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The gap between how health information is communicated and what people understand and can use to make informed health decisions is called health literacy. This gap was exacerbated by the rapidly changing and excessive volume of information, misinformation, and disinformation during the COVID-19 pandemic. People with lower health literacy may not have understood the importance of COVID-19 vaccination for themselves or for their communities. Our aim was to understand health literacy levels within Fulton County, Georgia, and their relationship to vaccine prevalence. Fulton county residents ages 18 and over (n = 425) completed an on-line Health Literacy Questionnaire. Individual, organizational, functional, interactive, and critical health literacy scales were created. Vaccination prevalence data were collected from the Georgia Vaccine Distribution Dashboard. All data were divided into one of three county areas. There were statistically significant variations in vaccine prevalence χ2(3) = 29.325, p < 0.001 among the three county areas. All levels of health literacy predicted overall county vaccination prevalence F (4,420) = 85.941, p < 0.001, There were significant differences in health literacy levels among two of the three county area pairs; the lowest resourced county area had the lowest vaccination prevalence and health literacy rates. This is the first example of relating direct health literacy measures across a major metropolitan US county with vaccine prevalence data.

To determine differences in lifestyle modification practices and use of prescription drugs in a representative sample of Mexican American (MA), non-Hispanic White (NHW), and non-Hispanic Black (NHB) elderly Americans with metabolic syndrome (MetS).Data from the United States National Health and Nutritional Examination Surveys were used in this study. Lifestyle modification practices include ongoing physical activity, weight control, and ongoing diet modifications. Prescription drugs include anti-diabetic, anti-obesity, lipid-lowering, insulin sensitizers, renin-angiotensin system (RAS) blockers, fibrates, and cilostazol. Race/ethnic-specific prevalence odds ratios from the multivariate logistic regression analyses were used to determine associations between selected independent variables and MetS control (defined as the use of lifestyle modification practices or prescription drugs), adjusting for covariates.The rates of ongoing weight control (73.4% versus 68.1% in MA and 66.3% in NHW) and diet modification practices (78.1% versus 77.4% in MA and 66.7% in NHW) were higher among NHB, and rate of ongoing physical activity (61.8% versus 52.8% in NHW and 56.4% in NHB) was higher among MA participants compared to their other racial/ethnic elderly counterparts (P 0.001). Lipid-lowering and insulin-sensitizing drugs were the most commonly used prescription drugs in the last 30 days. The prevalence of nonuse of lifestyle modification practices or prescription drugs for MetS management was 15.1%, 21.3%, and 12.7% in MA, NHW, and NHB participants, respectively. MA, NHB race/ethnicity, a higher level of education, and increased BMI were significantly associated with increased odds of MetS control. Lack of drug prescription insurance and increased age were associated with decreased odds of MetS control.Given the clinical importance of MetS, improving knowledge-based health decisions relative to lifestyle modification practices is very important. Moreover, sources of low-cost medications that links elderly patients with drug prescription coverage programs may help to improve the management of MetS.

Aim To compare the strength of associations between surrogate indexes of insulin resistance (sIR) and risk of metabolic syndrome (MetS) in non-Hispanic White (NHW), non-Hispanic Black (NHB) and Mexican American (MA) adults. Methods The 2013–2016 US National Health and Nutrition Examination Survey data (n = 3435) were used for this study. The associations between sIR that includes Triglyceride/HDL cholesterol ratio (TG/HDL-C), triglyceride glucose (TG) index, visceral adiposity index (VAI), lipid accumulation product (LAP), TG-body mass index (TG-BMI), and TG-waist circumference (TG-WC) and risk for MetS were determined using the prevalence odds ratio (OR) from the logistic regression analyses. Pseudo-R-squared tests were used to estimate the proportion of variance in MetS accounted for by each sIR. Akaike Information Criterion and Bayesian Information Criterion from the multinomial logistic regression analysis were used to compare models that included each sIR and its components separately as predictors of MetS. Areas under curves (AUC) from the receiver-operating characteristic (ROC) were used to detect their diagnostic capabilities. Results Compared with other sIR, TG-WC (AUC = 0.899; 95% CI: 0.884–0.913 in NHW) and (AUC = 0.893; 95% CI:0.871–0.915 in NHB), and LAP (AUC = 877; 95% CI: 0.861–0.894 in MA) exhibited the highest diagnostic and predictive accuracy for MetS. Compared with other sIR, TG-WC (OR = 22.8; 95% CI:16.6–31.0 in NHW) and (OR = 22.7; 95% CI:13.1–39.3 in NHB), and LAP (OR = 10.6; 95%:6.6–17.0 in MA) were most significantly associated with increased odds of MetS, adjusting for eGFR, age, marital status, CHD, CHF, income, education, physical activity, alcohol use, smoking and use of cholesterol-lowering medication. Conclusions TG-WC in NHW and NHB, and LAP in MA are more powerful than other proxies of IR in predicting MetS. TG-WC and LAP can serve as adjunctive tools for screening for MetS in NHW, NHB, and MA.

Racial disparities in breast cancer present a vexing and complex challenge for public health. A diverse array of factors contributes to disparities in breast cancer incidence and outcomes, and, thus far, efforts to improve racial equity have yielded mixed results. Systems theory offers a model that is well-suited to addressing complex issues. In particular, the concept of a systemic leverage point offers a clue that may assist researchers, policymakers, and interventionists in formulating innovative and comprehensive approaches to eliminating racial disparities in breast cancer. Naming systemic racism as a fundamental cause of disparities, we use systems theory to identify residential segregation as a key leverage point and a driver of racial inequities across the social, economic, and environmental determinants of health. We call on researchers, policymakers, and interventionists to use a systems-informed, community-based participatory approach, aimed at harnessing the power of place, to engage directly with community stakeholders in coordinating efforts to prevent breast cancer, and work toward eliminating disparities in communities of color.

Objective To evaluate the effects of walking, independent of diet and weight-loss, on lipids and lipoproteins in women with overweight and obesity. Data Source Academic Search Complete, Alternative Health Watch, Global Health, Health Source, CINAHL, MEDLINE, EMBASE, SportDiscus, and ProQuest. Study Inclusion and Exclusion Criteria (1) experiment-control design; (2) women with overweight or obesity; (3) walking as the experiment’s independent variable; (4) four or more weeks; and (5) pre- to post-assessment of lipids and/or lipoproteins. Excluded studies reported use of lipid-lowering medication, diet or other modes of physical activity, and alternative interventions as the control. Data Extraction Data extraction and study quality were completed by the first 2 authors using the Cochrane review protocol and risk of bias assessment. Data Synthesis Raw mean difference between the experiment and control groups using a random effects model. Results Meta-analyses of 21 interventions (N = 1129) demonstrated exclusive walking improves total cholesterol (raw mean difference = 6.67 mg/dL, P = .04) and low-density lipoproteins (raw mean difference = 7.38 mg/dL, P = .04). Greater improvement in total cholesterol, triglycerides, high-density lipoproteins, and low-density lipoproteins existed in women with obesity. Conclusions Exclusive walking aids in normalizing total cholesterol and LDLs in women with overweight and obesity. Exclusive walking can be used as a non-pharmacologic therapy, which may have positive clinical outcomes for individuals who especially struggle with diet and weight-reduction.

Objective: To develop a core set of capabilities and tasks for local health departments (LHDs) to engage in land use and transportation policy processes that promote active transportation. Design: We conducted a 3-phase modified Delphi study from 2015 to 2017. Setting: We recruited a multidisciplinary national expert panel for key informant interviews by telephone and completion of a 2-step online validation process. Participants: The panel consisted of 58 individuals with expertise in local transportation and policy processes, as well as experience in cross-sector collaboration with public health. Participants represented the disciplines of land use planning, transportation/public works, public health, municipal administration, and active transportation advocacy at the state and local levels. Main Outcome Measures: Key informant interviews elicited initial capabilities and tasks. An online survey solicited rankings of impact and feasibility for capabilities and ratings of importance for associated tasks. Feasibility rankings were used to categorize capabilities according to required resources. Results were presented via second online survey for final input. Results: Ten capabilities were categorized according to required resources. Fewest resources were as follows: (1) collaborate with public officials; (2) serve on land use or transportation board; and (3) review plans, policies, and projects. Moderate resources were as follows: (4) outreach to the community; (5) educate policy makers; (6) participate in plan and policy development; and (7) participate in project development and design review. Most resources were as follows: (8) participate in data and assessment activities; (9) fund dedicated staffing; and (10) provide funding support. Conclusions: These actionable capabilities can guide planning efforts for LHDs of all resource levels., Centers for Disease Control and Prevention (U.S.) (Agreement U48DP005031)

This exploratory study investigates counties in the southeast United States with mortality outcomes that were better than might be expected given their sociodemographic profiles (i.e., positive deviance). This study seeks to understand the community characteristics with the potential to moderate the negative health outcomes typically associated with social, geographic, or economic disadvantages. This article describes the process used to identify positive deviants and reports on the findings from key informant interviews in positive deviant counties to identify community factors or practices that might contribute to positive deviance in the observed outcomes. County Health Rankings and Roadmaps 2015 data and mortality trends were examined to identify positive deviant counties. The inclusion criteria were median household incomes in the lowest tertile of their state, ≥ 33% African American, and premature mortality rankings (as measured by Years of Potential Life Lost–YPLL) in the top quartile within their state. After benchmarking county rates against national figures and retaining counties with significant improvement trends, two counties emerged as positive deviants, Dooly County, Georgia and Washington County, North Carolina. Key informant interviews (n = 11) were conducted with community stakeholders in the study counties to better understand the community characteristics that could lead to the observed outcomes. Interview data were analyzed using qualitative methods. Key informant interviews revealed three emergent themes: 1. accessibility and availability of healthcare, 2. the provision of a robust EMS system, and 3. coordination of county-funded services targeting vulnerable populations. The positive deviance framework provides a foundation for the identification of community factors or practices with the potential to create a ‘culture of health’ in communities at the greatest risk for adverse health outcomes. Our findings suggest that healthcare supported by the coordination of non-emergency transportation and health and social services across numerous stakeholders may have contributed to observed outcomes in the study counties., Highlights • This study investigated premature mortality trends in counties in the southeast United States. • Two counties out of the 131 counties examined met the criteria for inclusion. • Community stakeholders (n=11) were identified and interviewed as part of a site visit to the study counties. • For premature death in the County Health Rankings, Dooly County ranked 20th in Georgia in 2015. • For premature death in the County Health Rankings, Washington County ranked 23rd in North Carolina in 2015.

African Americans in Atlanta, Georgia disproportionately reside in communities with limited access to healthy foods. Collaborations with local corner stores to provide healthy food options have been identified as an evidence-based intervention that could be used to increase food access. This paper describes the community-based participatory approach used to culturally-tailor a Healthy Corner Store Initiative (HCSI) in five Atlanta communities. A mixed method approach (qualitative/quantitative) was utilized. Spatial analysis and an environmental assessment were conducted to locate all corner stores in the partner communities that were listed in a business database. An environmental assessment was conducted at 34 corner stores using a structured log and checklist. Among them, 11 were selected and signed memorandums of understanding to implement the HCSI. A customer intercept survey was administered to 100 African American corner store customers at five of the healthy corner store sites. Descriptive statistics were used to analyze log/checklist and survey data. Corner store customers indicated that they typically purchase snacks, tobacco, and breads, but would purchase certain healthy foods, if offered. They also indicated that freshness of fruits and vegetables and positive relationships with corner store owners would influence healthy food purchases. Findings demonstrate that working collaboratively with community members, researchers and business owners is a critical step in nurturing trust, strengthening credibility, and building partnerships towards increased healthy food access and improved community health.

The community readiness model (CRM) was used to assess changes in community readiness across four counties in Georgia that were targeted as part of a 3-year Childhood Obesity Prevention Program. Key respondent interviews were conducted with community stakeholders in 2012 (n = 20) and 2017 (n = 18) using a semistructured questionnaire assessing six dimensions of community readiness (i.e., community efforts, community knowledge of efforts, leadership, community climate, community knowledge about the issue, and resources available to support efforts). Interviews were analyzed using the CRM scoring protocol and qualitative methods. Paired t tests were used to compare mean score differences between baseline and follow-up assessments. At baseline, overall mean readiness scores for the four counties ranged from 4.52 to 5.05 on the CRM 9-point scale. At follow-up, overall readiness scores ranged from 6.01 to 6.97 out of 9.00. Data revealed a statistically significant improvement in scores across all communities (+1.70, p = .007; 95% confidence interval [0.87, 2.51]). Data also revealed statistically significant improvements in every dimension of readiness, except community knowledge of the issue. Information gleaned from interviews suggested that investing in staff to support efforts, building awareness to shift the community climate, and cross sector collaboration contributed to improved community readiness among the study communities. The provision of technical assistance, peer learning opportunities, and financial support as part of a cooperative grant initiative holds promise for increasing the capacity of community coalitions to advance childhood obesity prevention efforts in their local communities.

Population-wide initiatives aim to educate individuals about the benefits of walking, such as Step It Up! (United States), Walking for Health (England), and Canada Walks (Canada). Low-income women are a strategic group to target for walking communications because lower-income individuals and women have lower rates of physical activity than the general population and men. For messages to motivate mothers to walk, however, they need to frame walking in ways that makes walking sufficiently relevant and compelling. We investigated what walking means to low-income urban mothers as a first step toward identifying more compelling and motivating ways to frame and communicate about walking to them. Focus groups were conducted across seven different urban areas in the United States among low-income urban mothers (n=52) and transcribed. Grounded theory was used to code and analyze the data. This study identified salient beliefs, barriers, and life concerns that should be addressed when framing and branding walking to low-income urban mothers. Communications emphasizing dose-based recommendations (e.g., time, intensity) are irrelevant to mothers’ lives and also appear to be confusing as well as ineffective motivators. While some participants desired experiential benefits from walking, such as time with family, others sought instrumental benefits, such as losing weight. Regardless of the benefits desired, however, there was a general consensus that walking was a low daily priority. Thus, for messages to successfully promote walking, they need to imbue walking with a compelling meaning that makes walking relevant to mothers in ways that can help them achieve their daily needs and wants. In addition, future communications should address the potentially negative meanings and stress low-income mothers experience when walking is a compulsory form of transportation. These data offer insights into preliminary suggestions for framing walking to boost its daily relevance, desirability, and usefulness to low-income urban mothers.

Background and objective Although obesity is a heterogeneous disease, little is known regarding chronic medical conditions (CMCs) that defines variability in obese populations. The characterization of obese populations using CMCs rather than categorization using BMI alone can advance understanding of obesity. The aims of this study are to phenotype obesity in a large representative sample of non-Hispanic White (NHW), non-Hispanic Black (NHB) and Mexican American (MA) obese adults using CMCs, and assess relationship between resulting phenotypes and self-rated health (SRH). Methods Sex-specific two-step cluster analysis was used to phenotype obese participants (n = 12,547) to CMC-based clusters. The prevalence of CMCs and lifestyle risk factors in each cluster was assessed. Sex and race/ethnic specific association between cluster membership and SRH was determined using odds ratio (OR) from logistic regression analysis. Results Distinct subgroups of obese men and women were observed: moderate dyslipidemic healthy young obese men, hypertensive-dyslipidemic middle-age obese men, hypertensive young obese men, hypertensive-dyslipidemic-asthmatic middle-age obese men, and syndemic elderly obese men, healthy young obese women, hypertensive-dyslipidemic middle-age obese women, dyslipidemic young adult obese women, syndemic middle-age obese women, and syndemic elderly obese women. Participants in the more CMCs symptomatic clusters reported high rates of behavioral risk factors and showed significantly greater odds of poor SRH than participants in the less symptomatic clusters. Compared to obese persons who are asymptomatic for CMCs, syndemic elderly obese and women men had much higher increased ORs for poor SRH with values of 3.88 [95% CI = 2.41–6.26], 3.96 [95% CI = 1.86–8.30] and 7.25 [95% CI = 2.41–9.6] for NHW, NHB and MA men, respectively. The corresponding ORs for women are 4.08 [95% CI = 2.71–6.14], 4.01 [95% CI = 2.40–6.69], and 2.62 [95% CI = 1.32–5.19], respectively. Conclusion Obesity treatment and intervention should consider heterogeneity within obese persons and pay greater attention to obesity related co-morbidities and metabolic manifestations.

Stress is a common belief among breast cancer patients and the public to explain variation in breast cancer incidence. Epidemiological studies interrogating the relationship between stress and cancer have reported mixed results. The impact of the topic and the lack of consensus has sparked this review of the literature to investigate gaps in knowledge and identify areas of research. We first present a brief summary of the biopsychosocial model generally used to conduct research on stress. We then divide the overview of the literature into areas of research focus. These include the role of distressing life events in breast cancer incidence, the role of adverse childhood events in later breast cancer incidence, the importance of race and socioeconomic status (SES) as social determinants of breast cancer incidence, and the specific role of chronic stress in relation to breast cancer. For each topic, we discuss the potential of stress as a risk factor and possible intervention strategies that could reduce the effects of stress. We then identify further research questions to be probed to fill the gaps in knowledge. We conclude with a discussion of future research directions for stress research as it relates to breast cancer incidence.

Background:Open Streets are community-based programs that promote the use of public space for physical activity (PA), recreation and socialization by closing streets temporarily to motorized vehicles, allowing access to pedestrians. The city of Atlanta hosted its first Open Streets event, Atlanta Streets Alive (ASA), in May 2010. An evaluation of the first 5 ASA events from May 2010 to May 2012 was conducted. The purpose was to learn about the characteristics of ASA participants, the influence of the event on their PA, and perceptions of safety and neighborhood social capital.Methods:ASA’s evaluation had 2 components: participant counts and a participant survey. Characteristics of participation were compared among the 3 different events in which surveys were conducted using the Pearson χ2 test and F test as appropriate.Results:The estimated participation at ASA increased from nearly 3,500 (ASA 1 to 4) to 12,520 (ASA 5). The number of events increased to 3 per year for a total of 10 events until 2014. Overall, 19.4% of participants met the weekly PA recommendation during 1 event.Conclusions:The expanding diversity of routes, participants, and sponsorships highlights the potential promise such programming offers in terms of establishing an urban culture of health.

Since 2004, the Active Living Research (ALR) Conference has focused on advancing knowledge and practice related to the creation of communities that increase opportunities for physical activity. Communities designed for active living are better for health, economic vitality, and environmental sustainability. The Annual ALR Conference serves as a premier venue for cross-disciplinary learning, as over 30 disciplines are represented among participants. This commentary serves as an introduction to a virtual Special Section of Journal of Transport and Health that includes several of the best transport-related studies that were presented at ALR 2017. The theme of the 2017 ALR Conference, Active Living across the Life Span, placed emphasis on the importance of promoting physical activity from childhood through mature adulthood and offered solutions for achieving this goal. The theme challenged attendees to consider the myriad needs across age cohorts and the ways that community design, policies, and programs affect opportunities for active living. The conference highlighted the importance of policy-relevant research and facilitated cross-sector exchange among scientists, practitioners, and policymakers to create and sustain active living environments where residents can grow, live, and thrive at any age. Jana Lyncott from the AARP Public Policy Institute delivered the Keynote Address on creating environments for active and engaged living for all ages. The presentation provided examples from communities across the United States that are promoting livability and fostering healthy, active, and engaged lifestyles. The presentation highlighted AARP's Livability Index, which scores neighborhoods and communities for the services and amenities that have a significant impact on residents. The featured panel included Drs. Adrian Bauman, NiCole Keith, and David Bann and focused on the challenges of integrating equity perspectives in research on active living across the lifespan. Dr. Bauman, from Australia, shared lessons from his research on middle-age-to-older adults and his international collaborations. Dr. Keith, from the United States, described the effort to ensure disadvantaged populations were given high priority in developing the multi-sector strategies of the US National Physical Activity Plan. Dr. Bann, from the UK, presented findings on active living across the lifespan from a large, long-term birth cohort study. The second panel featured Deputy Commissioner Adetokunbo 'Toks' Omishakin, (Tennessee Department of Transportation), Councillor Kristyn Wong-Tam (City of Toronto, Canada), and Otis Johnson (Former Mayor of Savannah, Georgia) and provided local and state examples of active transportation and lessons learned. A clear takeaway from the keynote and panelists was the need to integrate and apply life-course research and practice/policy lessons learned to most effectively create activity-supportive cities. The concept of active living includes physical activity for all purposes, including transport, recreation, occupation, and household. Active transport continues to be a dominant theme at ALR Conferences, and the link between transport and health outcomes is rising on research and policy agendas internationally, as shown by extensive coverage in Journal of Transport and Health and the 2016 Lancet Series on Urban Design, Transport, and Health. In the Lancet Series, Giles-Corti and colleagues (2016) reviewed a wide range of physical, mental, and social health problems linked with motorized transport. Stevenson and colleagues (2016) reported models that revealed a shift of just 10% of motorized trips to active modes could produce important reductions in mortality in cities as diverse as Copenhagen and Delhi. Thus, as co-chairs of the ALR 2017 Conference we want to thank Dr. Jennifer Mindell, Editor-in-Chief of Journal of Transport and Health, for facilitating this virtual special section of papers that will further advance evidence on active transport and health.

Schools have been identified as important settings for physical activity promotion, as they possess trained staff, facilities and resources, and have direct access to the majority of children and adolescents. In recent years, there has been extensive research focus on physical activity promotion within these settings. Previous research has demonstrated that multi-component interventions, addressing physical activity participation across multiple facets of the school day, are the most effective. Therefore, the aim of this chapter is to provide an overview of existing school-based physical activity programmes, using the United States Centers for Disease Control and Prevention’s Comprehensive School Physical Activity Programme (CSPAP) as a framework. This chapter will provide a synopsis of evidence-based physical activity programmes that align with the following CSPAP components: (i) physical education; (ii) physical activity during the school day; (iii) physical activity before and after school; (iv) staff involvement; and (v) family and community engagement. Finally, this chapter will discuss future directions for school-based physical activity programmes.

As investments are made to engage communities in childhood obesity prevention efforts, an approach to better understand local communities’ readiness to implement evidence-based strategies is needed. The Community Readiness Model (CRM) was used to assess the readiness of 15 communities in Georgia actively working to prevent childhood obesity. Seventy-nine key informant interviews were conducted assessing six dimensions of readiness. Data were analyzed and scored using the CRM protocol. Overall community readiness scores ranged from 2.8 to 5.1 on a 9-point scale. The mean readiness score, 4.3 ( SD = 0.5) corresponds with a preplanning level of readiness. Findings suggest that communities are recognizing the problem, organizing stakeholders, and beginning to develop solutions. There is a need for funders to match their community-based funding initiatives with the readiness levels of the communities being supported. Communities should focus their attention to the six dimensions of readiness while utilizing evidence-based frameworks and guidance on prevention.

Purpose The purpose of this study was to examine whether persons who are aware of their prediabetes were more likely than persons with normal glycemia to report lifestyle changes (weight control, physical activity and fat/calories intake), and to determine the interactive effect of persons aware of their prediabetes and persons reporting doctor/health care provider’s (DHCP) advice on overall lifestyle change. Methods Data from the 2005 to 2006 and 2007 to 2008 US National Health and Nutrition Examination Surveys were used for this investigation. Odds ratio from multiple logistic regression analysis was used to determine whether persons who are aware of their prediabetes were more likely than persons with normal glycemia to report lifestyle changes. Results Persons who are aware of their prediabetes were more likely than persons with normal glycemia to report increased weight control (OR = 1.72; 95% CI = 1.34–2.20) and physical activity (OR = 1.28; 95% CI = 1.02–1.61), and reduced fat/calorie intake (OR = 1.82; 95% CI = 1.41–2.34), after adjusting for age, BMI, persons reported DHCP advice, race/ethnicity, sex, education and household income. Persons who reported DHCP advice were more likely than persons who did not report DHCP advice to report increased weight control (OR = 1.87; 95% CI = 1.67–2.09) and physical activity (OR = 1.59; 95% CI = 1.43–1.78), and reduced fat/calorie intake (OR = 2.19; 95% CI = 1.96–2.46), after adjusting for confounders. There was no significant interaction between persons aware of their prediabetes and persons that reported DHCP advice with reported overall lifestyle change. Conclusions Creating diabetes risk awareness in at-risk groups and increased counseling of at-risk groups by doctors/health care providers may be the keys to prevent diabetes.

Introduction Transportation and land-use policies can affect the physical activity of populations. Local health departments (LHDs) are encouraged to participate in built-environment policy processes, which are outside their traditional expertise. Cross-sector collaborations are needed, yet stakeholders’ perceptions of LHD involvement are not well understood. The objective of this study was to describe the perceived value of LHD participation in transportation and land-use decision making and potential contributions to these processes among stakeholders. Methods We analyzed qualitative data from 49 semistructured interviews in 2015. Participants were professionals in 13 US states and 4 disciplines: land-use planning (n = 13), transportation/public works (n = 11), public health (n = 19), and other (municipal administration and bike and pedestrian advocacy [n = 6]). Two analysts conducted directed content analysis. Results All respondents reported that LHDs offer valuable contributions to transportation and land-use policy processes. They identified 7 contributions (interrater agreement 91%): 1) physical activity and health perspective (n = 44), 2) data analysis and assessment (n = 41), 3) partnerships in the community and across sectors (n = 35), 4) public education (n = 27), 5) knowledge of the public health evidence base and best practices (n = 23), 6) resource support (eg, grant writing, technical assistance) (n = 20), and 7) health equity (n = 8). Conclusion LHDs can leverage their strengths to foster cross-sector collaborations that promote physical activity opportunities in communities. Our results will inform development of sustainable capacity-building models for LHD involvement in built-environment decision making.

Physical inactivity among children is a public health problem associated with low levels of fitness, obesity, and increased risk of chronic diseases. Public health experts have identified policies targeting physical activity as a promising strategy to address this challenge. Understanding the process by which such policies are adopted may help to facilitate progress nationally. To examine lessons learned from the passage of the Student Health and Physical Education Act in Georgia, we conducted 15 interviews with people engaged in the adoption of the act. We found that several factors were vital to policy adoption: a shifting social and political climate, the organization and mobilization of diverse partners behind a common agenda, and the development of strategies to overcome impediments to legislative progress. These findings suggest that engagement and cooperation with partners, establishment of mutual interests as a basis for collaboration, and grassroots outreach and advocacy can facilitate adoption of policies that promote physical activity.

Background: Among underserved and racial/ethnic minority populations in Georgia, there are profound health disparities and a burden of chronic diseases. Such diseases, which are preventable, are influenced by risk factors, including poor nutrition, physical inactivity, lack of quality health care, and tobacco use and exposure. Awardees of the Racial and Ethnic Approaches to Community Health (REACH) and Partnerships to Improve Community Health (PICH) are implementing community-based initiatives using evidencebased, policy, systems, and environmental approaches to reduce racial and ethnic health disparities and the chronic disease burden in underserved urban and rural Georgia communities. Methods: Within the context of a social ecological framework, the REACH and PICH awardees selected interventions. Their impact in the areas of tobacco use and exposure, chronic disease prevention and management, and nutrition are described. Results: To date, the interventions of Georgia’s PICH and REACH awardees have reached approximately 805,000 Georgia residents. Conclusions: By implementing strategies for community-based policy, systems, and environmental improvement, Georgia’s PICH and REACH awardees are reducing tobacco use and exposure; increasing access to healthy foods; and providing chronic disease prevention, risk reduction, and management opportunities for underserved communities in urban and rural Georgia communities. Their efforts to address chronic disease risk factors at various social and ecological levels are contributing to a reduction in racial/ethnic health disparities and the chronic disease burden in Georgia.

Background:In the United States, health promotion efforts often begin with state-level strategic plans. Many states have obesity, nutrition, or other topic-related plans that include physical activity (PA). The purpose of this study was to assess PA content in these state plans and make recommendations for future plan development.Methods:Publically available plans were collected in 2010. A content analysis tool was developed based on the United States National PA Plan and included contextual information and plan content. All plans were double coded for reliability and analyzed using SPSS.Results:Forty-three states had a statewide plan adopted between 2002 and 2010, none of which focused solely on PA. Over 80% of PA-specific strategies included policy or environmental changes. Most plans also included traditional strategies to increase PA (eg, physical education, worksite). Few plans included a specific focus on land use/community design, parks/recreation, or transportation. Less than one-half of plans included transportation or land use/community design partners in plan development.Conclusions:Though the majority of states had a PA-oriented plan, comprehensiveness varied by state. Most plans lacked overarching objectives on the built environment, transportation, and land use/community design. Opportunities exist for plan revision and alignment with the National PA Plan sectors and strategies.

The amount of time children spend in child care each week has increased in recent years. The aim of this cross-sectional study was to describe the nutritional quality of foods served and the mealtime environment in 24 child care centers in Georgia.Data were collected between April 2010 and September 2010. Each child care center provided a sample 5-day menu (breakfast, lunch, and an afternoon snack) at baseline. Energy and nutrient contents of the menus were analyzed using NutriKids Menu PlanningNutritional Analysis software (LunchByte Systems, Inc., Rochester, NY). Foods and beverages on the menus were compared to MyPlate food group standards for preschoolers. The child care environment was assessed in each center over 1 full day using the Environment and Policy Assessment and Observation instrument.Menus met one half to two thirds of the recommended levels for energy, carbohydrate, protein, and vitamins A and C. However, the menus were high in saturated fat and sodium content and did not meet the recommendations for iron or fiber. The majority of the centers did not meet the recommendations for MyPlate food group standards for preschoolers. On the day of the observation, seven centers did not serve a vegetable and more than half of the centers (n=13) did not serve any whole grains. Nineteen centers served high-sugar and/or high-fat foods and 11 did not have visible water indoors.This study identified determinants of the child care environment and nutritional characteristics of the combined meals and snacks offered to children. Findings from this study could inform child care centers how to provide healthier nutrition environments to preschool children.

This study aims to evaluate compositional factors, including collaborative age and size, and community, policy, and political engagement activities that may influence collaboratives' effectiveness in advancing environmental improvements and policies for active living.Structured interviews were conducted with collaboratives' coordinators. Survey items included organizational composition, community, policy, and political engagement activities and reported environmental improvements and policy change. Descriptive statistics and multivariate models were used to investigate these relationships.Environmental improvement and policy change scores reflecting level of collaborative effectiveness across 8 strategy areas (eg, parks and recreation, transit, streetscaping, and land redevelopment).Fifty-nine collaborative groups participated in the interview, representing 22 states. Groups have made progress in identifying areas for environmental improvements and in many instances have received funding to support these changes. Results from multivariate models indicate that engagement in media communication and advocacy was statistically correlated with higher levels of environmental improvement, after adjusting for age of group and area poverty levels (P.01). Groups that frequently solicited endorsements from community leaders and offered testimony in policy or legal hearings reported significantly more policy change, after adjusting for age of group and area poverty levels (P.01 for both).Active living collaboratives are translating the evidence on environmental and policy approaches to promote active living from research to practice. Investing in community and policy engagement activities may represent important levers for achieving structural and policy changes to the built environment.

Context Built environment-focused interventions and policies are recommended as sustainable approaches for promoting physical activity. Physical activity has not traditionally been considered in land use and transportation decision making. Effective collaboration with non-public health partners requires knowledge of their perceived barriers to such consideration. Objective This analysis sought to (a) establish prevalence estimates of selected barriers to the consideration of physical activity in community design and layout decisions and (b) describe how barrier reporting by public health officials differs from other municipal officials among a wide range of job functions and departments in a geographically diverse sample. Design A Web-based survey was conducted among municipal officials in 94 cities and towns with populations of at least 50 000 residents in 8 states. Participants A total of 453 municipal officials from public health, planning, transportation/public works, community and economic development, parks and recreation, city management, and municipal legislatures in 83 cities and towns responded to the survey. Main outcome measures Five barriers to consideration of physical activity in community design and layout were assessed. Results The most common barriers included lack of political will (23.5%), limited staff (20.4%), and lack of collaboration across municipal departments (16.2%). Fewer participants reported opposition from the business community or residents as barriers. Public health department personnel were more likely to report the barriers of limited staff and lack of collaboration across municipal departments than other professionals. They were also more likely to report lack of political will than city managers or mayors and municipal legislators. Conclusions Barriers to increasing consideration of physical activity in decision making about community design and layout are encouragingly low. Implications for public health practice include the need to strategically increase political will despite public health staffing constraints and perceived lack of collaboration with relevant departments such as planning and public works/transportation.

The public health literature has not fully explored the complexities of the policy process as they relate to public health practice and obesity prevention. We conducted a review of the literature across the policy science and public health fields, distilled key theories of policy making, and developed a framework to inform policy, systems, and environmental change efforts on obesity prevention. Beginning with a conceptual description, we focus on understanding three domains of the policy process: the problem domain, the policy domain, and the political domain. We identify key activities in the policy process including the following: (a) assessing the social and political environment; (b) engaging, educating and collaborating with key individuals and groups; (c) identifying and framing the problem; (d) utilizing available evidence; (e) identifying policy solutions; and (f) building public support and political will. The article provides policy change resources and case studies to guide and support local and state efforts around obesity prevention.

Summary Background Excess body weight has been reported to be associated with excessive school absenteeism (ESA), but less is known about the association with perceived body weight. The study objective was to weigh the relative influence of perceived and measured weight status on school attendance. Methods We used the data from 3113 adolescents age 12–19 years who were interviewed as a part of the National Health and Nutrition Examination Surveys (NHANES), 2003–2008. Body weight and height were measured during the physical examination, while self-perceived body weight and the number of school days missed was assessed using questionnaires. Missing one or more days per school month (nine days per school year) was defined as, and indicative of, experiencing ESA. Results ESA was reported from 12.31 (SE = 0.89) % of adolescents. The highest prevalence occurred among healthy weight adolescents who erroneously self-perceived as overweight [21.6 (4.77) %], two times higher than adolescents with obesity who self-perceived as “just right weight” [10.3 (2.87) %]. The adjusted prevalence ratio (PR) of ESA for healthy weight adolescents who erroneously self-perceived as “overweight” was 1.91 (95%CI = 1.10–3.32) compared to healthy weight peers who correctly self-perceived as “just right” (reference group). The PRs were 0.99 (0.48–2.06) and 1.41 (0.86–2.32) respectively for adolescents with obesity who believed that their body weight was “just right” or “overweight”. No significant differences were observed between boys and girls, young (12–15 years) and older adolescents (16–19 years). Conclusions Perceived overweight rather than actual overweight is significantly associated ESA among adolescents.

The Recreovia program provides free physical activity (PA) classes in public spaces in Bogota, Colombia. The purpose of this study was to assess the effectiveness of the Recreovia program in increasing PA among users of nine parks in Bogota. This study was a natural experiment conducted between 2013 and 2015 in Bogota. Community members and park users living nearby three groups of parks were compared: Group 1 were parks implementing new Recreovias (n=3), Group 2 were control parks (n=3) without Recreovias, and Group 3 were parks with existing Recreovias. Individuals in the "intervention" group were exposed to newly implemented Recreovia programs in parks near their homes. Measurements were collected at baseline and 6-8months after the intervention started. A total of 1533 participants were enrolled in the study: 501 for the existing Recreovias (included in a cross-sectional assessment) and 1032 participants (from the new Recreovias and control parks) included in the cross-sectional and pre-post study. Most participants were low income females. Twenty-three percent of the intervention group started participating in the program. Users of existing Recreovias were significantly more active and less likely to be overweight/obese compared to new Recreovia users at baseline. No changes on PA were found when comparing the intervention and control groups. Recreovias may have potential for increasing PA at the population level in urban areas given their rapid scalability, the higher levels of PA observed among program users, and its potential to reach women, low-income, less educated populations, and the overweight and obese.

To analyze relationships between demographic characteristics of Georgia school systems and: (1) compliance with the Child Nutrition and WIC Reauthorization Act (CNRA); and (2) strength of wellness policy goals in nutrition, physical activity, and other school-based activities.Each local school district submitted their school-board-approved wellness policy to researchers. Each policy was reviewed and coded for compliance with CNRA and evaluated on the strength of its goals.Public school districts.One hundred seventy-six of 180 Georgia public school systems participated.Independent variables were demographic characteristics of Georgia school systems. Dependent variables were ratings from the policy evaluation instrument, grouped into composite indices to compare the strength (ie, ratings) of wellness policy goals.Pearson correlation, cross-tabulation.Significant positive associations were found between academic performance and: strength of overall wellness policy goals (P.05), goals in nutrition education (P.01), and other school-based activities (P.01). Economic status of the student population was found to be positively associated with strength of nutrition education goals (P.05).Districts with stronger academic performance had more comprehensive overall wellness policy goals and stronger goals in nutrition education and other school-based activities.

J Clin Hypertens(Greenwich). 2010;12:636–644. © 2010 Wiley Periodicals, Inc. The objective of this study was to determine independent and joint association of body mass index (BMI) percentile and leisure time physical activity (LTPA) with continuous metabolic syndrome (cMetS) risk score in 12‐ to 17‐year‐old American children. The 2003 to 2004 US National Health and Nutrition Examination Survey data were used for this investigation. LTPA was determined by self‐report. cMetS risk score was calculated using standardized residuals of arterial blood pressure, triglycerides, glucose, waist circumference, and high‐density lipoprotein cholesterol. Multiple linear regression analysis was used to evaluate association of BMI percentile and LTPA with cMetS risk score, adjusting for confounders. Increased BMI percentile and LTPA were each associated with increased and decreased cMetS risk score, respectively ((P

Highlights The combined use of fasting plasma glucose and hemoglobin A1c test is associated with significantly higher diagnostic rates of prediabetes across age, race/ethnicity, and BMI than using only one test. Combined use of fasting plasma glucose, hemoglobin A1c, and oral glucose tolerance test do not improve the overall and gender-specific prediabetes prevalence beyond what is observed using a combination fasting plasma glucose and hemoglobin A1c test. A redefined hemoglobin A1c test that incorporates racial/ethnic, gender, age, and BMI differences may provide a better way to use hemoglobin A1c test in population-based and clinical settings. Aim To determine combinations of blood glucose tests: oral glucose tolerance (OGT), fasting plasma glucose (FPG), and hemoglobin A1C (HbA1C) that are associated with highest diagnostic rates of prediabetes in non-diabetic American children and adults. Methods The 2007–2008 U.S. National Health and Nutrition Examination Surveys data were used for this study. Overall and specific prevalence of prediabetes (defined using OGT + FPG, OGT + HbA1C, HbA1C + FPG, and OGT + FPG + HbA1C tests) were determined across age, race/ethnicity, sex, and BMI categories. Results FPG + HbA1C test was associated with significantly higher diagnostic rates of prediabetes across age, race/ethnicity, and BMI. Estimates of overall prevalence of prediabetes using OGT + FPG, OGT + HbA1C, HbA1C + FPG, and OGT + FPG + HbA1C tests were 20.3, 24.2, 33, and 34.3%, respectively. Compared to OGT + FPG, the use of HbA1C + FPG test in screening was associated with 44.8, 135, 38.6, and 35.9% increased prevalence of prediabetes in non-Hispanic White, non-Hispanic Black, Mexican-American, and other racial/ethnic men, respectively. The corresponding values in women were 67.8, 140, 37.2, and 42.6%, respectively. Combined use of all blood glucose tests did not improve the overall and gender-specific prediabetes prevalence beyond what was observed using HbA1C + FPG test. Conclusion HbA1C criteria were associated with higher diagnosis rates of prediabetes than FPG and OGT tests in non-diabetic American children and adults. Using a combination of HbA1C and FPG test in screening for prediabetes reduces intrinsic systematic bias in using just HbA1C testing and offers the benefits of each test. A well-defined HbA1C that takes into consideration race/ethnicity, gender, age, and body mass index may improve detection of prediabetes in population and clinical settings.

Introduction Tracking the vital status of stroke patients through death data is one approach to assessing the impact of quality improvement in stroke care. We assessed the feasibility of linking Georgia hospital discharge data with mortality data to evaluate the effect of participation in the Georgia Coverdell Acute Stroke Registry on survival rates among acute ischemic stroke patients. Methods Multistage probabilistic matching, using a fine-grained record integration and linkage software program and combinations of key variables, was used to link Georgia hospital discharge data for 2005 through 2009 with mortality data for 2006 through 2010. Data from patients admitted with principal diagnoses of acute ischemic stroke were analyzed by using the extended Cox proportional hazard model. The survival times of patients cared for by hospitals participating in the stroke registry and of those treated at nonparticipating hospitals were compared. Results Average age of the 50,579 patients analyzed was 69 years, and 56% of patients were treated in Georgia Coverdell Acute Stroke Registry hospitals. Thirty-day and 365-day mortality after first admission for stroke were 8.1% and 18.5%, respectively. Patients treated at nonparticipating facilities had a hazard ratio for death of 1.14 (95% confidence interval, 1.03-1.26; P = .01) after the first week of admission compared with patients cared for by hospitals participating in the registry. Conclusion Hospital discharge data can be linked with death data to assess the impact of clinical-level or community-level chronic disease control initiatives. Hospitals need to undertake quality improvement activities for a better patient outcome.

Purpose. This study examined municipal officials' participation in built environment policy initiatives focused on land use design, transportation, and parks and recreation. Design. Web-based cross-sectional survey. Setting. Eighty-three municipalities with 50,000 or more residents in eight states. Subjects. Four hundred fifty-three elected and appointed municipal officials. Measures. Outcomes included self-reported participation in land use design, transportation, and parks and recreation policy to increase physical activity. Independent variables included respondent position; perceptions of importance, barriers, and beliefs regarding physical activity and community design and layout; and physical activity partnership participation. Analysis. Multivariable logistic regression models. Results. Compared to other positions, public health officials had lower participation in land use design (78.3% vs. 29.0%), transportation (78.1% vs. 42.1%), and parks and recreation (67.1% vs. 26.3%) policy. Perceived limited staff was negatively associated with participation in each policy initiative. Perceptions of the extent to which physical activity was considered in community design and physical activity partnership participation were positively associated with participation in each. Perceived lack of collaboration was associated with less land use design and transportation policy participation, and awareness that community design affects physical activity was associated with more participation. Perceived lack of political will was associated with less parks and recreation policy participation. Conclusion. Public health officials are underrepresented in built environment policy initiatives. Improving collaborations may improve municipal officials' policy participation.

Introduction The child care environment has emerged as an ideal setting in which to implement policies that promote healthy body weight of children. The purpose of this study was to assess the effect of a wellness policy and training program on the physical activity and nutrition environment in 24 child care centers in Georgia. Methods We used the Environment and Policy Assessment and Observation instrument to identify changes to foods served, staff behaviors, and physical activity opportunities. Observations were performed over 1 day, beginning with breakfast and concluding when the program ended for the day. Observations were conducted from February 2010 through April 2011 for a total of 2 observations in each center. Changes to nutrition and physical activity in centers were assessed on the basis of changes in scores related to the physical activity and nutrition environment documented in the observations. Paired t test analyses were performed to determine significance of changes. Results Significant improvements to total nutrition (P < .001) and physical activity scores (P < .001) were observed. Results indicate that centers significantly improved the physical activity environments of centers by enhancing active play (P = .02), the sedentary environment (P = .005), the portable environment (P = .002), staff behavior (P = .004), and physical activity training and education (P < .001). Significant improvements were found for the nutrition environment (P < .001), and nutrition training and education (P < .001). Conclusion Findings from this study suggest that implementing wellness policies and training caregivers in best practices for physical activity and nutrition can promote healthy weight for young children in child care settings.

Collaborative groups are integral in health promotion and disease prevention and use an ecological approach to address complex health conditions in community settings. Little is known about collaborative efforts to promote active living.The objective of this analysis is to explore successes and challenges of collaborative groups in promoting active living in their communities.One-time, structured telephone interviews were conducted to assess the composition tactics and activities and approaches used by collaboratives to promote active living.Collaborative groups were referred by Physical Activity Policy Research Network members or found through online searches. Interviews were conducted with coordinators of 59 collaborative groups.Analysis focused on successes and challenges of collaborative groups' policies, programs, and/or projects as described by collaborative group coordinators. We used the Grounded Theory method approach to code and abstract themes from 2 open-ended response sets.Collaboratives' most successful projects centered on strategies using environmental (41%) or policy (31%) approaches to promote active living. While 80% of groups reported that their most successful project was funded, funding was also identified as a primary challenge for 71% of the collaboratives. Personnel issues were a common challenge for 54%. Opposition to successful projects ranged from community issues to collaborative member issues, although more than half the groups experienced no opposition.Groups that aligned goals, strategies, and funding to advance changes to the built environment were likely to identify their projects as successful. Perceptions of opposition and attitudes toward success may be important precursors to project outcomes of active living collaboratives and warrant further investigation. Lessons from these active living collaborative groups can provide guidance for other groups planning for environmental and policy change.

INTRODUCTION: Changing the built environment to promote active lifestyles requires collaboration among diverse sectors. Multisectoral collaborative groups in the United States promote active lifestyles through environmental and policy changes. The objective of this study was to examine the characteristics of these collaborative groups and the extent to which they have achieved change. METHODS: We identified, recruited, and interviewed the coordinators of active living collaborative groups in the United States. We used descriptive statistics to characterize groups by composition, stakeholder engagement, and the extent of environmental and policy change in 8 strategic areas. RESULTS: Fifty-nine groups from 22 states participated in the study. Most groups had a diverse set of partners and used a range of activities to advance their agendas. Most groups achieved some form of environmental or policy change. On average, groups reported working on 5 strategy areas; parks and recreation (86%) and Safe Routes to School (85%) were named most frequently. More than half of groups reported their environmental initiatives as either in progress or completed. Groups reported the most success in changing policy for public plazas, street improvements, streetscaping, and parks, open space, and recreation. Complete Streets policy and zoning ordinances were the most frequently cited policy types. Engaging in media activities and the policy-making process in addition to engaging stakeholders appear to influence success in achieving change. CONCLUSION: Although many groups successfully worked on parks and recreation improvements, opportunities remain in other areas, including transit and infill and redevelopment. Additional time and resources may be critical to realizing these types of changes. KW: SW2S Language: en

Objective To explore the experiences of child care centers implementing a nutrition and physical activity (PA) program and identify supports and barriers as reported by center directors. Design Semi-structured interviews with 20 child care center directors following program implementation. Setting Twenty-two child care centers serving low-income children in Georgia. Participants Twenty child care center directors who led program implementation at their respective centers. Intervention The program focused on introducing wellness policies to centers and on providing training and technical assistance to support implementation. Phenomenon of Interest Center directors' perceptions, attitudes, and reflections on the process of implementing changes to nutrition and PA practices. Analysis Qualitative analysis of interview transcripts was conducted using NVivo 9 software. Researchers employed 2 levels of coding; 4 predominant themes emerged. Results Directors' insights included the importance of hands-on activities and printable materials to engage children in nutrition and PA education and healthy behaviors; challenges and supports to engaging parents in child wellness; recognition that children readily accept nutrition and PA changes; and the need for program implementation efforts to prioritize the provision of support for directors and staff in modifying nutrition and PA practices. Conclusion and Implications Directors consider nutrition and PA policy changes to be beneficial to the child care environment. This study highlights important considerations for efforts to promote healthy weight environments in the early care setting.

Purpose Although continuous values of metabolic syndrome risk scores (cMetS) has been suggested for modeling the association between potential risk factors and metabolic syndrome (MetS) in young people, the construct validity of cMetS has not been sufficiently examined in a representative sample of youngsters. This study examined: (i) sex and race/ethnic-specific optimal cut-off points of cMetS that are associated with MetS and (ii) the construct validity of cMetS in 12- to 19-year old non-Hispanic white (NHW), non-Hispanic black (NHB), and Mexican-American (MA) subjects. Methods Data (n = 1239) from the 2003 to 2004 and 2005 to 2006 National Health and Nutrition Examination Surveys were used in this study. cMetS was derived by aggregating age- and sex-standardized residuals of arterial blood pressure, triglycerides, glucose, waist circumference, and high-density lipoprotein cholesterol. Receiver operating characteristics analysis was used to determine the validity and performance of cMetS. The overall performance of the receiver operating characteristics test was quantified with area under the curve (AUC). Results A graded relationship between cMetS and increased number of MetS factors was observed, with MetS factors of 3 or greater yielding the greatest cMetS. In male adolescents, the optimal cMetS cut-off points of cMetS that are associated with MetS in NHW, NHB, and MA were 2.01, 2.45, and 2.34, respectively. The corresponding values in female adolescents for NBW, NHB, and MA were 1.93, 2.12, and 2.23, respectively. The construct validity of cMetS for MetS was high (AUC ≥0.885; sensitivity ≥66.7; specificity ≥74.8%). Conclusions cMetS appears to be a suitable index for investigating the association between potential risk factors and MetS in adolescents. An understanding of the role of genetic and environmental risk factors in MetS in children may be enhanced with the use of cMetS.

The prevalence of childhood obesity is increasing at an alarming rate. Many local governments have enacted policies to increase physical activity in schools as a way to combat childhood obesity. We conducted a systematic review and meta-analysis to determine the effect of school-based physical activity interventions on body mass index (BMI) in children.We searched MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials up to September 2008. We also hand-searched relevant journals and article reference lists. We included randomized controlled trials and controlled clinical trials that had objective data for BMI from before and after the intervention, that involved school-based physical activity interventions and that lasted for a minimum of 6 months.Of 398 potentially relevant articles that we identified, 18 studies involving 18 141 children met the inclusion criteria. The participants were primarily elementary school children. The study duration ranged from 6 months to 3 years. In 15 of these 18 studies, there was some type of co-intervention. Meta-analysis showed that BMI did not improve with physical activity interventions (weighted mean difference -0.05 kg/m(2), 95% confidence interval -0.19 to 0.10). We found no consistent changes in other measures of body composition.School-based physical activity interventions did not improve BMI, although they had other beneficial health effects. Current population-based policies that mandate increased physical activity in schools are unlikely to have a significant effect on the increasing prevalence of childhood obesity.

Obesity and its medical consequences are more prevalent among AfricanAmerican (AA) than European-American females,' and this ethnic difference is evident among children and adolescents.' While the higher rate of obesity in AAs is not entirely understood, it is likely that excess caloric intake and inadequate physical activity contribute to the problem."' Adiposity and diet and exercise patterns track from childhood through ad~lthood; '~~ providing a rationale for early interventi0n.j Health promotion programs should be matched to the social, cultural, and environmental characteristics of the target population.' For inner-city low-income AAs, these factors include unique attitudes regarding ideal body type, greater tolerance of o~enveight,~,' unique dietary patterns,''J' lower exercise rates," and environments that may impede healthy eating and physical acti~ity.~ There is a need for culturallv sensitive obesity prevention and treatment programs for AAs.j Few such programs have been developed, and most have targeted adult^'^-'^ or families.15 In response to this need, we developed a nutrition and physical activity intervention (a.k.a. G O GIRLS!) designed for innercity, overweight,AA adolescent females.

Aim: To determine the independent and commingling effect of android and gynoid percent fat (measured using Dual Energy X-Ray Absorptiometry) on cardiometabolic dysregulation in normal weight American adults. Methods: The 2005–2006 data (n=1802) from the United States National Health and Nutritional Examination Surveys (NHANES) were used in this study. Associations of android percent fat, gynoid percent fat and their joint occurrence with risks of cardiometabolic risk factors were estimated using prevalence odds ratios from logistic regression analyses. Results: Android-gynoid percent fat ratio was more highly correlated with cardiometabolic dysregulation than android percent fat, gynoid percent fat or body mass index. Commingling of android and gynoid adiposities was associated with much greater odds of cardiometabolic risk factors than either android or gynoid adiposities. Commingling of android and gynoid adiposities was associated with 1.75 (95% confidence interval (CI)=1.42–2.93), 1.48 (95% CI=1.32–1.91), 1.61 (95% CI=1.50–1.89), 3.56 (95% CI=2.91–4.11) and 1.86 (95% CI=1.49–1.96) increased odds of elevated glucose, elevated blood pressure, elevated low-density lipoprotein-cholesterol, elevated triglyceride and low high-density lipoprotein-cholesterol, respectively. Conclusions: Normal weight subjects who present with both android and gynoid adiposities should be advised of the associated health risks. Both android and gynoid fat accumulations should be considered in developing public health strategies for reducing cardiometabolic disease risk in normal weight subjects.