Search

Background: The Indonesian government faces a dilemma of promoting fish consumption for its health benefits and to ease food insecurity, while at the same time seeking effective approaches to reduce the high levels of marine pollution. However, the factors associated with fish consumption in the face of persistent high levels of marine pollution are not well elucidated in the literature. Objectives: This was an explorative study to investigate the sociodemographic factors related to fish consumption and to understand the perspectives of expert informants on marine pollution and its impact on fish quality and availability in Indonesia. Methods: We characterized fish consumption among respondents aged 15 years and older in the fifth wave of the Indonesian Family Life Survey (n = 31,032), based on their sociodemographic profiles, and developed multinomial regression models to assess the relationship between respondents’ sociodemographic profiles and quintiles of fish consumption. We also conducted in-depth interviews on fish consumption and marine pollution with key informants from Indonesia (n = 27). We then used a convergent mixed-methods design to synthesize the results of both datasets. Results: Fish was the most frequently consumed animal-source food reported by survey respondents: 2.8 (±2.6) days/week. More younger respondents (15–19 years) reported relatively lower consumption of fish (9.3% in Q1 versus 5.9% in Q5) compared to respondents 50 years and older (37% in Q1 versus 39.9% in Q5; p < 0.01). When classified by region, more respondents from the Java region reported lower consumption of fish (86.5% in Q1 versus 53% in Q5; p < 0.01). Key-informants’ perspectives corroborated the survey results by indicating that the younger generation tends not to want to consume fish; informants expanded the survey results by suggesting that fish is scarce in the Java region due to high levels of marine pollution. Informants further implied that there is low awareness about the impact of marine pollution on fish quality among most of the Indonesian population. Conclusion: Evidence from both data sources converge on differential preference for fish consumption by age group. Informants’ perspectives also link marine pollution to fish scarcity, which poses a threat to food security among low-income Indonesians and to human health globally. More studies are needed to corroborate our findings and inform policy guidelines to reduce marine pollution while promoting fish consumption in Indonesia.

We used qualitative methods to better understand wearable activity monitor (WAM) use and its relationship with physical activity (PA) among older adults. Four focus groups, stratified by current/past (“ever”) WAM users and “never” WAM users, were conducted with 57 participants aged ≥60 years. Data were coded with deductive and inductive approaches. Among ever WAM users, those with low pre-WAM PA levels reported higher PA related to WAM use while those with high pre-WAM PA levels reported they used WAM for tracking and monitoring their activity. Ever WAM users were motivated to increase PA through rewards and social support. Many never WAM users reported that WAM was unnecessary. WAM may be helpful for some older adults to increase their PA, particularly those who are motivated by setting and achieving PA goals. The results could help develop strategies to overcome barriers to WAM adoption and promote WAM use among older adults.

Background. This article looks at the role that arts, culture, and creativity play in promoting social cohesion and community well-being. It presents research on the role that a community arts center plays in an ethnic enclave that is under stress of immigration and gentrification. Method. An academic–community research partnership conducted this research. A mixed-methods approach was used. Twenty-four interviews were conducted with stakeholders (including community leaders, neighborhood residents, and business owners). Surveys ( n = 102) were done of community members and those who participate in the Center activities. Results. Interviewees and survey respondents point to the importance of the ethnic enclave as a close-knot community that helps to foster a sense of belonging, security, and cultural identity. Arts, culture, and creativity plays a role in maintaining this sense of social cohesion, despite the threat of gentrification. Engagement in the arts and creative practice are important for buffering the stress of immigration. Discussion. The center has an important role as a critical cultural, civic, and creative space for the neighborhood and the broader community who sees the ethnic enclave as their cultural home.

Purpose: To examine wearable activity monitor (WAM) use and its association with meeting the 2008 aerobic Physical Activity Guidelines (PAG) and walking among older adults. Design: Cross-sectional. Setting: FallStyles 2015 national consumer panel survey. Sample: 1,317 U.S. adults aged ≥ 60 years. Measures: Self-reported WAM use, meeting aerobic PAG, and walking. Covariates included age, sex, race/ethnicity, education level, marital status, annual household income, and geographic region of the country. Analysis: Chi-square tests to examine associations between WAM use and respondent demographic characteristics. Logistic regressions to explore associations between WAM use and meeting aerobic PAG and walking adjusted for demographics (e.g., education, income). Results: Among older adults, 8.0% were current WAM users and 11.3% were past WAM users. Current WAM use was most prevalent among those aged 65-74 (16.6%), females (9.4%), college graduates (13.8%), and those with incomes $75,000-$99,999 (14.8%). Current WAM users were more likely than never WAM users to report meeting aerobic PAG (OR: 3.98; 95% CI: 2.07, 7.66) and walking (OR: 3.90; 95% CI: 1.57, 9.69). Past and never WAM use were not associated with meeting aerobic PAG or walking. Conclusion: We found current WAM use is associated with meeting the aerobic PAG and walking among older adults. Further longitudinal research is needed to understand whether WAM could promote increased PA among older adults.

There is a marked increase in the intake of foods associated with higher risks for hypertension and obesity in Indonesia. However, studies assessing the relationship between dietary patterns and health outcomes are few.The purpose of this study was to characterize dietary patterns and investigate their relationship with hypertension and obesity in Indonesia.Exploratory factor analysis was used to derive dietary patterns from a brief food scanner filled by 31,160 respondents aged 15 y and older in the Indonesian Family Life Survey wave 5 (IFLS 5). Age- and gender-specific quintiles of consumption were created for each pattern and the association between quintiles of each dietary pattern and the odds for hypertension and obesity were assessed using multivariate logistic regression analyses.Two dietary patterns were identified: a modern dietary pattern characterized by fast foods, soft drinks, sweet snacks, and salty snacks and a traditional pattern characterized by fish, vegetables, and fruits. Younger age and being male were significantly correlated with higher consumption of the modern pattern (More studies using gold-standard measures of dietary intake are needed to better understand the relationship between the modern dietary pattern and hypertension in Indonesia. Also, both modern and traditional dietary patterns in Indonesia may be energy dense, leading to higher risk for obesity.

Background: Indonesia is undergoing a rapid nutrition transition—a shift in food consumption related to globalization, modernization, urbanization, and economic development—with potentially adverse impacts on diets, health, and the environment. This study sought to understand the perspectives of a multi-disciplinary group of experts on the effects of the nutrition transition on dietary behaviors, cardiovascular disease (CVD) risk factors, and the food environment in Indonesia. Methods: In-depth interviews were conducted online with 27 Indonesian experts, who are either healthcare providers, nutrition researchers, or environmental researchers. Interview question guides were developed based on a socio-ecological framework. We analyzed the data using deductive and inductive approaches. Results: Experts described a disconnect between awareness about and adherence to healthy diets among Indonesians. They highlighted a marked generational divide in food preferences between the younger population (

Objectives To describe the design, feasibility, and acceptability of a theory-informed obesity and dental caries prevention pilot study, Baby Steps to Health, conducted in an academic dental clinic among a primarily Asian immigrant population. Methods Baby Steps used self-determination theory and behavioral motivation strategies for a caregiver/child (6-36 months) nutrition and oral health behavior change intervention implemented in a pediatric dental clinic. Caregivers completed a dietary practice assessment to identify risk behaviors and potential courses of action. With assistance from dental providers, caregiver responses were matched to customized dietary behavioral guidance and a behavior change goal to reinforce caregivers' autonomous motivation to improve feeding practices. A 1-month, post-visit phone caregiver interview assessed adherence to the behavioral goal(s) and solicited qualitative input for further program development. Results Fifty caregivers (82 percent Asian) participated in the initial visit, and 46 (92 percent) participated in the follow-up interview. Reported obesogenic/cariogenic risk behaviors were prevalent: 57 percent of bottle-fed children consumed non-water beverages in bottles to aid sleep and 38 percent of parents offered snacks ad libitum. At follow-up, 93 percent of caregivers who selected goals reported positive behavior change and 91 percent said they would participate in a similar future program. Conclusions Tailored guidance delivered in a program that uses self-determination theory may represent a strategic use of the dental encounter to impart actionable information and motivate health-related behavior change for families with very young children. Partnerships between dental and nutrition professionals offer opportunities to address key dietary behaviors that may prevent obesity and improve oral health, particularly among at-risk children.

Objectives: The COVID-19 pandemic impacted food systems, health systems and the environment globally, with potentially greater negative effects in many lower-middle income countries (LMICs) including Indonesia. The purpose of this qualitative study was to investigate the potential impacts of the COVID-19 pandemic on diets, health and the marine environment in Indonesia, based on the perspectives of a multidisciplinary group of informants. Methods: We conducted remote in-depth interviews with 27 key informants from many regions of Indonesia, who are either healthcare providers, nutrition researchers or environmental researchers. Interview question guides were developed based on a socio-ecological framework. We analyzed the data using a qualitative content analysis approach. Results: Informants suggested that while the COVID-19 brought increased awareness about and adherence to good nutrition and health behaviors, the impact was transitory. Informants indicated that healthy food options became less affordable, due to job losses and reduced income, suggesting a likely increase in food insecurity and obesity. Environmental researchers described higher levels of marine pollution from increase in hygienic wastes as well as from plastic packaging from food orders. Conclusions: Our findings reveal perceptions by informants that the increased awareness and adherence to health behaviors observed during the pandemic was not sustained. Our results also suggest that the pandemic may have exacerbated the double-burden paradox and marine pollution in Indonesia. This study offers information for generating hypotheses for quantitative studies to corroborate our findings and inform policies and programs to mitigate the long-term impacts of the COVID-19 on diets, health, and the marine environment in Indonesia.

BACKGROUND: There remains a lack of evidence demonstrating a potential relationship between vitamin D and cardiometabolic risk among children. OBJECTIVES: We examined the effect of 3 different dosages of vitamin D on cardiometabolic risk factors among children at risk of deficiency. METHODS: Racially diverse schoolchildren aged 8–15 y were randomly assigned in a double-blind fashion to supplementation with 600, 1000, or 2000 IU vitamin D(3)/d for 6 mo. Changes in HDL cholesterol, triglycerides, LDL cholesterol, total cholesterol, and blood glucose over 6 mo and at 12 mo (6 mo post-supplementation) were assessed. Subgroup analyses were also performed by weight status and race. RESULTS: Among 604 children, 40.9% were vitamin D–inadequate at baseline (

Background. Whole-of-community interventions have been recommended and show promise for preventing obesity; however, research to understand the mechanisms underlying their success or failure is lacking. Complex systems approaches may be useful to address this gap. Purpose. To describe the evolution and utilization of qualitative and quantitative complex systems methods to understand and model whole-of-community obesity prevention interventions. Approach. We illustrate the retrospective qualitative development of a systems map representing community change dynamic within the Shape Up Somerville (SUS) intervention. We then describe how this systems map, and complementary work of other successful obesity prevention interventions (Romp & Chomp intervention), informed the COMPACT (childhood obesity modeling for prevention and community transformation) study. COMPACT’s design aligns complex systems science principles and community-engaged research to better understand stakeholders’ leadership roles in whole-of-community interventions. We provide an overview of the complex systems tools used in COMPACT: agent-based modeling, group model building, and social network analysis and describe how whole-of-community intervention stakeholders (“agents”) use their social networks to diffuse knowledge about and engagement with childhood obesity prevention efforts, laying the groundwork for community readiness for sustainable change. Conclusion. Complex systems approaches appear feasible and useful to study whole-of-community obesity prevention interventions and provide novel insights that expand on those gained from traditional approaches. Use of multiple methods, both qualitative and quantitative, from the complex systems toolkit working together can be important to success.

Associations between diet, physical activity, parenting, and acculturation among Chinese-American children are understudied. Parents/caregivers of children attending child-care programs in Boston Chinatown completed a self-administered survey on demographics, child's diet, physical activities, anthropometrics, and parenting practices. Associations were evaluated in multivariable regression analysis, stratified by survey language preference, a proxy for acculturation. Responding Asian families = 132; 86.4% were immigrants; 75.8% completed the Chinese-version survey. Children (mean ± SD: 4.9 ± 1.1 years) did not eat vegetables (31.8%), or play actively outside (45.4%) daily, 64.8% watched television/screens daily; 32.6% were overweight/obese (based on parent report). Parenting practices associated with obesity were apparent. Although healthy-living behavioral outcomes were less prevalent among less acculturated parents; multivariable adjustment attenuated the observed significant differences. Findings suggest opportunities for improvement in study children's diet and healthy-living behaviors, and underscore the need for further research on acculturation, and parenting styles in this population.

Background: Social media is rapidly changing how cancer survivors search for and share health information and can potentially serve as a cost-effective channel to reach cancer survivors and invite them to participate in nutrition intervention programs. Objective: This study aimed to assess the feasibility of using Twitter to recruit cancer survivors for a web-based survey and assess their willingness to complete web-based nutrition surveys, donate biospecimens, and to be contacted about web-based nutrition programs. Methods: We contacted 301 Twitter accounts of cancer organizations, advocates, and survivors to request assistance promoting a web-based survey among cancer survivors. The survey asked respondents whether they would be willing to complete web-based nutrition or lifestyle surveys, donate biospecimens, and be contacted about web-based nutrition programs. Survey promotion rate was assessed by the percentage of Twitter accounts that tweeted the survey link at least once. Survey response was assessed by the number of survey respondents who answered at least 85% (26/30). We compared the characteristics of cancer survivors who responded to this survey with those who participated in the National Health and Nutrition Examination Survey (NHANES) 1999-2010 and evaluated factors associated with willingness to complete web-based surveys, donate biospecimens, and be contacted to participate in web-based nutrition programs among those who responded to the social media survey. Results: Over 10 weeks, 113 Twitter account owners and 165 of their followers promoted the survey, and 444 cancer survivors provided complete responses. Two-thirds of respondents indicated that they would be willing to complete web-based nutrition or lifestyle surveys (297/444, 67.0%) and to be contacted to participate in web-based nutrition interventions (294/444, 66.2%). The percentage of respondents willing to donate biospecimens were 59.3% (263/444) for oral swab, 52.1% (231/444) for urine sample, 37.9% (168/444) for blood sample, and 35.6% (158/444) for stool sample. Compared with a nationally representative sample of 1550 cancer survivors in NHANES, those who responded to the social media survey were younger (53.1 years vs 60.8 years; P

OBJECTIVES: Housing stability, food security and healthy eating are interrelated. In 2015, a housing lottery for newly developed subsidized housing in Chinatown, Boston, MA was held for low- and moderate- income families who were randomly selected from a waitlist. Four years later (19/20), our study explores the associations between housing status (living in the new subsidized building (NSB) or being on the lottery waitlist) and Food Insecurity (FI); use of food safety net programs (SN), defined as use of SNAP, WIC and/or food pantries; weekly fruit and vegetable consumption (FV); weekly soda consumption; and monthly fast food consumption (FF). METHODS: Questionnaire links were sent to NSB (n = 95) and waitlist (n = 2498) households. Logistic regression was used to explore the association between housing status and (1) FI (2-item screener) and (2) use of SN (self-reported use in the past year). Linear regression with robust standard error estimation was used to explore the association between housing status and weekly consumption of (1) FV, (2) soda, and (3) monthly consumption of FF, (assessed through health behavior questions from the California Health Interview Survey). Models were adjusted for age, sex, ethnicity, household size, education, income, employment status and distance to grocery store. RESULTS: 138 respondents completed the survey; NSB = 36, waitlist = 102. The two housing status groups were demographically similar. Respondents in the NSB showed non-statistically significant lower odds of experiencing FI (OR 0.65, 95% CI [0.3, 1.6]) and of using SN (OR 0.45, 95% CI [0.1, 1.6]). Respondents in the NSB showed non-statistically significant higher weekly consumption of FV (β 2.03, 95% CI [−1.5, 5.6]); lower weekly consumption of soda (β −0.39, 95% CI [−1.9, 1.1]) and lower monthly consumption of FF (β −1.19, 95% CI [−3.9, 1.5]), when compared to respondents on the waitlist. CONCLUSIONS: In this small sample, main outcomes were not significantly different. Dietary intakes among NSB residents were consistently positive compared to waitlist residents. Future studies should continue to explore mechanisms through which living in a NSB may impact nutrition and health outcomes. FUNDING SOURCES: Tufts Collaborates Seed Grants. Conclusions do not represent any U.S. Department of Agriculture office or Government determination. This research was not part of MI's work at USDA.

Background Despite being motivated to improve nutrition and physical activity behaviors, cancer survivors are still burdened by suboptimal dietary intake and low levels of physical activity. Objective The aim of this study was to assess changes in nutrition and physical activity behaviors after cancer diagnosis or treatment, barriers to eating a healthy diet and staying physically active, and sources for seeking nutrition advice reported by breast cancer survivors. Design This was a cross-sectional study. Participants/setting The study included 315 survivors of breast cancer who were recruited through social media and provided completed responses to an online exploratory survey. Main outcome measures Self-reported changes in nutrition and physical activity behaviors after cancer diagnosis or treatment, perceived barriers to healthy eating and physical activity, and sources of nutrition advice were measured. Statistical analysis Frequency distribution of nutrition and physical activity behaviors and changes, barriers to healthy eating and physical activity, and sources of nutrition advice were estimated. Results About 84.4% of the breast cancer survivors reported at least 1 positive behavior for improving nutrition and physical activity after cancer diagnosis or treatment. Fatigue was the top barrier to both making healthy food choices (72.1%) and staying physically active (65.7%), followed by stress (69.5%) and treatment-related changes in eating habits (eg, change in tastes, loss of appetite, and craving unhealthy food) (31.4% to 48.6%) as barriers to healthy eating, and pain or discomfort (53.7%) as barriers to being physically active. Internet search (74.9%) was the primary source for seeking nutrition advice. Fewer than half reported seeking nutrition advice from health care providers. Conclusions Despite making positive changes in nutrition and physical activity behaviors after cancer diagnosis or treatment, breast cancer survivors experience treatment-related barriers to eating a healthy diet and staying physically active. Our results reinforce the need for developing tailored intervention programs and integrating nutrition into oncology care.

This study tested whether overweight/obese children’s attendance in a community-based physical activity (PA) program was associated with changes in cardiorespiratory fitness (CRF) and adiposity and whether in-program activity levels influenced those associations. Program sessions (offered twice/week, 2 hours/session, over 9 months) included structured exercise/sports. At baseline and follow-up, CRF was measured as Progressive Aerobic Cardiorespiratory Endurance Run (PACER) laps, height/weight were measured, and body mass index (BMI) was calculated. Attendance was recorded as sessions attended. Children wore pedometers in 10 representative sessions; in-program activity was calculated as mean steps/minute across sessions. Linear mixed models tested associations between attendance and changes in PACER score and BMI and the influence of in-program activity on those associations. A total of 101 participants (56% male, 93% Hispanic) completed baseline and one or two follow-up fitness/adiposity measurements. Attendance was associated with PACER change (β = .093, p = .01) but not BMI change (β = .00026, p = .97). There were significant interactions between attendance and in-program activity: Attendance more favorably affected PACER (p < .0001) and BMI (p = .03) as in-program activity levels increased. Attending community-based PA programs may improve CRF among overweight/obese children, particularly when participants are highly active during program time. Community practitioners should not only enroll overweight/obese children in PA programs but also promote adequate attendance/in-program activity levels.

Children of obese mothers are at increased risk of developmental adversities. Maternal obesity is linked to an inflammatory in utero environment, which, in turn, is associated with neurodevelopmental impairments in the offspring. This is an integrated mechanism review of animal and human literature related to the hypothesis that maternal obesity causes maternal and fetal inflammation, and that this inflammation adversely affects the neurodevelopment of children. We propose integrative models in which several aspects of inflammation are considered along the causative pathway linking maternal obesity with neurodevelopmental limitations.

Background As the largest nutrition safety net program in the United States, the Supplemental Nutrition Assistance Program (SNAP) enhances food security by providing low-income households with benefits for food-at-home (FAH) spending. A large literature finds a positive effect of SNAP on FAH spending, but it is unclear whether this relationship varies with area-level prices. SNAP benefits do not explicitly account for price variation across the contiguous United States. Objective Our objectives were to examine the SNAP/non-SNAP difference in FAH spending for households with varying levels of cash income and propensity for SNAP participation and to determine whether this difference varied with area-level prices. Design/participants Cross-sectional data on 2,524 SNAP and non-SNAP households with cash income at or below 185% of the Federal Poverty Level were obtained from the National Household Food Acquisition and Purchase Survey. Main outcome measures The outcome was FAH spending relative to the maximum SNAP benefit corresponding to household size. Statistical analyses performed Households were grouped into quintiles based on estimated propensity of SNAP participation. Regression models included interactions between a SNAP participation indicator, a continuous price index for all goods and services, and propensity score quintile indicators. Results According to some models, the SNAP/non-SNAP spending difference was positive, on average. Among households that tended to have lower cash income and higher propensity of SNAP participation, FAH spending relative to the maximum benefit was 29 to 30 percentage points higher for SNAP households compared to low-income non-SNAP households (P≤0.05). The spending difference was similar across areas with different price levels. Conclusions SNAP households spent more on FAH compared to low-income non-SNAP households. This association did not vary with area-level prices. Beyond food spending outcomes, future research could extend this work to understand SNAP’s role in promoting food security and other outcomes, given geographic price variation.

Background:Associations between physical activity (PA) intensity and volume and adolescents’ cardiometabolic health have research, policy, and practice implications. This study compares associations between cardiometabolic risk factors and 1) moderate-to-vigorous PA (MVPA) minutes versus total PA volume (accelerometer-derived total activity counts, TAC) and 2) light PA volume (counts at light intensity, L-TAC) versus moderate-to-vigorous PA volume (counts at moderate-to-vigorous intensity, MV-TAC).Methods:2105 adolescents from 2003– 2006 NHANES were included. Independent variables were MVPA minutes, TAC, L-TAC, and MV-TAC. Regression models tested associations between PA variables and continuous metabolic risk index (CMRI), waist circumference, systolic and diastolic blood pressure, HDL, insulin, and triglycerides.Results:TAC demonstrated a slightly stronger inverse association with CMRI (P = .004) than did MVPA (P = .013). TAC and MVPA were both associated with systolic and diastolic pressure, HDL, and insulin; associations were similar or slightly stronger for TAC. L-TAC and MV-TAC were both associated with CMRI and HDL. Only L-TAC was associated with diastolic pressure. Only MV-TAC was associated with waist circumference, systolic pressure, and insulin.Conclusions:Compared with MVPA minutes, TAC demonstrates similar or slightly stronger associations with cardiometabolic risk factors. L-TAC and MV-TAC appear similarly associated with adolescents’ clustered risk but differently associated with individual risk factors.

Objective We investigated the daily dose of vitamin D needed to achieve serum 25-hydroxyvitamin D [25(OH)D] sufficiency among schoolchildren at risk for deficiency. Study Design The Daily D Health Study was a randomized double-blind vitamin D supplementation trial among racially/ethnically diverse schoolchildren (n = 685) in the northeastern United States. Children were supplemented with vitamin D3 at 600, 1000, or 2000 IU/d for 6 months. Measurements included serum 25(OH)D at baseline (October to December), 3 months (January to March), 6 months (April to June), and 12 months (6 months after supplementation). Results At baseline, mean ± standard deviation serum 25(OH)D level was 22.0 ± 6.8 ng/mL, with 5.5% severely vitamin D deficient (

Background: While rarely used for supplementation trials in the United States, schools present a practical alternative to a clinical setting. Purpose: We describe the successful recruitment and retention of urban schoolchildren into a 6-month randomized, double-blind vitamin D3 supplementation trial. Methods: Boston-area urban schoolchildren, aged 8–15 years, were recruited in 2011–2012 through classroom and auditorium presentations. Informed consent forms in five languages were sent home to parents. Retention methods included regular telephone calls and gift cards for completed study visits. Results: In total, 691 schoolchildren enrolled. Their mean (standard deviation) age was 11.7 (1.4) years; 59% were racial/ethnic minorities and 68% qualified for free or reduced-price school meals. Multi-level, culturally sensitive, creative approaches contributed to success in recruitment and retention. Of 691 participants, 81% completed the 6-month intervention period. Reasons for attrition included missed appointments and fear of a blood draw. More children from households with higher incomes were retained than those from households with lower incomes (85% vs 79%, respectively, P = 0.04). Limitations: The need for three fasting blood draws over the 6-month supplementation period was a limiting factor in the recruitment and retention of children in this study. Conclusion: Recruitment of urban children into a school-based randomized controlled trial represents a feasible approach for a supplementation study. Particular attention to children of lower socioeconomic status may enhance participation and retention when conducting intervention studies among diverse populations.

Objective: The purpose of this quasi-experimental study was to examine the effect of a computerized point-of-care alert with clinical decision support on the rates of diagnosis of childhood obesity in a multisite group practice in Massachusetts; Cambridge Health Alliance (CHA) which implemented an alert, relative to a separate group practice, Harvard Vanguard Medical Associates (HVMA), that did not. Design and Methods: Height and weight data from 19,466 children of 2-18 years with 34,908 well-child care visits in CHA and 123,446 children with 282,271 visits in HVMA between 2006 and 2008 were collected. The alert and decision support tool was activated for CHA patients with an age- and sex-specific body mass index of ≥95th percentile. The main outcome measure was documentation of an International Classification of Diseases, Ninth Revision [ICD-9] code for obesity before and after implementation of the alert at CHA in 2007. Results: Among obese children, the adjusted rate of an ICD-9 diagnosis of obesity increased from 2006-2007 to 2008 significantly more at CHA than at HVMA (P < 0.001 for time-by-provider group interaction). In 2006-2007, the rate of ICD-9 diagnosis of obesity was significantly lower at CHA than at HVMA (adjusted odds ratio [OR]: 0.57; 95% confidence interval [CI]: 0.52-0.62); but by 2008 was significantly higher at CHA than HVMA (adjusted OR: 1.25; 95% CI: 1.14-1.38). Conclusion: A point-of-care alert was effective in improving obesity diagnosis in a multisite group practice, relative to a separate group practice that did not adopt an alert. Clinical decision support tools could help improve obesity diagnosis in pediatric primary care.

BACKGROUND A supportive school-based physical activity environment (PAE) is integral to children's physical activity behaviors, but less understood is its association with academic achievement. We aimed to assess the association between PAE and academic performance and whether a stronger relationship exists in lower-income schools (LIS) compared to middle-income schools (MIS). METHODS Schoolchildren (grades 3rd to 5th) were recruited from 17 Massachusetts public schools. Schools were classified based on geographic characteristics and free/reduced-price lunch (FRPL) eligibility (LIS = 7, Median FRPL = 86%; MIS = 10, Median FRPL = 20%). PAE was measured using a 10-item survey. Mixed-effects logistic regression models were used to examine associations between PAE and scoring Advanced/Proficient on standardized Math and English Language Arts (ELA) tests. RESULTS Demographic characteristics differed between LIS (N = 278, 5% non-Hispanic white) and MIS (N = 297, 73% non-Hispanic white). In LIS, PAE was associated with Math (odds ratio = 5.40, 95% CI = 2.52-11.54 p .05). There was no relationship between PAE and MIS test scores (p > .05). Schooltime moderate-to-vigorous physical activity was not associated with test scores (p > .05). CONCLUSIONS A beneficial relationship exists between a high-PAE and test scores among LIS children, suggesting that the PAE may be associated with a more supportive environment and may be more fundamentally important for lower-income students.

OBJECTIVES We examined the longitudinal relationship between cardiovascular fitness (CRF) and academic performance (AP) among students in a diverse public school district. Furthermore, we determined whether the relationship between CRF and AP varied by student sociodemographic characteristics. METHODS This study used data from 2005-2006 to 2008-2009. AP was assessed by Massachusetts Comprehensive Assessment System (MCAS) math (N = 1224) and English Language Arts (ELA) (N = 1248) z-scores. CRF was assessed by an age- and sex-adjusted 20-yard shuttle run (pass/fail). Multilevel growth models were used to estimate the relationship between MCAS z-scores and changes in grade, CRF, and weight status, controlling for student sociodemographic characteristics. RESULTS Students who passed the fitness test performed better on MCAS tests (ELA: .159, p

Dietary factors vary widely among ethnic groups. However, the effect of specific nutrients on cardiometabolic risk is not well understood, especially in children. Four dietary factors known to influence cardiometabolic risk (ie, carbohydrate, saturated, monounsaturated, and polyunsaturated fat intake) were assessed by the Block Kids 2004 Food Frequency Questionnaire in a cross-sectional sample of racially diverse fourth- through eighth-grade students (n=148) in a Boston-area school district studied between January and April 2010. Fasting total cholesterol, low-density lipoprotein, high-density lipoprotein (HDL) cholesterol, triglyceride, C-reactive protein (CRP), and interleukin-6 (IL-6) levels, and body mass index z scores were measured. Differences in dietary factors and cardiometabolic risk factors were examined among the following racial/ethnic groups: white (39%), Hispanic (32%), black (8%), Asian (10%), and multiracial/other (11%). In bivariate analyses, total, saturated, and polyunsaturated fat intakes differed by race/ethnicity (P

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

Physical fitness is often inversely associated with adiposity in children cross-sectionally, but the effect of becoming fit or maintaining fitness over time on changes in weight status has not been well studied in children. We investigated the impact of changes in fitness over 1–4 years of follow-up on the maintenance or achievement of healthy weight among 2,793 schoolchildren who were first measured as 1st to 7th graders. Students were classified as “fit” or “underfit” according to age- and gender-specific norms in five fitness domains: endurance, agility, flexibility, upper body strength, and abdominal strength. Weight status was dichotomized by BMI percentile: “healthy weight” (

Background:There is growing recognition of the importance of recreational space utilization for promoting physical activity (PA) among youth.Methods:An cross-sectional study was conducted with a sample of 926 diverse 6th-8th grade students in Somerville, MA. Participants completed the 2007 Youth Risk Surveillance Survey (YRBS). Chi-square testing and logistical regression modeling were performed to predict meeting national PA recommendations for moderate, vigorous, and 60 minutes or more (60+) PA.Results:The participants reported meeting recommended PA levels for moderate (27%), vigorous (70%) and 60+ (21%) PA. In multivariate analysis, being male and speaking English were significantly associated with meeting all 3 PA recommendations. Recreational spaces significantly associated with meeting PA recommendations included neighborhood parks and walk/bike paths, playing fields and courts, and recreational centers. Recreational space utilization varied by gender, race/ethnicity, and language.Conclusions:Recreational space utilization was an important predictor of meeting PA recommendations among middle school students. Our results showed that PA attainment and recreational space utilization varied by demographic characteristics. The role of each recreational space in predicting PA varied depending on the outcome used. This study demonstrates the potential use of YRBS data to inform resource allocation for PA promotion in diverse communities.

The objective of this study was to assess the impact of a community-based healthy weight intervention on child weight and fitness. Cambridge Public Schools (CPS) have monitored BMI and fitness annually since 2000. Annual increases of overweight and obesity from 2000 (37.0%) to 2004 (39.1%), triggered a multidisciplinary team of researchers, educators, health care, and public health professionals to mobilize environmental and policy interventions. Guided by the social-ecological model and community-based participatory research (CBPR) principles, the team developed and implemented Healthy Living Cambridge Kids (HLCK), a multicomponent intervention targeting community, school, family, and individuals. The intervention included city policies and community awareness campaigns; physical education (PE) enhancements, food service reforms, farm-to-school-to-home programs; and family outreach and "BMI and fitness reports". Baseline (2004) to follow-up (2007) evaluation design assessed change in children's weight and fitness status. A cohort of 1,858 K-5th grade children participated: 37.3% black, 14.0% Hispanic, 37.1% white, 10.2% Asian, 1.7% other race; 43.3% were lower income. BMI z-score (0.67-0.63 P < 0.001) and proportion obese (20.2-18.0% P < 0.05) decreased, and mean number of fitness tests (0-5) passed increased (3.7-3.9 P < 0.001). Whereas black and Hispanic children were more likely to be obese at baseline (27.0 and 28.5%, respectively) compared with white (12.6%) and Asian (14.3%) children, obesity among all race/ethnicity groups declined. Concurrent with a 3-year community intervention, modest improvements in obesity and fitness were observed among CPS children from baseline to follow-up. The CBPR approach facilitated sustaining policies and program elements postintervention in this diverse community.

BACKGROUND: Somerville, Massachusetts, an ethnically diverse, urban community northwest of Boston, presents opportunities and challenges for active living. With a dense street grid, well-maintained sidewalks, neighborhood parks, and existing Community Path, Somerville is very walkable. However, two major surface arteries traverse and bisect neighborhoods, creating pedestrian safety and environmental justice issues. INTERVENTION: Major goals included promoting increased collaboration and communication among existing active-living efforts; managing the Community Path extension project; encouraging Portuguese-speaking adults to incorporate daily physical activity; leveraging existing urban planning work to establish secure, attractive walking/biking corridors; and embedding active-living messages in everyday life. RESULTS: The Somerville Active Living by Design Partnership (ALbD) successfully created a robust task force that was integrated with citywide active-living efforts, secured resources to increase infrastructure and support for active living, including city-level coordinator positions, and changed decision-making practices that led to incorporation of pedestrian and bicycle transportation priorities into city planning and that influenced the extension of the Community Path. LESSONS LEARNED: Partnerships must employ sustainability planning early on, utilize skilled facilitative leaders to manage leadership transitions, and engage new partners. Identifying, cultivating, and celebrating champions, especially those with political power, are critical. Working closely with research partners leads to rich data sources for planning and evaluation. Changing the built environment is difficult; working toward smaller wins is realistic and achievable. CONCLUSIONS: The synergy of ALbD and other community interventions created a foundation for short-term successes and accelerated political-cultural changes already underway with respect to active living. Language: en

OBJECTIVES: To determine relationships between physical fitness and academic achievement in diverse, urban public school children. METHODS: This cross-sectional study used public school data from 2004 to 2005. Academic achievement was assessed as a passing score on Massachusetts Comprehensive Assessment System (MCAS) achievement tests in Mathematics (fourth, sixth, and eighth grade, n = 1103) and in English (fourth and seventh grade, n = 744). Fitness achievement was assessed as the number of physical fitness tests passed during physical education (PE). Multivariate logistic regression analyses were conducted to assess the probability of passing the MCAS tests, controlling for students’ weight status (BMI z score), ethnicity, gender, grade, and socioeconomic status (school lunch enrollment). RESULTS: The odds of passing both the MCAS Mathematics test and the MCAS English test increased as the number of fitness tests passed increased (p < .0001 and p < .05, respectively). CONCLUSIONS: Results show statistically significant relationships between fitness and academic achievement, though the direction of causation is not known. While more research is required, promoting fitness by increasing opportunities for physical activity during PE, recess, and out of school time may support academic achievement.

Insufficient levels of daily physical activity (PA) among children in the USA and worldwide have profound implications for pediatric obesity and children's health and well-being more generally. Public health recommendations highlight the central role that schools play in providing equitable opportunities for PA for all children. This review identifies evidence-based approaches for increasing children's PA throughout the school day and discusses multilevel factors that support implementation of such approaches. Opportunities to increase school-day PA span not only in-school time (e.g., quality recess and physical education, classroom activity breaks) but also time before school (e.g., active commuting initiatives) and after school (e.g., intramural and interscholastic sports programs). For such approaches to impact children's PA, dimensions of implementation such as adoption, fidelity, penetration, implementation costs, and sustainability are critical. Multilevel factors that influence implementation include policies, school environment and organizational factors, teacher and classroom factors, child and family characteristics, and attributes of the PA approach itself. Research and field observations reinforce the importance of understanding challenges specific to working with schools, including multiple stakeholders, competing priorities, limited facilities and staff capacity, and heterogeneity of students. Thus, while schools hold promise as promoters and equalizers of PA engagement for all children, more research is needed on the levers that influence implementation of effective school-based PA policies and programs.

OBJECTIVE. The role of sugar-sweetened beverages (SSBs) in promoting obesity is controversial. Observational data link SSB consumption with excessive weight gain; however, randomized, controlled trials are lacking and necessary to resolve the debate. We conducted a pilot study to examine the effect of decreasing SSB consumption on body weight.METHODS. We randomly assigned 103 adolescents aged 13 to 18 years who regularly consumed SSBs to intervention and control groups. The intervention, 25 weeks in duration, relied largely on home deliveries of noncaloric beverages to displace SSBs and thereby decrease consumption. Change in SSB consumption was the main process measure, and change in body mass index (BMI) was the primary end point.RESULTS. All of the randomly assigned subjects completed the study. Consumption of SSBs decreased by 82% in the intervention group and did not change in the control group. Change in BMI, adjusted for gender and age, was 0.07 ± 0.14 kg/m2 (mean ± SE) for the intervention group and 0.21 ± 0.15 kg/m2 for the control group. The net difference, −0.14 ± 0.21 kg/m2, was not significant overall. However, baseline BMI was a significant effect modifier. Among the subjects in the upper baseline-BMI tertile, BMI change differed significantly between the intervention (−0.63 ± 0.23 kg/m2) and control (+0.12 ± 0.26 kg/m2) groups, a net effect of −0.75 ± 0.34 kg/m2. The interaction between weight change and baseline BMI was not attributable to baseline consumption of SSBs.CONCLUSIONS. A simple environmental intervention almost completely eliminated SSB consumption in a diverse group of adolescents. The beneficial effect on body weight of reducing SSB consumption increased with increasing baseline body weight, offering additional support for American Academy of Pediatrics guidelines to limit SSB consumption.

Objectives. To monitor annual changes in weight status, we determined incidence and remission rates of overweight among school-aged children with longitudinal school-based surveillance. Methods. We estimated 1-year changes in weight status among students enrolled in public schools in Cambridge, Mass. Physical education teachers measured height and weight annually. Adjusted odds ratios (ORs) were estimated via multivariate logistic regression, accounting for repeated observations of individual children across years. Results. The 1-year incidence of overweight was 4%, and the remission rate was 15%. Among overweight children, 85% remained overweight at a 1-year follow-up, while 18% of children at risk for overweight became overweight. Overweight incidence rates were higher among children aged 7 and 8 years than among those aged 11 to 13 years (boys: OR=1.68; 95% confidence interval [CI]=1.14, 2.47; girls: OR=1.86; 95% CI=1.25, 2.77). Conclusions. Both incidence and remission rates were higher among younger children. Children who were at risk for overweight were more likely to change their weight status than those who were already overweight. Our results support targeting overweight prevention efforts toward younger children and children at risk for overweight.

Objective To describe correlates of physical activity (PA) in structured exercise and structured sports sessions among low-income, overweight children participating in a community-based PA program. Methods A total of 93 children (55% male; 91% Hispanic) aged 8–14 years were included. Participants wore pedometers in a sample of 10 of 59 total sessions offered; mean steps per minute were calculated for structured exercise and sports sessions. Separate multivariable regression models tested associations between steps per minute in exercise and sports sessions and 5 potential correlates: baseline body mass index z -score, aerobic fitness (Progressive Aerobic Cardiorespiratory Endurance Run laps), perceived athletic competence (Harter self-perception profile), sex, and age. Results Only age (s = –2.9; P = .02) significantly predicted steps per minute in exercise sessions. Age (s = –4.3; P = .007), fitness (s = 0.45; P = .03), and male sex (s = 8.7; P = .02) significantly predicted steps per minute in sports. Conclusion and Implications In structured exercise and sports, perceived competence may not influence overweight and obese children's PA. However, girls and older or less fit children may engage less actively, especially in sports.

Background: Intakes of sugar-sweetened beverages (SSB) and added sugars have been targeted in efforts to reduce childhood obesity and cardiovascular disease risk factors in children. Although evidence is sparse in children, overconsumption of SSB and added sugars has been linked to greater dyslipidemia in adults. Objectives: To examine the association between intakes of SSB, added sugars, and total sugars, with blood lipids in a multi-ethnic sample of children with prevalent obesity. Methods: In this cross-sectional study, we examined associations between intakes of SSB, added sugars, and total sugars with high-density lipoprotein cholesterol (HDL-C) and triglycerides (TG) in a sample of 276 children aged 8-15 y (mean age 11.8 y; 39% white, 14% black, 16% Hispanic/Latino, 12% Asian, and 19% multi-racial/other) with prevalent overweight/obesity (45% with ≥85 th BMI percentile and 25% with ≥95 th ). Percentage of daily calories from SSB, as well as intakes of added sugars (tsp) and total sugars (g), were estimated using the 2004 Block Food Frequency Questionnaire for Children. HDL-C and TG were obtained from a fasting blood sample. Percentage of calories from SSB, added sugars, and energy-adjusted total sugars were dichotomized at their upper tertile cut-points, specifically, at 7%, 13 tsp, and 116 g, respectively, creating two intake categories for each dietary exposure. ANCOVA was used to analyze the data; covariates were age, sex, race/ethnicity, obesity, total calories, and intakes of saturated fat and dietary fiber. TG was log-transformed prior to analysis; low HDL-C was defined as ≤45 mg/dL and borderline/high TG, as ≥75 (aged ≤9 y) or ≥90 mg/dL (≥10 y). Results: Median daily intake of total sugars was 94.2 g, 47% of which was derived from added sugars (median: 9.9 tsp, range: 1-76 tsp). Only 12% of children followed the American Heart Association calorie-specific recommendations for intake of added sugars. Median contribution of SSB to total calories was 4.4% (range: 0 to 51%), and SSB calories contributed 36% (range: 0 to 100%) of calories from added sugars. Both low HDL-C and borderline/high TG were prevalent (26-27% overall) and were more common in children classified as obese (61% and 53%, respectively) than in those who were not obese (16% and 17%, respectively, P Conclusions: Among children with prevalent obesity, higher intakes of SSB and total sugars were associated with higher TG concentrations, but not with lower HDL-C. Further research is needed on the health implications of lower SSB and sugar intakes in diverse samples.

BACKGROUND: To address the obesity epidemic among children and youth, school-based body mass index (BMI) screening and surveillance is proposed or mandated in 30 states. In Cambridge, MA, physical education (PE) teachers are responsible for these measurements. This research reports the reliability of height and weight measures collected by these PE teachers. METHODS: Using Bland-Altman plots, mean absolute differences, and intraclass correlation coefficients (ICC), we estimated intra- and inter-rater reliability among PE teachers in a controlled setting and PE teacher-vs-expert inter-rater reliability in a natural classroom setting. We also qualitatively assessed barriers to reliability. RESULTS: For the controlled setting, of 150 measurements, 3 height (2.0%) and 2 weight (1.33%) measurement outliers were detected; intra-rater mean absolute differences for height/weight were 0.52 inches (SD 1.61) and 0.8 lbs (SD 3.2); intra- and inter-rater height/weight ICCs were ≥0.96. For the natural setting, of 105 measurements, 1 weight measurement outlier (0.9%) was detected; PE teacher-vs-expert-rater mean absolute differences for height/weight were 0.22 inches (SD 0.21) and 0.7 lbs (SD 0.8), and ICCs were both 0.99. Equipment deficiencies, data recording issues, and lack of students' preparation were identified as challenges to collecting reliable measurements. CONCLUSION: According to ICC criteria, reliability of PE teachers' measurements was “excellent.” However, the criteria for mean absolute differences were not consistently met. Results highlight the importance of staff training and data cleaning.

Throughout life, vitamin D is important for Ca absorption and bone growth(1). Emerging evidence suggests that low vitamin D levels are also associated with obesity, diabetes and CVD, and that ethnic minorities are most affected(2). Recently, vitamin D has received growing attention due to the increased awareness of possible deficiencies among certain racial/ethnic populations at risk of vitamin D deficiency(3,4). Various studies have found that attaining optimal serum 25-hydroxyvitamin D (25(OH)D) concentrations is more challenging for certain racial/ethnic groups(2). Ethnic minorities have significantly higher rates of vitamin D deficiency (25(OH)D

Community policies and programs can encourage active living and promote physical activity among residents. Somerville MA implemented an Active Living by Design project in 2003-2008 that promoted partnerships and advocacy to encourage physical activity.To evaluate the Active Living by Design project implemented in Somerville.A retrospective design assessed relative differences in the rates of meeting moderate or vigorous physical activity recommendations among middle- and high-school students and adults at baseline and follow-up within Somerville and at follow-up only in Everett MA, a comparison community. The middle- and high-school Youth Risk Behavior Surveys and the adult Behavioral Risk Factor Surveillance Survey were supplemented with Active Living by Design evaluation-specific questions at follow-up. Analyses included chi-square and logistic regression modeling to assess relationships.Approximately 1000 youth completed surveys at baseline and follow-up in Somerville and at follow-up in Everett. Similarly, adult residents completed surveys at baseline (n=1081) and follow-up in Somerville (n=644) and follow-up in Everett (n=608). Within Somerville, high school-aged students and adults were more likely to meet physical activity recommendations at follow-up after adjusting for demographic, health, and behavioral variables (OR=1.6 [95% CI=1.34, 1.92] and 2.36 [95% CI=2.29, 2.43], respectively). Between cities, Somerville adults were 1.47 (95% CI=1.37, 1.56) times more likely than Everett adults to meet physical activity recommendations.Community-based active living interventions may help residents meet physical activity recommendations. To improve community health, public health surveillance data can identify predictors of meeting physical activity recommendations that can be used to inform city policy and planning.

To determine the relationship between serum vitamin D levels and cardiometabolic risk factors independent of adiposity in urban schoolchildren.We assessed the relationships among serum 25-hydroxyvitamin D [25(OH)D], adiposity measured by body mass index (BMI) z-score (BMIz), and 6 cardiometabolic risk factors (total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, interleukin-6, and C-reactive protein [CRP]) in a cross-sectional sample of 263 racially and ethnically diverse schoolchildren from the Boston area during late winter. Multivariate regression analyses adjusting for sociodemographic characteristics and BMIz examined associations of 25(OH)D and cardiometabolic risk factors.Overall, 74.6% of the children were vitamin D deficient [25(OH)D50 nmol/L; mean, 41.8 ± 13.7 nmol/L]; 45% were overweight or obese (20% and 25%, respectively; BMIz = 0.75 ± 1.1). The 25(OH)D level was not associated with BMIz, but was positively associated with the cardiometabolic risk factor CRP (β = 0.03; P.05). BMIz was associated with elevated triglycerides (β = 0.13), CRP (β = 0.58), and interleukin-6 (β= 0.14) and low high-density lipoprotein cholesterol (β = -0.09; all P.01).Vitamin D deficiency is highly prevalent during the late winter months in urban schoolchildren living in the northeastern United States. This widespread deficiency may contribute to the lack of associations between 25(OH)D and both BMIz and cardiometabolic risk factors. The association between 25(OH)D and CRP warrants further study.