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At the start of the COVID-19 pandemic in the US, 42.5% of adults and 18.5% of children had obesity1,2 and less than 50% of the population met physical activity recommendations.3 Emerging evidence indicates that physical activity declined during the pandemic, likely due in part to school closures and restricted access to common indoor and outdoor places where people are active. Public health interventions are urgently needed to promote an active lifestyle and engagement in physical activity to mitigate the physical and mental adverse impact of COVID-19. 4 The association between obesity and the increased risk of COVID-19 infections, hospitalizations, intensive care unit admissions and death is unequivocal.5,6 Furthermore, obesity increases the risk of intubation and death in patients less than 65 years old infected with COVID-19, independent of diabetes and hypertension.

Solving Population-wide Obesity The global obesity rate has tripled since the mid-1970s. Major investments have been made in this area, and there have been some legislative and regulatory successes...

Few health crises have been as predictable as the unfolding obesity pandemic. Clinical and public health services remain the front line of efforts to reduce the burden of obesity. While a range of clinical practice guidelines exist, the need for clinical interventions exceeds the capacity of health systems to provide care for those affected with obesity, and routine clinical practices fall far short of guidelines recommendations even in high-income countries. In this manuscript, we discuss current recommendations regarding obesity interventions and key challenges facing global health systems in managing the health needs of people with obesity. Improving the provision of obesity-related health care is a considerable challenge and will require changing existing perceptions of obesity as a matter of personal failure to its recognition as a disease, innovative approaches to health system reform, clinician capacity building and implementation support, a focus on prevention, and wise resource allocation. Leadership from governments, the medical profession, and patient and community groups to address the issues raised in this manuscript is urgently needed to address the growing health concern.

Objective The aim of this work is to develop a practical, tangible, measurable, and simple standard of care for the treatment of adult obesity that provides guidance for both clinical providers and community settings. Methods Three roundtables with relevant stakeholder groups were convened by the STOP Obesity Alliance at The George Washington University to develop the proposed standard of care. Results The proposed standard of care for adult obesity treatment proposes practices for the spectrum of clinical, community, and digitally based entities and for clinical providers. Coverage and payment policy standards are also provided. Conclusions These standards are intended to augment published guidelines developed for obesity care providers and can also be viewed as the first step to define an optimal benefit package.

Summary Introduction This report presents a synopsis of a three‐part, cross‐sector, seminar series held at the George Washington University (GWU) in Washington, DC from February–April, 2018. The overarching goal of the seminar series was to provide a neutral forum for diverse stakeholders to discuss and critically evaluate approaches to address added sugar intake, with a key focus on the role of low‐calorie sweeteners (LCS). Methods During three seminars, twelve speakers from academic institutions, federal agencies, non‐profit organizations, and the food and beverage industries participated in six interactive panel discussions to address: 1) Do Farm Bill Policies Impact Population Sugar Intake? 2) What is the Impact of Sugar‐sweetened Beverage (SSB) Taxes on Health and Business? 3) Is Sugar Addictive? 4) Product Reformulation Efforts: Progress, Challenges, and Concerns? 5) Low‐calorie Sweeteners: Helpful or Harmful, and 6) Are Novel Sweeteners a Plausible Solution? Discussion of each topic involved brief 15‐minute presentations from the speakers, which were followed by a 25‐minute panel discussion moderated by GWU faculty members and addressed questions generated by the audience. Sessions were designed to represent opposing views and stimulate meaningful debate. Given the provocative nature of the seminar series, attendee questions were gathered anonymously using Pigeonhole™, an interactive, online, question and answer platform. Results This report summarizes each presentation and recapitulates key perspectives offered by the speakers and moderators. Conclusions The seminar series set the foundation for robust cross‐sector dialogue necessary to inform meaningful future research, and ultimately, effective policies for lowering added sugar intakes.

Background Sugary drinks (SDs) are key contributors to excess added sugar intake and the predominant source of caffeine among children. Chronic caffeine intake causes dependence, and evidence for sugar dependence is emerging. Development of withdrawal symptoms may pose an obstacle to SD cessation among children. We examined the feasibility and acceptability of a three-arm randomized controlled trial (RCT) designed to investigate withdrawal symptoms resulting from replacement of children's usual caffeinated SD intake with either caffeine-free alternatives or caffeine-free and sugar-free alternatives, compared with continued consumption of caffeinated SDs. Methods Twenty-nine children 8–12 years old, who consumed ≥12 ounces caffeinated SDs daily, enrolled. The two-week RCT required three in-person meetings and daily completion of electronic questionnaires to assess withdrawal symptoms and intervention adherence. Children were randomized to replace their usual caffeinated SD consumption with 1) caffeine-free alternatives, 2) caffeine-free and sugar-free alternatives, or 3) caffeinated SDs (control), provided by the study team. Feasibility and acceptability were assessed quantitatively and qualitatively. Results Twenty-eight participants (97%) completed the study. Adherence was high, with 73% reporting compliance with beverage assignments, and 76% completing all questionnaires. In qualitative interviews at follow-up, children described feelings of importance and commitment, and parents did not find the procedures to be overly burdensome. While challenges to adherence were reported (e.g., child wanting other SDs, time commitment), participants described innovative strategies (e.g., designating a place for study drinks in the refrigerator) to maintain adherence. Conclusion Results indicated high levels of RCT feasibility and acceptability. The reported barriers and strategies for adherence will inform modifications required to design a larger and longer-term trial investigating withdrawal symptoms after SD cessation in children.

* Abbreviations: HEI 2010 — : Healthy Eating Index 2010 HHFKA — : Healthy, Hunger-Free Kids Act WIC — : Special Supplemental Nutrition Program for Women, Infants, and Children The reductions in the prevalence of childhood obesity achieved by the Healthy, Hunger-Free Kids Act (HHFKA) and the changes in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package have not been widely recognized. Both the HHFKA and the regulatory updates to the WIC package substantially changed the quality of the foods provided. Both changes improved diets and led to reductions in the prevalence of obesity in the most vulnerable youth served by these programs. The HHFKA was passed by Congress in 2010, and its implementation was required in schools by 2012. In the Act, Congress set age-appropriate caloric ranges, required that at least 51% of grains be whole grains, required students to take at least one-half cup serving of fruits or vegetables with every school breakfast or lunch, and required that schools offer 1 cup of flavored or unflavored fat-free milk or 1% milk. Despite concerns, the changes were not associated with an increase in plate waste.1 In several studies, researchers have confirmed an increase in the quality of school meals and in improved consumption. For example, dietary quality was assessed before and after implementation of the new HHFKA standards by using the Healthy Eating Index 2010 (HEI 2010) and food consumption data from the nationally representative NHANES.2 The HEI 2010 score reflected the degree to which dietary intake was consistent with the 2010 Dietary Guidelines for Americans. The HEI 2010 scores among students aged 5 to 18 years were stratified by low-income, low-middle–income, and middle-high–income students and compared to those among non–school lunch participants in the same income categories. The HEI 2010 scores increased from 42.7 to 54.6 among school lunch participants compared to a decrease from 34.8 to 34.1 among nonparticipants. The differences in comparison with non–school lunch participants were 12.6, … Address correspondence to William H. Dietz, MD, PhD, Sumner M. Redstone Global Center for Prevention and Wellness, Milken Institute School of Public Health, The George Washington University, 214 11th St NE, Washington, DC 20002. E-mail: dietzwcd4{at}gmail.com

Obesity is a chronic relapsing condition affecting a rapidly increasing number of people worldwide. The United Nations has stated that universal health coverage is an essential element of the globally-agreed sustainable development goals. This article provides a preliminary report of a survey of relevant health professionals and other interest groups on the readiness of health systems to provide obesity treatment services. Interviews and questionnaires were completed by 274 respondents from a total of 68 low, middle and high income countries. Respondents in the majority of countries stated that there were professional guidelines for obesity treatment, but that there was a lack of adequate services, especially in lower income countries, and in rural areas of most countries. Lack of treatment was attributed to a broad range of issues including: no clear care pathways from primary care to secondary services; absent or limited secondary services in some regions; lack of trained multi-disciplinary support professionals; potentially high costs to patients; long waiting times for surgery; and stigma experienced by patients within the health care services. Defining obesity as a disease may help to overcome stigma and may also help to secure better funding streams for treatment services. However, the survey found that few countries were ready to accept this definition. Furthermore, until countries fully adopt and implement obesity prevention policies the need for treatment will continue to rise while the necessary conditions for treatment will remain inadequate.

Objective This study examined changes in coverage for adult obesity treatment services in Medicaid and state employee health insurance programs between 2009 and 2017. Methods Administrative materials from Medicaid and state employee health insurance programs in all 50 states and the District of Columbia were reviewed for indications of coverage and payment policies specific to evidence-based treatment modalities for adults (≥ 21 years of age) with obesity, including nutritional counseling, pharmacotherapy, and bariatric surgery. Results From 2009 to 2017, the proportion of state employee programs indicating coverage increased by 75% for nutritional counseling (from 24 to 42 states), 64% for pharmacotherapy (from 14 to 23 states), and 23% for bariatric surgery (from 35 to 43 states). The proportion of Medicaid programs indicating coverage increased by 133% for nutritional counseling (from 9 to 21 states) and 9% for bariatric surgery (from 45 to 49 states), with no net increase for pharmacotherapy (16 states in both plan years). Conclusions Coverage for adult obesity care improved substantially in Medicaid and state employee insurance programs since 2009. However, recommended treatment modalities are still not covered in many states. Where coverage has expanded, educating providers and beneficiaries on the availability and proper use of evidence-based obesity treatments may improve health outcomes.

Background The prevalence of obesity and type 2 diabetes continues to increase. These conditions disproportionately affect minorities and are associated with poor nutrition early in life. Current food-consumption patterns can inform pending dietary guidelines for infants and toddlers. Objective The aim of this study was to describe infant feeding, complementary feeding, and food and beverage consumption patterns of 0- to 23.9-mo-olds in the general population. Methods The Feeding Infants and Toddlers Study 2016 is a cross-sectional survey of caregivers of children aged 400 food groups was calculated. Differences in the percentage consuming between Hispanic, non-Hispanic white, and non-Hispanic black children aged 0–23.9 mo were evaluated with the use of ORs and 95% CIs. Results Eighty-three percent of 0- to 23.9-mo-olds (n = 2635) were ever breastfed, 34% of 0- to 3.9-mo-olds (n = 305) and 15% of 4- to 5.9-mo-olds (n = 295) were exclusively breastfed, and 24% of 12- to 14.9-mo-olds (n = 412) consumed breast milk on the day of the recall. Complementary foods were more likely to be introduced before 4 mo in formula-fed infants (27%) than in infants who did not consume formula (5%). Half of 4- to 5.9-mo-olds consumed iron-fortified infant cereal, but few consumed iron-rich meats. Among toddlers (12–23.9 mo; n = 1133), >20% consumed no servings of fruit or vegetables on the day of the recall, approximately half consumed 100% fruit juice, and one-quarter to one-third consumed a sugar-sweetened beverage (SSB). Conclusions Breastfeeding initiation and duration have improved, but exclusivity remains low. Low consumption of iron-rich foods, fruit, and vegetables and lack of variety in vegetable consumption are problems. Efforts to reduce the consumption of SSBs and 100% fruit juice are warranted in early childhood.

Objective The objective of this study was to assess health care professionals' knowledge of evidence-based guidelines for the nonsurgical treatment of obesity. Methods A nationally representative sample of internists, family practitioners, obstetricians/gynecologists, and nurse practitioners completed a web-based survey between June 9 and July 1, 2016 (n = 1,506). Results Only 16% of respondents indicated that obesity counseling should be provided approximately twice monthly in an individual or group setting for at least 6 months, in accordance with United States Preventive Services Task Force and Centers for Medicare and Medicaid Services guidelines. Only 15% of respondents identified BMI ≥ 27 kg/m2 with an obesity-associated comorbid condition as the appropriate indication to prescribe pharmacotherapy for patients. Two-thirds of respondents indicated that it is appropriate to continue long-term pharmacotherapy under conditions inconsistent with evidence-based guidelines, with nearly one-quarter indicating that obesity medications should never be prescribed beyond 3 months regardless of weight loss. Conclusions These findings suggest that provider understanding of appropriate clinical care for obesity is inconsistent with evidence-based recommendations. As coverage for behavioral counseling services and pharmacotherapy expands, it is imperative that health care professionals understand how to effectively leverage these treatment modalities to optimize health outcomes for patients with obesity.

The prevalence of obesity, measured by body mass index, has risen to unacceptable levels in both men and women in the United States and worldwide with resultant hazardous health implications. Genetic, environmental, and behavioral factors influence the development of obesity, and both the general public and health professionals stigmatize those who suffer from the disease. Obesity is associated with and contributes to a shortened life span, type 2 diabetes mellitus, cardiovascular disease, some cancers, kidney disease, obstructive sleep apnea, gout, osteoarthritis, and hepatobiliary disease, among others. Weight loss reduces all of these diseases in a dose-related manner—the more weight lost, the better the outcome. The phenotype of “medically healthy obesity” appears to be a transient state that progresses over time to an unhealthy phenotype, especially in children and adolescents. Weight loss is best achieved by reducing energy intake and increasing energy expenditure. Programs that are effective for weight loss include peer-reviewed and approved lifestyle modification programs, diets, commercial weight-loss programs, exercise programs, medications, and surgery. Over-the-counter herbal preparations that some patients use to treat obesity have limited, if any, data documenting their efficacy or safety, and there are few regulatory requirements. Weight regain is expected in all patients, especially when treatment is discontinued. When making treatment decisions, clinicians should consider body fat distribution and individual health risks in addition to body mass index.

Mounting evidence suggests that weight management and physical activity (PA) improve overall health and well being, and reduce the risk of morbidity and mortality among cancer survivors. Although many opportunities exist to include weight management and PA in routine cancer care, several barriers remain. This review summarizes key topics addressed in a recent National Academies of Science, Engineering, and Medicine workshop entitled, "Incorporating Weight Management and Physical Activity Throughout the Cancer Care Continuum." Discussions related to body weight and PA among cancer survivors included: 1) current knowledge and gaps related to health outcomes; 2) effective intervention approaches; 3) addressing the needs of diverse populations of cancer survivors; 4) opportunities and challenges of workforce, care coordination, and technologies for program implementation; 5) models of care; and 6) program coverage. While more discoveries are still needed for the provision of optimal weight-management and PA programs for cancer survivors, obesity and inactivity currently jeopardize their overall health and quality of life. Actionable future directions are presented for research; practice and policy changes required to assure the availability of effective, affordable, and feasible weight management; and PA services for all cancer survivors as a part of their routine cancer care. CA Cancer J Clin 2018;68:64-89. © 2017 American Cancer Society.

Objective We propose a transformative approach to foster collaboration across child health, public health, and community-based agencies to address the root causes of toxic stress and childhood adversity and to build community resilience. Methods Physicians, members of social service agencies, and experts in toxic stress and adverse childhood experiences (ACEs) were interviewed to inform development of the Building Community Resilience (BCR) model. Through a series of key informant interviews and focus groups, we sought to understand the role of BCR for child health systems and their partners to reduce toxic stress and build community resilience to improve child health outcomes. Results Key informants indicated the intentional approach to ACEs and toxic stress through continuous quality improvement (data-driven decisions and program development, partners testing and adapting to changes to their needs, and iterative development and testing) which provides a mechanism by which social determinants or a population health approach could be introduced to physicians and community partners as part of a larger effort to build community resilience. Structured interviews also reveal a need for a framework that provides guidance, structure, and support for child health systems and community partners to develop collective goals, shared work plans, and a means for data-sharing to reinforce the components that will contribute to community resilience. Conclusions Key informant interviews and focus group dialogues revealed a deep understanding of the factors related to toxic stress and ACEs. Respondents endorsed the BCR approach as a means to explore capacity issues, reduce fragmented health care delivery, and facilitate integrated systems across partners in efforts to build community resilience. Current financing models are seen as a potential barrier, because they often do not support restructured roles, partnership development, and the work to sustain upstream efforts to address toxic stress and community resilience.

Summary Introduction Relatively few patients receive obesity counselling consistent with the USPSTF guidelines, and many health care professionals (HCPs) are biased in their attitudes towards obesity management. Methods A national sample of family physicians, internists, OB/GYN physicians, and nurse practitioners (NPs) completed a web-based survey of beliefs, practice, and knowledge regarding obesity management. Results A majority of HCPs believe that it is both the patient’s and the provider’s responsibility to ensure that the patient is counselled about obesity. Obesity (77%), obesity-related diseases (79%), or obesity-related risk factors (71%) prompt HCPs to offer obesity counselling; 59% of HCPs wait for the patient to broach the subject of their weight. Increased blood pressure (89%) and heart disease risks (90%) are the most common themes in counselling. Across all HCPs except NPs “exercise” is discussed more frequently than “physical activity” (85% vs 81%), “diet” more frequently than “eating habits” (77% vs 75%), and “obesity” more frequently than “unhealthy weight” (60% vs 45%). NPs are more likely to discuss physical activity, eating habits, and unhealthy weight instead. To improve counselling for obesity, HCPs reported needing more time (70%), training in obesity management (53%), improved reimbursement (53%), and better tools to help patients recognise obesity risks (50%). Obesity-related diseases, risk factors, or obesity alone predict obesity counselling amongst HCPs. Conclusion Better training in weight management and tools to help patients recognise risks appear to be key elements in helping patients compare the risks of what they may consider invasive therapy against the risks of continued obesity.

Purpose of Review This review provides background on the formation of the Partnership for a Healthier America (PHA), that was created in conjunction with the Let’s Move! initiative, and an overview of its work to date. Recent Findings To encourage industry to offer and promote healthier options, PHA partners with the private sector. Principles that guide PHA partnerships include ensuring that partnerships represent meaningful change, partners sign a legally binding contract and progress is monitored and publicly reported. Summary Since 2010, PHA has established private sector partnerships in an effort to transform the marketplace to ensure that every child has the chance to grow up at a healthy weight. Many agreements between PHA and its industry partners align with the White House Task Force Report on Childhood Obesity. The reach and impact of over 200 partnerships attest to the success of this initiative.

Background. Despite evidence that social network members influence the eating behaviors of adults, no study to date has had the primary aim of examining children as support partners for parents in a weight loss intervention. Aim. To evaluate parent adherence with eating/exercise goals and weight loss in a 6-month study engaging children as support partners. Method. Adults with obesity (body mass index ≥ 30 kg/m2, n = 102) and at least one child ≥12 years were randomized to a child support or control group. In the child support group, children enrolled with their parent and engaged in a supportive behavior 2 days/week. In the control group, there was no enrolled child support. Parents in both groups selected a healthy eating strategy and daily step goal. Results. There was no difference in weight loss between the child support and control groups (−5.97 vs. −5.42 lbs, p = .81). In the child support group, 30% of children did not engage in the study. The majority of parents whose children did not engage withdrew from the study. In secondary analyses, parent adherence with eating/exercise goals increased with the days of child support ( p < .001). For all participants, low chaos in the home environment ( p < .04) and increased parent adherence with follow-ups ( p < .008) predicted weight loss. Conclusions. We found no treatment effect of child support on weight loss. Active child support of eating/exercise goals appeared to facilitate goal adherence, while anticipated but unrealized child support may have had iatrogenic consequences. Further investigation of family-focused weight loss interventions is warranted.

Excess consumption of added sugars, especially from sugary drinks, poses a grave health threat to children and adolescents, disproportionately affecting children of minority and low-income communities. Public policies, such as those detailed in this statement, are needed to decrease child and adolescent consumption of added sugars and improve health.

* Abbreviations: COPTR — : Childhood Obesity Prevention and Treatment Research Consortium CPP — : community policy and program CPP-Strat — : community policy and program created to assess either nutrition or physical activity strategy GEMS — : Girls’ Health Enrichment Multi-site Studies HCS — : Healthy Communities Study In the last 2 decades, the National Institutes of Health invested in 2 major multicenter trials aimed at the prevention of obesity in high-risk populations of low-income Hispanic and African American children.1 The trials were the Childhood Obesity Prevention and Treatment Research Consortium (COPTR) and the Girls’ Health Enrichment Multi-site Studies (GEMS). Despite intensive, state-of-the-art, and often creative interventions conducted by seasoned investigators, all 5 of the studies considered below failed to alter the trajectory of weight gain in their participants compared with controls. In this issue of Pediatrics , Moore et al2 describe the most recent of the COPTR studies. This study, conducted in Cleveland, Ohio, is 1 of 4 randomized controlled intervention trials, 2 of which have already been published. In this trial, 360 predominantly African American middle school children (mean age 11.6 years) and their parents were randomly assigned to a HealthyChange intervention, which relied on cognitive behavioral and motivational interviewing strategies that focused on goal setting, problem solving, self-monitoring, and relapse prevention. The control group was a SystemChange intervention that sought to establish family routines, restructured to develop new healthy habits. Both interventions focused on improving diet, physical activity, sleep and stress management, and reducing sedentary behavior. Both interventions included intensive engagement through 25 small-group sessions in the first year, alternating face-to-face and individualized phone sessions in year 2, and 4 face-to-face sessions and 8 individualized phone sessions in year 3. At the end of the 3-year intervention, 90% of enrolled participants remained in the study. No significant differences were observed in annual changes of BMI, waist circumference, or triceps skinfold thickness. Furthermore, no significant differences were observed in diet, physical activity measured by accelerometry, sleep, perceived stress, or cardiometabolic factors. In 2 other COPTR studies that included randomized intensive obesity interventions in low-income, … Address correspondence to William H. Dietz, MD, PhD, Sumner M. Redstone Global Center for Prevention and Wellness, Milken Institute School of Public Health, George Washington University, Room 319, 950 New Hampshire Ave NW, Washington, DC 20052. E-mail: bdietz{at}email.gwu.edu

Objective To improve systems of care to advance implementation of the U.S. Preventive Services Task Force recommendations for childhood obesity treatment (i.e., clinicians offer/refer children with obesity to intensive, multicomponent behavioral interventions of >25 h over 6 to 12 months to improve weight status) and to expand payment for these services. Methods In July 2015, 43 cross-sector stakeholders attended a conference supported by the Agency for Healthcare Research and Quality, American Academy of Pediatrics Institute for Healthy Childhood Weight, and The Obesity Society. Plenary sessions presenting scientific evidence and clinical and payment practices were interspersed with breakout sessions to identify consensus recommendations. Results Consensus recommendations for childhood obesity treatment included: family-based multicomponent behavioral therapy; integrated care model; and multidisciplinary care team. The use of evidence-based protocols, a well-trained healthcare team, medical oversight, and treatment at or above the minimum dose (e.g., >25 h) are critical components to ensure effective delivery of high-quality care and to achieve clinically meaningful weight loss. Approaches to secure reimbursement for evidence-based obesity treatment within payment models were recommended. Conclusions Continued cross-sector collaboration is crucial to ensure a unified approach to increase payment and access for childhood obesity treatment and to scale up training to ensure quality of care.

Interventions for obesity have not often been based on considerations that could predict their effectiveness. However, advances in research provide several new approaches that can inform priorities for public health interventions directed at nutrition, physical activity, and obesity. These approaches include estimation of the effect size, comparison of the calorie gap with the caloric deficit induced by the intervention, population reach and impact, cost and cost effectiveness of the intervention, time required to evaluate the effect of the intervention on weight change, and feasibility of the intervention. Incorporation of these considerations by policymakers and public health practitioners will help identify those interventions most likely to achieve changes in the prevalence of obesity.

Summary Introduction Rates of obesity pharmacotherapy use, bariatric surgery and intensive behavioural counselling have been extremely low. Objectives The primary objective of this study was to survey healthcare provider beliefs, practice and knowledge regarding obesity management. Methods Primary care physicians (PCPs), OB-GYN physicians and nurse practitioners (NPs) responded to a web-based survey related to drug therapy practice, bariatric surgery referral and reimbursement coding practice. Results Rates of reported use of obesity pharmacotherapy appear to be increasing among PCPs, which is likely related to the approval of four new obesity pharmacotherapy agents since 2012. Rates of pharmacotherapy use among OB-GYNs and NPs appear much lower. Similarly, few PCPs are averse to recommending bariatric surgery, but aversion among OB-GYNs and NPs is significantly higher. Conclusion Together, these observations suggest that OB-GYN and NP populations are important targets for education about obesity management. Very few PCPs, OB-GYNs or NPs use behavioural counselling coding for obesity. Better understanding of why this benefit is not being fully used could inform outreach to improve counselling rates.

Improved patient experience, population health, and reduced cost of care for patients with obesity and other chronic diseases will not be achieved by clinical interventions alone. We offer here a new iteration of the Chronic Care Model that integrates clinical and community systems to address chronic diseases. Obesity contributes substantially to cardiovascular disease, type 2 diabetes mellitus, and cancer. Dietary and physical activity interventions will prevent, mitigate, and treat obesity and its related diseases. Challenges with the implementation of this model include provider training, the need to provide incentives for health systems to move beyond clinical care to link with community systems, and addressing the multiple elements necessary for integration within clinical care and with social systems. The Affordable Care Act, with its emphasis on prevention and new systems for care delivery, provides support for innovative strategies such as those proposed here.

Summary Although the caloric deficits achieved by increased awareness, policy, and environmental approaches have begun to achieve reductions in the prevalence of obesity in some countries, these approaches are insufficient to achieve weight loss in patients with severe obesity. Because the prevalence of obesity poses an enormous clinical burden, innovative treatment and care-delivery strategies are needed. Nonetheless, health professionals are poorly prepared to address obesity. In addition to biases and unfounded assumptions about patients with obesity, absence of training in behaviour-change strategies and scarce experience working within interprofessional teams impairs care of patients with obesity. Modalities available for the treatment of adult obesity include clinical counselling focused on diet, physical activity, and behaviour change, pharmacotherapy, and bariatric surgery. Few options, few published reports of treatment, and no large randomised trials are available for paediatric patients. Improved care for patients with obesity will need alignment of the intensity of therapy with the severity of disease and integration of therapy with environmental changes that reinforce clinical strategies. New treatment strategies, such as the use of technology and innovative means of health-care delivery that rely on health professionals other than physicians, represent promising options, particularly for patients with overweight and patients with mild to moderate obesity. The co-occurrence of undernutrition and obesity in low-income and middle-income countries poses unique challenges that might not be amenable to the same strategies as those that can be used in high-income countries.

Purpose: The U.S. Preventive Services Task Force (USPSTF) recommends an evidence-based approach to treating pediatric obesity, including obesity screening of all children over the age of 6 years and provision of or referral to a comprehensive, behavioral intervention of moderate to high intensity (> 26 contact hours within 6 months) for children with obesity. Yet the majority of U.S. children with obesity do not have access to these services. The purpose of this project was to advance the translation of the USPSTF recommendations to develop feasible, acceptable, effective, and sustainable …

* Abbreviations: ΔBMIp95 — : BMI minus BMI at the 95th percentile BMIp95 — : BMI as a percent of the 95th percentile BMIz — : BMI z score CDC — : Centers for Disease Control and Prevention The ideal measure of weight gain and loss should distinguish children and adolescents across the distribution of weight and height and should include the capacity for changes in weight adjusted for height over time. Over short intervals, in which there is little growth in height, absolute changes in weight or BMI provide suitable indicators of weight gain or loss. However, over longer intervals, during which height increases significantly, weight change must be adjusted for changes in height and age by sex. BMI, which is calculated as weight (in kg) divided by the square of height (in m2), adjusts body weight for height. Although the correlation of BMI with various measures of body fat percentage is modest across the distribution of BMI, the correlation of BMI with body fat improves at the upper part of the body fat distribution. Increases in BMI greater than the 95th percentile are associated with increases in body fat.1,2 In addition, BMI has benefits in feasibility, reliability, and measurement and clinical validity.3 Changes in BMI, BMI percentiles, or changes in BMI expressed as an SD score (BMI z score [BMIz]) provide a reasonably … Address correspondence to William H. Dietz, MD, PhD, George Washington University, Sumner M. Redstone Global Center for Prevention and Wellness, 950 New Hampshire Ave, NW, Washington, DC 20052. E-mail: dietzwcd4{at}gmail.com

This cohort analysis uses Nurses’ Health Study and Health Professionals Follow-Up Study data to examine the association between weight gain in early to middle adulthood and heart disease, cancer, and death later in life.

The FDA is considering changes to its Nutrition Facts label, but other labeling changes would help consumers select nutritious foods. One key concern is sugar- and calorie-related claims, especially with regard to nonnutritive sweeteners and product sweetness.

Two recent reports from the Centers for Disease Control and Prevention and reports from a number of states and municipalities suggest that we are making progress in the control of the obesity epidemic, particularly with respect to younger children. The 2 national surveys that have provided the most valid and reliable data are the National Health and Nutrition Examination Survey (NHANES) and the Pediatric Nutrition Surveillance System (PedNSS). NHANES has been conducted annually since 1999, and when data from each 2-year cycle are combined, NHANES provides a representative sample of the US population. A total sample of >3300 2- to 19-year-old children and adolescents were included in NHANES in 2011–2012; 871 of these children were 2 to 5 years old. The most recent NHANES report1 described a statistically significant absolute decrease of 5.5% in the prevalence of obesity among 2- to 5-year-olds between 2003–2004 and 2011–2012. Inspection of prevalence rates over time show that after a consistent increase which began after 1980, the prevalence of obesity in 2- to 5-year-old children began to plateau between 2003 and 2004 (Fig 1). Data between 2003–2004 and 2009–2010 showed no statistically significant change in childhood obesity rates, whereas a decrease of 3.7% occurred between 2009–2010 and 2011–2012 in 2- to 5-year old children. No significant changes were observed in the prevalence of obesity among children and adolescents in other age groups. Because of the small sample size, trends in ethnic groups other than non-Hispanic white subjects could not be reliably assessed. Furthermore, due to the relatively small sample … Address correspondence to William H. Dietz, MD, PhD, Redstone Global Center for Prevention and Wellness, Milken Institute School of Public Health, George Washington University, Washington, DC 20052. E-mail: dietzwcd4{at}gmail.com

SummaryWhat is already known about this subject Severe obesity prevalence in adults has close to doubled from the 1990s to 2010 and is expected to double again by 2030. Over 3 million reports of child maltreatment were received by child protective services in 2008. While clinic and population-based studies have found high rates of adult psychological distress among severely obese individuals, little is known about how the experience of abuse during childhood relates to the risk of severe obesity later in life. What this study adds Using data from a nationally representative, longitudinal study, we found that incidence rates and 13-year risk of developing severe obesity in adulthood varied by abuse type. We found significantly higher risk of incident severe obesity in non-minority females and males who experienced the combined occurrence of sexual and physical abuse during childhood, relative to individuals with no history of abuse. In addition to other social and emotional risks, exposure to sexual and physical abuse during childhood may increase risk of severe obesity later in life. Background Severe obesity has increased, yet childhood antecedents of adult severe obesity are not well understood. Objective Estimate adult-onset severe obesity risk in individuals with history of childhood physical and/or sexual abuse compared with those who did not report abuse. Methods Longitudinal analysis of participants from the US National Longitudinal Study of Adolescent Health (n = 10 774) wave II (1996; aged 12–22 years) followed through wave IV (2008–2009; aged 24–34 years). New cases of adult-onset severe obesity (body mass index [BMI] ≥ 40 kg/m2 using measured height and weight) in individuals followed over 13 years who were not severely obese during adolescence (BMI

Energy intake is a key determinant of weight.Our objective was to examine trends in energy intake in adults in the United States from 1971-1975 to 2009-2010.The study was a trend analysis of 9 national surveys in the United States that included data from 63,761 adults aged 20-74 y.Adjusted mean energy intake increased from 1955 kcal/d during 1971-1975 to 2269 kcal/d during 2003-2004 and then declined to 2195 kcal/d during 2009-2010 (P-linear trend0.001, P-nonlinear trend0.001). During the period from 1999-2000 to 2009-2010, no significant linear trend in energy intake was observed (P = 0.058), but a significant nonlinear trend was noted (P = 0.042), indicating a downward trend in energy intake. Significant decreases in energy intake from 1999-2000 to 2009-2010 were noted for participants aged 20-39 y, men, women, and participants with a BMI (in kg/m(2)) of 18.5 to25 and ≥30.After decades of increases, mean energy intake has decreased significantly since 2003-2004.

Background: The cutoffs from the Centers for Disease Control and Prevention (CDC) growth charts and from the Cooper Institute (FitnessGram) are widely used to identify children who have a high body mass index (BMI). Objective: We compared the abilities of these 2 systems to identify children who have adverse lipid concentrations and blood pressure measurements and the reliability (consistency) of each classification system over time (mean follow-up: 7 y). Design: A cross-sectional analysis based on data from 22,896 examinations of 5- to 17-y-olds was conducted. Principal components analyses were used to summarize levels of the 5 risk factors, and likelihood ratios and the κ statistic were used to compare the screening abilities of the 2 systems. Of these children, 3972 were included in longitudinal analyses. Results: There were marked differences in the prevalence of a high FitnessGram BMI by age, with the prevalence among boys increasing from 2.5% to 21% between the ages of 5 and 11 y. The identification of adverse risk factors by the 2 systems was only fair (κ = 0.25), but there was little difference in the abilities of the CDC and FitnessGram cutoffs to identify high-risk children. Longitudinal analyses, however, indicated that the agreement between initial and follow-up FitnessGram classifications was substantially lower than that based on CDC cutoffs (κ = 0.28 compared with 0.49). Conclusions: The FitnessGram and CDC cutoffs have similar abilities to identify high-risk children. However, a high FitnessGram BMI is difficult to interpret because the reliability over time is low, and the prevalence increases markedly with age.

OBJECTIVE:A 2008 report from the American Academy of Pediatrics recommended both population and individual approaches (including pharmacologic interventions) for adolescents who had low-density lipoprotein (LDL) cholesterol levels above various cutoff points (130, 160, and 190 mg/dL). However, the tracking and variability of these very high levels have not been investigated.METHODS:A total of 6827 subjects underwent multiple LDL cholesterol determinations in childhood and adulthood in the Bogalusa Heart Study. The total number of determinations was 26748, and the median interval between examinations was 3 years.RESULTS:Correlations between initial and subsequent LDL cholesterol levels ranged from r ∼ 0.8 for measurements made within the same year to r ∼ 0.5 for periods of ≥20 years. Most children who had very high LDL cholesterol levels, however, had substantially lower levels at the next examination. LDL cholesterol levels between 160 and 189 mg/dL (n = 201) decreased, on average, by 21 mg/dL at the next examination, whereas levels of ≥190 mg/dL (n = 44) decreased by 34 mg/dL. In contrast, the mean increase for LDL cholesterol levels of CONCLUSIONS:There can be large changes in extreme levels of LDL cholesterol because of regression to the mean, and practitioners should be aware that very high levels may decrease substantially in the absence of any intervention.

A robust discussion followed the presentation of each paper at the forum. In the sections below we have tried to capture the most salient points raised during the discussion. As a result, many of these points were not considered in the articles that comprise this supplement but are highly relevant to the screening, surveillance, and reporting of BMI. There was general agreement that BMI was a sound epidemiologic tool for the assessment of overweight and obesity in populations, as well as a useful clinical tool. Several limitations with respect to the use of BMI were raised or confirmed. These limitations included use of triceps skinfold measurements to further differentiate children at risk whose BMI was between the 85th and 95th percentiles, additional efforts to clarify BMI measurements beyond the 97th percentile, self- or parent-reported height and weight, and challenges with communication of the meaning of BMI to parents. As Freedman and Sherry1 indicated, the use of the triceps skinfold does not provide much useful additional information except for children between the 85th and 95th percentiles. In this group, an increased triceps skinfold helps distinguish children who are overweight but not overfat from children who are overweight because of increased body frame or muscle mass. Although 1 published article suggested use of the 99th percentile for the classification of severe obesity, extrapolation of BMI categories beyond the 97th percentile are based on few measurements and, therefore, should be done with caution. Efforts should be made to achieve a consensus on how to classify severely obese children. Several investigators emphasized the limitations of self- or parent-reported height and weight for calculating BMI. Himes2 indicated that the direction of biases in parental reports is uncertain. However, staff of the National Center for Health Statistics have noted that BMIs based on parent-reported … Address correspondence to William H. Dietz, MD, PhD, Centers for Disease Control and Prevention, Division of Nutrition, Physical Activity, and Obesity, 4770 Buford Hwy NE, Mailstop K-24, Atlanta, GA 30341-3717. E-mail: wcd4{at}cdc.gov

To calculate return-on-investment (ROI) from workplace obesity interventions, employers require information about costs saved by the intervention. This article presents a simulation model used to calculate ROI for workplace obesity interventions.We estimated annual savings in medical expenditures and absenteeism costs by amount of average weight loss for a nationally representative company. We also present several examples that use the model to evaluate the ROI for published workplace obesity interventions.Across all overweight and obese employees, 5% weight loss would result in a reduction in total annual costs (medical plus absenteeism) of $90 per person.The results suggest that low-cost policy or environmental change interventions in worksites may be more likely to be cost saving than high cost, individually targeted behavioral change interventions unless they result in substantial weight loss.

Background: Adverse levels of cardiovascular disease (CVD) risk factors are related to skinfold thicknesses and body mass index (BMI) among children, but the relative strengths of these associations are unknown. Objective: The objective was to determine whether the sum of the triceps and subscapular skinfold thicknesses (SF sum) is more strongly related to levels of 6 risk factors (triglycerides, LDL and HDL cholesterol, insulin, and systolic and diastolic blood pressure) than is BMI. Design: Cross-sectional analyses of schoolchildren examined in the Bogalusa Heart Study from 1981 to 1994 (n = 6866) were conducted. A risk factor summary index was derived by using principal components analysis. Results: After race, sex, study period, and age were controlled for, almost all comparisons indicated that BMI was more strongly related to risk factor levels than was the SF sum. Although the differences were generally small, many were statistically significant. Associations with the risk factor summary, for example, were r = 0.50 for BMI and r = 0.47 for SF sum (P < 0.001 for difference). Furthermore, an adverse risk factor summary was observed among 62% of the children with the highest (upper 5%) BMI levels but among only 54% of children with the highest SF sum levels. Conclusions: BMI is at least as accurate as SF sum in identifying children and adolescents who are at metabolic risk. Because of the training and errors associated with skinfold-thickness measurements, the advantages of BMI should be considered in the design and interpretation of clinical and epidemiologic studies.