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Using data from 2017, the authors have previously examined the coverage of obesity-related services in state employee health plans since 2009 and found improvements in coverage for obesity-related treatments. This study repeated the collection of similar data for 2021 and explored whether coverage had continued to increase or decline.Data on obesity benefits for state employees were obtained from publicly available documents from relevant state websites. Source documents were reviewed for language that would indicate the availability of coverage for nutritional counseling, pharmacotherapy, and bariatric surgery. Use data were collected when available, but availability was limited.Coverage for some treatments of obesity continued to trend upward, as was the case between 2009 and 2017, but coverage for pharmacotherapy declined from 2017 to 2021. Use data were received from only eight states; analysis of these data indicated underuse of obesity benefits by plan enrollees compared with each state's rate of obesity.Despite promising new therapies, states in 2021 were less likely to provide coverage for antiobesity medications. Additionally, limited use data suggested that few eligible individuals may be receiving these services. In conclusion, state employee health plans are currently inadequate given the prevalence, severity, and costs of obesity.

Climate change poses serious threats to public health and is exacerbating health inequities. Policy changes are essential to mitigate climate change impacts on human and planetary health. The purpose was to describe recommendations by the Policy and Advocacy Subgroup of the Society of Behavioral Medicine (SBM) Climate Change, Behavior Change and Health Presidential Working Group (PWG). The Policy and Advocacy subgroup was comprised of experts in public health, climate policy, and health behavior change, who worked together to identify priorities and develop recommendations. We worked under the premise that building political will for climate policy action is the most urgent goal, and we recommended promotion of citizen advocacy for this purpose. Because citizen advocacy is a set of behaviors, SBM members can use behavioral science to identify and scale up interventions, working collaboratively with communities targeted for marginalization. Recommendations for SBM included establishing an organizational home for climate and health work, providing training and resources, engaging in climate advocacy as an organization, and networking with other organizations. Recommendations for a proposed SBM Climate and Health Committee, Council, or Special Interest Group included developing trainings and resources, seeking opportunities for networking and collaborations, and identifying a research agenda. Individual behavior changes are insufficient to address climate change; policy actions are needed. SBM and similar organizations can support their members to work in developing, evaluating, and scaling up advocacy interventions for action on climate policy to magnify the power of the health and medical sectors to protect planetary and human health.

The goal of this manuscript is to identify dietary and active transport strategies that reduce greenhouse gases and obesity, and thereby mitigate the effects of climate change on crop yields and micronutrient content.This report builds on our earlier publication that described the Global Syndemic of Obesity, Undernutrition, and Climate Change. We focus here on the contributions that the USA makes to the Global Syndemic and the policy solutions necessary to reduce the effects of the transport and food and agriculture systems on greenhouse gas emissions and environmental degradation. A recent study suggests that people are interested and ready to address local solutions to climate change. Changing the individual behaviors that sustain the US transport and food and agriculture systems is the first step to the broader engagement necessary to build the political will that to achieve institutional, municipal, state, and federal policy.

Objective To establish a model for Public Health 3.0 in order to define and measure community resilience (CR) as a method to measure equity, address structural racism, and improve population health. Design To develop the CR model, we conducted a literature review in medicine, psychology, early childhood development, neurobiology, and disaster preparedness and response and applied system dynamics modeling to analyze the complex interactions between public systems, policies, and community. Main outcome measures The CR model focuses on community and population health outcomes associated with the policies and practices of the housing, public education, law enforcement, and criminal justice sectors as CR measures. The model demonstrates how behaviors of these systems interact and produce outcome measures such as employment, homelessness, educational attainment, incarceration, and mental and physical health. Results The policies and practices within housing, public schools, law enforcement, and criminal justice can suppress resilience for families and communities because they are shaped by structural racism and influence the character and nature of resources that promote optimal community health and well-being. Conclusions Community resilience is relational and place-based and varies depending on the demographic makeup of residents, historical patterns of place-based racism and discrimination, jurisdictional policy, and investment priorities-all influenced by structural racism. Implications for policy and practice Using system dynamics modeling and the CR approach, chief health strategists can convene partners from multiple sectors to systematically identify, measure, and address inequities produced by structural racism that result in and contribute to adverse childhood and community experiences.

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

OBJECTIVE The objective of this study was to develop a simple and practical guide for discussing and managing obesity in primary care settings. METHODS This study convened representatives from 12 primary care and obesity specialty organizations for a series of roundtable meetings to discuss the key components of obesity treatment in primary care. Attendees identified the need for a guide for primary care providers that outlined the key steps for discussing obesity with patients and managing their care while recognizing the significant time constraints on such provider/patient encounters. RESULTS Prevailing themes from the roundtable sessions suggested that the key components of addressing obesity in primary care settings are obtaining patient permission, addressing weight bias, providing a diagnosis, and emphasizing shared decision-making. A modified "6A" framework with the steps "Ask," "Assess," "Advise," "Agree," "Assist," and "Arrange" was deemed appropriate to organize the process of weight management in primary care. An algorithm was developed to provide a script for the patient/provider encounter. CONCLUSIONS The expert panel developed a short, accessible, practical, and informative guide for obesity management by primary care clinicians. Efforts are under way to disseminate the guide to primary care providers through the 11 participating organizations that have endorsed it.

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

BACKGROUND AND OBJECTIVES Addressing food insecurity while promoting healthy body weights among children is a major public health challenge. Our objective is to examine longitudinal associations between food insecurity and obesity in US children aged 1 to 19 years. METHODS Sources for this research include PubMed, CINAHL, and Scopus databases (January 2000 to February 2022). We included English language studies that examined food insecurity as a predictor of obesity or increased weight gain. We excluded studies outside the United States and those that only considered the unadjusted relationship between food security and obesity. Characteristics extracted included study design, demographics, methods of food security assessment, and anthropometric outcomes. RESULTS Literature searches identified 2272 articles; 13 met our inclusion criteria. Five studies investigated the relationship between food insecurity and obesity directly, whereas 12 examined its relationship with body mass index or body mass index z-score. Three studies assessed multiple outcomes. Overall, evidence of associations between food insecurity and obesity was mixed. There is evidence for possible associations between food insecurity and obesity or greater weight gain in early childhood, for girls, and for children experiencing food insecurity at multiple time points. Heterogeneity in study methods limited comparison across studies. CONCLUSIONS Evidence is stronger for associations between food insecurity and obesity among specific subgroups than for children overall. Deeper understanding of the nuances of this relationship is critically needed to effectively intervene against childhood obesity.

Despite public health efforts to reduce sugary drink consumption, children’s intake continues to exceed recommendations. While numerous barriers to lowering sugary drink consumption have been identified, aversive feelings during sugary drink cessation may further challenge sustained reduction in children’s sugary drink consumption. Herein, we describe “Stop the Pop”, an intervention to examine children’s physical and emotional responses during three days of sugary drink cessation. Children (n = 150) ages 8–14, who reported habitual consumption of ≥12 ounces of sugary drinks daily, were instructed to avoid sweetened beverages for three days. At baseline and on each day of cessation, children completed a daily feelings questionnaire, and a subset of children (n = 30) also completed a qualitative interview following cessation. During sugary drink cessation, children reported physical and emotional improvements, including being less tired, angry, and annoyed; having less trouble sleeping; and less frequently arguing with others, getting in trouble, and getting mad. However, unfavorable responses, such as mood disturbances and having less energy, were reported by some participants. Our results suggest that children who habitually consume sugary drinks may experience physical and emotional improvements during short-term sugary drink cessation, although longer-term examination is needed and inter-individual variability in responses to cessation warrants further study.

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

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

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

Additional co-authors: Prof Corinna Hawkes PhD, Mario Herrero PhD, Prof Peter S Hovmand PhD, Prof Mark Howden PhD, Lindsay M Jaacks PhD, Ariadne B Kapetanaki PhD, Matt Kasman PhD, Prof Harriet V Kuhnlein PhD, Prof Shiriki K Kumanyika PhD, Prof Bagher Larijani MD, Tim Lobstein PhD, Michael W Long PhD, Victor K R Matsudo MD, Susanna D H Mills PhD, Gareth Morgan PhD, Alexandra Morshed, Patricia M Nece JD, Prof An Pan PhD, David W Patterson, Gary Sacks PhD, Meera Shekar PhD, Geoff L Simmons, Warren Smit PhD, Ali Tootee PhD, Stefanie Vandevijvere PhD, Wilma E Waterlander PhD, Luke Wolfenden PhD, Prof William H Dietz MD

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

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

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

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

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

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

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

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

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

Background Biliary atresia (BA) is a congenital, progressive, fibro-obliterative disease of the extrahepatic biliary tree and the most common cause of end-stage liver disease in children. BA is characterized by extensive intrahepatic proliferating ductular reactions that may contribute to biliary fibrosis. Lineage tracing during experimental cholestasis indicates that cells within ductular reactions derive from PROM1-expressing hepatic progenitor cells. Given the role of Notch signaling in normal biliary development, we hypothesize that activated Notch signaling promotes the formation of ductular reactions in BA. Methods Liver samples collected from BA infants at Kasai portoenterostomy and age-matched controls, as well as from wild-type and Prom1 knockout mice with 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC)-induced experimental cholestasis were analyzed histologically using immunofluorescence and by quantitative polymerase chain reaction. Results Increased expression of genes encoding Notch ligand JAG1 and its receptor NOTCH2 was observed in BA livers compared with control by quantitative polymerase chain reaction analyses. Livers of DDC-treated mice, which exhibit cytokeratin-19–positive ductular reactions typical of BA livers, demonstrated significant increases in the expression level of the gene encoding Notch2, as well as downstream Notch target gene Hes1 compared with control. Prom1 knockout mice exhibit diminished ductular reactions and decreased levels of Jag1 and Hes1 compared with littermate controls. Conclusions Human BA and cholestasis induced by DDC are associated with Notch signaling activation. Null mutation of Prom1 is associated with decreased ductular reactions and decreased Notch signaling activation during DDC treatment. These data are consistent with Notch signaling promoting ductular reactions of Prom1 expressing progenitor cells in BA.

Background Intrahepatic biliary fibrosis, as seen with cholestatic liver injuries such as biliary atresia, is mechanistically distinct from fibrosis caused by hepatocyte toxicity. We previously demonstrated the expansion of cells expressing the stem/progenitor cell marker Prominin-1 , within regions of developing fibrosis in biliary atresia. Thus, we hypothesized that Prominin-1 expression is biliary fibrosis-specific. Methods Gene expression of Prominin-1 was analyzed in adult mice undergoing either cholestatic bile duct ligation or hepatotoxic carbon tetrachloride administration by quantitative polymerase chair reaction. Lineage tracing of Prominin-1 -expressing cells and Collagen-1α-expressing cells was performed after bile duct ligation in Prominin-1 cre-ert2−lacz ;Gfp lsl and Collagen-1α Gfp transgenic mice, respectively. Results Prominin-1 expression increased significantly after bile duct ligation compared with sham (6.6 ± 0.9-fold change at 2 weeks, P Prominin-1 was observed histologically throughout the liver as early as 5 days after bile duct ligation in Prominin-1 cre-ert2−lacz mice by LacZ staining in nonhepatocyte cells. Lineage tracing of Prominin-1 -expressing cells labeled prior to bile duct ligation in Prominin-1 cre-ert2−lacz ;Gfp lsl mice, demonstrated increasing colocalization of GREEN FLUORESCENT PROTEIN with biliary marker CYTOKERATIN-19 within ductular reactions up to 5 weeks after bile duct ligation consistent with biliary transdifferentiation. In contrast, rare colocalization of GREEN FLUORESCENT PROTEIN with mesenchymal marker α-SMOOTH MUSCLE ACTIN in Prominin-1 cre-ert2−lacz ;Gfp lsl mice and some colocalization of GREEN FLUORESCENT PROTEIN with PROMININ-1 in Collagen-1α Gfp mice, indicate minimal contribution of Prominin-1 progenitor cells to the pool of collagen-producing myofibroblasts. Conclusion During biliary fibrosis Prominin-1 -expressing progenitor cells transdifferentiate into cells within ductular reactions. This transdifferentiation may promote fibrosis.

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

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

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

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

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

Nutrition plays an important role in health promotion and disease prevention and treatment across the lifespan. Physicians and other healthcare professionals are expected to counsel patients about nutrition, but recent surveys report minimal to no improvements in medical nutrition education in US medical schools. A workshop sponsored by the National Heart, Lung, and Blood Institute addressed this gap in knowledge by convening experts in clinical and academic health professional schools. Representatives from the National Board of Medical Examiners, the Accreditation Council for Graduate Medical Education, the Liaison Committee on Medical Education, and the American Society for Nutrition provided relevant presentations. Reported is an overview of lessons learned from nutrition education efforts in medical schools and health professional schools including interprofessional domains and competency-based nutrition education. Proposed is a framework for coordinating activities of various entities using a public-private partnership platform. Recommendations for nutrition research and accreditation are provided.

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

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