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Supplemental Security Income (SSI) expansions for disabled children in the early 1990s provoked criticism that eligibility criteria were too lax and motivated the subsequent retraction of benefits for many children. However, little evidence exists on whether the clinical needs of SSI children declined during this period. The authors used Medicaid data to examine changes in average expenditures between 1989 and 1992, using an Aid to Families with Dependent Children (AFDC) comparison group to control for confounding time trends (e.g., in access). Results showed declines in average expenditures in Georgia and Tennessee but increases in California and Michigan, which are thought to have started with more liberal eligibility policies.

OBJECTIVES: To examine social disparities and behavioral correlates of overweight and obesity over time among college students. METHODS: Multilevel analyses of BMI, physical activity, and television viewing from 2 representative surveys of US college students (n=24,613). RESULTS: Overweight and obesity increased over time and were higher among males, African Americans, and students of lower socioeconomic position and lower among Asians. Television viewing and in activity were associated with obesity, and disparities in these behaviors partially accounted for excess weight among African Americans. CONCLUSIONS: Social disparities in overweight and obesity exist among college students. Promoting physical activity and reducing television viewing may counteract increasing trends. [ABSTRACT FROM AUTHOR]

Children and youth with perinatally acquired HIV infection are living longer because of improved drug therapies, but they may be at risk for poor health-related quality of life (HRQOL) outcomes because of nondisease factors. Families affected by HIV disease are more likely to experience major negative life events (NLEs). The effects of NLEs, shown to impact HRQOL in children with other chronic illnesses, have not been evaluated in children with HIV infection. The primary objective of this study was to determine if NLEs occurring in the previous 12 months were associated with increased risk for poorer outcomes in three measures of HRQOL (health perception, behavior problems, and symptom distress) in a cohort of children and youth with HIV infection. The authors conducted a cross-sectional analysis of data determined in 1999 from 1,018 children and youth 5 to 21 years of age enrolled in a longitudinal follow-up study. Multivariate logistic regressions estimated the odds for worse HRQOL outcomes. Children and youth with one or more NLEs had significantly lower health perceptions, more behavior problems, and greater symptom distress than children with no reported NLEs. The occurrence of NLEs may present a significant nondisease risk for diminished HRQOL among children and youth challenged by HIV disease. Nursing efforts to support these younger patients and their families sustaining major family disruption caused by NLEs may improve overall health outcomes in this vulnerable population. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This analysis tested the relation between dieting frequency and risk of smoking initiation in a longitudinal sample of adolescents. METHODS: From 1995 to 1997, 1295 middle school girls and boys participated in a nutrition and physical activity intervention study. The prospective association between dieting frequency at baseline and smoking initiation 2 years later was tested. RESULTS: Compared with girls who reported no dieting at baseline, girls who dieted up to once per week had 2 times the adjusted odds of becoming smokers (odds ratio = 2.0; 95% confidence interval = 1.1, 3.5), and girls who dieted more often had 4 times the adjusted odds of becoming smokers (odds ratio = 3.9; 95% confidence interval = 1.5, 10.4). CONCLUSIONS: Dieting among girls may exacerbate risk of initiating smoking, with increasing risk with greater dieting frequency. [ABSTRACT FROM AUTHOR]

Context: With the success of zidovudine chemoprophylaxis for prevention of perinatal transmission of the human immunodeficiency virus (HIV), an increasing number of HIV-exposed but uninfected children will have in utero exposure to zidovudine and other antiretroviral drugs.Objective: To evaluate the long-term effects of in utero exposure to zidovudine vs placebo among a randomized cohort of uninfected children.Design: Prospective cohort study based on data collected during Pediatric AIDS Clinical Trials Group Protocol 076, a perinatal zidovudine HIV prevention trial, and Protocol 219, a long-term observational protocol.Setting: Pediatric research clinics in the United States.Patients: Two hundred thirty-four uninfected children born to 230 HIV-infected women enrolled in Protocol 076 and followed up through February 28, 1997, in Protocol 219 (122 in the zidovudine group and 112 in the placebo group).Main Outcome Measures: Physical growth measurements, immunologic parameters, cognitive/developmental function, occurrence of neoplasms, and mortality data assessed every 6 months for children younger than 24 months and yearly thereafter or as clinically indicated. Baseline echocardiogram and funduscopic evaluations were collected before 36 months of age.Results: Median age of children at time of last follow-up visit was 4.2 years (range, 3.2-5.6 years). There were no significant differences between children exposed to zidovudine and those who received placebo in terms of sequential data on lymphocyte subsets; weight, height, and head circumference z scores; and cognitive/developmental function. No deaths or malignancies occurred. Two children (both exposed to zidovudine) are being followed up for abnormal, unexplained ophthalmic findings. One child exposed to zidovudine had a mild cardiomyopathy on echocardiogram at the age of 48 months; the child is clinically asymptomatic.Conclusions: No adverse effects were observed in HIV-uninfected children with in utero and neonatal exposure to zidovudine followed up for as long as 5.6 years. Continued prospective evaluations of children born to HIV-infected women who are exposed to antiretroviral or immunotherapeutic agents are critical to assess the long-term safety of interventions that prevent perinatal HIV transmission. [ABSTRACT FROM AUTHOR]

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) approximately 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. [ABSTRACT FROM AUTHOR]

Many young people do not meet recommended levels of participation in physical activity. Neighborhoods may play a role in supporting healthy behavior via social and physical environmental features. We examine whether neighborhood-levels of social cohesion, range of youth services and educational attainment were associated with participation in recreational programs and general physical activity among young people. Hierarchical regression analyses were carried out using data from 680 young people (ages 11-15 years at baseline) participating in the Project on Human Development in Chicago Neighborhoods. The participants' primary caregiver reported recreational program participation at baseline and self-reported general physical activity were assessed at follow-up 2-3 years later. Neighborhood-level characteristics were obtained from census data and via a community survey. Neighborhood social cohesion was inversely associated with participation in recreational programs at baseline, controlling for availability of neighborhood services for youth, neighborhood education status, race/ethnicity, individual-level parental education, overweight status, sex, and age. Residing in an area with greater social cohesion was directly associated with frequency of reported general physical activity, independent of previously reported participation in recreational programs and other neighborhood and individual-level covariates. The present findings suggest that neighborhood social cohesion influences participation in physical activity. [ABSTRACT FROM AUTHOR]

Background: Although interventions to change nutrition policies, systems, and environments (PSE) for children are generally cost-effective for preventing childhood obesity, existing evidence suggests that nutrition education curricula, without accompanying PSE changes, are more commonly implemented., Objective: Estimate the societal costs and potential for cost-effectiveness of three nutrition education curricula frequently implemented in U.S. public schools for childhood obesity prevention., Methods: In 2021, we searched for nutrition education curricula in the SNAP-Ed Toolkit, a catalogue of interventions for obesity prevention coordinated by the federal government. Standard costing methodologies estimated the societal costs from 2023-2032 of nationwide implementation of each identified curriculum. Using the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) microsimulation model, which projects the costs, healthcare costs saved, and cases of obesity prevented for childhood obesity prevention interventions, we conducted threshold analyses for each curriculum, estimating the cost per quality-adjusted life year (QALY) for a range of hypothetical effects on child body mass index (BMI) to determine how large of an effect each curriculum would need to have to meet a cost-effectiveness threshold of $150,000 per QALY., Results: Three nutrition education curricula without PSE were identified from SNAP-Ed; none had evidence of an impact on obesity risk. From 2023 to 2032, the estimated implementation costs of the curricula nationwide ranged from $1.80 billion (95% UI: $1.79-$1.82 billion) to $3.48 billion (95% UI: $3.44-$3.51 billion). Each curriculum would have to reduce average child BMI by 0.10 kg/m 2 or more-an effect size that has not been reported by any of the three curricula, or by more comprehensive existing prevention programs-to be considered cost-effective at this threshold., Conclusions: SNAP-Ed-endorsed nutrition education curricula alone are unlikely to be cost-effective for preventing childhood obesity. Continued efforts to implement interventions with strong evidence for effectiveness, including PSE approaches, are needed., Competing Interests: Declaration of Competing Interest ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors have no conflicts to disclose., (Copyright © 2024 American Society for Nutrition. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study is to estimate health-related quality of life (HRQoL) by continuous BMI by age, sex, and demographic group in the United States., Methods: We estimated HRQoL (overall and by domain) by continuous BMI using SF-6D (Short-Form Six-Dimension) data from 182,778 respondents ages 18 years and older from the repeated cross-sectional Medical Expenditure Panel Survey (MEPS) 2008 to 2016. We adjusted for BMI self-report bias and for potential confounding between BMI and HRQoL., Results: We found an inverse J-shaped curve of HRQoL by BMI, with lower values for female individuals and the highest health utilities occurring at BMI of 20.4 kg/m 2 (95% CI: 20.32-20.48) for female individuals and 26.5 kg/m 2 (95% CI: 26.45-26.55) for male individuals. By BMI category, excess weight contributed to HRQoL loss of 0.0349 for obesity overall, rising to 0.0724 for class III obesity. By domain, pain was the largest cause of HRQoL loss for obesity (26%), followed by role limitations (22%)., Conclusions: HRQoL is lower for people with excess body weight across a broad range of ages and BMI levels, especially at high levels of BMI, with pain being the largest driver of HRQoL loss. 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., (© 2024 The Obesity Society.)

Introduction: The US has required chain food establishments-including supermarkets-to display calorie labels on prepared (i.e., ready-to-eat) foods since 2018. Implementation of this supermarket calorie labeling policy reduced purchases of prepared foods from supermarkets, but it remains unknown whether the policy is cost-effective., Methods: In 2023-2024, this study applied the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) microsimulation model to estimate the effects of the supermarket calorie labeling policy on health, costs, and cost-effectiveness over 10 years (2018-2027) for the US population. The model projected benefits overall and among racial, ethnic, and income subgroups. Sensitivity analyses varied assumptions about the extent to which consumers replace calorie reductions from prepared foods with calories from other sources (i.e., caloric compensation)., Results: From 2018-2027, the supermarket calorie labeling policy was projected to save $348 million in healthcare costs (95% Uncertainty Interval [UI]: $263-426 million), prevent 21,700 cases of obesity (95% UI: 18,200-25,400), including 3,890 cases of childhood obesity (95% UI: 2,680-5,120), and lead to 15,100 quality-adjusted life years (QALYs) gained across the US population (95% UI: 10,900-20,500). The policy was projected to prevent cases of obesity and childhood obesity across all racial, ethnic, and income groups. The policy was projected to be cost-saving when assuming low and moderate caloric compensation and cost-effective when assuming very high caloric compensation., Conclusions: A policy requiring calorie labels on prepared foods in supermarkets was projected to be cost-saving or cost-effective and lead to reductions in obesity across all racial, ethnic, and income groups., Competing Interests: Declaration of competing Interest No financial disclosures have been reported by the authors of this paper., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Amid national efforts to align priorities for nutrition and food assistance programs, little is known about the implementation of community-led efforts for children. This study aimed to estimate U.S. public school participation in weekend backpack programs (WBPs), to document program structure, and to consider characteristics of programs with more nutritious food offerings., Methods: The prevalence of WBP participation in 2022 was estimated using a state-stratified, random sample of n=413 public schools. Administrators from WBPs at 49 schools completed measures of implementation characteristics and nutritional quality of foods offered. In 2022-2023, using a multivariable-adjusted linear regression model, the authors explored the association between hypothesized implementation characteristics and Healthy Eating Index-2015 scores of foods provided., Results: Half of public schools (53.7%, 95% CI: 46.8%, 60.7%) in the national sample reported participating in WBPs. Many WBPs in the subsample were affiliated with anti-hunger organizations (41%), led by school counselors and volunteers (55%), and funded by grants (51%). WBPs spent an average of $0.56 (sd=$0.36) per item. Foods provided averaged a Healthy Eating Index-2015 score of 58.4 (sd=12.3), similar to children's average diets. About half of WBPs (41%) reported accessing nutrition resources., Conclusions: Despite the decentralized structure and absence of dedicated funding mechanisms, WBPs were common in our national sample of schools, suggesting widespread perceptions of unmet food needs and extensive efforts from community members to mitigate weekend hunger. Further research on food procurement methods and program impacts on child nutrition outcomes is needed to advance national priorities for nutrition and food security., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The evidence-based nutrition standards of the Healthy, Hunger-Free Kids Act of 2010 significantly improved school meal nutrition, yet little is known about how school food authorities (SFAs) were supported to translate the standards into practice in schools., Objective: This study tested whether or not 2 implementation supports, SFA receipt of training/technical assistance (TA) and purchase of new equipment, for implementing the nutrition standards were associated with the nutritional quality of school lunches., Design: This study used a cross-sectional design., Participants/setting: The study sample included 365 SFAs derived from the US Department of Agriculture's School Nutrition and Meal Cost Study (2014 to 2015 school year), the only national data of school nutrition environments since the Healthy, Hunger-Free Kids Act of 2010., Main Outcome Measures: Implementation supports included reported participation in training/TA and the purchase of new equipment between the 2012 to 2013 (year of policy adoption) and 2014 to 2015 school years. The primary outcome, nutritional quality of school lunches served, was defined as low/high Healthy Eating Index 2010 scores during the 2014 to 2015 school year. Secondary implementation supports included the number of areas covered by training/TA, the adequacy of training/TA, and the degree of implementation challenges., Statistical Analyses: Multivariable-adjusted logistic regression models assessed if receipt of implementation supports was associated with lunch Healthy Eating Index 2010 scores., Results: The median lunch Healthy Eating Index 2010 score was 81.7 (95% CI 80.4 to 82.9). Most SFAs (78.4%, 95% CI 72.0% to 85.0%) reported having participated in training/TA and one-third (33.8%, 95% CI 24.4% to 43.2%) reported having purchased new equipment-neither were associated with the odds of having higher Healthy Eating Index 2010 scores for lunches served at the time of data collection., Conclusions: Many SFAs accessed implementation supports to adopt the nutrition standards. Information on dose, quality, and nutrition-related impact of implementation supports using measures of change are needed to determine how best to support SFAs with implementation of new nutrition standards., (Copyright © 2024 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to project the cost-effectiveness of implementing the Healthy Weight Clinic (HWC), a primary care-based intervention for 6- to 12-year-old children with overweight or obesity, at federally qualified health centers (FQHCs) nationally., Methods: We estimated intervention costs from a health care sector and societal perspective and used BMI change estimates from the HWC trial. Our microsimulation of national HWC implementation among all FQHCs from 2023 to 2032 estimated cost per child and per quality-adjusted life year (QALY) gained and projected impact on obesity prevalence by race and ethnicity. Probabilistic sensitivity analyses assessed uncertainty around estimates., Results: National implementation is projected to reach 888,000 children over 10 years, with a mean intervention cost of $456 (95% uncertainty interval [UI]: $409-$506) per child to the health care sector and $211 (95% UI: $175-$251) to families (e.g., time participating). Assuming effect maintenance, national implementation could result in 2070 (95% UI: 859-3220) QALYs gained and save $14.6 million (95% UI: $5.6-$23.5 million) in health care costs over 10 years, yielding a net cost of $278,000 (95% CI: $177,000-$679,000) per QALY gained. We project greater reductions in obesity prevalence among Hispanic/Latino and Black versus White populations., Conclusions: The HWC is relatively low-cost per child and projected to reduce obesity disparities if implemented nationally in FQHCs., (© 2024 The Obesity Society.)

Background: Despite federal regulations limiting saturated fat and sodium levels on a weekly average basis, daily nutrient content of school meals in the United States is not regulated, leading to potential large fluctuations and intake well in excess of dietary recommendations., Objective: To assess the daily prevalence of potential public elementary school meal combinations that were high in saturated fat and sodium (using cutoffs based on the US Department of Agriculture weekly average reimbursable meal thresholds), and to identify saturated fat and sodium thresholds for entrées to limit full meals exceeding those cutoffs., Design: Cross-sectional., Participants and Setting: Four weeks of publicly available public elementary school (kindergarten through grade five) breakfast and lunch menus with associated nutrition data were collected from a national stratified random sample of 128 school districts during fall 2019., Main Outcome Measures: Percent of meal combinations exceeding the saturated fat and Target 1 sodium thresholds were calculated, as well as thresholds for saturated fat and sodium levels in breakfast and lunch entrées., Statistical Analyses: Descriptive statistics and logistic regression were used to examine the odds of alignment with sodium and saturated fat US Department of Agriculture thresholds., Results: The prevalence of elementary breakfast and lunch meal combinations that were high in sodium was on average 11% and 12.4%, respectively, and for saturated fat was 10.6% and 34%, respectively. Entrées above certain thresholds (≥400 and ≥1,000 mg sodium and ≥4.5 and ≥6 g saturated fat for breakfast and lunch, respectively) had a higher odds of producing a reimbursable meal that was high in sodium and saturated fat., Conclusions: There is widespread availability of high-saturated fat and sodium elementary school meal combinations on a daily basis. Daily thresholds, in addition to weekly nutrient thresholds, as well as limits on sodium and saturated fat for entrées, may therefore be needed to prevent daily excess intake of saturated fat and sodium among elementary students., (Copyright © 2024 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) prevents food insecurity and supports nutrition for more than 3 million low-income young children. Our objectives were to determine the cost-effectiveness of changes to WIC's nutrition standards in 2009 for preventing obesity and to estimate impacts on socioeconomic and racial/ethnic inequities., Methods: We conducted a cost-effectiveness analysis to estimate impacts from 2010 through 2019 of the 2009 WIC food package change on obesity risk for children aged 2 to 4 years participating in WIC. Microsimulation models estimated the cases of obesity prevented in 2019 and costs per quality-adjusted-life year gained., Results: An estimated 14.0 million 2- to 4-year old US children (95% uncertainty interval (UI), 13.7-14.2 million) were reached by the updated WIC nutrition standards from 2010 through 2019. In 2019, an estimated 62 700 (95% UI, 53 900-71 100) cases of childhood obesity were prevented, entirely among children from households with low incomes, leading to improved health equity. The update was estimated to cost $10 600 per quality-adjusted-life year gained (95% UI, $9760-$11 700). If WIC had reached all eligible children, more than twice as many cases of childhood obesity would have been prevented., Conclusions: Updates to WIC's nutrition standards for young children in 2009 were estimated to be highly cost-effective for preventing childhood obesity and contributed to reducing socioeconomic and racial/ethnic inequities in obesity prevalence. Improving nutrition policies for young children can be a sound public health investment; future research should explore how to improve access to them., (Copyright © 2024 by the American Academy of Pediatrics.)

Introduction: Calorie labeling of standard menu items has been implemented at large restaurant chains across the U.S. since 2018. The objective of this study was to evaluate the cost effectiveness of calorie labeling at large U.S. fast-food chains., Methods: This study evaluated the national implementation of calorie labeling at large fast-food chains from a modified societal perspective and projected its cost effectiveness over a 10-year period (2018-2027) using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model. Using evidence from over 67 million fast-food restaurant transactions between 2015 and 2019, the impact of calorie labeling on calorie consumption and obesity incidence was projected. Benefits were estimated across all racial, ethnic, and income groups. Analyses were performed in 2022., Results: Calorie labeling is estimated to be cost saving; prevent 550,000 cases of obesity in 2027 alone (95% uncertainty interval=518,000; 586,000), including 41,500 (95% uncertainty interval=33,700; 50,800) cases of childhood obesity; and save $22.60 in healthcare costs for every $1 spent by society in implementation costs. Calorie labeling is also projected to prevent cases of obesity across all racial and ethnic groups (range between 126 and 185 cases per 100,000 people) and all income groups (range between 152 and 186 cases per 100,000 people)., Conclusions: Calorie labeling at large fast-food chains is estimated to be a cost-saving intervention to improve long-term population health. Calorie labeling is a low-cost intervention that is already implemented across the U.S. in large chain restaurants., (Copyright © 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Amid the successes of local sugar-sweetened beverage (SSB) taxes, interest in state-wide policies has grown. This study evaluated the cost effectiveness of a hypothetical 2-cent-per-ounce excise tax in California and its implications for population health and health equity., Methods: Using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model, tax impacts on health, health equity, and cost effectiveness over 10 years in California were projected, both overall and stratified by race/ethnicity and income. Expanding on previous models, differences in the effect of intake of SSBs on weight by BMI category were incorporated. Costing was performed in 2020, and analyses were conducted in 2021-2022., Results: The tax is projected to save $4.55 billion in healthcare costs, prevent 266,000 obesity cases in 2032, and gain 114,000 quality-adjusted life years. Cost-effectiveness metrics, including cost/quality-adjusted life year gained, were cost saving. Spending on SSBs was projected to decrease by $33 per adult and $26 per child overall in the first year. Reductions in obesity prevalence for Black and Hispanic Californians were 1.8 times larger than for White Californians, and reductions for adults with lowest incomes (<130% Federal Poverty Level) were 1.4 times the reduction among those with highest incomes (>350% Federal Poverty Level). The tax is projected to save $112 in obesity-related healthcare costs per $1 invested., Conclusions: A state-wide SSB tax in California would be cost saving, lead to reductions in obesity and improvement in SSB-related health equity, and lead to overall improvements in population health. The policy would generate more than $1.6 billion in state tax revenue annually that can also be used to improve health equity., (Copyright © 2023 American Journal of Preventive Medicine. All rights reserved.)

We sought to identify evidence-based healthy weight, nutrition, and physical activity strategies related to obesity prevention in large local health department (LHD) Community Health Improvement Plans (CHIPs). We analyzed the content of the most recent, publicly available plans from 72 accredited LHDs serving a population of at least 500 000 people. We matched CHIP strategies to the County Health Rankings and Roadmaps' What Works for Health (WWFH) database of interventions. We identified 739 strategies across 55 plans, 62.5% of which matched a "WWFH intervention" rated for effectiveness on diet and exercise outcomes. Among the 20 most commonly identified WWFH interventions in CHIPs, 10 had the highest evidence for effectiveness while 4 were rated as likely to decrease health disparities according to WWFH. Future prioritization of strategies by health agencies could focus on strategies with the strongest evidence for promoting healthy weight, nutrition, and physical activity outcomes and reducing health disparities., Competing Interests: Conflicts of Interest: None., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: This study aimed to estimate the 10-year cost-effectiveness of school-based BMI report cards, a commonly implemented program for childhood obesity prevention in the US where student BMI is reported to parents/guardians by letter with nutrition and physical activity resources, for students in grades 3 to 7., Methods: A microsimulation model, using data inputs from evidence reviews on health impacts and costs, estimated: how many students would be reached if the 15 states currently measuring student BMI (but not reporting to parents/guardians) implemented BMI report cards from 2023 to 2032; how many cases of childhood obesity would be prevented; expected changes in childhood obesity prevalence; and costs to society., Results: BMI report cards were projected to reach 8.3 million children with overweight or obesity (95% uncertainty interval [UI]: 7.7-8.9 million) but were not projected to prevent any cases of childhood obesity or significantly decrease childhood obesity prevalence. Ten-year costs totaled $210 million (95% UI: $30.5-$408 million) or $3.33 per child per year with overweight or obesity (95% UI: $3.11-$3.68)., Conclusions: School-based BMI report cards are not cost-effective childhood obesity interventions. Deimplementation should be considered to free up resources for implementing effective programs., (© 2023 The Obesity Society.)

Introduction: Adults with severe obesity are at increased risk for poor metabolic health and may need more intensive clinical and community supports. The prevalence of severe obesity is underestimated from self-reported weight and height data. We examined severe obesity prevalence among US adults by sociodemographic characteristics and by state after adjusting for self-report bias., Methods: Using a validated bias-correction method, we adjusted self-reported body mass index (BMI) data from the 2020 Behavioral Risk Factor Surveillance System (BRFSS) by using measured data from the National Health and Nutrition Examination Survey. We compared bias-corrected prevalence of severe obesity (BMI ≥40) with self-reported estimates by sociodemographic characteristics and state., Results: Self-reported BRFSS data significantly underestimated the prevalence of severe obesity compared with bias-corrected estimates. In 2020, 8.8% of adults had severe obesity based on the bias-corrected estimates, whereas 5.3% of adults had severe obesity based on self-reported data. Women had a significantly higher prevalence of bias-corrected severe obesity (11.1%) than men (6.5%). State-level prevalence of bias-corrected severe obesity ranged from 5.5% (Massachusetts) to 13.2% (West Virginia). Based on bias-corrected estimates, 16 states had a prevalence of severe obesity greater than 10%, a level not seen in the self-reported estimates., Conclusion: Self-reported BRFSS data underestimated the overall prevalence of severe obesity by 40% (5.3% vs 8.8%). Accurate state-level estimates of severe obesity can help public health and health care decision makers prioritize and plan to implement effective prevention and treatment strategies for people who are at high risk for poor metabolic health.

Objective: The Mediterranean diet is associated with lower risks for type 2 diabetes (T2D) and cardiovascular disease in certain populations, although data among diverse groups are limited. This study evaluated cross-sectional and prospective associations between a novel South Asian Mediterranean-style (SAM) diet and cardiometabolic risk among US South Asian individuals., Methods: The study included 891 participants at baseline in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. Culturally relevant foods were grouped into nine categories to construct the SAM score. The study examined associations of this score with cardiometabolic risk factors and incident T2D., Results: At baseline, higher adherence to the SAM diet was associated with lower glycated hemoglobin (-0.43% ± 0.15% per 1-unit increase in SAM score; p = 0.004) and lower pericardial fat volume (-1.22 ± 0.55 cm 3 ; p = 0.03), as well as a lower likelihood of obesity (odds ratio [OR]: 0.88, 95% CI: 0.79-0.98) and fatty liver (OR: 0.82, 95% CI: 0.68-0.98). Over the follow-up (~5 years), 45 participants developed T2D; each 1-unit increase in SAM score was associated with a 25% lower odds of incident T2D (OR: 0.75, 95% CI: 0.59-0.95)., Conclusions: A greater intake of a SAM diet is associated with favorable adiposity measures and a lower likelihood of incident T2D., (© 2023 The Obesity Society.)

Objective: We sought to evaluate the use of behavioral economics approaches to promote the carrying of epinephrine auto-injectors (EAIs) among adolescents with food allergies. We hypothesized that adolescents who receive frequent text message nudges (Intervention 1) or frequent text message nudges plus modest financial incentives (Intervention 2) would be more likely to carry their epinephrine than members of the usual care control group., Methods: We recruited 131 adolescents ages 15 to 19 with a food allergy and a current prescription for epinephrine to participate in a cohort multiple randomized controlled trial. Participants were randomly assigned to participate in Intervention 1, Intervention 2, or to receive usual care. The primary outcome was consistency of epinephrine-carrying, measured as the proportion of checkpoints at which a participant could successfully demonstrate they were carrying their EAI, with photo-documentation of the device., Results: During Intervention 1, participants who received the intervention carried their EAI 28% of the time versus 38% for control group participants (P = .06). During Intervention 2, participations who received the intervention carried their EAI 45% of the time versus 23% for control group participants (P = .002)., Conclusions: Text message nudges alone were unsuccessful at promoting EAI-carrying but text message nudges combined with modest financial incentives almost doubled EAI-carriage rates among those who received the intervention compared with the control group. However, even with the intervention, adolescents with food allergies carried their EAI <50% of the time. Alternative strategies for making EAIs accessible to adolescents at all times should be implemented., (Copyright © 2023 by the American Academy of Pediatrics.)

Importance: Calorie labels for prepared (ie, ready-to-eat) foods are required in large chain food establishments in the US. Large evaluations in restaurants suggest small declines in purchases of prepared foods after labeling, but to the authors' knowledge, no studies have examined how this policy influences supermarket purchases., Objective: To estimate changes in calories purchased from prepared foods and potential packaged substitutes compared with control foods after calorie labeling of prepared foods in supermarkets., Design, Setting, and Participants: This controlled interrupted time series compared sales 2 years before labeling implementation (April 2015-April 2017) with sales 7 months after labeling implementation (May 2017-December 2017). Data from 173 supermarkets from a supermarket chain with locations in Maine, Massachusetts, New Hampshire, New York, and Vermont were analyzed from March 2020 to May 2022., Intervention: Implementation of calorie labeling of prepared foods in April 2017., Main Outcomes and Measures: Purchased items were classified as prepared foods, potential packaged substitutes for prepared foods, or all other (ie, control) foods. The primary outcome was mean weekly calories per transaction purchased from prepared foods, and the secondary outcome was mean weekly calories per transaction purchased from similar packaged items (for substitution analyses). Analyses of prepared and packaged foods were stratified by food category (bakery, entrées and sides, or deli meats and cheeses)., Results: Among the included 173 supermarkets, calorie labeling was associated with a mean 5.1% decrease (95% CI, -5.8% to -4.4%) in calories per transaction purchased from prepared bakery items and an 11.0% decrease (95% CI, -11.9% to -10.1%) from prepared deli items, adjusted for changes in control foods; no changes were observed for prepared entrées and sides (change = 0.3%; 95% CI, -2.5% to 3.0%). Labeling was also associated with decreased calories per transaction purchased from packaged bakery items (change = -3.9%; 95% CI, -4.3% to -3.6%), packaged entrées and sides (change = -1.2%; 95% CI, -1.4% to -0.9%), and packaged deli items (change = -2.1%; 95% CI, -2.4% to -1.7%)., Conclusions and Relevance: In this longitudinal study of supermarkets, calorie labeling of prepared foods was associated with small to moderate decreases in calories purchased from prepared bakery and deli items without evidence of substitution to similar packaged foods.

Competing Interests: None.

Background: The obesity epidemic in the USA continues to grow nationwide. Although excess weight-related mortality has been studied in general, less is known about how it varies by demographic subgroup within the USA. In this study we estimated excess mortality associated with elevated body weight nationally and by state and subgroup., Methods: We developed a nationally-representative microsimulation (individual-level) model of US adults between 1999 and 2016, based on risk factor data from 6,002,012 Behavioral Risk Factor Surveillance System respondents. Prior probability distributions for hazard ratios relating body-mass index (BMI) to mortality were informed by a global pooling dataset. Individual-level mortality risks were modelled accounting for demographics, smoking history, and BMI adjusted for self-report bias. We calibrated the model to empirical all-cause mortality rates from CDC WONDER by state and subgroup, and assessed the predictive accuracy of the model using a random sample of data withheld from model fitting. We simulated counterfactual scenarios to estimate excess mortality attributable to different levels of excess weight and smoking history., Findings: We estimated that excess weight was responsible for more than 1300 excess deaths per day (nearly 500,000 per year) and a loss in life expectancy of nearly 2·4 years in 2016, contributing to higher excess mortality than smoking. Relative excess mortality rates were nearly twice as high for women compared to men in 2016 (21·9% vs 13·9%), and were higher for Black non-Hispanic adults. By state, overall excess weight-related life expectancy loss ranged from 1·75 years (95% UI 1·57-1·94) in Colorado to 3·18 years (95% UI 2·86-3·51) in Mississippi., Interpretation: Excess weight has substantial impacts on mortality in the USA, with large disparities by state and subgroup. Premature mortality will likely increase as obesity continues to rise., Funding: The JPB Foundation, NIH, CDC., Competing Interests: The authors declare no competing interests., (© 2022 The Author(s).)

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.

Introduction: The 2010 Affordable Care Act required chain retail food establishments, including supermarkets, to post calorie information for prepared (i.e., ready to eat) foods. Implementation of calorie labeling could spur companies to reduce the calorie content of prepared foods, but few studies have explored this. This study evaluates the changes in the calorie content of prepared foods at 2 large U.S. supermarket chains after they implemented calorie labels in April 2017., Methods: The chains (≈1,200 stores) provided data on the calorie content and labeling status of all items sold between July 2015 and January 2019. In 2021, analyses used a difference-in-differences approach to examine the changes in the calorie content of prepared bakery, entree, and deli items introduced before calorie labeling to those introduced after the labeling compared with changes in similar foods not subject to the new labeling requirement. Primary analyses examined continuously available items; exploratory analyses examined items newly introduced to the marketplace., Results: Relative to changes in comparison foods not subject to the labeling requirement, continuously available prepared bakery items decreased by 7.7 calories per item after calorie labels were implemented (95% CI= -12.9, -2.5, p=0.004, ≈0.5% reduction). In exploratory analyses, prepared bakery items introduced after calorie labeling contained 440 fewer calories per item than those introduced before calorie labeling (95% CI= -773.9, -106.1, p=0.01, ≈27% reduction), driven by reductions in product size. No changes were observed in the calorie content of continuously available or newly introduced prepared entrees or deli items., Conclusions: Implementing calorie labels could encourage product reformulation among some types of prepared supermarket foods. These supply-side changes could lead to reductions in caloric intake., (Copyright © 2021 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Although proven effective interventions for childhood obesity exist, there remains a substantial gap in the adoption of recommended practices by clinicians. Objective: The aims are to: (1) package implementation and training supports to facilitate the adoption of the evidence-based Healthy Weight Clinic Pediatric Weight Management Intervention (PWMI) (based on three previous effectiveness trials); (2) pilot and evaluate the packaged Healthy Weight Clinic PWMI; and (3) develop a sustainability and dissemination plan. Design/Methods: We used the Consolidated Framework of Implementation Research constructs to create an Implementation Research Logic Model that defined the facilitators and barriers of the Healthy Weight Clinic PWMI. We linked these constructs to implementation strategies and mechanisms. Packaging and design will be informed by the core essential components and functions of the PWMI along with stakeholder engagement. Once the package is complete, we will pilot the PWMI by using a Type III effectiveness-implementation hybrid design. Implementation outcomes will be evaluated by using the RE-AIM framework. Results: We will create an integrated, multisystems level package for national dissemination. The package will include training and a suite of resources for primary care physicians and healthy weight clinic staff, including: patient and caregiver facing videos, patient and caregiver handouts, group curriculum guide, online provider trainings, and access to a virtual learning collaborative. Conclusion: The results will highlight the extent to which the package of the Healthy Weight Clinic PWMI facilitates the adoption of effective strategies for treating childhood obesity. Lessons learned will inform modifications to the Healthy Weight Clinic PWMI and strategies for future scaling.

Background: Despite evidence that offering multidisciplinary treatment for children with obesity is effective, access to evidence-based pediatric weight management interventions (PWMIs) is limited. The Healthy Weight Clinic PWMI is a multidisciplinary approach in primary care that improves BMI among children with a BMI ≥ 85th percentile. Objective: To describe the method by which we will evaluate the adoption, acceptability, and feasibility of integrating and implementing a multidisciplinary Healthy Weight Clinic (HWC) into primary care. Design/Methods: We used the Consolidated Framework for Implementation Research (CFIR) domains and constructs to inform our implementation strategies. We will use a Type III hybrid effectiveness-implementation design to test our implementation strategies and improvement in BMI. Sources of data collection will include qualitative interviews with patient caregivers, HWC staff and surveys with HWC staff, patient caregivers, and electronic health record data. Our outcomes are guided by the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework. Results: We identified all five CFIR domains as integral for successful implementation. Some strategies to address barriers within these domains include online self-paced training modules for the HWC staff, a virtual learning collaborative, and engagement of site leadership. Outcomes will be measured at the patient and pilot site levels, and they will include patients reached, patient health outcomes such as BMI and quality of life, level of adoption, acceptability, feasibility, and sustainability of the PWMI. Conclusion: Our use of implementation science frameworks in the planning of Healthy Weight Clinic PWMI could create a sustainable and effective program for dissemination.