological and behavioral parameters, such as sexual maturation, bone mass, and behaviors including eating disorders and smoking. The Coordinating Center: 9. Assist the Field Centers with measurement training, quality control of both measurement and intervention, and data analyses of the key variables contained in the collaborative data base. 10. Maintain a distributed data entry system and a collaborative data base. Phase 3: Dissemination Research The purpose of Phase 3 may be to develop, implement, and evaluate a process for disseminating the efficacious interventions from Phase 2 that have been adapted for broader ethnic application, especially Hispanic. The specific objectives of Phase 3 would be determined after Phase 2 and would be addressed in a future RFA. Scientific Plan Target Population Sexual maturation has been found to be strongly related to adiposity (Morrison et al, 1994). Significant race-by-sexual maturation interaction observed in the NHLBI Growth and Health Study suggests that adiposity increases more in Black girls than in White girls during puberty (Kimm et al, 1997). At age 9 approximately one-third and by age 10 approximately 70% of Black girls have entered puberty (NGHS, 1992). These observations suggest that intervention in girls who are entering puberty is a promising age to target interventions to decrease weight gain. Thus it is suggested that African-American girls, aged 8-10, be eligible for this study. To enrich the population sample for girls at high risk of obesity, it is suggested that girls be eligible if they have at least one obese parent (Eck et al, 1992). Other or alternative criteria for selection of high-risk participants may be proposed by the applicant. All Field Centers will recruit participants based on standardized eligibility criteria, agreed upon collaboratively. Phase 1 Because there is little experience with obesity prevention interventions, it is desirable that distinct and separate interventions be developed by each Field Center. Phase 1 research will be supported for 2-3 years to conduct the evaluative research necessary for each Field Center to develop an intervention. The needs assessment and formative research may employ methods such as interviews, surveys, focus groups, or key informant interviews. Information is envisioned to be obtained on factors hypothesized to influence diet and physical activity behaviors that affect weight gain. These may include factors such as knowledge, attitudes, beliefs, self-efficacy, outcome expectations, body image, perceptions of ideal body weight, cultural norms, social context, and/or peer, family, social, and environmental influences. The rationale for the factors to be studied should be presented. Identification of behavioral theory to help define factors to examine is strongly encouraged. Field Center applicants should specify the methods to be employed, the rationale for these methods, and how the results will be used to develop the intervention. Based on the evaluative research results, each Field Center will develop an intervention which it will pilot-test for a 12-week period to demonstrate feasibility, acceptability, and potential impact of the intervention. The intervention to be developed must be appropriate for testing in a randomized controlled trial in Phase 2. The Field Centers, along with the Coordinating Center and Project Office, will work collaboratively to determine measurement areas to pilot test and approaches to evaluation of the measurements tested. Pilot testing should be conducted in an intervention and control group composed of girls meeting the eligibility criteria for the Phase 2 study, and include process evaluation and measurement of intermediate factors hypothesized to be related to diet and physical activity behaviors important for decreasing weight gain (e.g., knowledge, skills, self-efficacy, outcome expectations). Applicants should specify the proposed intermediate factors, measurement methods, and the rationale for their selection. The theory development and formative research should be completed in 1-2 years and pilot testing and data analysis should be completed within the third year of funding. It is envisioned that the average time to complete Phase 1 will be about 2-1/2 years and that the Field Centers will collaborate to follow similar schedules. Phase 2 Phase 2, single-center randomized controlled trials conducted at each Field Center, may cover a 4-5 year period: about half year of final collaborative planning for measurement and protocol development, about 3 years to complete the 2-year intervention which includes about a 1-year recruitment period, and about a half year for closeout and data analysis. The protocols will be reviewed by a Protocol Review Committee, appointed by the Director of the NHLBI, prior to implementation of Phase 2 recruitment and intervention. The Coordinating Center will prepare the report to the Protocol Review Committee, and subsequent reports to the future Data and Safety Monitoring Board. It is envisioned that review of the protocols would occur no later than the early half of the third year of funding and that completion of procedures manuals would occur at about the same time. Recruitment would begin about midway through the fourth year and intervention would begin shortly thereafter. Completion of the 2-year intervention and follow-up measurement would occur early in the last year of the 7-year project. The Coordinating Center will have an additional half year for analysis. Phase 2: Study Design Phase 2 would provide support for the conduct of separate randomized controlled trials at each Field Center funded to do Phase 1 research and having achieved Phase 1 objectives. Each center would conduct its own randomized controlled trial with individual assignment to intervention and control conditions. (In the absence of compelling reasons not to, individuals will be the units of randomization and analysis.) Each Field Center will have a sample size sufficient to have high power to detect a significant effect size difference between the intervention and control groups after 2 years of intervention and should provide the rationale for its choice of significant effect size difference. Phase 2: Eligibility and Measurements To facilitate comparison of the effects of the interventions tested, the collaborative effort between centers and the Project Office will include collaboration in defining the eligibility criteria and in collecting data using identical measurement procedures and instruments and schedules of follow-up visits for key impact and outcome variables (at a minimum). Common eligibility criteria and data collection procedures may more easily allow comparison of intervention effects across sites, and may allow for subsequent meta-analytic approaches. The Coordinating Center will assist the Field Centers with standardization of measurement methodology, including data forms, procedures manuals, training, quality control of both measurement and intervention, and data analysis. Field Centers may collect, manage, and analyze data specific to their center that is in addition to the data collected for collaborative purposes. The primary outcome variable for Phase 2 may be body mass index (BMI), which has been recently recommended as the measure of choice for adolescent preventive services (Himes and Dietz, 1994). BMI has been used in this initiative for purposes of sample size estimation. Alternative adiposity outcomes may be proposed, such as skinfolds, percent body fat from bioelectrical impedance, and/or other measures of body fat or body fat distribution. The effect size between the intervention and control group would be a lesser increase in BMI by 0.75 kg/m2 (e.g., about 2-3 kg), which is similar to the difference that has been observed previously between Black and White 9-year- old girls over a 2-year period. A standard deviation of the change of 1.8 is assumed. Thus, each Field Center is estimated to need a sample size of approximately 120 per treatment arm. The Coordinating Center and Steering Committee will redetermine the sample size after all centers agree on the primary outcome variable. Intervening factors should be measured, including dietary intake, physical activity, and psychosocial factors. Because sexual maturation plays a strong role in accumulation of body fat in girls during puberty, sexual maturation should be measured as an explanatory variable. Measures of candidate genes for obesity should be included in order to test the effects of the intervention in individuals with different genetic polymorphisms. Secondary outcomes may include blood pressure, blood lipoproteins, blood insulin levels, and/or safety measures such as eating disorders. Information collected on parents and data collection from subsamples could also be proposed. Phase 2: Intervention The goal of the intervention would be to reduce weight gain during adolescence. The interventions to be tested should be appropriate for a controlled trial in which individuals are randomized. Innovative and theory- based interventions will be given preference. Because children age 8-10 are not independent, interventions that involve the family would be expected. Interventions could be delivered in various settings, for example, pediatric clinic, community organization, church, school, or housing development. A Field Center could test an intervention based on a specific theory or behavioral approach, for example: (1) family-based intervention requiring attendance of a family member along with the participant and including behavioral techniques for improving dietary and physical activity patterns in both child and family member; (2) center-based intervention with supervised physical activity and dietary instruction; (3) individual-based counseling intervention which incorporates behavioral techniques; (4) group-based intervention focusing on changing perceived social norms and including trained peer leaders and group social support. Additionally, a Field Center could test an intervention based on various behavioral goals for the dietary component of the intervention (for example, controlling total energy intake, decreasing high-fat and energy-dense foods, and/or promoting general healthful eating habits including increased fruits, vegetables, and whole grains) and/or for the physical activity component of the intervention (for example, decreasing time spent in sedentary activities, increasing moderate-intensity physical activity such as walking, incorporating more active lifestyle into daily living, and/or increasing vigorous-intensity exercise). The applicant should specify the setting, behavioral approach, behavioral goals, and any other components of the intervention proposed to be developed. The rationale for the intervention to be developed should be given. Phase 3: Dissemination Research If the experiences and results of Phase 2 are positive, it is possible that the most efficacious interventions would be adapted for broader audiences, especially Hispanic children, and Phase 3 would be an evaluation of dissemination approaches. The dissemination process may involve development of transportable intervention materials, an intervention manual, training materials, and training procedures. The investigators could train individuals in clinical practice or community settings to implement the interventions. It is envisioned that evaluation of the dissemination process could be conducted by comparing the degree of implementation and the outcomes in intervention and comparison sites. SPECIAL REQUIREMENTS Upon initiation of the project, periodic meetings to encourage exchange of information among investigators and the NHLBI will take place. In the budget of the grant application, travel funds for 1-1/2-day meetings 2-4 times a year in the Washington Metropolitan DC area should be included. Applicants should also include a statement in their applications indicating their willingness to participate in these meetings. The Coordinating Center will provide the logistical arrangements for these meetings and will schedule and sponsor approximately monthly conference calls for telephone meetings of the Steering Committee, as well as other project subcommittees. Collaboration in this project for the Field Centers means their willingness to work with the other Field Centers, the Coordinating Center and the Project Office. Applicants should include in their applications a statement of their intent to share information during the intervention development phase, to cooperate in identifying and defining key primary and secondary outcomes for the randomized controlled trials, to cooperatively develop procedures for standardized measurement, and to participate in quality control procedures. Field Centers should state their flexibility in adapting to a common timeline, their ability to complete tasks in a timely manner, and their intent to be in synchrony with other Field Centers for training and data collection periods during Phase 2. Field Centers should state their ability to participate in a distributed data entry system with the Coordinating Center, their approach to blinding of primary and secondary outcome measurements, and intent to cooperate with the other Field Centers, Coordinating Center, and Project Office in determining the content of the collaborative data base, prioritizing data analyses by the Coordinating Center, and in collaborative publications. All applicants should state their intent to fully participate in the Steering Committee and subcommittees and the willingness of their investigators to lead a project committee or subcommittee. The Field Centers will report regularly their recruitment progress to the Project Office and Coordinating Center. In order to ensure the timely sharing of information and materials, applicants are requested to describe how, when, and in what manner data and materials will be made available to the scientific community and the NHLBI. Each plan will be considered as part of the methodology for carrying out the research. As such, the adequacy of the plan, will be evaluated through the peer review process and by program staff. If an application is funded, the approved plan will become a condition of the award, and compliance will be monitored annually through the non-competitive renewal progress reports, which should address this issue explicitly. Upon completion of the project, Field Center awardees are expected to put their intervention materials and procedure manuals into the public domain/and or make them available to other investigators for the conduct of research at no charge other than the costs of reproduction and distribution. Field Center applicants should include their plans within their applications. The Coordinating Center will describe its plans to provide all Field Centers, the NHLBI Project Office, and the scientific community, with copies of final, cleaned data on electronic media with accompanying documentation. STUDY ORGANIZATION The Steering Committee will be the main governing body of the project and, at a minimum, will be composed of the Principal Investigators (PIs) of the Field Centers, the PI of the Coordinating Center, and the NHLBI Project Scientist (Prevention Scientific Research Group, DECA). Each center and the NHLBI will have one vote. The Committee may meet as often as 3 times in the first 12 months of the project, equally often in the third year of the project (prior to implementation of Phase 2) and one to two times in other years. In addition, it may convene monthly conference calls. All major scientific decisions will be determined by majority vote of the Steering Committee. The Chairperson, who will be other than an NHLBI staff member, should be selected in a process assisted by the Project Office by the end of the second meeting of the Steering Committee. The first two meetings of the Steering Committee will be convened by the NHLBI Project Scientist. Although each Field Center will be responsible for its own unique protocol, the Steering Committee will have primary responsibility for the development of the common prototype for the measurement and data management sections and eligibility criteria. It will also have primary responsibility for facilitating the conduct of the trials and reporting the project's results. Subcommittees of the Steering Committee will be established as necessary and may include Measurement and Quality Control, Project Coordinators, Intervention, and Eligibility and Recruitment. The NHLBI may have representatives on each subcommittee. The collaborative sections of the protocols, as mentioned above, will be developed by the Steering Committee, assisted by Coordinating Center staff. These sections will define rules regarding access to data, which will be managed through a distributed data entry system, and publications. A Data and Safety Monitoring Board (initially a Protocol Review Committee), to be appointed by the NHLBI, will review progress at least annually and report to the NHLBI. The Coordinating Center will be responsible for developing the reports for the DSMB and for assuming the costs of PRC/DSMB meetings. It is required that a Data and Safety Monitoring Board (DSMB) be established to monitor data and oversee patient safety in clinical trials. The DSMB is an operational component of National Heart, Lung, and Blood Institute (NHLBI) trials. Its charge is to periodically monitor baseline, adverse effects, and response variable data, and to evaluate clinic and coordinating center performance. It has the responsibility to recommend whether the study should continue, whether the protocol should be modified, or whether there should be early termination. Thus, its ethical responsibilities to the participants, as well as to the integrity of the study, are of paramount importance to the NHLBI. Members will be appointed by the Director, NHLBI. The DSMB will provide reports to the Institute through an Executive Secretary (usually the NHLBI Project Officer). The Chairperson of the Steering Committee of the study, the Principal Investigator of the Coordinating Center, and the NHLBI Project Officer (Program Administrator for Grants) will attend meetings of this Board. Progressions from protocol development to participant enrollment is dependent upon the favorable recommendation of a Protocol Review Committee (a distinct entity from the DSMB but usually with substantially overlapping membership) and the approval of NHLBI. TERMS AND CONDITIONS OF AWARD The cooperative agreement is an award instrument establishing an "assistance" relationship (in contrast to an "acquisition" relationship) between NHLBI and a recipient, in which substantial NHLBI scientific and/or programmatic involvement with the recipient is anticipated during performance of the activity. The NHLBI purpose is to support and/or stimulate the recipient's activity by involvement in and otherwise facilitating the activity in a "partner" role, but avoiding a dominant role, direction or prime responsibility. The terms and conditions, below, elaborate on these actions and responsibilities, and the awardee agrees to these collaborative actions with the NHLBI Project Scientist toward achieving the project objectives. It is anticipated that these terms and conditions will enhance the relationship between the NHLBI staff and the Principal Investigator(s), and will facilitate the successful conduct and completion of the study. These agreements will be in addition to, and not in lieu of, the relevant NIH procedures for grants administration. The terms and conditions will be as follows (with "trial" referring to a single-center randomized controlled trial conducted by a Field Center awardee and "project" referring to the collaborative activities among awardees called for in the RFA): 1. The awardee(s) will have lead responsibilities in all aspects of their trials and the project, including any modification of trial designs, conduct of the trials, quality control, data analysis and interpretation, preparation of publications, and collaboration with other investigators, unless otherwise provided for in these terms or by action of the Steering Committee. 2. The NHLBI Project Scientist will serve on the Steering Committee; she or another NHLBI scientist may serve on other project committees, when appropriate. The NHLBI Project Scientist (and the other cited NHLBI scientists) may work with awardees on issues coming before the Steering Committee and, as appropriate, other committees, e.g., recruitment, intervention, follow up, quality control, adherence to protocol, assessment of problems affecting the project and potential changes in the protocols of which there will be one per Field Center, interim data and safety monitoring, final data analysis and interpretation, preparation of publications, and development of solutions to major problems such as insufficient participant enrollment. The Project Scientist will have similar responsibilities in working with each awardee on their trial. 3. Awardee(s) agree to the governance of the project through a Steering Committee. Steering Committee voting membership shall consist of the Principal Investigators (i.e., cooperative agreement awardees) and the NHLBI Project Scientist. Meetings of the Steering Committee will ordinarily be held by telephone conference call or in the Washington Metropolitan DC area. 4. A Data and Safety Monitoring Board (DSMB) to provide overall monitoring of interim data and safety issues will be appointed by the Director, NHLBI. The Steering Committee will nominate members for the DSMB. Meetings of the DSMB will ordinarily be held in the Washington Metropolitan DC area. The NHLBI Project Scientist shall serve as Executive Secretary to the DSMB. 5. Awardees will retain custody of and have primary rights to their center- specific and collaborative data developed under these awards, subject to Government rights of access consistent with current HHS, PHS, and NIH policies. The protocols and governance policies will call for the continual submission of data centrally to the Coordinating Center for collaborative database, which at a minimum will contain the key variables selected by the Steering Committee for standardization across all Field Centers; the submittal of copies of the collaborative datasets to each Principal Investigator upon completion of the project; procedures for data analysis, reporting and publication; and procedures to protect and ensure the privacy of medical and genetic data and records of individuals. The NHLBI Project Scientist, on behalf of the NHLBI, will have the same access, privileges and responsibilities regarding the collaborative data as the other members of the Steering Committee (i.e., cooperative agreement awardees). 6. Support or other involvement of industry or any other third party in the trials or the project -- e.g., participation by the third party; involvement of project resources or citing the name of the project or NHLBI support; or special access to project results, data, findings or resources -- may be advantageous and appropriate. However, except for licensing of patents or copyrights, support or involvement of any third party will occur only following notification of and concurrence by NHLBI. 7. Awardees are encouraged to publish and to publicly release and disseminate results, data, and other products of the project, concordant with the project protocols and governance, and the approved plan for making data and materials available to the scientific community and to the NHLBI. However, during or within three years beyond the end date of the project period of NHLBI support, unpublished data, unpublished results, data sets not previously released, or other study materials or products are to be made available to any third party only with the approval of the Steering Committee and in accordance with paragraph 6. 8. Upon completion of the project, Field Center awardees are expected to put their intervention materials and procedure manuals into the public domain and/or make them available to other investigators, according to the approved plan for making data and materials available to the scientific community and the NHLBI, for the conduct of research at no charge other than the costs of reproduction and distribution. 9. The NHLBI reserves the right to terminate or curtail the project (or an individual award) in the event of (a) failure to develop or implement mutually agreeable collaborative measurement, participant eligibility, and data management sections of the protocols, (b) substantial shortfall in participant recruitment, follow up, data reporting, quality control, or other major breech of protocol, (c) substantive changes in the agreed-upon protocols with which NHLBI cannot concur, (d) reaching a major project outcome substantially before schedule with persuasive statistical significance, or (e) human subject ethical issues that may dictate a premature termination. 10. Any disagreement that may arise in scientific/programmatic matters (within the scope of the award) between award recipients and the NHLBI may be brought to arbitration. An arbitration panel will be composed of three members -- one selected by the Steering Committee (with the NHLBI member not voting) or by the individual awardee in the event of an individual disagreement, a second member selected by NHLBI, and the third member selected by the two prior members. This special arbitration procedure in no way affects the awardee's right to appeal an adverse action that is otherwise appealable in accordance with the PHS regulations at 42 CRF part 50, Subpart D and HHS regulation at 45 CRF part 16 or the rights of NHLBI under applicable statutes, regulations and terms of the award. 11. These special terms of award are in addition to and not in lieu of otherwise applicable OMB administrative guidelines, HHS Grant Administration Regulations at 45 CFR part 74, and other HHS, PHS, and NIH grant administration policy statements. INCLUSION OF WOMEN AND MINORITIES IN RESEARCH INVOLVING HUMAN SUBJECTS It is the policy of the NIH that women and members of minority groups and their subpopulations must be included in all NIH supported biomedical and behavioral research projects involving human subjects, unless a clear and compelling rationale and justification is provided that inclusion is inappropriate with respect to the health of the subjects or the purpose of the research. This policy results from the NIH Revitalization Act of 1993 (Section 492B of Public Law 103-43). All investigators proposing research involving human subjects should follow the "NIH Guidelines for Inclusion of Women and Minorities as Subjects in Clinical Research," which have been published in the Federal Register of March 28, 1994 (FR 59 14508-14513), and in the NIH Guide for Grants and Contracts of March 18, 1994, Volume 23, Number 11. LETTER OF INTENT Prospective applicants are asked to submit, by May 18, 1998, a letter of intent that includes a descriptive title of the proposed research, the name, address, and telephone number of the Principal Investigator, the identities of other key personnel and participating institutions, and the number and title of the RFA in response to which the application may be submitted. Although a letter of intent is not required, is not binding, and does not enter into the review of subsequent applications, the information that it contains allows NHLBI staff to estimate the potential review workload and to avoid conflict of interest in the review. The letter of intent is to be faxed or sent to: C. James Scheirer, Ph.D. Division of Extramural Affairs National Heart, Lung, and Blood Institute 6701 Rockledge Drive, Room 7216 Bethesda, MD 20892-7924 Telephone: (301) 435-0266 FAX: (301) 480-3541 Email: [email protected] APPLICATION PROCEDURES The research grant application form PHS 398 (rev. 5/95) is to be used in applying for these grants and the modified instructions in this RFA must be followed. Application kits are available at most institutional offices of sponsored research and may be obtained from the Division of Extramural Outreach and Information Resources, National Institute of Health, 6701 Rockledge Drive, MSC 7910, Bethesda, MD 20898-7910, telephone 301-710-0267, E- mail: [email protected]. The RFA label found in the PHS 398 application form must be affixed to the bottom of the face page of the application. Failure to use this label could result in delayed processing of the application such that it may not reach the review committee in time for review. In addition, the RFA title and number must be typed on line 2 of the face page of the application form and the YES box must be marked. Submit a signed, typewritten original of the application and three signed photocopies in one package to: CENTER FOR SCIENTIFIC REVIEW NATIONAL INSTITUTES OF HEALTH 6701 ROCKLEDGE DRIVE, ROOM 1040 - MSC 7710 BETHESDA, MD 20892-7710 BETHESDA, MD 20817 (for express/courier service) At the time of submission, two additional copies of the application must be sent to Dr. C. James Scheirer, at the address listed under LETTER OF INTENT. Applications must be received by July 30, 1998. If an application is received after that date, it will be returned to the applicant without review. The Center for Scientific Review (CSR) will not accept any application in response to this RFA that is essentially the same as one currently pending initial review, unless the applicant withdraws the pending application. The CSR will not accept any application that is essentially the same as one already reviewed. This does not preclude the submission of substantial revisions of applications already reviewed, but such applications must include an introduction addressing the previous critique. If an application is determined to be unresponsive to the RFA, it will be returned to the applicant. REVIEW CONSIDERATIONS Applications will be reviewed by the CSR for completeness and by the NHLBI for responsiveness. Incomplete and/or non-responsive applications will be returned to the applicant without further review. Applications that are complete and responsive to the RFA will be evaluated for scientific and technical merit by a peer review group convened by the NHLBI, in accordance with NIH peer review procedures. As part of the initial merit review, all applications will receive a written critique and undergo a review in which only those applications deemed to have the highest scientific merit of the applications under review (usually two to three times the number of applications that the NHLBI anticipates being able to fund under the program) will be discussed, assigned a priority score, and receive a second level review by the National Heart, Lung, and Blood Advisory Council. The personnel category will be reviewed for appropriate staffing based on the requested percent effort. The direct costs budget request will be reviewed for consistency with the proposed methods and specific aims. The duration of support will be reviewed to determine if it is appropriate to ensure successful completion of the recommended scope of the project. Review Criteria The goals of NIH-supported research are to advance our understanding of biological systems, improve the control of disease, and enhance health. In the written review, comments on the following aspects of the application will be made in order to judge the likelihood that the proposed research will have a substantial impact on the pursuit of these goals. Each of these criteria will be addressed and considered in the assignment of the overall score, which is to reflect the overall impact of the project on the field, weighing the criteria appropriately for each application. An application does not need to be strong in all categories to be judged likely to have a major scientific impact and thus deserve a high merit rating. For example, an investigator may propose to carry out important work, that by its nature is not innovative, but is essential to move a field forward. Significance: Does this study address an important problem? If the aims of the application are achieved, how will scientific knowledge be advanced? What will be the effect of these studies on the concepts or methods that drive this field? Approach: Are the conceptual framework, design, methods, and analyses adequately developed, well-integrated, and appropriate to the aims of the project? Does the applicant acknowledge potential problem areas and consider alternative tactics? Innovation: Does the project employ novel concepts, approaches or method? Are the aims original and innovative? Does the project challenge existing paradigms or develop new methodologies or technologies? Investigator: Is the investigator appropriately trained and well suited to carry out this work? Is the work proposed appropriate to the experience level of the Principal Investigator and other researchers (if any)? Environment: Does the scientific environment in which the work will be done contribute to the probability of success? Do the proposed experiments take advantage of unique features of the scientific environment or employ useful collaborative arrangements? Is there evidence of institutional support? The initial review group will also examine: the adequacy of plans to include minorities and their subgroups as appropriate for the scientific goals of the research and plans for the recruitment and retention of subjects; the provisions for the protection of human and animal subjects; and the safety of the research environment. AWARD CRITERIA The following will be considered in making funding decisions: scientific merit as determined by peer review, availability of funds, and program priority. The anticipated date of award is April 1, 1999. INQUIRIES Inquiries concerning this RFA are encouraged. The opportunity to clarify any issues or questions from potential applicants is welcome. Direct inquiries regarding programmatic issues to: Marguerite Evans, M.S., R.D. Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute 6701 Rockledge Drive, Room 8126 Bethesda, MD 20892-7936 Telephone: (301) 435-0380 FAX: (301) 480-1669/1773 Email: [email protected] Direct inquiries regarding fiscal matters to: Marie A. Willett Division of Extramural Affairs National Heart, Lung, and Blood Institute 6701 Rockledge Drive Bethesda, MD 20892 Telephone: (301) 435-0148 FAX: (301) 480-3310 AUTHORITY AND REGULATIONS This program is described in the Catalog of Federal Domestic Assistance No. 93.837. Awards are made under authorization of the Public Health Service Act, Title IV, Part A (Public Law 78-410, as amended by Public Law 99-158, 42 USC 241 and 285) and administered under PHS grants policies and Federal Regulations 42 CFR 52 and 45 CFR Part 74. This program is not subject to the intergovernmental review requirements of Executive Order 12372 or a Health Systems Agency Review. The Public Health Service (PHS) strongly encourages all grant and contract recipients to provide a smoke-free workplace and promote the non-use of all tobacco products. In addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in certain facilities (or in some cases, any portion of a facility) in which regular or routine education, library, day care, health care or early childhood development services are provided to children. This is consistent with the PHS mission to protect and advance the physical and mental health of the American people. REFERENCES American Academy of Pediatrics, Committee on Nutrition. Statement on cholesterol. Pediatrics 1992; 90:469-473. Bouchard C, Perusse L. Genetic aspects of obesity. NY Acad Sci 1993; 699:26- 35. Clarke WR, Woolson RF, Lauer RM. Changes in ponderosity and blood pressure in childhood: The Muscatine Study. Am J Epidemiol 1986; 124:195-206. Davis K, Christoffel KK. Obesity in preschool and school-age children. Arch Pediatr Adolesc 1994; 148:1257-1261. Denke MA, Sempos CT, Grundy SM. Excess body weight: An underrecognized contributor to high blood cholesterol levels in White American men. Arch Intern Med 1993; 153:1093-1103. DISC Collaborative Research Group. Efficacy and safety of lowering dietary intake of fat and cholesterol in children with elevated low-density lipoprotein cholesterol. JAMA 1995;273:1429-1435. Donnelly JE, Jacobsen DJ, Whatley JE, Hill JO, Swift LL, Cherrington A, Polk B, Tran ZV, Reed G. Nutrition and physical activity program to attenuate obesity and promote physical and metabolic fitness in elementary school children. Obes Research 1996; 4:229-243. Eck LH, Klesges RC, Hanson RC, Slawson D. Children at familial risk for obesity: An examination of dietary intake, physical activity and weight status. In J Obes 1992; 16:71-78. Epstein LH, Valoski A, Wing RR, McCurly J. Ten-year follow-up of behavioral, family-based treatment for obese children. JAMA 1990; 264:2519-2523. Epstein LH, Wing RR, Koeske R, Valoski A. Effects of diet plus exercise on weight change in parents and children. Journal of Consulting and Clinical Psychology 1984; 52:429-437. Fingerhut LA, Warner M. Injury Chartbook. Health, United States, 1996-1997. Hyattsville, Maryland: National Center for Health Statistics. 1997. Fitzgibbon ML, Stolley MR, Kirschenbaum DS. An obesity prevention pilot program for African-American mothers and daughters. J Nutr Educ 1995; 27:93- 99. Foster TA, Voors AW, Webber LS, Frerichs RR, Berenson GS. Anthropometric and maturation measurements of children, ages 5 to 14 years, in a biracial community--the Bogalusa Heart Study. Am J Clin Nutr 1977; 30:582-591. Freedman DS, Burke GL, Harsha DW, Srinivasan SR, Cresanta JL, Webber LS, Berenson GS. Relationship of changes in obesity to serum lipid and lipoprotein changes in childhood and adolescence. JAMA 1985; 254:515-520. French SA, Story M, Downes B, Resnick MD, Blum RW. Frequent dieting among adolescents: Psychosocial and health behavior correlates. Am J Public Health 1995; 86:695-701. Himes JH, Dietz WH. Guidelines for overweight in adolescent preventive services: Recommendations from an expert committee. Am J Clin Nutr 1994; 59:307-316. Kimm SYS, Barton BA, Morrison JA, Sabry ZI, Schreiber GB, McMahon R, Obarzanek E. Adiposity and coronary heart disease (CHD) risk factors in adolescent females: NHLBI Growth and Health Study (abstract). Circulation 1994; 90(Part 2):I-26. Kimm SYS, Barton BA, Obarzanek E, Crawford P. Changes in adiposity in a biracial cohort during puberty: NHLBI Growth and Health Study. Can J Cardiol 1997; 13(Suppl B):218B. Kramer FM, Jeffery RW, Forster JL, Snell MK. Long-term follow-up of behavioral treatment for obesity: Patterns of weight regain among men and women. Int J Obes 1989; 13:123-136. Kumanyika SK, Obarzanek E, Stevens VJ, Hebert PR, Whelton PK. Weight-loss experience of black and white participants in NHLBI-sponsored clinical trials. Am J Clin Nutr 1991; 53:1631S-1638S. Leupker RV, Perry CL, McKinlay SM, Nader PR, Parcel GS, Stone EJ, Webber LS, Elder JP, Feldman HA, Johnson CC, Kelder SH, Wu M. Outcomes of a field trial to improve children's dietary patterns and physical activity. The Child and Adolescent Trial for Cardiovascular Health (CATCH). JAMA 1996; 275:768-776. Liu K, Ruth KJ, flack JM, Jones-Webb R, Burke G, Savage PJ, Hulley SB. Blood pressure in young blacks and whites: Relevance of obesity and lifestyle factors in determining differences. The CARDIA Study. Circulation 1996; 93:60-66. Malina RM, Bouchard C. Adipose tissue changes during growth, chapter 9, in: Growth, Maturation, and Physical Activity. Champaign, IL: Human Kinetics Books, 1991, pp. 133-149. Morrison JA, Barton B, Biro FM, Sprecher DL, Falkner F, Obarzanek E. Sexual maturation and obesity in 9- and 10-year-old black and white girls: The National Heart, Lung, and Blood Institute Growth and Health Study. J Pediatr 1994; 124:889-895. National Heart, Lung, and Blood Institute Growth and Health Study. Obesity and cardiovascular disease risk factors in black and white girls: The NHLBI Growth and Health Study. Am J Public Health 1992; 82:1613-1620. Resnicow K. School-based obesity prevention. Ann NY Acad Sci 1993; 699:154- 166. Schreiber GB, Robins M, Striegel-Moore R, Obarzanek E, Morrison JA, Wright DJ. Weight modification efforts reported by black and white preadolescent girls: National Heart, Lung, and Blood Institute Growth and Health Study. Pediatrics 1996; 98:63-70. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med 1993; 22:167-177. Smoak CG, Burke GL, Webber LS, Harsha DW, Srinivasan SR, Berenson GS. Relation of obesity to clustering of cardiovascular disease risk factors in children and young adults. The Bogalusa Heart Study. Am J Epidemiol 1987; 125:362-372. Stolley MR, Fitzgibbon ML. Effects of an obesity prevention program on the eating behavior of African-American mothers and daughters. Health Educ Behav 1997; 24:152-164. Troiano RP, Flegal KM, Kuczmarski RJ, Campbell SM, Johnson CL. Overweight prevalence and trends for children and adolescents. Arch Pediatr Adolesc Med 1995; 149:1085-1091. U.S. Department of Agriculture and U.S. Department of Health and Human Services. Nutrition and Your Health: Dietary Guidelines for Americans, Fourth Edition, Home and Garden Bulletin No. 232, 1995. U.S. Department of Health and Human Services. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA:U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 1996. Williams DP, Going SB, Lohman TG, Harsha DW, Srinivasan SR, Webber LS, Berenson GS. Body fatness and risk for elevated blood pressure, total cholesterol, and serum lipoprotein ratios in children and adolescents. Am J Public Health 1992; 82:358-363.
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