Search

Objective: To quantify the potential population-wide costs, number of individuals reached, and impact on obesity of five effective interventions to reduce children's television viewing if implemented nationally. Study Design: Utilizing evidence from systematic reviews, the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES) microsimulation model estimated the cost, population reach, and impact on childhood obesity from 2020 to 2030 of five hypothetical policy strategies to reduce the negative impact of children's TV exposure: (1) eliminating the tax deductibility of food and beverage advertising; (2) targeting TV reduction during home visiting programs; (3) motivational interviewing to reduce home television time at Women, Infants, and Children (WIC) clinic visits; (4) adoption of a television-reduction curriculum in child care; and (5) limiting noneducational television in licensed child care settings. Results: Eliminating the tax deductibility of food advertising could reach the most children [106 million, 95% uncertainty interval (UI): 105–107 million], prevent the most cases of obesity (78,700, 95% UI: 30,200–130,000), and save more in health care costs than it costs to implement. Strategies targeting young children in child care and WIC also cost little to implement (between $0.19 and $32.73 per child reached), and, although reaching fewer children because of the restricted age range, were estimated to prevent between 25,500 (95% UI: 4600–59,300) and 35,400 (95% UI: 13,200–62,100) cases of obesity. Home visiting to reduce television viewing had high costs and a low reach. Conclusions: Interventions to reduce television exposure across a range of settings, if implemented widely, could help prevent childhood obesity in the population at relatively low cost.

Objective:Online grocery shopping could improve access to healthy food, but it may not be equally accessible to all populations – especially those at higher risk for food insecurity. The current study aimed to compare the socio-demographic characteristics of families who ordered groceries online v. those who only shopped in-store.Design:We analysed enrollment survey and 44 weeks of individually linked grocery transaction data. We used univariate χ2 and t-tests and logistic regression to assess differences in socio-demographic characteristics between households that only shopped in-store and those that shopped online with curbside pickup (online only or online and in-store).Setting:Two Maine supermarkets.Participants:863 parents or caregivers of children under 18 years old enrolled in two fruit and vegetable incentive trials.Results:Participants had a total of 32 757 transactions. In univariate assessments, online shoppers had higher incomes (P < 0 0001), were less likely to participate in Special Supplemental Nutrition Program for Women, Infants, and Children or Supplemental Nutrition Assistance Program (SNAP; P < 0 0001) and were more likely to be female (P = 0·04). Most online shoppers were 30–39 years old, and few were 50 years or older (P = 0·003). After controlling for age, gender, race/ethnicity, number of children, number of adults, income and SNAP participation, female primary shoppers (OR = 2·75, P = 0·003), number of children (OR = 1·27, P = 0·04) and income (OR = 3·91 for 186–300 % federal poverty line (FPL) and OR = 6·92 for >300 % FPL, P < 0·0001) were significantly associated with likelihood of shopping online.Conclusions:In the current study of Maine families, low-income shoppers were significantly less likely to utilise online grocery ordering with curbside pickup. Future studies could focus on elucidating barriers and developing strategies to improve access.

Although the national obesity epidemic has been well documented, less is known about obesity at the U.S. state level. Current estimates are based on body measures reported by persons themselves that underestimate the prevalence of obesity, especially severe obesity.We developed methods to correct for self-reporting bias and to estimate state-specific and demographic subgroup-specific trends and projections of the prevalence of categories of body-mass index (BMI). BMI data reported by 6,264,226 adults (18 years of age or older) who participated in the Behavioral Risk Factor Surveillance System Survey (1993-1994 and 1999-2016) were obtained and corrected for quantile-specific self-reporting bias with the use of measured data from 57,131 adults who participated in the National Health and Nutrition Examination Survey. We fitted multinomial regressions for each state and subgroup to estimate the prevalence of four BMI categories from 1990 through 2030: underweight or normal weight (BMI [the weight in kilograms divided by the square of the height in meters],25), overweight (25 to30), moderate obesity (30 to35), and severe obesity (≥35). We evaluated the accuracy of our approach using data from 1990 through 2010 to predict 2016 outcomes.The findings from our approach suggest with high predictive accuracy that by 2030 nearly 1 in 2 adults will have obesity (48.9%; 95% confidence interval [CI], 47.7 to 50.1), and the prevalence will be higher than 50% in 29 states and not below 35% in any state. Nearly 1 in 4 adults is projected to have severe obesity by 2030 (24.2%; 95% CI, 22.9 to 25.5), and the prevalence will be higher than 25% in 25 states. We predict that, nationally, severe obesity is likely to become the most common BMI category among women (27.6%; 95% CI, 26.1 to 29.2), non-Hispanic black adults (31.7%; 95% CI, 29.9 to 33.4), and low-income adults (31.7%; 95% CI, 30.2 to 33.2).Our analysis indicates that the prevalence of adult obesity and severe obesity will continue to increase nationwide, with large disparities across states and demographic subgroups. (Funded by the JPB Foundation.).

OBJECTIVES The objective was to evaluate if 2 pediatric weight management interventions delivered to Hispanic, low-income children (one in a health center the other in a Young Men’s Christian Association) were effective in reducing BMI. We hypothesized that they would be equally effective. METHODS A total 407 children aged 6 to 12 years with BMI ≥ 85th percentile receiving care at 2 health centers were randomly assigned to a healthy weight clinic (HWC) at the health center or to a modified Healthy Weight and Your Child (M-HWYC) intervention delivered in Young Men’s Christian Associations. A total of 4037 children served as the comparison group. We completed a noninferiority test comparing the M-HWYC with the HWC, which was supported if the bounds of the 90% confidence interval (CI) for the difference in percentage of the 95th percentile (%BMIp95) change did not contain what we considered a minimally clinically important difference, on the basis of previous data (0.87). Then, using linear mixed models, we assessed yearly changes in BMI among intervention participants compared with the comparison sites. RESULTS The mean difference in %BMIp95 between the M-HWYC and the HWC was 0.75 (90% CI: 0.07 to 1.43), which did not support noninferiority. Compared with the comparison sites, per year, children in the HWC had a −0.23 (95% CI: −0.36 to −0.10) decrease in BMI and a −1.03 (95% CI −1.61 to −0.45) %BMIp95 decrease. There was no BMI effect in the M-HWYC. CONCLUSIONS We were unable to establish noninferiority of the M-HWYC. The HWC improved BMI, offering an effective treatment of those disproportionately affected.

Alexandra Chung and colleagues call for governments to prioritise child obesity as they implement measures to recover from the pandemic

Background Estimates of health care costs associated with excess weight are needed to inform the development of cost-effective obesity prevention efforts. However, commonly used cost estimates are not sensitive to changes in weight across the entire body mass index (BMI) distribution as they are often based on discrete BMI categories. Methods We estimated continuous BMI-related health care expenditures using data from the Medical Expenditure Panel Survey (MEPS) 2011–2016 for 175,726 respondents. We adjusted BMI for self-report bias using data from the National Health and Nutrition Examination Survey (NHANES) 2011–2016, and controlled for potential confounding between BMI and medical expenditures using a two-part model. Costs are reported in $US 2019. Results We found a J-shaped curve of medical expenditures by BMI, with higher costs for females and the lowest expenditures occurring at a BMI of 20.5 for adult females and 23.5 for adult males. Over 30 units of BMI, each one-unit BMI increase was associated with an additional cost of $253 (95% CI $167-$347) per person. Among adults, obesity was associated with $1,861 (95% CI $1,656-$2,053) excess annual medical costs per person, accounting for $172.74 billion (95% CI $153.70-$190.61) of annual expenditures. Severe obesity was associated with excess costs of $3,097 (95% CI $2,777-$3,413) per adult. Among children, obesity was associated with $116 (95% CI $14-$201) excess costs per person and $1.32 billion (95% CI $0.16-$2.29) of medical spending, with severe obesity associated with $310 (95% CI $124-$474) excess costs per child. Conclusions Higher health care costs are associated with excess body weight across a broad range of ages and BMI levels, and are especially high for people with severe obesity. These findings highlight the importance of promoting a healthy weight for the entire population while also targeting efforts to prevent extreme weight gain over the life course.

Background There is a great need to identify implementation strategies to successfully scale-up public health interventions in order to achieve their intended population impact. The Out-of-school Nutrition and Physical Activity group-randomized trial previously demonstrated improvements in children’s vigorous physical activity and the healthfulness of foods and beverages consumed. This implementation study aimed to assess the effects and costs of two training models to scale-up this evidence-based intervention. Methods A 3-arm group-randomized trial was conducted to compare effectiveness of in-person and online training models for scaling up the intervention compared to controls. One-third of sites were randomized to the in-person train-the-trainer model: local YMCA facilitators attended a training session and then conducted three learning collaborative meetings and technical assistance. One-third were assigned to the online model, consisting of self-paced monthly learning modules, videos, quizzes, and facilitated discussion boards. Remaining sites served as controls. Fifty-three afterschool sites from three YMCA Associations in different regions of the country completed baseline and follow-up observations using a validated tool of afterschool nutrition and physical activity practices. We used multivariable regression models, accounting for clustering of observations, to assess intervention effects on an aggregate afterschool practice primary outcome, and conducted secondary analyses of nine intervention goals (e.g. serving water). Cost data were collected to determine the resources to implement each training model. Results Changes in the primary outcome indicate that, on average, sites in the in-person arm achieved 0.44 additional goals compared to controls (95%CI 0.02, 0.86, p = 0.04). Increases in the number of additional goals achieved in sites in the online arm were not significantly greater than control sites (+ 0.28, 95% CI -0.18, 0.73, p = 0.24). Goal-specific improvements were observed for increasing water offered in the in-person arm and fruits and vegetables offered in the online arm. The cost per person trained was $678 for the in-person training model and $336 for the on-line training model. Conclusions This pilot trial presents promising findings on implementation strategies for scale-up. It validated the in-person training model as an effective approach. The less expensive online training may be a useful option for geographically disbursed sites where in-person training is challenging. Trial registration Although this study does not report the results of a health care intervention on human subjects, it is a randomized trial and was therefore retrospectively registered in ClinicalTrials.gov on July 4, 2019 in accordance with the BMC guidelines to ensure the complete publication of all results (NCT04009304).

Although the current obesity epidemic has been well documented in children and adults, less is known about long-term risks of adult obesity for a given child at his or her present age and weight. We developed a simulation model to estimate the risk of adult obesity at the age of 35 years for the current population of children in the United States.We pooled height and weight data from five nationally representative longitudinal studies totaling 176,720 observations from 41,567 children and adults. We simulated growth trajectories across the life course and adjusted for secular trends. We created 1000 virtual populations of 1 million children through the age of 19 years that were representative of the 2016 population of the United States and projected their trajectories in height and weight up to the age of 35 years. Severe obesity was defined as a body-mass index (BMI, the weight in kilograms divided by the square of the height in meters) of 35 or higher in adults and 120% or more of the 95th percentile in children.Given the current level of childhood obesity, the models predicted that a majority of today's children (57.3%; 95% uncertainly interval [UI], 55.2 to 60.0) will be obese at the age of 35 years, and roughly half of the projected prevalence will occur during childhood. Our simulations indicated that the relative risk of adult obesity increased with age and BMI, from 1.17 (95% UI, 1.09 to 1.29) for overweight 2-year-olds to 3.10 (95% UI, 2.43 to 3.65) for 19-year-olds with severe obesity. For children with severe obesity, the chance they will no longer be obese at the age of 35 years fell from 21.0% (95% UI, 7.3 to 47.3) at the age of 2 years to 6.1% (95% UI, 2.1 to 9.9) at the age of 19 years.On the basis of our simulation models, childhood obesity and overweight will continue to be a major health problem in the United States. Early development of obesity predicted obesity in adulthood, especially for children who were severely obese. (Funded by the JPB Foundation and others.).

Objective To quantify the relationships between youth use of television (TV) and other screen devices, including smartphones and tablets, and obesity risk factors. Study design TV and other screen device use, including smartphones, tablets, computers, and/or videogames, was self-reported by a nationally representative, cross-sectional sample of 24 800 US high school students (2013-2015 Youth Risk Behavior Surveys). Students also reported on health behaviors including sugar-sweetened beverage (SSB) intake, physical activity, sleep, and weight and height. Sex-stratified logistic regression models, adjusting for the sampling design, estimated associations between TV and other screen device use and SSB intake, physical activity, sleep, and obesity. Results Approximately 20% of participants used other screen devices for ≥5 hours daily. Watching TV ≥5 hours daily was associated with daily SSB consumption (aOR = 2.72, 95% CI: 2.23, 3.32) and obesity (aOR = 1.78, 95% CI: 1.40, 2.27). Using other screen devices ≥5 hours daily was associated with daily SSB consumption (aOR = 1.98, 95% CI: 1.69, 2.32), inadequate physical activity (aOR = 1.94, 95% CI: 1.69, 2.25), and inadequate sleep (aOR = 1.79, 95% CI: 1.54, 2.08). Conclusions Using smartphones, tablets, computers, and videogames is associated with several obesity risk factors. Although further study is needed, families should be encouraged to limit both TV viewing and newer screen devices.

OBJECTIVES: To evaluate the association of the 2009 changes to the US Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package and childhood obesity trends. We hypothesized that the food package change reduced obesity among children participating in WIC, a population that has been especially vulnerable to the childhood obesity epidemic. METHODS: We used an interrupted time-series design with repeated cross-sectional measurements of state-specific obesity prevalence among WIC-participating 2- to 4-year-old children from 2000 to 2014. We used multilevel linear regression models to estimate the trend in obesity prevalence for states before the WIC package revision and to test whether the trend in obesity prevalence changed after the 2009 WIC package revision, adjusting for changes in demographics. In a secondary analysis, we adjusted for changes in macrosomia and high prepregnancy BMI. RESULTS: Before the 2009 WIC food package change, the prevalence of obesity across states among 2- to 4-year-old WIC participants was increasing by 0.23 percentage points annually (95% confidence interval: 0.17 to 0.29; P < .001). After 2009, the trend was reversed (−0.34 percentage points per year; 95% confidence interval: −0.42 to −0.25; P < .001). Changes in sociodemographic and other obesity risk factors did not account for this change in the trend in obesity prevalence. CONCLUSIONS: The 2009 WIC food package change may have helped to reverse the rapid increase in obesity prevalence among WIC participants observed before the food package change.

Objective This study aimed to estimate the cost-effectiveness and impact on childhood obesity of installation of chilled water dispensers ("water jets") on school lunch lines and to compare water jets' cost, reach, and impact on water consumption with three additional strategies. Methods The Childhood Obesity Intervention Cost Effectiveness Study(CHOICES) microsimulation model estimated the cost-effectiveness of water jets on US childhood obesity cases prevented in 2025. Also estimated were the cost, number of children reached, and impact on water consumption of the installation of water jets and three other strategies. Results Installing water jets on school lunch lines was projected to reach 29.6 million children (95% uncertainty interval [UI]: 29.4 million-29.8 million), cost $4.25 (95% UI: $2.74-$5.69) per child, prevent 179,550 cases of childhood obesity in 2025 (95% UI: 101,970-257,870), and save $0.31 in health care costs per dollar invested (95% UI: $0.15-$0.55). In the secondary analysis, installing cup dispensers next to existing water fountains was the least costly but also had the lowest population reach. Conclusions Installating water jet dispensers on school lunch lines could also save almost half of the dollars needed for implementation via a reduction in obesity-related health care costs. School-based interventions to promote drinking water may be relatively inexpensive strategies for improving child health.

BACKGROUND/OBJECTIVES: State-specific obesity prevalence data are critical to public health efforts to address the childhood obesity epidemic. However, few states administer objectively-measured BMI surveillance programs. This study reports state-specific childhood obesity prevalence by age and sex correcting for parent-reported child height and weight bias. SUBJECTS/METHODS: As part of the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES), we developed childhood obesity prevalence estimates for states for the period 2005–2010 using data from the 2010 U.S. Census and American Community Survey (ACS), 2003–2004 and 2007–2008 National Survey of Children’s Health (NSCH) (n=133,213), and 2005–2010 National Health and Nutrition Examination Surveys (NHANES) (n=9,377; ages 2–17). Measured height and weight data from NHANES were used to correct parent-report bias in NSCH using a non-parametric statistical matching algorithm. Model estimates were validated against surveillance data from five states (AR, FL, MA, PA, and TN) that conduct censuses of children across a range of grades. RESULTS: Parent-reported height and weight resulted in the largest overestimation of childhood obesity in males ages 2–5 years (NSCH: 42.36% vs. NHANES: 11.44%). The CHOICES model estimates for this group (12.81%) and for all age and sex categories were not statistically different from NHANES. Our modeled obesity prevalence aligned closely with measured data from five validation states, with a 0.64 percentage point mean difference (range: 0.23–1.39) and a high correlation coefficient (r=0.96, p=0.009). Estimated state-specific childhood obesity prevalence ranged from 11.0% to 20.4%. CONCLUSION: Uncorrected estimates of childhood obesity prevalence from NSCH vary widely from measured national data, from a 278% overestimate among males aged 2–5 years to a 44% underestimate among females aged 14–17 years. This study demonstrates the validity of the CHOICES matching methods to correct the bias of parent-reported BMI data and highlights the need for public release of more recent data from the 2011–2012 NSCH.

An intervention study showed that promoting water consumption in schoolchildren prevented overweight, but a mechanism linking water consumption to overweight was not substantiated. We investigated whether increased water consumption replaced sugar-containing beverages and whether changes in water or sugar-containing beverages influenced body weight outcomes. In a secondary analysis of the intervention study in Germany, we analysed combined longitudinal data from the intervention and control groups. Body weight and height were measured and beverage consumption was self-reported by a 24-h recall questionnaire at the beginning and end of the school year 2006/2007. The effect of a change in water consumption on change in sugar-containing beverage (soft drinks and juices) consumption, change in BMI (kg/m2) and prevalence of overweight and obesity at follow-up was analysed using regression analyses. Of 3220 enroled children, 1987 children (mean age 8·3 (sd 0·7) years) from thirty-two schools were analysed. Increased water consumption by 1 glass/d was associated with a reduced consumption of sugar-containing beverages by 0·12 glasses/d (95 % CI −0·16, −0·08) but was not associated with changes in BMI (P=0·63). Increased consumption of sugar-containing beverages by 1 glass/d was associated with an increased BMI by 0·02 (95 % CI 0·00, 0·03) kg/m2 and increased prevalence of obesity (OR 1·22; 95 % CI 1·04, 1·44) but not with overweight (P=0·83). In conclusion, an increase in water consumption can replace sugar-containing beverages. As sugar-containing beverages were associated with weight gain, this replacement might explain the prevention of obesity through the promotion of water consumption.

Efforts to expand Medicaid while controlling spending must be informed by a deeper understanding of the extent to which the high medical costs associated with severe obesity (having a body mass index of [Formula: see text] or higher) determine spending at the state level. Our analysis of population-representative data indicates that in 2013, severe obesity cost the nation approximately $69 billion, which accounted for 60 percent of total obesity-related costs. Approximately 11 percent of the cost of severe obesity was paid for by Medicaid, 30 percent by Medicare and other federal health programs, 27 percent by private health plans, and 30 percent out of pocket. Overall, severe obesity cost state Medicaid programs almost $8 billion a year, ranging from $5 million in Wyoming to $1.3 billion in California. These costs are likely to increase following Medicaid expansion and enhanced coverage of weight loss therapies in the form of nutrition consultation, drug therapy, and bariatric surgery. Ensuring and expanding Medicaid-eligible populations' access to cost-effective treatment for severe obesity should be part of each state's strategy to mitigate rising obesity-related health care costs.

OBJECTIVES: To estimate the cost-effectiveness and population impact of the national implementation of the Study of Technology to Accelerate Research (STAR) intervention for childhood obesity. METHODS: In the STAR cluster-randomized trial, 6- to 12-year-old children with obesity seen at pediatric practices with electronic health record (EHR)-based decision support for primary care providers and self-guided behavior-change support for parents had significantly smaller increases in BMI than children who received usual care. We used a microsimulation model of a national implementation of STAR from 2015 to 2025 among all pediatric primary care providers in the United States with fully functional EHRs to estimate cost, impact on obesity prevalence, and cost-effectiveness. RESULTS: The expected population reach of a 10-year national implementation is ∼2 million children, with intervention costs of $119 per child and $237 per BMI unit reduced. At 10 years, assuming maintenance of effect, the intervention is expected to avert 43 000 cases and 226 000 life-years with obesity at a net cost of $4085 per case and $774 per life-year with obesity averted. Limiting implementation to large practices and using higher estimates of EHR adoption improved both cost-effectiveness and reach, whereas decreasing the maintenance of the intervention’s effect worsened the former. CONCLUSIONS: A childhood obesity intervention with electronic decision support for clinicians and self-guided behavior-change support for parents may be more cost-effective than previous clinical interventions. Effective and efficient interventions that target children with obesity are necessary and could work in synergy with population-level prevention strategies to accelerate progress in reducing obesity prevalence.

BACKGROUND: Afterschool interventions have been found to improve the nutritional quality of snacks served. However, there is limited evidence on how these interventions affect children’s snacking behaviors. OBJECTIVE: To determine the impact of an afterschool intervention focused at the school district, site, family, and child levels on dietary consumption of foods and beverages served at snack. DESIGN: Secondary analysis of a group-randomized controlled trial. PARTICIPANTS/SETTING: Data were collected from 400 children at 20 Boston, MA afterschool sites before (fall 2010) and after (spring 2011) intervention implementation. INTERVENTION: The Out-of-School Nutrition and Physical Activity intervention aimed to promote fruits, vegetables, whole grains, and water, while limiting sugary drinks and trans fats. Researchers worked with district foodservice staff to change snack foods and beverages. Teams of afterschool staff participated in three three-hour learning collaborative sessions to build skills and created action plans for changing site practices. The intervention included family and child nutrition education. MAIN OUTCOME MEASURES: Research assistants observed dietary snack consumption using a validated measure on two days per site at baseline and follow-up. STATISTICAL ANALYSES PERFORMED: This study used multivariable regression models, accounting for clustering of observations, to assess the intervention effect, and conducted post-hoc stratified analyses by foodservice type. RESULTS: Children in intervention sites had greater decreases in consumption of juice (−0.61 ounces/snack, 95% CI −1.11 – −0.12), beverage calories (−29.0 kcal/snack, 95% CI −40.1 – −17.9), foods with trans fats (−0.12 servings/snack, 95% CI −0.19 – −0.04), total calories (−47.8 kcal/snack, 95% CI −68.3 – −27.3) and increases in consumption of whole grains (0.10 servings/snack, 95% CI 0.02–0.18) compared to controls. In post hoc analyses, sites with on-site foodservice had significant improvements for all outcomes (p

Objectives. We evaluated a low-cost strategy for schools to improve the convenience and appeal of drinking water. Methods. We conducted a group-randomized, controlled trial in 10 Boston, Massachusetts, schools in April through June 2013 to test a cafeteria-based intervention. Signage promoting water and disposable cups were installed near water sources. Mixed linear regression models adjusting for clustering evaluated the intervention impact on average student water consumption over 359 lunch periods. Results. The percentage of students in intervention schools observed drinking water during lunch nearly doubled from baseline to follow-up compared with controls (+9.4%; P Conclusions. The current default of providing water through drinking fountains in cafeterias results in low water consumption. This study shows that an inexpensive intervention to improve drinking water’s convenience by providing cups can increase student water consumption.

Introduction Many American children do not meet recommendations for moderate to vigorous physical activity (MVPA). Although school-based physical education (PE) provides children with opportunities for MVPA, less than half of PE minutes are typically active. The purpose of this study is to estimate the cost effectiveness of a state “active PE” policy implemented nationally requiring that at least 50% of elementary school PE time is spent in MVPA. Methods A cohort model was used to simulate the impact of an active PE policy on physical activity, BMI, and healthcare costs over 10 years for a simulated cohort of the 2015 U.S. population aged 6–11 years. Data were analyzed in 2014. Results An elementary school active PE policy would increase MVPA per 30-minute PE class by 1.87 minutes (95% uncertainty interval [UI]=1.23, 2.51) and cost $70.7 million (95% UI=$51.1, $95.9 million) in the first year to implement nationally. Physical activity gains would cost $0.34 per MET-hour/day (95% UI=$0.15, $2.15), and BMI could be reduced after 2 years at a cost of $401 per BMI unit (95% UI=$148, $3,100). From 2015 to 2025, the policy would cost $235 million (95% UI=$170 million, $319 million) and reduce healthcare costs by $60.5 million (95% UI=$7.93 million, $153 million). Conclusions Implementing an active PE policy at the elementary school level could have a small impact on physical activity levels in the population and potentially lead to reductions in BMI and obesity-related healthcare expenditures over 10 years.

Introduction Food and beverage TV advertising contributes to childhood obesity. The current tax treatment of advertising as an ordinary business expense in the U.S. subsidizes marketing of nutritionally poor foods and beverages to children. This study models the effect of a national intervention that eliminates the tax subsidy of advertising nutritionally poor foods and beverages on TV to children aged 2–19 years. Methods We adapted and modified the Assessing Cost Effectiveness framework and methods to create the Childhood Obesity Intervention Cost Effectiveness Study model to simulate the impact of the intervention over the 2015–2025 period for the U.S. population, including short-term effects on BMI and 10-year healthcare expenditures. We simulated uncertainty intervals (UIs) using probabilistic sensitivity analysis and discounted outcomes at 3% annually. Data were analyzed in 2014. Results We estimated the intervention would reduce an aggregate 2.13 million (95% UI=0.83 million, 3.52 million) BMI units in the population and would cost $1.16 per BMI unit reduced (95% UI=$0.51, $2.63). From 2015 to 2025, the intervention would result in $352 million (95% UI=$138 million, $581 million) in healthcare cost savings and gain 4,538 (95% UI=1,752, 7,489) quality-adjusted life-years. Conclusions Eliminating the tax subsidy of TV advertising costs for nutritionally poor foods and beverages advertised to children and adolescents would likely be a cost-saving strategy to reduce childhood obesity and related healthcare expenditures.

ObjectiveThis study examines the extent to which insufficient sleep is associated with diet quality in students taking part in the Massachusetts Childhood Obesity Research Demonstration Project.MethodsData were collected in Fall 2012 for all 4th and 7th grade children enrolled in public schools in two Massachusetts communities. During annual body mass index (BMI) screening, students completed a survey that assessed diet, physical activity, screen time, and sleep. Of the 2456 enrolled students, 1870 (76%) had complete survey data. Generalized estimating equations were used to examine associations between sleep duration and dietary outcomes (vegetables, fruits, 100% juice, juice drinks, soda, sugar-sweetened beverages and water), accounting for clustering by school. Models were adjusted for community, grade, race/ethnicity, gender, television in the bedroom, screen time, and physical activity.ResultsIn adjusted models, students who reported sleeping < 10 hours/day consumed soda more frequently (β = 0.11, 95% CI: 0.03, 0.20) and vegetables less frequently (β = -0.09, 95% CI: -0.18, -0.01) compared with students who reported ≥ 10 hours/day. No significant associations were observed between sleep duration and fruits, 100% juice, juice drinks or water.ConclusionsIn this population, insufficient sleep duration was associated with more frequent soda and less frequent vegetable consumption. Longitudinal research is needed to further examine these relationships.

We evaluated the impact of a brief primary-care-based intervention, The Maine Youth Overweight Collaborative (MYOC), on BMI (kg/m(2)) z-score change among participants with obesity (BMI ≥95th percentile for age and sex), overweight (BMI ≥85th and95th percentile), and healthy weight (≥50th and85th percentile).A quasi-experimental field trial with nine intervention and nine control sites in urban and rural areas of Maine, MYOC focused on improvements in clinical decision support, charting BMI percentile, identifying patients with obesity, appropriate lab tests, and counseling families/patients. Retrospective longitudinal record reviews assessed BMI z-scores preintervention (from 1999 through October 2004) and one postintervention time point (between December 2006 and March 2008). Participants were youth ages 5-18 having two visits before the intervention with weight percentile greater than or equal to 95% (N=265). Secondary analyses focused on youths who are overweight (N=215) and healthy weight youth (N=506).Although the MYOC intervention demonstrated significant provider and office system improvements, we found no significant changes in BMI z-scores in intervention versus control youth pre- to postintervention and significant flattening of upward trends among both intervention and control sites (p0.001).This brief office-based intervention was associated with no significant improvement in BMI z-scores, compared to control sites. An important avenue for obesity prevention and treatment as part of a multisector approach in communities, this type of primary care intervention alone may be unlikely to impact BMI improvement given the limited dosage-an estimated 4-6 minutes for one patient contact.

BACKGROUND AND OBJECTIVE: Associations of inadequate sleep with numerous health outcomes among youth necessitate identifying its modifiable determinants. Television (TV) has been associated with sleep curtailment, but little is known about small screens (eg, smartphones), which can be used in bed and emit notifications. Therefore, we examined associations of different screens in sleep environments with sleep duration and perceived insufficient rest or sleep. METHODS: Participants included 2048 fourth- and seventh-graders participating in the Massachusetts Childhood Obesity Research Demonstration Study in 2012 to 2013. Using linear and log binomial regression, we examined cross-sectional associations of small screens and TVs in sleep environments and screen time with weekday sleep duration and perceived insufficient rest or sleep in the past week. RESULTS: Children who slept near a small screen (compared with never) reported 20.6 fewer minutes of sleep (95% confidence interval [CI], −29.7 to −11.4) and had a higher prevalence of perceived insufficient rest or sleep (prevalence ratio, 1.39; 95% CI, 1.21 to 1.60). Children who slept in a room with a TV (compared with no TV) reported 18.0 fewer minutes of sleep (95% CI, −27.9 to −8.1). TV or DVD viewing and video or computer game playing were associated with both sleep outcomes (P < .01). Some associations were stronger among Hispanic, non-Hispanic black, and older children (P < .05 for heterogeneity). CONCLUSIONS: Sleeping near a small screen, sleeping with a TV in the room, and more screen time were associated with shorter sleep durations. Presence of a small screen, but not a TV, in the sleep environment and screen time were associated with perceived insufficient rest or sleep. These findings caution against unrestricted screen access in children’s bedrooms.

Author(s): Blaine, Rachel E; Franckle, Rebecca L; Ganter, Claudia; Falbe, Jennifer; Giles, Catherine; Criss, Shaniece; Kwass, Jo-Ann; Land, Thomas; Gortmaker, Steven L; Chuang, Emmeline; Davison, Kirsten K; MA-CORD Project Group | Abstract: IntroductionAlthough evidence-based interventions to prevent childhood obesity in school settings exist, few studies have identified factors that enhance school districts' capacity to undertake such efforts. We describe the implementation of a school-based intervention using classroom lessons based on existing "Eat Well and Keep Moving" and "Planet Health" behavior change interventions and schoolwide activities to target 5,144 children in 4th through 7th grade in 2 low-income school districts.MethodsThe intervention was part of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) project, a multisector community-based intervention implemented from 2012 through 2014. Using mixed methods, we operationalized key implementation outcomes, including acceptability, adoption, appropriateness, feasibility, implementation fidelity, perceived implementation cost, reach, and sustainability.ResultsMA-CORD was adopted in 2 school districts that were facing resource limitations and competing priorities. Although strong leadership support existed in both communities at baseline, one district's staff reported less schoolwide readiness and commitment. Consequently, fewer teachers reported engaging in training, teaching lessons, or planning to sustain the lessons after MA-CORD. Interviews showed that principal and superintendent turnover, statewide testing, and teacher burnout limited implementation; passionate wellness champions in schools appeared to offset implementation barriers.ConclusionFuture interventions should assess adoption readiness at both leadership and staff levels, offer curriculum training sessions during school hours, use school nurses or health teachers as wellness champions to support teachers, and offer incentives such as staff stipends or play equipment to encourage school participation and sustained intervention activities.

Objective To examine the extent to which a clinical intervention resulted in reduced body mass index (BMI) z-scores among 2–12 year old children compared to routine practice (treatment as usual, TAU). Methods The Massachusetts Childhood Obesity Research Demonstration project (MA-CORD) is a multifaceted initiative to prevent childhood obesity among low-income children. In the federally qualified community health centers (FQHC) of two communities (Intervention Site #1 and #2), we implemented (1) pediatric weight management training; (2) electronic decision supports for clinicians; (3) on-site Healthy Weight Clinics; (4) community health worker integration; and (5) healthful clinical environment changes. One FQHC in a demographically-matched community served as the TAU site. Using electronic health records, we assessed BMI z-scores and used linear mixed models to examine BMI z-score change over 2 years in each intervention site compared to a TAU site. Results Compared to children in the TAU site (n=2286), children in Intervention site #2 (n=1368) had a significant decline in BMI z-scores following the start of the intervention (−0.16 units/year; 95% CI: −0.21, −0.12). We found no evidence of an effect in Intervention site #1 (n=111). Conclusions The MA-CORD clinical interventions were associated with modest improvement in BMI z-scores in one of two intervention communities compared to a TAU community.

Motivational interviewing (MI) shows promise for pediatric obesity prevention, but few studies address parental perceptions of MI. The aim of this study was to identify correlates of parental perceptions of helpfulness of and satisfaction with a MI-based pediatric obesity prevention intervention. We studied 253 children 2 to 6 years of age in the intervention arm of High Five for Kids, a primary care–based randomized controlled trial. In multivariable models, parents born outside the United States (odds ratio [OR] = 8.81; 95% confidence interval [CI] = 2.44, 31.8), with lower household income (OR = 3.60; 95% CI = 1.03, 12.55), and with higher BMI (OR = 2.86; 95% CI = 1.07, 7.65) were more likely to perceive MI-based visits as helpful in improving children’s obesity-related behaviors after the first year of the intervention. Parents of female (vs male), black (vs white), and Latino (vs white) children had lower intervention satisfaction. Our findings underscore the importance of tailoring pediatric obesity prevention efforts to target populations.

Purpose: We assessed public support for required water access in schools and parks and perceived safety and taste of water in these settings to inform efforts to increase access to and consumption of tap water. Design: Cross-sectional survey of the US public collected from August to November 2011. Setting: Random digit-dialed telephone survey. Participants: Participants (n = 1218) aged 17 and older from 1055 US counties in 46 states. Measures: Perceived safety and taste of water in schools and parks as well as support for required access to water in these settings. Analysis: Survey-adjusted perceived safety and taste as well as support for required access were estimated. Results: There was broad support for required access to water throughout the day in schools (96%) and parks (89%). Few participants believed water was unsafe in schools (10%) or parks (18%). Conclusion: This study provides evidence of public support for efforts to increase access to drinking water in schools and parks and documents overall high levels of perceived taste and safety of water provided in these settings.

Introduction Routine collection, analysis, and reporting of data on child height, weight, and body mass index (BMI), particularly at the state and local levels, are needed to monitor the childhood obesity epidemic, plan intervention strategies, and evaluate the impact of interventions. Child BMI surveillance systems operated by the US government do not provide state or local data on children across a range of ages. The objective of this study was to describe the extent to which state governments conduct child BMI surveillance. Methods From August through December 2014, we conducted a structured telephone survey with state government administrators to learn about state surveillance of child BMI. We also searched websites of state health and education agencies for information about state surveillance. Results State agency administrators in 48 states and Washington, DC, completed telephone interviews (96% response rate). Based on our interviews and Internet research, we determined that 14 states collect child BMI data in a manner consistent with standard definitions of public health surveillance. Conclusion The absence of child BMI surveillance systems in most states limits the ability of public health practitioners and policymakers to develop and evaluate responses to the childhood obesity epidemic. Greater investment in surveillance is needed to identify the most effective and cost-effective childhood obesity interventions.

A media competition was part of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) Study. Criss et al., previously outlined the development and implementation of the competition, including variation in reach and adoption of the intervention across schools and afterschool programs. In this qualitative study, we examine community, provider, and organizational factors that explain the variation of media competition reach in school and afterschool programs, and describe the awareness of the media competition across other community sectors. Durlak and DuPre's ecological framework for understanding effective implementation provided the theoretical underpinnings for this study. Fifty-four key informant interviews were conducted, transcribed, and analyzed. Organizational capacity of committed teachers/staff and adaptability of the media competition seemed to be drivers for higher reach within school and afterschool programs. Salient themes that emerged as facilitators of effective implementation were having a cascade of champions and providing opportunity to participate in the media competition outside traditional class time. Clinics and coalitions were identified as additional sectors aware of the media competition. Specifically, our findings offer a new perspective on intervention design and a recommended direction for further study.

Background State-level estimates from the Centers for Disease Control and Prevention (CDC) underestimate the obesity epidemic because they use self-reported height and weight. We describe a novel bias-correction method and produce corrected state-level estimates of obesity and severe obesity. Methods Using non-parametric statistical matching, we adjusted self-reported data from the Behavioral Risk Factor Surveillance System (BRFSS) 2013 (n = 386,795) using measured data from the National Health and Nutrition Examination Survey (NHANES) (n = 16,924). We validated our national estimates against NHANES and estimated bias-corrected state-specific prevalence of obesity (BMI≥30) and severe obesity (BMI≥35). We compared these results with previous adjustment methods. Results Compared to NHANES, self-reported BRFSS data underestimated national prevalence of obesity by 16% (28.67% vs 34.01%), and severe obesity by 23% (11.03% vs 14.26%). Our method was not significantly different from NHANES for obesity or severe obesity, while previous methods underestimated both. Only four states had a corrected obesity prevalence below 30%, with four exceeding 40%–in contrast, most states were below 30% in CDC maps. Conclusions Twelve million adults with obesity (including 6.7 million with severe obesity) were misclassified by CDC state-level estimates. Previous bias-correction methods also resulted in underestimates. Accurate state-level estimates are necessary to plan for resources to address the obesity epidemic.

Introduction Competitive beverages are drinks sold outside of the federally reimbursable school meals program and include beverages sold in vending machines, a la carte lines, school stores, and snack bars. Competitive beverages include sugar-sweetened beverages, which are associated with overweight and obesity. We described competitive beverage availability 9 years after the introduction in 2004 of district-wide nutrition standards for competitive beverages sold in Boston Public Schools. Methods In 2013, we documented types of competitive beverages sold in 115 schools. We collected nutrient data to determine compliance with the standards. We evaluated the extent to which schools met the competitive-beverage standards and calculated the percentage of students who had access to beverages that met or did not meet the standards. Results Of 115 schools, 89.6% met the competitive beverage nutrition standards; 88.5% of elementary schools and 61.5% of middle schools did not sell competitive beverages. Nutrition standards were met in 79.2% of high schools; 37.5% did not sell any competitive beverages, and 41.7% sold only beverages meeting the standards. Overall, 85.5% of students attended schools meeting the standards. Only 4.0% of students had access to sugar-sweetened beverages. Conclusion A comprehensive, district-wide competitive beverage policy with implementation support can translate into a sustained healthful environment in public schools.

From the New Balance Foundation Obe- sity Prevention Center (C.B.E., D.S.L.) and the Clinical Research Center (H.A.F., T.A.A., S.K.O.), Boston Children's Hospi - tal, Boston; the Institute for Community Health, Cambridge (V.R.C.); and the De- partment of Society, Human Develop- ment, and Health, Harvard School of Public Health, Boston (S.L.G.) — all in Massachusetts. Address reprint requests to Dr. Ludwig at the New Balance Foun- dation Obesity Prevention Center, Bos- ton Children's Hospital, 300 Longwood Ave., Boston, MA 02115, or at david A B S T R AC T Background Consumption of sugar-sweetened beverages may cause excessive weight gain. We aimed to assess the effect on weight gain of an intervention that included the provi- sion of noncaloric beverages at home for overweight and obese adolescents. Methods We randomly assigned 224 overweight and obese adolescents who regularly con- sumed sugar-sweetened beverages to experimental and control groups. The experi- mental group received a 1-year intervention designed to decrease consumption of sugar-sweetened beverages, with follow-up for an additional year without interven- tion. We hypothesized that the experimental group would gain weight at a slower rate than the control group. Results Retention rates were 97% at 1 year and 93% at 2 years. Reported consumption of sugar-sweetened beverages was similar at baseline in the experimental and control groups (1.7 servings per day), declined to nearly 0 in the experimental group at 1 year, and remained lower in the experimental group than in the control group at 2 years. The primary outcome, the change in mean body-mass index (BMI, the weight in ki- lograms divided by the square of the height in meters) at 2 years, did not differ sig- nificantly between the two groups (change in experimental group minus change in control group, −0.3; P = 0.46). At 1 year, however, there were significant between- group differences for changes in BMI (−0.57, P = 0.045) and weight (−1.9 kg, P = 0.04). We found evidence of effect modification according to ethnic group at 1 year (P = 0.04) and 2 years (P = 0.01). In a prespecified analysis according to ethnic group, among Hispanic participants (27 in the experimental group and 19 in the control group), there was a significant between-group difference in the change in BMI at 1 year (−1.79, P = 0.007) and 2 years (−2.35, P = 0.01), but not among non-Hispanic partici- pants (P>0.35 at years 1 and 2). The change in body fat as a percentage of total weight did not differ significantly between groups at 2 years (−0.5%, P = 0.40). There were no adverse events related to study participation. Conclusions Among overweight and obese adolescents, the increase in BMI was smaller in the experimental group than in the control group after a 1-year intervention designed to reduce consumption of sugar-sweetened beverages, but not at the 2-year follow- up (the prespecified primary outcome). (Funded by the National Institute of Diabe- tes and Digestive and Kidney Diseases and others; ClinicalTrials.gov number, NCT00381160.)

Background Obesity in childhood and adolescence has important health consequences, but its relation to risk of adult depression remains uncertain. Objective To examine the effect of perceived and actual obesity during childhood and adolescence on prevalence and incidence of adult depression risk. Methods Cohort study of 91 798 female registered nurses followed longitudinally for 12 years. Results As compared with lean women of the same age, women in the two highest categories of body shape at age 10 had both higher prevalence (OR=2.59, 95% CI 1.46 to 4.61) and incidence (OR=2.01, 95% CI 1.08 to 3.71) of depression. Similar results were obtained for body shape at age 20 (OR=3.43 for prevalence and OR=2.03 for incidence) and for body mass index (BMI) at age 18 (OR=2.92 for BMI ≥40 kg/m 2 ). These associations remained significant after adjustment for multiple confounders. Conclusion These results indicate that childhood–adolescence obesity is a strong and independent risk factor for adult depression.

Importance Millions of children attend after-school programs in the United States. Increasing physical activity levels of program participants could have a broad effect on children’s health. Objective To test the effectiveness of the Out of School Nutrition and Physical Activity (OSNAP) Initiative in increasing children’s physical activity levels in existing after-school programs. Design, Setting, and Participants Cluster-randomized controlled trial with matched program pairs. Baseline data were collected September 27 through November 12, 2010, with follow-up data collected April 25 through May 27, 2011. The dates of our analysis were March 11, 2014, through August 18, 2015. The setting was 20 after-school programs in Boston, Massachusetts. All children 5 to 12 years old in participating programs were eligible for study inclusion. Interventions Ten programs participated in a series of three 3-hour learning collaborative workshops, with additional optional opportunities for training and technical assistance. Main Outcomes and Measures Change in number of minutes and bouts of moderate to vigorous physical activity, vigorous physical activity, and sedentary activity and change in total accelerometer counts between baseline and follow-up. Results Participants with complete data were 402 racially/ethnically diverse children, with a mean age of 7.7 years. Change in the duration of physical activity opportunities offered to children during program time did not differ between conditions (−1.2 minutes; 95% CI, −14.2 to 12.4 minutes; P = .87). Change in moderate to vigorous physical activity minutes accumulated by children during program time did not differ significantly by intervention status (−1.0; 95% CI, −3.3 to 1.3; P = .40). Total minutes per day of vigorous physical activity (3.2; 95% CI, 1.8-4.7; P P P = .01) increased significantly during program time among intervention participants compared with control participants. Conclusions and Relevance Although programs participating in the OSNAP Initiative did not allot significantly more time for physical activity, they successfully made existing time more vigorously active for children receiving the intervention. Trial Registration clinicaltrials.gov Identifier:NCT01396473

Objective. This study aimed to identify socioeconomic correlates of computer/Internet use among parents of overweight preschool-aged children. Methods. A total of 470 baseline participants in a trial to prevent obesity in children 2 to 6.9 years old with body mass index ≥95th percentile or 85th to 95th percentile with one overweight parent were studied. Interviews with parents used Health Information National Trends Survey questions. Results/conclusions. Overall, 94% of the participants had home computers and 93% reported Internet usage. In adjusted models, parents with ≤college degree (odds ratio = 4.8; 95% confidence interval = 1.2-18.3) or with household income ≤$50 000 (odds ratio = 7.6; 95% confidence interval = 2.2-26.8) had decreased likelihood of computer ownership. Of parents who reported going online, 63% used Internet to look for health/medical information for themselves and 42% for their children. Parents with ≤a college degree or with body mass index 2were less likely to use Internet. Results support using the Internet for early childhood obesity prevention with enhanced outreach efforts for low socioeconomic status families.

Summary Rising prevalence of obesity is a worldwide health concern because excess weight gain within populations forecasts an increased burden from several diseases, most notably cardiovascular diseases, diabetes, and cancers. In this report, we used a simulation model to project the probable health and economic consequences in the next two decades from a continued rise in obesity in two ageing populations—the USA and the UK. These trends project 65 million more obese adults in the USA and 11 million more obese adults in the UK by 2030, consequently accruing an additional 6–8·5 million cases of diabetes, 5·7–7·3 million cases of heart disease and stroke, 492 000–669 000 additional cases of cancer, and 26–55 million quality-adjusted life years forgone for USA and UK combined. The combined medical costs associated with treatment of these preventable diseases are estimated to increase by $48–66 billion/year in the USA and by £1·9–2 billion/year in the UK by 2030. Hence, effective policies to promote healthier weight also have economic benefits.

An urban advantage in terms of lower risk of child undernutrition has been observed in many developing countries, but child obesity is often more prevalent in urban than rural areas. This study aimed to assess whether urban-rural disparities in undernutrition and obesity were attributable to concentrations of socioeconomically advantaged children into urban communities or to specific aspects of the urban environment. A sample of 4610 children ages 2-10 years was derived from the 2004 Round of the Kanchanaburi Demographic Surveillance System, monitoring health and demographic change in the province of Kanchanaburi, Thailand. We used multi-level logistic regression to model the odds of short stature, underweight, and obesity for children in 102 communities. Models tested whether child socioeconomic conditions accounted for urban-rural disparities or if aspects of the social and physical environment accounted for disparities, adjusting for child characteristics. 27.8% of children were underweight, while 19.9% had short stature, and 8.3% were obese. Bivariate associations showed urban residence associated with lower risk of undernutrition and a greater risk of obesity. Urban-rural disparities in odds of short stature and underweight were accounted for by child socioeconomic characteristics. Urban residence persisted as a risk factor for obesity after adjusting for child characteristics. Community wealth concentration, television coverage, and sanitation coverage were independently associated with greater risk of obesity. Undernutrition was strongly associated with household poverty, while household affluence and characteristics of the urban environment were associated with odds of obesity. Further research is needed to characterize how urban environments contribute to children's risks of obesity in developing countries.

Purpose. To study informal skill transfer via staff networks as a complement to formal training among afterschool childcare providers implementing a health promotion program. Design. Cross-sectional, sociometric network analysis. Setting. Boston Young Men's Christian Association (YMCA) afterschool programs implementing the iPLAY program. Participants. All 91 staff members at 20 sites were eligible; 80 completed the survey (88% response rate). Measures. At the network level, network density measured system-level connectedness. At the staff level, the independent variable was out degree, the number of individuals to whom respondents noted a program-related connection. The dependent variable was skill gains, the number of key implementation skills gained from the network. Analysis. We mapped the staff program-related social network. We utilized multiple linear regression to estimate the relationship between out degree and skill gains, and we adjusted for clustering of staff in sites. Results. Most staff (77%) reported gaining at least one skill from the network, but only 2% of potential network connections were established. The regression model showed that out degree (i.e., number of program-related contacts) was significantly associated with skill gains (β = .48, p < .01) independent of other variables. Conclusion. Informal skill transfer in staff networks may be a useful complement to formal training for implementation of health promotion programs, but informal skill transfer was likely underutilized in this network. Future research employing longitudinal and/or multisite data should examine these findings in greater detail.

As organizations implement novel health promotion programs across multiple sites, they face great challenges related to knowledge management. Staff social networks may be a useful medium for transferring program-related knowledge in multi-site implementation efforts. To study this potential, we focused on the role of extra-team connections (ties between staff members based in different site teams) as potential channels for knowledge sharing. Data come from a cross-sectional study of after-school child-care staff implementing a health promotion program at 20 urban sites of the Young Men's Christian Association of Greater Boston. We conducted a sociometric social network analysis and attempted a census of 91 program staff members. We surveyed 80 individuals, and included 73 coordinators and general staff, who lead and support implementation, respectively, in this study. A multiple linear regression model demonstrated a positive relationship between extra-team connections (beta = 3.41, P0.0001) and skill receipt, a measure of knowledge transfer. We also found that intra-team connections (within-team ties between staff members) were also positively related to skill receipt. Connections between teams appear to support knowledge transfer in this network, but likely require greater active facilitation, perhaps via organizational changes. Further research on extra-team connections and knowledge transfer in low-resource, high turnover environments is needed.

OBJECTIVE. To evaluate the effect of a pediatric primary care–based intervention, on improved clinical decision support and family management of risk behaviors for childhood overweight. METHODS. An experimental field trial was conducted with 12 intervention sites in urban and rural areas of Maine and nonrandomized control sites. Change was assessed by using clinical and parent measures from 9 intervention and 10 control sites before and during the Maine Youth Overweight Collaborative intervention. Longitudinal information was collected from chart audits of patients aged 5–18 years (n = 600), systematic samples of parents collected before (n = 346) and during (n = 386) the intervention in 12 sites, and systematic samples of parents in 9 intervention (n = 235) and 10 control (n = 304) sites collected during the intervention. Surveys of health care providers (n = 14 and 17) before and during the intervention were also collected. Teams worked over 18 months to implement improvements in clinical decision support, including tracking BMI percentiles, identification of overweight patients, appropriate laboratory tests, counseling of families and patients use of a behavioral screening tool, and other improvements following the chronic-care model targeting patients aged 5 to 18 and their families. RESULTS. Large changes occurred in clinical practice from before to during the Maine Youth Overweight Collaborative: increases in assessment of BMI (38%–94%), BMI percentile for age and gender (25%–89%), use of the 5-2-1-0 behavioral screening tool (0%–82%), and weight classification (19%–75%). Parent surveys indicated improvements in providers’ behavior and rates of counseling. Intervention providers reported improvements in knowledge, attitudes, self-efficacy, and practice. CONCLUSIONS. The Maine Youth Overweight Collaborative intervention improved clinical decision support and family management of risk behaviors, indicating a promising primary care–based approach to address overweight risk among children and youth.

Background: Consumption of sugar-sweetened beverages (SSBs) has been linked to obesity and type 2 diabetes. Objective: We examined national trends in SSB consumption among US adults by sociodemographic characteristics, body weight status, and weight-loss intention. Design: We analyzed 24-h dietary recall data to estimate beverage consumption among adults (aged � 20 y) obtained from the third National Health and Nutrition Examination Survey (NHANES III, 1988–1994; n ¼ 15979) and NHANES 1999–2004 (n ¼ 13431). Results: From 1988–1994 to 1999–2004 on the survey day, the percentage of adult SSB drinkers increased from 58% to 63% (P , 0.001), per capita consumption of SSB increased by 46 kcal/d (P ¼ 0.001), and daily SSB consumption among drinkers increased by 6 oz (P , 0.001). In both survey periods, per capita SSB consumption was highest among young adults (231–289 kcal/d) and lowest among the elderly (68–83 kcal/d). Young blacks had the highest percentage of SSB drinkers and the highest per capita consumption compared with white and Mexican American adults (P , 0.05). Overweight-obese adults with weight-loss intention (compared with those without) were significantly less likely to drink SSB, but they still consumed a considerable amount in 1999–2004 (278 kcal/d). Among young adults, 20% of SSB calories was consumed at work. Conclusions: Over the past decade, US adult SSB consumption has increased. SSB comprises a considerable source of total daily intake and is the largest source of beverage calories. SSB consumption is highest among subgroups also at greatest risk of obesity and type 2 diabetes. Am J Clin Nutr 2009;89:1–10.

Objective: To examine parental perceptions of primary care efforts aimed at childhood obesity prevention Methods and Procedures: We interviewed 446 parents of children, aged 2–12 years, with an age- and sex-specific BMI ≥85th percentile; interviews occurred within 2 weeks of their child's primary care visit. We assessed parental ratings of the nutrition and physical activity advice received. Using children's clinical heights and weights and parents' self-reported heights and weights, we classified children into three categories: BMI 85th–94th percentile without an overweight parent, BMI 85th–94th percentile with an overweight parent (adult BMI ≥25 kg/m2), and BMI ≥95th percentile. Results: In multivariate analyses, compared to parents of children with BMI ≥95th percentile, overweight parents with children whose BMI was 85th–94th percentile were more likely to report receiving too little advice on nutrition and physical activity (odds ratio (OR) 3.05; 95% confidence interval (CI) 1.49, 6.25) and to rate as poor or fair the quality of advice they received (OR 2.23; 95% CI 1.18, 4.24). Independently, African-American (OR 2.55; 95% CI 1.18, 5.51) and Hispanic/Latino (OR 2.78; 95% CI 1.27, 6.10) parents were more likely than white parents to rate as poor or fair the quality of advice they received. Discussion: Parental overweight is associated with low subjective ratings of overweight counseling in pediatric primary care. Our findings of poorer perceived quality among racial/ethnic minority parents need further investigation.

OBJECTIVE. We sought to document increases in caloric contributions from sugar-sweetened beverages and 100% fruit juice among US youth during 1988–2004. PATIENTS AND METHODS. We analyzed 24-hour dietary recalls from children and adolescents (aged 2–19) in 2 nationally representative population surveys: National Health and Nutrition Examination Survey III (1988–1994, N = 9882) and National Health and Nutrition Examination Survey 1999–2004 (N = 10 962). We estimated trends in caloric contribution, type, and location of sugar-sweetened beverages and 100% fruit juice consumed. RESULTS. Per-capita daily caloric contribution from sugar-sweetened beverages and 100% fruit juice increased from 242 kcal/day (1 kcal = 4.2 kJ) in 1988–1994 to 270 kcal/day in 1999–2004; sugar-sweetened beverage intake increased from 204 to 224 kcal/day and 100% fruit juice increased from 38 to 48 kcal/day. The largest increases occurred among children aged 6 to 11 years (∼20% increase). There was no change in per-capita consumption among white adolescents but significant increases among black and Mexican American youths. On average, respondents aged 2 to 5, 6 to 11, and 12 to 19 years who had sugar-sweetened beverages on the surveyed day in 1999–2004 consumed 176, 229, and 356 kcal/day, respectively. Soda contributed ∼67% of all sugar-sweetened beverage calories among the adolescents, whereas fruit drinks provided more than half of the sugar-sweetened beverage calories consumed by preschool-aged children. Fruit juice drinkers consumed, on average, 148 (ages 2–5), 136 (ages 6–11), and 184 (ages 12–19) kcal/day. On a typical weekday, 55% to 70% of all sugar-sweetened beverage calories were consumed in the home environment, and 7% to 15% occurred in schools. CONCLUSIONS. Children and adolescents today derive 10% to 15% of total calories from sugar-sweetened beverages and 100% fruit juice. Our analysis indicates increasing consumption in all ages. Schools are a limited source for sugar-sweetened beverages, suggesting that initiatives to restrict sugar-sweetened beverage sales in schools may have an only marginal impact on overall consumption. Pediatricians’ awareness of these trends is critical for helping children and parents target suboptimal dietary patterns that may contribute to excess calories and obesity.

Objective: We examined youths’ report of receiving specific overweight-related preventive counseling and perceived readiness to adopt nutrition and physical activity behaviors recommended by their clinicians. Research Methods and Procedures: We surveyed 324 youth 10 to 18 years old who had a physical exam within the past year. The survey included questions on height, weight, race/ethnicity, mother's education, and topics they discussed with their clinician during their visit. We used multivariable analyses to examine whether weight status and sociodemographic characteristics were predictors of which youth received counseling from their clinicians and which youth were ready to change. Results: The mean (standard deviation) age of participants was 13.7 (1.8) years; 54% were black, and 22% were Hispanic. Less than one-half of participants reported discussing sugar-sweetened beverages [38%; 95% confidence interval (CI), 32% to 43%] or television viewing (41%; 95% CI, 36% to 47%) with their clinicians. In multivariable analyses adjusting for participant's age, sex, race/ethnicity, overweight status, and mother's educational attainment, youth whose mothers lacked education beyond high school were significantly less likely to report receiving counseling on any overweight-specific topic including television viewing [odds ratio (OR), 0.46; 95% CI, 0.27, 0.79], sugar-sweetened beverage (OR, 0.47; 95% CI, 0.28, 0.80), and fast food consumption (OR, 0.54; 95% CI, 0.32, 0.92). In addition, youth 10 to 14 years old were more likely than those 15 to 18 years old to report they would try to change their television viewing (OR, 4.10; 95% CI, 1.78, 9.44) if recommended by their clinician. Discussion: Youth report infrequently receiving counseling on specific overweight prevention topics during routine primary care visits. Our findings suggest that greater efforts may be needed to reduce social class disparities in overweight prevention counseling and that counseling to prevent overweight in youth may be more acceptable to younger children.

The obesity epidemic has spared no age group, even young infants. Most childhood obesity is incident by the age of 5 years, making prevention in preschool years a priority.To examine 2-year changes in age- and sex-specific BMI z-scores and obesity-related behaviours among 441 of the 475 originally recruited participants in High Five for Kids, a cluster randomized controlled trial in 10 paediatric practices.The intervention included a more intensive 1-year intervention period (four in-person visits and two phone calls) followed by a less intensive 1-year maintenance period (two in-person visits) among children who were overweight or obese and age 2-6 years at enrolment. The five intervention practices restructured care to manage these children including motivational interviewing and educational modules targeting television viewing and intakes of fast food and sugar-sweetened beverages.After 2 years, compared with usual care, intervention participants had similar changes in BMI z-scores (-0.04 units; 95% CI -0.14, 0.06), television viewing (-0.20 h/d; -0.49 to 0.09) and intakes of fast food (-0.09 servings/week; -0.34 to 0.17) and sugar-sweetened beverages (-0.26 servings/day; -0.67 to 0.14).High Five for Kids, a primarily clinical-based intervention, did not affect BMI z-scores or obesity-related behaviours after 2 years.

Objectives. We evaluated the hydration status of US children and adolescents. Methods. The sample included 4134 participants aged 6 to 19 years in the National Health and Nutrition Examination Survey from 2009 to 2012. We calculated mean urine osmolality and the proportion with inadequate hydration (urine osmolality > 800 mOsm/kg). We calculated multivariable regression models to estimate the associations between demographic factors, beverage intake, and hydration status. Results. The prevalence of inadequate hydration was 54.5%. Significantly higher urine osmolality was observed among boys (+92.0 mOsm/kg; 95% confidence interval [CI] = 69.5, 114.6), non-Hispanic Blacks (+67.6 mOsm/kg; 95% CI = 31.5, 103.6), and younger children (+28.5 mOsm/kg; 95% CI = 8.1, 48.9) compared with girls, Whites, and older children, respectively. Boys (OR = 1.76; 95% CI = 1.49, 2.07) and non-Hispanic Blacks (odds ratio [OR] = 1.34; 95% CI = 1.04, 1.74) were also at significantly higher risk for inadequate hydration. An 8-fluid-ounce daily increase in water intake was associated with a significantly lower risk of inadequate hydration (OR = 0.96; 95% CI = 0.93, 0.98). Conclusions. Future research should explore drivers of gender and racial/ethnic disparities and solutions for improving hydration status.

The prevalence of childhood overweight and obesity has risen substantially worldwide in less than one generation. In the USA, the average weight of a child has risen by more than 5 kg within three decades, to a point where a third of the country's children are overweight or obese. Some low-income and middle-income countries have reported similar or more rapid rises in child obesity, despite continuing high levels of undernutrition. Nutrition policies to tackle child obesity need to promote healthy growth and household nutrition security and protect children from inducements to be inactive or to overconsume foods of poor nutritional quality. The promotion of energy-rich and nutrient-poor products will encourage rapid weight gain in early childhood and exacerbate risk factors for chronic disease in all children, especially those showing poor linear growth. Whereas much public health effort has been expended to restrict the adverse marketing of breastmilk substitutes, similar effort now needs to be expanded and strengthened to protect older children from increasingly sophisticated marketing of sedentary activities and energy-dense, nutrient-poor foods and beverages. To meet this challenge, the governance of food supply and food markets should be improved and commercial activities subordinated to protect and promote children's health.

OBJECTIVE. Our goal was to quantify the magnitude of energy imbalance responsible for the increase in body weight among US children during the periods 1988–1994 and 1999–2002.METHODS. We adopted a counterfactual approach to estimate weight gains in excess of normal growth and the implicit “energy gap”—the daily imbalance between energy intake and expenditure. On the basis of Centers for Disease Control and Prevention growth charts, we constructed weight, height, and BMI percentile distributions for cohorts 2 to 4 and 5 to 7 years of age in the 1988–1994 National Health and Nutrition Examination Survey (N = 5000). Under the counterfactual “normal-growth-only” scenario, we assumed that these percentile distributions remained the same as the cohort aged 10 years. Under this assumption, we projected the weight and height distributions for this cohort at 12 to 14 and 15 to 17 years of age on the basis of their baseline weight-for-age and stature-for-age percentiles. We compared these distributions with those for corresponding age groups in the 1999–2002 National Health and Nutrition Examination Survey (N = 3091) ∼10 years after the 1988–1994 National Health and Nutrition Examination Survey. We calculated differences between the counterfactual and observed weight distributions and translated this difference into the estimated average energy gap, adjusting for increased total energy expenditure attributable to weight gain. In addition, we estimated the average excess weight accumulated among overweight adolescents in the 1999–2002 National Health and Nutrition Examination Survey, validating our counterfactual assumptions by analyzing longitudinal data from the National Longitudinal Survey of Youth and Bogalusa Heart Study.RESULTS. Compared with the counterfactual scenario, boys and girls who were aged 2 to 7 in the 1988–1994 National Health and Nutrition Examination Survey gained, on average, an excess of 0.43 kg/year over the 10-year period. Assuming that 3500 kcal leads to an average of 1-lb weight gain as fat, our results suggest that a reduction in the energy gap of 110–165 kcal/day could have prevented this increase. Among overweight adolescents aged 12 to 17 in 1999–2002, results indicate an average energy imbalance ranging from 678 to 1017 kcal/day because of an excess of 26.5 kg accumulated over 10 years.CONCLUSIONS. Quantifying the energy imbalance responsible for recent changes in weight distribution among children can provide salient targets for population intervention. Consistent behavioral changes averaging 110 to 165 kcal/day may be sufficient to counterbalance the energy gap. Changes in excess dietary intake (eg, eliminating one sugar-sweetened beverage at 150 kcal per can) may be easier to attain than increases in physical activity levels (eg, a 30-kg boy replacing sitting for 1.9 hours with 1.9 hours walking for an extra 150 kcal). Youth at higher levels of weight gain will likely need changes in multiple behaviors and environments to close the energy gap.

OBJECTIVE. The purpose of this study was to examine whether depressive symptoms are predictive of subsequent sexual risk behavior in a national probability sample of US middle and high school students.METHODS. Sexually active, unmarried, middle and high school students (n = 4152) participated in home interviews in waves I and II of the National Longitudinal Study of Adolescent Health, at an ∼1-year interval. Associations between baseline depressive symptoms and sexual risk behaviors over the course of the following year were examined separately for boys and girls, adjusting for demographic variables, religiosity, same-sex attraction/behavior, sexual intercourse before age 10, and baseline sexual risk behavior.RESULTS. In adjusted models, boys and girls with high depressive symptom levels at baseline were significantly more likely than those with low symptom levels to report ≥1 of the examined sexual risk behaviors over the course of the 1-year follow-up period. For boys, high depressive symptom levels were specifically predictive of condom nonuse at last sex, birth control nonuse at last sex, and substance use at last sex; these results were similar to those of parallel analyses with a continuous depression measure. For girls, moderate depressive symptoms were associated with substance use at last sex, and no significant associations were found between high depressive symptom levels and individual sexual risk behaviors. Parallel analyses with the continuous depression measure found significant associations for condom nonuse at last sex, birth control nonuse at last sex, ≥3 sexual partners, and any sexual risk behavior.CONCLUSION. In this study, depressive symptoms predicted sexual risk behavior in a national sample of male and female middle and high school students over a 1-year period.

Background Nutrition and physical activity interventions have been effective in creating environmental changes in afterschool programs. However, accurate assessment can be time-consuming and expensive as initiatives are scaled up for optimal population impact. This study aims to determine the criterion validity of a simple, low-cost, practitioner-administered observational measure of afterschool physical activity, nutrition, and screen time practices and child behaviors. Methods Directors from 35 programs in three cities completed the Out-of-School Nutrition and Physical Activity Observational Practice Assessment Tool (OSNAP-OPAT) on five days. Trained observers recorded snacks served and obtained accelerometer data each day during the same week. Observations of physical activity participation and snack consumption were conducted on two days. Correlations were calculated to validate weekly average estimates from OSNAP-OPAT compared to criterion measures. Weekly criterion averages are based on 175 meals served, snack consumption of 528 children, and physical activity levels of 356 children. Results OSNAP-OPAT validly assessed serving water (r = 0.73), fruits and vegetables (r = 0.84), juice >4oz (r = 0.56), and grains (r = 0.60) at snack; sugary drinks (r = 0.70) and foods (r = 0.68) from outside the program; and children’s water consumption (r = 0.56) (all p

Objective: Early menarche is a risk factor for breast cancer. Since body composition influences age at menarche we decided to estimate the effects of a school-based intervention for the prevention of obesity on the initiation of menses in young girls. Methods: Ten schools were randomized to a modified curriculum or no curricular changes for 2 school-years. Data of 508 pre-menarcheal girls at baseline (age range: 10–13 years) were analyzed. Results: Girls attending an intervention school experienced menarche less frequently than girls attending control schools during the intervention period (intervention schools = 54%, control schools = 59%; RR = 0.76; 95% CI [0.66, 0.87]). Attending an intervention school was also associated with lower increase in BMI (−0.3 kg/m2; p = 0.003), lower gains in triceps skinfold thickness (−1.5 mm; p = 0.007), decreased television viewing (−0.6 h/day; p