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Competing Interests: Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Background: Calorie menu labeling is a policy that requires food establishments to post the calories on menu offerings to encourage healthy food choice. Calorie labeling has been implemented in the United States since May 2018 per the Affordable Care Act, but to the best of our knowledge, no studies have evaluated the relationship between calorie labeling and meal purchases since nationwide implementation of this policy. Our objective was to investigate the relationship between calorie labeling and the calorie and nutrient content of purchased meals after a fast food franchise began labeling in April 2017, prior to the required nationwide implementation, and after nationwide implementation of labeling in May 2018, when all large US chain restaurants were required to label their menus., Methods and Findings: We obtained weekly aggregated sales data from 104 restaurants that are part of a fast food franchise for 3 national chains in 3 US states: Louisiana, Mississippi, and Texas. The franchise provided all sales data from April 2015 until April 2019. The franchise labeled menus in April 2017, 1 year prior to the required nationwide implementation date of May 2018 set by the US Food and Drug Administration. We obtained nutrition information for items sold (calories, fat, carbohydrates, protein, saturated fat, sugar, dietary fiber, and sodium) from Menustat, a publicly available database with nutrition information for items offered at the top revenue-generating US restaurant chains. We used an interrupted time series to find level and trend changes in mean weekly calorie and nutrient content per transaction after franchise and nationwide labeling. The analytic sample represented 331,776,445 items purchased across 67,112,342 transactions. Franchise labeling was associated with a level change of -54 calories/transaction (95% confidence interval [CI]: -67, -42, p < 0.0001) and a subsequent 3.3 calories/transaction increase per 4-week period (95% CI: 2.5, 4.1, p < 0.0001). Nationwide implementation was associated with a level decrease of -82 calories/transaction (95% CI: -88, -76, p < 0.0001) and a subsequent -2.1 calories/transaction decrease per 4-week period (95% CI: -2.9, -1.3, p < 0.0001). At the end of the study, the model-based predicted mean calories/transaction was 4.7% lower (change = -73 calories/transaction, 95% CI: -81, -65), and nutrients/transaction ranged from 1.8% lower (saturated fat) to 7.0% lower (sugar) than what we would expect had labeling not been implemented. The main limitations were potential residual time-varying confounding and lack of individual-level transaction data., Conclusions: In this study, we observed that calorie labeling was associated with small decreases in mean calorie and nutrient content of fast food meals 2 years after franchise labeling and nearly 1 year after implementation of labeling nationwide. These changes imply that calorie labeling was associated with small improvements in purchased meal quality in US chain restaurants., Competing Interests: The authors have declared that no competing interests exist.

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., Competing Interests: The authors have declared that no competing interests exist.

The Healthy, Hunger-Free Kids Act of 2010 strengthened nutrition standards for meals and beverages provided through the National School Lunch, Breakfast, and Smart Snacks Programs, affecting fifty million children daily at 99,000 schools. The legislation's impact on childhood obesity is unknown. We tested whether the legislation was associated with reductions in child obesity risk over time using an interrupted time series design for 2003-18 among 173,013 youth in the National Survey of Children's Health. We found no significant association between the legislation and childhood obesity trends overall. For children in poverty, however, the risk of obesity declined substantially each year after the act's implementation, translating to a 47 percent reduction in obesity prevalence in 2018 from what would have been expected without the legislation. These results suggest that the Healthy, Hunger-Free Kids Act's science-based nutritional standards should be maintained to support healthy growth, especially among children living in poverty.

Ensuring students' access to safe drinking water at school is essential. However, many schools struggle with aging infrastructure and subsequent water safety problems and have turned to bottled water delivery systems. Little is known about whether such systems are feasible and effective in providing adequate student water access. This study was a mixed-methods investigation among six schools in an urban district in the U.S. with two types of water delivery systems: (1) tap water infrastructure, with updated water fountains and bottle fillers, and (2) bottled water coolers. We measured students' water consumption and collected qualitative data from students and teachers about their perceptions of school drinking water. Student water consumption was low-between 2.0 (SD: 1.4) ounces per student and 2.4 (SD: 1.1) ounces per student during lunch. Students and teachers reported substantial operational hurdles for relying on bottled water as a school's primary source of drinking water, including difficulties in stocking, cleaning, and maintaining the units. While students and teachers perceived newer bottle filler units positively, they also reported a distrust of tap water. Bottled water delivery systems may not be effective long-term solutions for providing adequate school drinking water access and robust efforts are needed to restore trust in tap water.

Background: 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., Methods: 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 to <30), moderate obesity (30 to <35), and severe obesity (≥35). We evaluated the accuracy of our approach using data from 1990 through 2010 to predict 2016 outcomes., Results: 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)., Conclusions: 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.)., (Copyright © 2019 Massachusetts Medical Society.)

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., (© 2019 The Obesity Society.)

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).

Objective: To evaluate the potential cost-effectiveness of and stakeholder perspectives on a sugar-sweetened beverage (SSB) excise tax and a Supplemental Nutrition Assistance Program (SNAP) policy that would not allow SSB purchases in Maine, US., Design: A cost-effectiveness simulation model combined with stakeholder interviews., Setting: Maine, US., Participants: Microsimulation of the Maine population in 2015 and interviews with stakeholders (n = 14). Study conducted from 2013 to 2017., Main Outcome Measures: Health care cost savings, net costs, and quality-adjusted life-years (QALYs) from 2017 to 2027. Stakeholder positions on policies. Retail SSB cost and implementation cost data were collected., Analysis: Childhood Obesity Intervention Cost-Effectiveness Study project microsimulation model with uncertainty analysis to estimate cost-effectiveness. Thematic stakeholder interview coding., Results: Over 10 years, the SSB and SNAP policies were projected to reduce health care costs by $78.3 million (95% uncertainty interval [UI], $31.7 million-$185 million) and $15.3 million (95% UI, $8.32 million-$23.9 million), respectively. The SSB and SNAP policies were projected to save 3,560 QALYs (95% UI, 1,447-8,361) and 749 QALYs (95% UI, 415-1,168), respectively. Stakeholders were more supportive of SSB taxes than the SNAP policy because of equity concerns associated with the SNAP policy., Conclusions and Implications: Cost-effectiveness analysis provided evidence of potential health improvement and cost savings to state-level stakeholders weighing broader implementation considerations., (Copyright © 2019 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

An excise tax of 1 peso per liter on sugar-sweetened beverages was implemented in Mexico in 2014. We estimated the cost-effectiveness of this tax and an alternative tax scenario of 2 pesos per liter. We developed a cohort simulation model calibrated for Mexico to project the impact of the tax over ten years. The current tax is projected to prevent 239,900 cases of obesity, 39 percent of which would be among children. It could also prevent 61,340 cases of diabetes, lead to gains of 55,300 quality-adjusted life-years, and avert 5,840 disability-adjusted life-years. The tax is estimated to save $3.98 per dollar spent on its implementation. Doubling the tax to 2 pesos per liter would nearly double the cost savings and health impact. Countries with comparable conditions could benefit from implementing a similar tax.

Many children are not sufficiently physically active. This study uses a quasi-experimental design to evaluate whether participation in a before-school physical activity program called Build Our Kids' Success (BOKS) increases physical activity. Participants ( n  = 426) were students in Fall, 2016 enrolled in BOKS programming and matched non-BOKS control students from the same grades (Kindergarten-6) and schools in Massachusetts and Rhode Island. Analyses conducted in 2017 examined differences between children in BOKS versus controls in total daily steps, minutes of moderate-to-vigorous (MVPA), vigorous (VPA), and total physical activity (TPA) assessed via Fitbit Charge HR™ monitors. Additional analyses compared physical activity on program days and non-program days. Students (mean age = 8.6 y; 47% female, 58% White, Non-Hispanic) wore monitors an average of 21.7 h/day on 3.2 days during the school week. Compared with controls, on BOKS days, BOKS participants accumulated more steps (1147, 95% confidence interval (CI): 583-1712, P  < 0.001), MVPA minutes (13.4, 95% CI: 6.6-20.3, P < 0.001), and VPA minutes (4.0, 95% CI: 1.2-6.7, P  = 0.005). Across all school days, BOKS participants accumulated more total steps than controls (716, 95% CI: 228-1204, P  = 0.004). Compared to days without BOKS programming, on BOKS days, BOKS participants accumulated more steps (1153; 95% CI: 841-1464, P  < 0.001) and daily minutes of MVPA (8.8, 95% CI: 5.3-12.2, P < 0.001), VPA (3.0, 95% CI: 1.6-4.5, P < 0.001), and TPA (20.8, 95% CI: 13.6-28.1, P < 0.001). BOKS programming promotes engagement in additional accumulated steps during the school week and physical activity on days that students participate. Clinical Trial Registration: www.ClinicalTrials.gov, NCT03403816, available at: https://clinicaltrials.gov/ct2/show/NCT03403816?term=NCT03403816&rank=1.

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., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Physical activity engagement during childhood is associated with positive health outcomes in adulthood. Exercise and sport science research links physical activity enjoyment with physical activity adoption and maintenance, among other positive health behaviors. However, public health researchers rarely measure enjoyment or discuss its role in interventions or theory. In this paper, we present the rationale for bringing enjoyment to the forefront of public health dialogue and action to increase physical activity in children and across the life course. We outline five potential explanations for the lack of physical activity enjoyment research in public health, and offer solutions and action steps for each. Enjoyment research has the potential to improve people's health by working on multiple levels, from individuals to schools to public sectors, and could have positive implications for various health behaviors.

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: Our aim was 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: This was a secondary analysis of a group-randomized controlled trial., Participants/setting: Data were collected from 400 children at 20 afterschool sites in Boston, MA 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 3-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 2 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 oz/snack, 95% CI -1.11 to -0.12), beverage calories (-29.1 kcal/snack, 95% CI -40.2 to 18.0), foods with trans fats (-0.12 servings/snack, 95% CI -0.19 to -0.04), total calories (-47.7 kcal/snack, 95% CI -68.2 to -27.2), and increases in consumption of whole grains (0.10 servings/snack, 95% CI 0.02 to 0.18) compared to controls. In post-hoc analyses, sites with on-site foodservice had significant improvements for all outcomes (P<0.001), with no effect for sites with satellite foodservice., Conclusions: Results demonstrate that an afterschool intervention can improve children's dietary snack consumption, particularly at sites with on-site foodservice., (Copyright © 2018 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Objective: Financial conflicts of interest involving the food industry have been reported to bias nutrition studies. However, some have hypothesized that independently funded studies may be biased if the authors have strong a priori beliefs about the healthfulness of a food product ('white hat bias'). The extent to which each source of bias may affect the scientific literature has not been examined. We aimed to explore this question with research involving sugar-sweetened beverages (SSB) as a test case, focusing on a period during which scientific consensus about the adverse health effects of SSB emerged from uncertainty., Design: PubMed search of worldwide literature was used to identify articles related to SSB and health risks published between 2001 and 2013. Financial relationships and article conclusions were classified by independent groups of co-investigators. Associations were explored by Fischer's exact tests and regression analyses, controlling for covariates., Results: A total of 133 articles published in English met inclusion criteria. The proportion of industry-related scientific studies decreased significantly with time, from approximately 30 % at the beginning of the study period to <5 % towards the end (P=0·003). A 'strong' or 'qualified' scientific conclusion was reached in 82 % of independent v. 7 % of industry-related SSB studies (P<0·001). Industry-related studies were overwhelmingly more likely to reach 'weak/null' conclusions compared with independent studies regarding the adverse effects of SSB consumption on health (OR=57·30, 95 % CI 7·12, 461·56)., Conclusion: Industry-related research during a critical period appears biased to underestimate the adverse health effects of SSB, potentially delaying corrective public health action.

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.

Background: 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., Methods: 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., Results: 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., Conclusions: 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.).

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., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Objectives: To evaluate whether differences in tap water and other beverage intake explain differences in inadequate hydration among US adults by race/ethnicity and income., Methods: We estimated the prevalence of inadequate hydration (urine osmolality ≥ 800 mOsm/kg) by race/ethnicity and income of 8258 participants aged 20 to 74 years in the 2009 to 2012 National Health and Nutrition Examination Survey. Using multivariable regression models, we estimated associations between demographic variables, tap water intake, and inadequate hydration., Results: The prevalence of inadequate hydration among US adults was 29.5%. Non-Hispanic Blacks (adjusted odds ratio [AOR] = 1.44; 95% confidence interval [CI] = 1.17, 1.76) and Hispanics (AOR = 1.42; 95% CI = 1.21, 1.67) had a higher risk of inadequate hydration than did non-Hispanic Whites. Lower-income adults had a higher risk of inadequate hydration than did higher-income adults (AOR = 1.23; 95% CI = 1.04, 1.45). Differences in tap water intake partially attenuated racial/ethnic differences in hydration status. Differences in total beverage and other fluid intake further attenuated sociodemographic disparities., Conclusions: Racial/ethnic and socioeconomic disparities in inadequate hydration among US adults are related to differences in tap water and other beverage intake. Policy action is needed to ensure equitable access to healthy beverages.

Objective: To examine the extent to which a clinical intervention resulted in reduced BMI z scores among 2- to 12-year-old children compared to routine practice (treatment as usual [TAU])., Methods: The Massachusetts Childhood Obesity Research Demonstration (MA-CORD) project is a multifaceted initiative to prevent childhood obesity among low-income children. At the federally qualified community health centers (FQHCs) of two communities (Intervention Site #1 and #2), the following were 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 = 2,286), children in Intervention Site #2 (n = 1,368) had a significant decline in BMI z scores following the start of the intervention (-0.16 units/y; 95% confidence interval: -0.21 to -0.12). No evidence of an effect was found 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., (© 2017 The Obesity Society.)

Background: More than 14 million children in the United States attend summer camp annually, yet little is known about the food environment in day camps., Objective: Our aim was to describe the nutritional quality of meals served to, brought by, and consumed by children attending summer day camps serving meals and snacks, and to describe camp water access., Design: We conducted a cross-sectional study., Participants/settings: Participants were 149 children attending five summer camps in Boston, MA, in 2013., Main Outcome Measures: Foods and beverages served were observed for 5 consecutive days. For 2 days, children's dietary intake was directly observed using a validated protocol. Outcome measures included total energy (kilocalories) and servings of different types of foods and beverages served and consumed during breakfast, lunch, and snack., Statistical Analyses Performed: Mean total energy, trans fats, sodium, sugar, and fiber served per meal were calculated across the camps, as were mean weekly frequencies of serving fruits, vegetables, meat/meat alternates, grains, milk, 100% juice, sugar-sweetened beverages, whole grains, red/highly processed meats, grain-based desserts, and salty snacks. Mean consumption was calculated per camper per day., Results: Camps served a mean (standard deviation) of 647.7 (134.3) kcal for lunch, 401.8 (149.6) kcal for breakfast, and 266.4 (150.8) kcal for snack. Most camps served red/highly processed meats, salty snacks, and grain-based desserts frequently, and rarely served vegetables or water. Children consumed little (eg, at lunch, 36.5% of fruit portions, 35.0% of meat/meat alternative portions, and 37.6% of milk portions served) except for salty snacks (66.9% of portions) and grain-based desserts (64.1% of portions). Sugar-sweetened beverages and salty snacks were frequently brought to camp. One-quarter of campers drank nothing throughout the entire camp day., Conclusions: The nutritional quality of foods and beverages served at summer day camps could be improved. Future studies should assess barriers to consumption of healthy foods and beverages in these settings., (Copyright © 2017 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the extent to which a Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) intervention improved BMI z scores and obesity-related behaviors among children age 2 to 4 years., Methods: In two Massachusetts communities, practice changes in WIC were implemented as part of the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) initiative to prevent obesity among low-income children. One WIC program was the comparison. Changes in BMI z scores pre and post intervention and prevalence of obesity-related behaviors of WIC participants were assessed. Linear mixed models were used to examine BMI z score change, and logistic regression models were used to examine changes in obesity-related behaviors in each intervention site versus comparison over 2 years., Results: WIC-enrolled children in both intervention sites (vs. comparison) had improved sugar-sweetened beverage consumption and sleep duration. Compared to the comparison WIC program (n = 626), no differences were observed in BMI z score among children in Intervention Site #1 (n = 198) or #2 (n = 637). In sensitivity analyses excluding Asian children, a small decline was observed in BMI z score (-0.08 units/y [95% confidence interval: -0.14 to -0.02], P = 0.01) in Intervention Site #2 versus comparison., Conclusions: Among children enrolled in WIC, the MA-CORD intervention was associated with reduced prevalence of obesity risk factors in both intervention communities and a small improvement in BMI z scores in one of two intervention communities in non-Asian children., (© 2017 The Obesity Society.)

Background: 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., Objective: 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., Methods: 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., Results: 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)., Conclusion: High Five for Kids, a primarily clinical-based intervention, did not affect BMI z-scores or obesity-related behaviours after 2 years., (© 2016 World Obesity Federation.)

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., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Participation in recommended levels of physical activity promotes a healthy body weight and reduced chronic disease risk. To inform investment in prevention initiatives, we simulate the national implementation, impact on physical activity and childhood obesity and associated cost-effectiveness (versus the status quo) of six recommended strategies that can be applied throughout childhood to increase physical activity in US school, afterschool and childcare settings. In 2016, the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES) systematic review process identified six interventions for study. A microsimulation model estimated intervention outcomes 2015-2025 including changes in mean MET-hours/day, intervention reach and cost per person, cost per MET-hour change, ten-year net costs to society and cases of childhood obesity prevented. First year reach of the interventions ranged from 90,000 youth attending a Healthy Afterschool Program to 31.3 million youth reached by Active School Day policies. Mean MET-hour/day/person increases ranged from 0.05 MET-hour/day/person for Active PE and Healthy Afterschool to 1.29 MET-hour/day/person for the implementation of New Afterschool Programs. Cost per MET-hour change ranged from cost saving to $3.14. Approximately 2500 to 110,000 cases of children with obesity could be prevented depending on the intervention implemented. All of the six interventions are estimated to increase physical activity levels among children and adolescents in the US population and prevent cases of childhood obesity. Results do not include other impacts of increased physical activity, including cognitive and behavioral effects. Decision-makers can use these methods to inform prioritization of physical activity promotion and obesity prevention on policy agendas., (Copyright © 2016. Published by Elsevier Inc.)

Introduction: Although 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., Methods: The 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., Results: MA-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., Conclusion: Future 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.

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., (Copyright © 2016 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

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 body mass index (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 US 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=9377; 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 to 2012 NSCH.

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.

Purpose: Providing children and youth with safe, adequate drinking water access during school is essential for health. This study used objectively measured data to investigate the extent to which schools provide drinking water access that meets state and federal policies., Methods: We visited 59 middle and high schools in Massachusetts during spring 2012. Trained research assistants documented the type, location, and working condition of all water access points throughout each school building using a standard protocol. School food service directors (FSDs) completed surveys reporting water access in cafeterias. We evaluated school compliance with state plumbing codes and federal regulations and compared FSD self-reports of water access with direct observation; data were analyzed in 2014., Results: On average, each school had 1.5 (standard deviation: .6) water sources per 75 students; 82% (standard deviation: 20) were functioning and fewer (70%) were both clean and functioning. Less than half of the schools met the federal Healthy Hunger-Free Kids Act requirement for free water access during lunch; 18 schools (31%) provided bottled water for purchase but no free water. Slightly over half (59%) met the Massachusetts state plumbing code. FSDs overestimated free drinking water access compared to direct observation (96% FSD reported vs. 48% observed, kappa = .07, p = .17)., Conclusions: School drinking water access may be limited. In this study, many schools did not meet state or federal policies for minimum student drinking water access. School administrative staff may not accurately report water access. Public health action is needed to increase school drinking water access., (Copyright © 2016 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

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.

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.

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 < .001), vigorous physical activity minutes in bouts (4.1; 95% CI, 2.7-5.6; P < .001), and total accelerometer counts per day (16,894; 95% CI, 5101-28,686; 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.

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., (Project HOPE—The People-to-People Health Foundation, Inc.)

Policy makers seeking to reduce childhood obesity must prioritize investment in treatment and primary prevention. We estimated the cost-effectiveness of seven interventions high on the obesity policy agenda: a sugar-sweetened beverage excise tax; elimination of the tax subsidy for advertising unhealthy food to children; restaurant menu calorie labeling; nutrition standards for school meals; nutrition standards for all other food and beverages sold in schools; improved early care and education; and increased access to adolescent bariatric surgery. We used systematic reviews and a microsimulation model of national implementation of the interventions over the period 2015-25 to estimate their impact on obesity prevalence and their cost-effectiveness for reducing the body mass index of individuals. In our model, three of the seven interventions--excise tax, elimination of the tax deduction, and nutrition standards for food and beverages sold in schools outside of meals--saved more in health care costs than they cost to implement. Each of the three interventions prevented 129,000-576,000 cases of childhood obesity in 2025. Adolescent bariatric surgery had a negligible impact on obesity prevalence. Our results highlight the importance of primary prevention for policy makers aiming to reduce childhood obesity., (Project HOPE—The People-to-People Health Foundation, Inc.)

Introduction: Intake of sugar-sweetened beverages (SSBs) is associated with negative health effects. Access to healthy beverages may be promoted by policies such as the Healthy Beverage Executive Order (HBEO) established by former Boston mayor Thomas M. Menino, which directed city departments to eliminate the sale of SSBs on city property. Implementation consisted of "traffic-light signage" and educational materials at point of purchase. This study evaluates the impact of the HBEO on changes in beverage availability., Methods: Researchers collected data on price, brand, and size of beverages for sale in spring 2011 (899 beverage slots) and for sale in spring 2013, two years after HBEO implementation (836 beverage slots) at access points (n = 31) at city agency locations in Boston. Nutrient data, including calories and sugar content, from manufacturer websites were used to determine HBEO beverage traffic-light classification category. We used paired t tests to examine change in average calories and sugar content of beverages and the proportion of beverages by traffic-light classification at access points before and after HBEO implementation., Results: Average beverage sugar grams and calories at access points decreased (sugar, -13.1 g; calories, -48.6 kcal; p<.001) following the implementation of the HBEO. The average proportion of high-sugar ("red") beverages available per access point declined (-27.8%, p<.001). Beverage prices did not change over time. City agencies were significantly more likely to sell only low-sugar beverages after the HBEO was implemented (OR = 4.88; 95% CI, 1.49-16.0)., Discussion: Policies such as the HBEO can promote community-wide changes that make healthier beverage options more accessible on city-owned properties.

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 < .001). The intervention was associated with a 0.58-ounce increase in water intake across all students (P < .001). Without cups, children were observed drinking 2.4 (SE = 0.08) ounces of water from fountains; with cups, 5.2 (SE = 0.2) ounces. The percentage of intervention students observed with sugar-sweetened beverages declined (-3.3%; P < .005)., 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.

Background/objectives: Worse educational outcomes for obese children regardless of academic ability may begin early in the life course. This study tested whether an increase in children's relative weight predicted lower teacher- and child-perceived academic ability even after adjusting for standardized test scores., Subjects/methods: Three thousand three hundred and sixty-two children participating in the Early Childhood Longitudinal Study-Kindergarten Cohort were studied longitudinally from fifth to eighth grade. Heights, weights, standardized test scores in maths and reading, and teacher and self-ratings of ability in maths and reading were measured at each wave. Longitudinal, within-child linear regression models estimated the impact of a change in body mass index (BMI) z-score on change in normalized teacher and student ratings of ability in reading and maths, adjusting for test score., Results: A change in BMI z-score from fifth to eighth grade was not independently associated with a change in standardized test scores. However, adjusting for standardized test scores, an increasing BMI z-score was associated with significant reductions in teacher's perceptions of girls' ability in reading (-0.12, 95% confidence interval (CI): -0.23, -0.03, P=0.03) and boys' ability in math (-0.30, 95% CI: -0.43, -0.17, P<0.001). Among children who were overweight at fifth grade and increased in BMI z-score, there were even larger reductions in teacher ratings for boys' reading ability (-0.37, 95% CI: -0.71, -0.03, P=0.03) and in girls' self-ratings of maths ability (-0.47, 95% CI: -0.83, -0.11, P=0.01)., Conclusions: From fifth to eighth grade, increase in BMI z-score was significantly associated with worsening teacher perceptions of academic ability for both boys and girls, regardless of objectively measured ability (standardized test scores). Future research should examine potential interventions to reduce bias and promote positive school climate.

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.

Introduction: Child care facilities influence diet and physical activity, making them ideal obesity prevention settings. The purpose of this study is to quantify the health and economic impacts of a multi-component regulatory obesity policy intervention in licensed U.S. child care facilities., Methods: Two-year costs and BMI changes resulting from changes in beverage, physical activity, and screen time regulations affecting a cohort of up to 6.5 million preschool-aged children attending child care facilities were estimated in 2014 using published data. A Markov cohort model simulated the intervention's impact on changes in the U.S. population from 2015 to 2025, including short-term BMI effects and 10-year healthcare expenditures. Future outcomes were discounted at 3% annually. Probabilistic sensitivity analyses simulated 95% uncertainty intervals (UIs) around outcomes., Results: Regulatory changes would lead children to watch less TV, get more minutes of moderate and vigorous physical activity, and consume fewer sugar-sweetened beverages. Within the 6.5 million eligible population, national implementation could reach 3.69 million children, cost $4.82 million in the first year, and result in 0.0186 fewer BMI units (95% UI=0.00592 kg/m(2), 0.0434 kg/m(2)) per eligible child at a cost of $57.80 per BMI unit avoided. Over 10 years, these effects would result in net healthcare cost savings of $51.6 (95% UI=$14.2, $134) million. The intervention is 94.7% likely to be cost saving by 2025., Conclusions: Changing child care regulations could have a small but meaningful impact on short-term BMI at low cost. If effects are maintained for 10 years, obesity-related healthcare cost savings are likely., (Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Reducing sugar-sweetened beverage consumption through taxation is a promising public health response to the obesity epidemic in the U.S. This study quantifies the expected health and economic benefits of a national sugar-sweetened beverage excise tax of $0.01/ounce over 10 years., Methods: A cohort model was used to simulate the impact of the tax on BMI. Assuming ongoing implementation and effect maintenance, quality-adjusted life-years gained and disability-adjusted life-years and healthcare costs averted were estimated over the 2015-2025 period for the 2015 U.S., Population: Costs and health gains were discounted at 3% annually. Data were analyzed in 2014., Results: Implementing the tax nationally would cost $51 million in the first year. The tax would reduce sugar-sweetened beverage consumption by 20% and mean BMI by 0.16 (95% uncertainty interval [UI]=0.06, 0.37) units among youth and 0.08 (95% UI=0.03, 0.20) units among adults in the second year for a cost of $3.16 (95% UI=$1.24, $8.14) per BMI unit reduced. From 2015 to 2025, the policy would avert 101,000 disability-adjusted life-years (95% UI=34,800, 249,000); gain 871,000 quality-adjusted life-years (95% UI=342,000, 2,030,000); and result in $23.6 billion (95% UI=$9.33 billion, $54.9 billion) in healthcare cost savings. The tax would generate $12.5 billion in annual revenue (95% UI=$8.92, billion, $14.1 billion)., Conclusions: The proposed tax could substantially reduce BMI and healthcare expenditures and increase healthy life expectancy. Concerns regarding the potentially regressive tax may be addressed by reduced obesity disparities and progressive earmarking of tax revenue for health promotion., (Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: The childhood obesity epidemic continues in the U.S., and fiscal crises are leading policymakers to ask not only whether an intervention works but also whether it offers value for money. However, cost-effectiveness analyses have been limited. This paper discusses methods and outcomes of four childhood obesity interventions: (1) sugar-sweetened beverage excise tax (SSB); (2) eliminating tax subsidy of TV advertising to children (TV AD); (3) early care and education policy change (ECE); and (4) active physical education (Active PE)., Methods: Cost-effectiveness models of nationwide implementation of interventions were estimated for a simulated cohort representative of the 2015 U.S. population over 10 years (2015-2025). A societal perspective was used; future outcomes were discounted at 3%. Data were analyzed in 2014. Effectiveness, implementation, and equity issues were reviewed., Results: Population reach varied widely, and cost per BMI change ranged from $1.16 (TV AD) to $401 (Active PE). At 10 years, assuming maintenance of the intervention effect, three interventions would save net costs, with SSB and TV AD saving $55 and $38 for every dollar spent. The SSB intervention would avert disability-adjusted life years, and both SSB and TV AD would increase quality-adjusted life years. Both SSB ($12.5 billion) and TV AD ($80 million) would produce yearly tax revenue., Conclusions: The cost effectiveness of these preventive interventions is greater than that seen for published clinical interventions to treat obesity. Cost-effectiveness evaluations of childhood obesity interventions can provide decision makers with information demonstrating best value for the money., (Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2015 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

We conducted a systematic review and meta-analysis evaluating the relationship between menu calorie labeling and calories ordered or purchased in the PubMed, Web of Science, PolicyFile, and PAIS International databases through October 2013. Among 19 studies, menu calorie labeling was associated with a -18.13 kilocalorie reduction ordered per meal with significant heterogeneity across studies (95% confidence interval = -33.56, -2.70; P = .021; I(2) = 61.0%). However, among 6 controlled studies in restaurant settings, labeling was associated with a nonsignificant -7.63 kilocalorie reduction (95% confidence interval = -21.02, 5.76; P = .264; I(2) = 9.8%). Although current evidence does not support a significant impact on calories ordered, menu calorie labeling is a relatively low-cost education strategy that may lead consumers to purchase slightly fewer calories. These findings are limited by significant heterogeneity among nonrestaurant studies and few studies conducted in restaurant settings.

Background: 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 and <95th percentile), and healthy weight (≥50th and <85th percentile)., Methods: 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)., Results: 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 (p<0.001)., Conclusions: 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.