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Objectives Examine differences in perceptions of tap water (TW) and bottled water (BW) safety and TW taste and their associations with plain water (PW) and sugar-sweetened beverage (SSB) intake.Design Quantitative, cross-sectional study.Setting United States.Subjects 4,041 U.S. adults (≥18 years) in the 2018 SummerStylessurvey data.Measures Outcomes were intake of TW, BW, PW (tap and bottled water), and SSB. Exposures were perceptions of TW and BW safety and TW taste (disagree, neutral, or agree). Covariates included sociodemographics.Analysis We used chi-square analysis to examine sociodemographic differences in perceptions and multivariable logistic regressions to estimate adjusted odds ratios (AOR) for consuming TW ≤ 1 cup/day, BW > 1 cup/day, PW ≤ 3 cups/day, and SSB ≥ 1 time/day by water perceptions.Results One in 7 (15.1%) of adults did not think their home TW was safe to drink, 39.0% thought BW was safer than TW, and 25.9% did not think their local TW tasted good. Adults who did not think local TW was safe to drink had higher odds of drinking TW ≤1 cup/day (AOR = 3.12) and BW >1 cup/day (AOR = 2.69). Adults who thought BW was safer than TW had higher odds of drinking TW ≤1 cup/day (AOR = 2.38), BW > 1 cup/day (AOR = 5.80), and SSB ≥ 1 time/day (AOR = 1.39). Adults who did not think TW tasted good had higher odds of drinking TW ≤1 cup/day (AOR = 4.39) and BW > 1 cup/day (AOR = 2.91).Conclusions Negative perceptions of TW safety and taste and a belief BW is safer than TW were common and associated with low TW intake. Perceiving BW is safer than TW increased the likelihood of daily SSB intake. These findings can guide programs and services to support water quality to improve perceptions of TW safety and taste, which might increase TW intake and decrease SSB intake.

Purpose Food service guidelines (FSG) policies can impact the nutritional quality of millions of meals sold or served to government employees, citizens in public places, or institutionalized persons. This study examines state FSG policies adopted January 1, 2015 to April 1, 2019, and uses a FSG Classification Tool (FSG Tool) to quantify alignment with nutrition recommendations for public health impact.Design Quantitative Content AnalysisSetting State Government Worksites and FacilitiesParticipants 50 states and District of Columbia (D.C.) in the United States.Measures Frequency of policies and percent alignment to FSG tool.Analysis FSG policies were identified using legal databases to assess state statutes, regulations, and executive orders. Content analysis and coding determined attributes of policies across 4 FSG Tool domains, (1) nutrition standards referenced; (2) behavioral design strategies encouraging selection of healthier offerings; (3) facility efficiency and environmental sustainability; and (4) FSG implementation supports.Results From 2015-2019, 5 FSG policies met study inclusion criteria. Four out of 5 policies earned a perfect nutrition score (100%) by referencing nutrition standards that align with the Dietary Guidelines for Americans (DGA) and are operationalized for use in food service venues. Four out of 5 policies included at least 1 implementation supports provision, such as naming an implementing agency, and 2 included provisions that encourage local food sourcing.Conclusion From 2015-2019, overall FSG policy comprehensiveness scores ranged from 24% to 73%, with most policies referencing food and nutrition standards that align to national nutrition recommendations. Public health practitioners can educate decision makers on the potential impact of FSG policies on diet-related health outcomes and associated cost savings, as well as other important co-benefits that support locally grown products and environmental sustainability practices.

Background: Laboratory-based investigations indicate that the consumption of foods with a low energy density (kcal/g) decreases energy intake. Although low-energy-dense diets are recommended for weight management, relations between energy density, energy intake, and weight status have not been clearly shown in free-living persons. Objectives: A representative US sample was used to determine whether dietary energy density is associated with energy intake, the weight of food consumed, and body weight and to explore the influence of food choices (fruit, vegetable, and fat consumption) on energy density and body weight. Design: A cross-sectional survey of adults (n = 7356) from the 1994-1996 Continuing Survey of Food Intakes by Individuals and two 24-h dietary recalls were used. Results: Men and women with a low-energy-dense diet had lower energy intakes ([approximately equal to] 425 and 275 kcal/d less, respectively) than did those with a high-energy-dense diet, even though they consumed more food ([approximately equal to] 400 and 300 g/d more, respectively). Normal-weight persons had diets with a lower energy density than did obese persons. Persons with a high fruit and vegetable intake had the lowest energy density values and the lowest obesity prevalence. Conclusions: Adults consuming a low-energy-dense diet are likely to consume more food (by weight) but to have a lower energy intake than do those consuming a higher-energy-dense diet. The energy density of a variety of dietary patterns, including higher-fat diets, can be lowered by adding fruit and vegetables, Our findings support the hypothesis that a relation exists between the consumption of an energy-dense diet and obesity and provide evidence of the importance of fruit and vegetable consumption for weight management. KEY WORDS Energy density, obesity, weight management, food patterns, fruit and vegetables, Continuing Survey of Food Intakes by Individuals, CSFII

Background:Obesity remains a significant public health issue in the United States. Each week, millions of infants and children are cared for in early care and education (ECE) programs, making it an important setting for building healthy habits. Since 2010, 39 states promulgated licensing regulations impacting infant feeding, nutrition, physical activity, or screen time practices. We assessed trends in ECE regulations across all 50 states and the District of Columbia (D.C.) and hypothesized that states included more obesity prevention standards over time.Methods:We analyzed published ratings of state licensing regulations (2010–2018) and describe trends in uptake of 47 high-impact standards derived from Caring for Our Children's, Preventing Childhood Obesity special collection. National trends are described by (1) care type (Centers, Large Care Homes, and Small Care Homes); (2) state and U.S. region; and (3) most and least supported standards.Results:Center regulations included the most obesity prevention standards (∼13% in 2010 vs. ∼29% in 2018) compared with other care types, and infant feeding and nutrition standards were most often included, while physical activity and screen time were least supported. Some states saw significant improvements in uptake, with six states and D.C. having a 30%-point increase 2010–2018.Conclusions:Nationally, there were consistent increases in the percentage of obesity prevention standards included in ECE licensing regulations. Future studies may examine facilitators and barriers to the uptake of obesity prevention standards and identify pathways by which public health and health care professionals can act as a resource and promote obesity prevention in ECE.

Purpose: Determine prevalence of overweight and obesity as reported in Head Start Program Information Reports.Design: Serial cross-sectional census reports from 2012–2018.Setting: Head Start programs countrywide, aggregated from program level to state and national level.Subjects: Population of children enrolled in Head Start with reported weight status data.Measures: Prevalence of overweight (body mass index [BMI] ≥85th percentile to <95th percentile) and obesity (BMI ≥95th percentile).Analysis: Used descriptive statistics to present the prevalence of overweight and obesity by state. Performed unadjusted regression analysis to examine annual trends or average annual changes in prevalence.Results: In 2018, the prevalence of overweight was 13.7% (range: 8.9% in Alabama to 20.4% in Alaska). The prevalence of obesity was 16.6% (range: 12.5% in South Carolina to 27.1% in Alaska). In the unadjusted regression model, 34 states and the District of Columbia did not have a linear trend significantly different from zero. There was a statistically significant positive trend in obesity prevalence for 13 states and a negative trend for 3 states.Conclusion: The prevalence of obesity and overweight in Head Start children remained stable but continues to be high. Head Start reports may be an additional source of surveillance data to understand obesity prevalence in low-income young children.

Purpose: During a pandemic, persons might experience worry because of threats (real or perceived), or as part of stress-related reactions. We aimed to provide insight into Americans’ worry about food during COVID-19. Design, Subjects, Measures:Online survey data from June 2020 (n = 4,053 U.S. adults; 62.7% response rate) was used to assess 2 outcomes: worry about food availability (FA); food safety (FS). Adults with missing information about FA and FS were excluded from analysis (final n = 3,652).Analysis: We used descriptive statistics and multivariable logistic regression to examine characteristics associated with the outcomes and estimate adjusted odds ratios (aOR) and 95% confidence intervals (95%CI) for associations between sociodemographic variables and outcomes.Results: 58.3% of respondents reported worry about FA; 57.5% about FS, with higher odds of worry for FA and FS (versus referents) in lower income households (FA: aOR = 1.76 95%CI [1.30, 2.39]; FS: 1.84[1.35, 2.51]); unemployed (1.54[1.05, 2.28]; 1.90[1.26,2.81]); non-Hispanic Black (1.55[1.14,2.12]); 2.25[1.65,3.07]); Hispanic (1.39[1.06,1.82]; 1.94[1.46,2.56]).Conclusion: Findings highlight the importance of strategies to reduce consumer worry about FA and FS and negative food behaviors, and the need for continued access to hunger safety net programs, which could have positive effects on nutrition security.

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Purpose: To examine factors associated with frequency of plain water (ie, tap, bottled, and unflavored sparkling water) intake among US high school students.Design: Quantitative, cross-sectional study.Setting: The 2017 national Youth Risk Behavior Survey data.Subjects: US high school students with plain water intake data (N = 10 698).Measures: The outcome was plain water intake. Exposure variables were demographics, academic grades, and behavioral characteristics.Analysis: We used logistic regression to estimate adjusted odds ratios (aOR) and 95% confidence intervals (CIs) for factors associated with infrequent plain water intake (<3 vs ≥3 times/day).Results: Overall, 48.7% of high school students reported drinking plain water <3 times/day. Factors associated with infrequent plain water intake were younger age (≤15 years; aOR = 1.20, CI = 1.05-1.37); earning mostly D/F grades (aOR = 1.37, CI = 1.07-1.77); consuming regular soda 1 to 6 times/week (aOR = 1.92, CI = 1.67-2.20) or ≥1 time/day (aOR = 3.23, CI = 2.65-3.94), sports drinks 1 to 6 times/week (aOR = 1.30, CI = 1.14-1.49), milk <2 glasses/day (aOR = 1.51, CI = 1.31-1.73), fruits <2 times/day (aOR = 1.92, CI = 1.66-2.22), and vegetables <3 times/day (aOR = 2.42, CI = 2.04-2.89); and being physically active ≥60 minutes/day on <5 days/week (aOR = 1.83, CI = 1.60-2.08). Students with obesity were less likely to have infrequent water intake (aOR = 0.63, CI = 0.53-0.74).Conclusions: Infrequent plain water intake was associated with younger age, poor academic grades, poor dietary behaviors, and physical inactivity. These findings can inform intervention efforts to increase water intake to promote healthy lifestyles among adolescents.

Purpose: To examine associations of adolescent sugar-sweetened beverage (SSB) intake with parent SSB intake and parent and adolescent attitudes about limiting SSB and junk food (SSB/JF) intake.Design: Quantitative, cross-sectional study.Setting: The 2014 Family Life, Activity, Sun, Health, and Eating study.Sample: Parent–adolescent dyads (N = 1555).Measures: The outcome was adolescent SSB intake. Exposure variables were parent SSB intake, sociodemographics, and parent and adolescent attitudes about SSB/JF intake (responses: agree, neither, or disagree).Analysis: Multinomial logistic regressions estimated adjusted odds ratios (aOR) and 95% confidence intervals (CIs).Results: Half (49.5%) of adolescents and 33.7% of parents consumed SSB ≥1 time/day. Parent daily SSB intake was associated with adolescent daily SSB intake (aOR = 8.9; CI = 4.6-17.3) [referent: no consumption]. Adolescents who disagreed on having confidence to limit SSB/JF intake had higher odds of daily SSB intake (aOR = 3.5; CI = 1.8-6.8), as did those who disagreed they felt bad about themselves if they did not limit SSB/JF intake (aOR = 1.9; CI=1.1-3.3), compared to adolescents who agreed with these attitudes. No parental attitudes were significant.Conclusion: Higher odds of daily SSB intake among adolescents was associated with parent SSB intake and adolescent attitudes about confidence in, and feeling bad about, limiting SSB/JF intake. Parent attitudes were not associated with daily adolescent SSB intake. Efforts to reduce adolescent SSB intake could consider strategies geared toward improving adolescent attitudes and dietary behaviors and parental SSB intake.

Purpose: To examine associations between knowledge of health conditions and sugar-sweetened beverage (SSB) intake among Hispanic adults.Design: Quantitative, cross-sectional study.Setting: The 2015 Estilossurvey data.Participants: One thousand US Hispanic adults (≥18 years).Measures: The outcome variable was frequency of SSB intake (regular soda, fruit drink, sports/energy drink, and sweetened coffee/tea drink). Exposure variables were knowledge of 6 SSB-related health conditions (weight gain, diabetes, dental caries, high cholesterol, heart disease, and hypertension).Analysis: Six multinomial logistic regression models were used to estimate adjusted odds ratios for consuming SSBs ≥3 times/day (high intake), in relation to knowledge of SSB-related health conditions.Results: Overall, 58% of Hispanic adults consumed SSBs ≥2 times/day and 36% consumed SSBs ≥3 times/day. Although most identified that weight gain (75%) and diabetes (76%) were related to drinking SSBs, only half identified this relation with dental caries (57%) and hypertension (41%). Even fewer identified high cholesterol (32%) and heart disease (32%) as related. In crude analyses, SSB intake was significantly associated with knowledge of the associations between SSBs and weight gain, dental caries, and heart disease; however, after adjusting for sociodemographics and acculturation, associations were no longer significant.Conclusions: Although SSB intake was very high, knowledge of SSB-related health conditions was low and was not related to high SSB intake among US Hispanic adults. Education efforts alone may not be adequate for Hispanic adults to change their behaviors.

Purpose: To examine associations of adolescent sugar-sweetened beverage (SSB) intake with parent SSB intake and parent and adolescent knowledge of SSB-related health risks.Design: Quantitative, cross-sectional.Setting: 2014 SummerStylessurvey.Subjects: Nine hundred and ninety parent and adolescent (12-17 years) pairs.Measures: The outcome was self-reported adolescent intake (0, >0 to <1, or ≥1 time/day) of SSBs (soda, fruit drinks, sports/energy drinks, other SSBs). The exposures were self-reported parent SSB intake (0, >0 to <1, ≥1 to <2, or ≥2 times/day) and parent and adolescent knowledge of SSB-related health risks (weight gain, diabetes, and dental caries).Analysis: Separate multinomial logistic regression models were used to estimate adjusted odds ratios (aORs) for adolescent SSB intake ≥1 time/day (ref: 0 times/day), according to (1) parent SSB intake and (2) parent and (3) adolescent knowledge.Results: About 31% of adolescents consumed SSBs ≥1 time/day, and 43.2% of parents consumed SSBs ≥2 times/day. Adolescent and parent knowledge that SSB intake is related to health conditions ranged from 60.7% to 80.4%: weight gain (75.0% and 80.4%, respectively), diabetes (60.7% and 71.4%, respectively), and dental caries (77.5% and 72.9%, respectively). In adjusted models, adolescent SSB intake ≥1 time/day was associated with parent intake ≥2 times/day (aOR = 3.30; 95% confidence interval = 1.62-6.74) but not with parent or adolescent knowledge of health risks.Conclusion: Parental SSB intake may be an important factor in understanding adolescent behavior; knowledge of SSB-related health conditions alone may not influence adolescent SSB behavior.

Purpose: This study examined associations between knowledge of sugar-sweetened beverage (SSB)-related health conditions and SSB intake among US adults.Design: Quantitative, cross-sectional study.Subject: The 2014 SummerStylessurvey data for 4163 US adults (≥18 years) were used.Measures: The outcome measure was frequency of SSB intake (regular soda, fruit drinks, sports or energy drinks, sweetened coffee/tea drinks). Exposure measures were knowledge of 6 SSB-related health conditions: weight gain, diabetes, cavities, high cholesterol, heart disease, and hypertension.Analysis: Six logistic regression models were used to estimate adjusted odds ratios (ORs) for consuming SSBs ≥2 times/d according to knowledge of SSB-related health conditions.Results: Overall, 37.8% of adults reported consuming SSBs ≥2 times/d. Although most adults identified that weight gain (80.2%), diabetes (73.6%), and cavities (71.8%) are related to drinking SSBs, fewer adults identified high cholesterol (24.1%), heart disease (31.5%), and hypertension (33.0%) as being related to drinking SSBs. Crude analyses indicated that lower SSB intake was significantly associated with knowledge of the associations between SSBs and weight gain, diabetes, cavities, and heart disease. However, after adjustment for covariates, only lack of knowledge of the association between heart disease and SSBs was significantly associated with consuming SSBs ≥2 times/d (OR = 1.29) than non-SSB consumers.Conclusions: The finding that knowledge of SSB-related health conditions, in general, was not associated with high SSB intake suggests that knowledge on SSB-related health conditions alone may not be sufficient for adult behavior change.

Purpose: To compare the performance of a 1-question survey screener measuring total sugar-sweetened beverage (SSB) intake to a screener measuring SSB types separately using 4 questions.Design: Cross-sectional.Setting: Web-based 2014 SummerStylessurvey.Participants: A total of 4167 US adults (≥18 years).Measures: Frequency of SSB intake measured using a 1-question screener was compared to frequency using a 4-question screener (regular soda, fruit drinks, sports/energy drinks, sweetened coffee/tea). SSB intake (number of time/day) was categorized as 0, >0 to <1, and ≥1 time/day; difference in mean intake was calculated between 4 questions versus 1.Analysis: Paired ttests were used, and agreement was evaluated using weighted κ and Lin’s concordance correlation coefficient (CCC).Results: Mean SSB intake was 1.7 (95% confidence interval [CI]: 1.65-1.79) times/day using 4 questions and 0.6 (95% CI: 0.56-0.62) times/day using 1 question (P< .001). Intake frequency based on 4 questions versus 1 was 16.0% versus 38.5% for 0 time/day, 15.6% versus 42.5% for >0 to <1 time/day, and 68.4% versus 18.9% for ≥1 time/day. There was fair agreement for the 3 SSB intake categories (κ: .27) and poor absolute agreement between the 2 continuous measures (Lin’s CCC: 0.31).Conclusion: Daily SSB intake was significantly lower using a 1-question screener versus a 4-question screener. Researchers should assess SSB types separately or consider that daily SSB intake is likely underestimated with 1 question.

IMPORTANCE: Severe obesity in childhood is associated with negative health consequences. A previous study examined trends in severe obesity among preschool-aged children in low-income families during 1998 to 2010. No recent trends have been reported. OBJECTIVE: To examine trends in severe obesity by age, sex, and race/ethnicity among enrollees in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) aged 2 to 4 years during 2000 to 2014. DESIGN, SETTING, AND PARTICIPANTS: Serial cross-sectional data from 22.6 million young children enrolled in WIC from 50 states, the District of Columbia, and 5 US territories from 2000 to 2014. Data analysis was conducted from February 16, 2017, to March 9, 2017. MAIN OUTCOMES AND MEASURES: Prevalence of severe obesity. Severe obesity was defined as a sex-specific body mass index-for-age 120% or more of the 95th percentile on the 2000 Centers for Disease Control and Prevention growth charts. Children’s weights and heights were measured. Children whose sex, weight, height, or body mass index was missing or biologically implausible were excluded. RESULTS: The prevalence of severe obesity was 1.96% in 2014. During 2000 to 2004, the prevalence increased significantly overall from 1.80% to 2.11% (adjusted prevalence difference [APD], 0.26%) and among all the age, sex, and racial/ethnic groups except for Asian/Pacific Islander (APD, 0.05%-0.54% across groups with increases). The largest relative increase occurred in children aged 4 years (adjusted prevalence ratio [APR], 1.21) and non-Hispanic white (APR, 1.22) and American Indian/Alaska Native children (APR, 1.19). During 2004 to 2010, the prevalence decreased significantly overall (APD, −0.05%), among boys, children aged 2 and 3 years, and non-Hispanic black and Asian/Pacific Islander children (APD, −0.05% to −0.18%). During 2010 to 2014, the prevalence decreased significantly overall from 2.12% to 1.96% (APD, −0.14%) and among all demographic groups (APD, −0.04% to −0.30% across groups). The largest relative decrease occurred in children aged 2 years (APR, 0.88) and Hispanic (APR, 0.92), American Indian/Alaska Native (APR, 0.89), and Asian/Pacific Islander (APR, 0.87) children. CONCLUSIONS AND RELEVANCE: This study provides updated prevalence and trends of severe obesity among young children enrolled in WIC and reports recent modest declines in severe obesity in all subgroups. Ongoing surveillance can assess whether declines continue into the future among low-income children.

Purpose: Characteristics of parents who purchased kids’ meals, reasons for the purchase, and desire for healthy options were examined.Design: Quantitative, cross-sectional study.Setting: National.Participants: The SummerStyles survey data of 1147 parents (≥18 years).Measures: Self-reported outcome variables were purchase of kids’ meals (yes/no), reasons for the purchase (13 choices), and desire for healthy options (yes/no).Analysis: We used multivariable logistic regression to estimate odds ratios (ORs) for purchasing kids’ meals based on parental sociodemographic and behavioral characteristics.Results: Over half (51%) of parents reported purchasing kids’ meals in the past month. The adjusted OR of purchasing kids’ meals were significantly higher among younger parents (OR = 3.44 vs ≥50 years) and among parents who consumed sugar-sweetened beverages (SSBs) daily (OR = 2.70 vs none). No differences were found for race/ethnicity, income, and education. Parents who purchased kids’ meals reported that the top 3 reasons for purchase were (1) because their children asked for kids’ meals, (2) habit, and (3) offering of healthier sides such as fruits or fruit cups. Thirty-seven percent of parents who did not purchase kids’ meals expressed willingness to purchase kids’ meals if healthy options were available; this willingness was highest among younger parents (47%; P< .05).Conclusions: Kids’ meal purchases were somewhat common. Our findings on characteristics of parents who frequently bought kids’ meals (ie, younger parents and SSB consumers), common reasons for purchasing kids’ meals, and willingness to buy healthier kids’ meal can be used to inform intervention efforts to improve quality of kids’ meals.

Background:Youth with excess weight are at risk of developing type 2 diabetes (T2DM). Guidelines recommend screening for prediabetes and/or T2DM after 10 years of age or after puberty in youth with excess weight who have ≥1 risk factor(s) for T2DM. Electronic health records (EHRs) offer an opportunity to study the use of tests to detect diabetes in youth.Methods:We examined the frequency of (1) diabetes testing and (2) elevated test results among youth aged 10–19 years with at least one BMI measurement in an EHR from 2019 to 2021. We examined the presence of hemoglobin A1C (A1C), fasting plasma glucose (FPG), or oral glucose tolerance test (2-hour plasma glucose [2-hrPG]) results and, among those tested, the frequency of elevated values (A1C ≥6.5%, FPG ≥126 mg/dL, or 2-hrPG ≥200 mg/dL). Patients with pre-existing diabetes (n= 6793) were excluded.Results:Among 1,024,743 patients, 17% had overweight, 21% had obesity, including 8% with severe obesity. Among patients with excess weight, 10% had ≥1 glucose test result. Among those tested, elevated values were more common in patients with severe obesity (27%) and obesity (22%) than in those with healthy weight (8%), and among Black youth (30%) than White youth (13%). Among patients with excess weight, >80% of elevated values fell in the prediabetes range.Conclusions:In youth with excess weight, the use of laboratory tests for prediabetes and T2DM was infrequent. Among youth with test results, elevated FPG, 2hrPG, or A1C levels were most common in those with severe obesity and Black youth.

Background:Data sources for assessing pediatric chronic diseases and associated screening practices are rare. One example is non-alcoholic fatty liver disease (NAFLD), a common chronic liver disease prevalent among children with overweight and obesity. If undetected, NAFLD can cause liver damage. Guidelines recommend screening for NAFLD using alanine aminotransferase (ALT) tests in children ≥9 years with obesity or those with overweight and cardiometabolic risk factors. This study explores how real-world data from electronic health records (EHRs) can be used to study NAFLD screening and ALT elevation.Research Design:Using IQVIA's Ambulatory Electronic Medical Record database, we studied patients 2–19 years of age with body mass index ≥85th percentile. Using a 3-year observation period (January 1, 2019 to December 31, 2021), ALT results were extracted and assessed for elevation (≥1 ALT result ≥22.1 U/L for females and ≥25.8 U/L for males). Patients with liver disease (including NAFLD) or receiving hepatotoxic medications during 2017–2018 were excluded.Results:Among 919,203 patients 9–19 years of age, only 13% had ≥1 ALT result, including 14% of patients with obesity and 17% of patients with severe obesity. ALT results were identified for 5% of patients 2–8 years of age. Of patients with ALT results, 34% of patients 2–8 years of age and 38% of patients 9–19 years of age had ALT elevation. Males 9–19 years of age had a higher prevalence of ALT elevation than females (49% vs. 29%).Conclusions:EHR data offered novel insights into NAFLD screening: despite screening recommendations, ALT results among children with excess weight were infrequent. Among those with ALT results, ALT elevation was common, underscoring the importance of screening for early disease detection.

Purpose. Low availability and affordability of healthier foods in food stores on the Navajo Nation (NN) may be a community-level risk factor for the high prevalence of obesity among the Navajo people. This study assessed the availability and pricing of foods and beverages in supermarkets and convenience stores throughout the NN.Design. Descriptive study design using the Nutrition Environment Measurement Survey in Stores audit tool.Setting. Supermarkets (n = 13) and convenience stores (n = 50) on NN and border-town supermarkets (n = 9).Subjects. Not applicable.Measures. Availability and pricing of healthy and less-healthy foods.Analysis. Descriptive and χ2analyses.Results. Navajo convenience stores offered fewer healthier food options compared to Navajo supermarkets. In Navajo convenience stores, 100% whole grain products, reduced-fat cheese, lean meats, reduced-fat chips, and fat-free or light hot dogs were available in fewer stores than their corresponding less-healthy versions (all with p < .05). In both Navajo supermarkets and convenience stores, 100% whole wheat bread, lean cold cuts, and reduced-fat cheese were all more expensive per unit than their corresponding less-healthy versions (all with p < .05).Conclusions. According to this study, healthier foods are not as readily available in Navajo convenience stores as they are in Navajo supermarkets. Improving access to and affordability of healthier foods in reservation stores of all sizes may support healthy eating among Navajo residents.

Purpose: This study examined associations between sugar-sweetened beverage (SSB) intake and acculturation among a sample representing civilian noninstitutionalized U.S. adults.Design: Quantitative, cross-sectional study.Setting: National.Subjects: The 2010 National Health Interview Survey data for 17,142 Hispanics and U.S.-born non-Hispanic whites (≥18 years).Measures: The outcome variable was daily SSB intake (nondiet soda, fruit drinks, sports drinks, energy drinks, and sweetened coffee/tea drinks). Exposure variables were Hispanic ethnicity and proxies of acculturation (language of interview, birthplace, and years living in the United States).Analysis: We used multivariate logistic regression to estimate adjusted odds ratios (ORs) for the exposure variables associated with drinking SSB ≥1 time/d after controlling for covariates.Results: The adjusted odds of drinking SSB ≥1 time/d was significantly higher among Hispanics who completed the interview in Spanish (OR = 1.65) than U.S.-born non-Hispanic whites. Compared with those who lived in the United States for <5 years, the adjusted odds of drinking SSB ≥1 time/d was higher among adults who lived in the United States for 5 to <10 years (OR = 2.72), those who lived in the United States for 10 to <15 years (OR = 2.90), and those who lived in the United States for ≥15 years (OR = 2.41). However, birthplace was not associated with daily SSB intake.Conclusion: The acculturation process is complex and these findings contribute to identifying important subpopulations that may benefit from targeted intervention to reduce SSB intake.

AbstractBackground:Comprehensive multisector, multilevel approaches are needed to address childhood obesity. This article introduces the structure of a multidisciplinary team approach used to support and guide the multisite, multisector interventions implemented as part of the Childhood Obesity Research Demonstration (CORD) project. This article will describe the function, roles, and lessons learned from the CDC-CORD approach to project management.Methods:The CORD project works across multisectors and multilevels in three demonstration communities. Working with principal investigators and their research teams who are engaging multiple stakeholder groups, including community organizations, schools and child care centers, health departments, and healthcare providers, can be a complex endeavor. To best support the community-based research project, scientific and programmatic expertise in a wide range of areas was required. The team was configured based on the skill sets needed to interact with the various levels of staff working with the project.Conclusions:By thoughtful development of the team and processes, an efficient system for supporting the multisite, multisector intervention project sites was developed. The team approach will be formally evaluated at the end of the project period.

AbstractBackground:This is the first of a set of articles in this issue on the Childhood Obesity Research Demonstration (CORD) project and provides an overview of the multisite approach and community-wide interventions. Innovative multisetting, multilevel approaches that integrate primary healthcare and public health interventions to improve outcomes for children with obesity need to be evaluated. The CORD project aims to improve BMI and obesity-related behaviors among underserved 2- to 12-year-old children by utilizing these approaches.Methods:The CORD consortium, structure, model terminology and key components, and common measures were solidified in year 1 of the CORD project. Demonstration sites applied the CORD model across communities in years 2 and 3. Evaluation plans for year 4 include site-specific analyses as well as cross-site impact, process, and sustainability evaluations.Results:The CORD approach resulted in commonalities and differences in participant, intervention, comparison, and outcome elements across sites. Products are to include analytic results as well as cost assessment, lessons learned, tools, and materials.Discussion:Foreseen opportunities and challenges arise from the similarities and unique aspects across sites. Communities adapted interventions to fit their local context and build on strengths, but, in turn, this flexibility makes cross-site evaluation challenging.Conclusion:The CORD project represents an evidence-based approach that integrates primary care and public health strategies and evaluates multisetting multilevel interventions, thus adding to the limited research in this field. CORD products will be disseminated to a variety of stakeholders to aid the understanding, prevention, and management of childhood obesity.

Let’s go to the park today! This familiar phrase is heard routinely throughout the year in many U.S. households. Access to parks, trails, open spaces, and recreational facilities not only provides increased opportunities for children and adults to play and be physically active, but these venues also influence other behaviors. As the health and wellbeing of our children are impacted by the daily environment in which they live, learn, and play, the use of parks and other recreation spaces as a healthful venue is important to consider in a comprehensive view of childhood and family obesity prevention. This article briefly summarizes some of the obesityrelated benefits of parks across the local, state, and national park systems and highlights specific initiatives as examples of the commitment by park agencies to benefit the public’s health and play a role in obesity and chronic disease prevention.

Objective To examine factors associated with water filter use (WFU) for drinking tap water at home and its association with consuming plain water and sugar-sweetened beverages (SSBs).Design Quantitative, cross-sectional study.Setting The 2018 SummerStyles survey data.Subjects U.S. adults (≥18 years; N=4042).Measures Outcomes were intake of plain water (tap/bottled water) and SSBs. Exposure was WFU (yes, no, not drinking tap water at home). Covariates included sociodemographics, weight status, Census regions, and home ownership status.Analysis We used multivariable logistic regressions to estimate adjusted odds ratios (AOR) and 95% confidence interval (CI) for consuming tap water, bottled water, or total plain water >3 cups/day (vs. ≤3 cups) and SSBs ≥1 time/day (vs. <1 time) by WFU.Results Overall, 36% of adults reported using a filter for drinking tap water at home; 14% did not drink tap water at home. Hispanics had significantly higher odds of using a water filter (AOR=1.50, 95% CI=1.14-1.98) vs non-Hispanic White. Factors significantly associated with lower odds of WFU were lower education (AOR=.69, 95% CI=.55-.86 for ≤high school; AOR=.78, 95% CI=.64-.95 for some college, vs college graduate), not being married (AOR=.81, 95% CI=.66-.98, vs married/domestic partnership), and lower household income (AOR=.68, 95% CI=.68-.90 for <$35,000, vs ≥$100,000). Using a water filter was associated with higher odds of drinking >3 cups/day of tap water (AOR=1.33, 95% CI=1.13-1.56) and lower odds of SSBs ≥1 time/day (AOR=.76, 95% CI=.62-.92). Not drinking tap water at home was associated with higher odds of drinking >3 cups/day bottled water (AOR=3.46, 95% CI=2.70-4.44).Conclusions WFU was associated with higher tap water intake and lower SSB intake among U.S. adults. WFU was higher among Hispanics, but lower among those with lower education and income and not married adults. Although WFU was associated with healthful beverage habits, additional considerations for WFU may include source water quality, oral health, cost, and proper use.

Background:Infants and young children with high weight-for-length are at increased risk for obesity in later life. This study describes prevalence of high weight-for-length and examines changes during 2010–2018 among 11,366,755 infants and young children 3–23 months of age in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).Methods:Children's weights and lengths were measured. High weight-for-length was defined as ≥2 standard deviations above sex and age-specific median on World Health Organization growth charts. Adjusted prevalence differences (APDs) between years were calculated as 100 times marginal effects from logistic regression models. APD was statistically significant if 95% confidence interval did not include 0.Results:Adjusted prevalence of high weight-for-length decreased from 2010 to 2014, and leveled off through 2018 overall, in boys and girls, those 6–11 and 18–23 months of age, and non-Hispanic whites, non-Hispanic blacks, Hispanics, and Asians/Pacific Islanders. For 12–17 months old and American Indian/Alaska Native infants and young children, adjusted prevalence decreased from 2010 to 2014, and then increased slightly through 2018. Among 56 WIC state or territorial agencies, 33 had significant decreases between 2010 and 2018, whereas 8 had significant increases. Between 2014 and 2018, prevalence decreased significantly in 12 agencies and increased significantly in 23.Conclusions:The results indicate overall declines in prevalence of high weight-for-length from 2010 to 2018, with a prevalence stabilization since 2014. Continued surveillance is needed. Obesity prevention strategies in WIC and multiple settings are important for ensuring healthy child growth.

Added sugars intake increases risk of obesity, hypertension, dyslipidemia, and cardiovascular diseases (CVD) and may impact disease management. We examined factors related to added sugars intake among US adults with or without CVD and risk factors using 2015 National Health Interview Survey (NHIS) (n=30616). NHIS used the National Cancer Institute (NCI) Dietary Screener Questionnaire (DSQ) to assess individual’s dietary intake. The DSQ used 8 questions to assess added sugar intake over the last 30 days. We used the NCI’s scoring algorithm to convert screener responses to estimate total added sugars intake (tsp/day) by characteristics within 3 strata—adults with a history of heart disease/stroke (CVD, n=4658), adults with hypertension/high cholesterol but without CVD (HTHC, n=10476), and adults without CVD or HTHC (no CVD, n=15482). Because our goal was not to look at association between added sugar and CVD risk, comparisons among the groups were not made. Characteristics included age, sex, race/ethnicity, education, income, marital status, smoking, and weight status. We used multiple linear regression to assess independent associations between intake and characteristics. Added sugars intake was similar in magnitude across all 3 strata (CVD 16.9, HTHC 17.0, and no CVD 17.3 tsp, respectively). We found increased added sugars intake with younger age, lower education, lower income, and smoking among adults regardless of CVD status. Having obesity was positively related to increased intake for adults without CVD, but no association was found between the weight status and intake in adults with CVD or HTHC. Improving diet may prevent CVD and aid disease self-management. Product reformulation to reduce added sugars and strategies to counsel and support individuals to reduce dietary added sugars may be needed to optimize heart health.