November 2014





In-store calorie signage results in teens purchasing fewer sugary beverages

Oct. 16, 2014, Robert Wood Johnson Foundation

A new study reveals that adolescents who saw printed signs with easy-to-understand calorie information about sugar-sweetened beverages — including the amount of exercise required to burn off the calories in these beverages or the numbers of teaspoons of sugar in these beverages — were more likely to purchase a drink with fewer calories. Researchers also found that the purchasing behavior persisted for six weeks after the signs came down. The study was published on Oct. 16, 2014 by the American Journal of Public Health.

The signage caused the likelihood of buying a sugar-sweetened beverage to drop from 98 percent before the signage was displayed to 89 percent while the signs were posted, and the number of sugar-sweetened beverage calories purchased went from 203 to 184. Additionally, the likelihood of buying a sugar-sweetened beverage larger than 16 ounces dropped from 54 percent before the signs were displayed to 37 percent while the signs were posted. The reduction in calories purchased can be attributed to teens buying fewer sodas and sports drinks and more bottled water and diet soda.

The information conveyed by the signs proved to have a lasting effect. During a six-week period after the signs were removed, teens’ likelihood of buying a sugar-sweetened beverage dropped from 98 percent before the signs were posted to 91 percent, and the number of sugar-sweetened beverage calories purchased went from 203 to 178. Additionally, the likelihood of buying a sugar-sweetened beverage larger than 16 ounces in that six-week period after the signs were removed dropped from 54 percent before the signage was displayed to 37 percent.

The study, which was supported by the Robert Wood Johnson Foundation (RWJF) through its Healthy Eating Research program, was conducted in six corner stores located in low-income, predominantly black neighborhoods in Baltimore. The researchers used four randomly posted signs with caloric information: absolute calories; number of teaspoons of sugar in a sugar-sweetened beverage; and number of minutes of running, or miles of walking, necessary to burn off a sugar-sweetened beverage. Then they collected the purchase data of a sample of black adolescents who appeared to be between the ages of 12 to 18.

When compared with purchasing behaviors during times when there was no signage, the most effective sign was the one that told consumers they would have to walk five miles to burn off the sugary beverage calories.

“This study reinforces that when provided with understandable calorie information, black teenagers will make healthier beverage choices,” said Sara Bleich, PhD, associate professor at the Johns Hopkins Bloomberg School of Public Health and lead author of the study. “After seeing the signs, these young consumers selected beverages for purchase that were smaller in volume or contained no added sugars.”

“Sugary beverages are a major source of excess calories in children’s diets, and lowering their consumption is a critical step in reversing the nation’s epidemic of childhood obesity,” said Ginny Ehrlich, EdD, MPH, MS, director, Robert Wood Johnson Foundation. “The results of this study show that, when provided with easily understandable calorie information, black teenagers will choose a healthier beverage option. This is encouraging news because obesity rates are higher among black youth than white or Asian youth.”

This study builds on the results of a similar study published in 2011, led by the same research team, and funded by RWJF. In the earlier work, the researchers found that black teenagers purchased fewer sugary beverage calories when provided with easily understandable calorie information. However, this new study added to prior findings by more closely examining purchasing behaviors and whether those behaviors persisted after the signs were removed.

Sugar-sweetened beverages, such as soda, energy drinks, sports drinks, and sweetened coffees and teas, add large numbers of calories to the diets of children and adults and are associated with an increased risk of chronic diseases, including type 2 diabetes, heart disease, and obesity. Increasing public awareness about healthier beverage options is seen as a way to influence consumers’ behavior to help prevent obesity and improve overall health.

To translate calories into a walking and running equivalent, researchers calculated that a 15-year-old weighing 100 pounds would need to replace sitting with running for 50 minutes, or walking for five miles, to burn off 250 calories from a bottle of soda.


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Publications & Tools

From implementation to evaluation, two new supplements explore CPPW initiative

The Centers for Disease Control and Prevention’s Communities Putting Prevention to Work (CPPW) initiative was one of the largest federal investments ever to combat chronic diseases in the United States. CPPW supported high-impact, jurisdiction-wide policy, systems, and environmental changes to improve health. Two recent supplements published in Preventing Chronic Disease and Preventive Medicine describe implementation and evaluation efforts of strategies implemented by CPPW awardees. Preventing Chronic Disease includes a collection of eight articles that focus on healthy retail initiatives, and the collection in Preventive Medicine includes nine articles focused on a range of interventions related to preventing tobacco use and smoke exposure and preventing obesity through healthy eating and active living strategies.



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NYC child care regulations highlighted in Preventing Chronic Disease

In 2007, the New York City Department of Health and Mental Hygiene implemented new regulations for early childhood centers to increase physical activity, limit screen time, and provide healthful beverage offerings. The latest collection of Preventing Chronic Disease includes eight articles that present the results of an evaluation conducted on the 2007 child care regulations. The articles help build an understanding best practices for reducing childhood obesity by exploring whether these regulations were feasible to implement, effective, and if they can be replicated.


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Minority, low-income children more likely to be exposed to food and beverage ads

A five-year study across 88 media markets found that markets with more low-income and black children and adolescents had higher levels of exposure to food and beverage advertisements. The research brief, “Targeting Food and Beverage TV Ads at Minority and Low Income Children,” was released by the Robert Wood Johnson Foundation’s Bridging the Gap program and the African American Collaborative Obesity Research Network. Each percentage point increase in the proportion of black children and adolescents in the population was linked with an average weekly increase of 2.2 and 2.9 more food and beverage ads seen respectively.

In addition to increased exposure, the content of advertisements varied for low-income and minority children and adolescents. Black racial and lower-income groups had greater exposure to fast food restaurant ads compared to ads for full service restaurants. The same groups also had greater exposure to sugar-sweetened beverage ads compared to non-sugar-sweetened beverage ads. Overall, the study authors note that despite industry pledges to promote only healthy products to children, the majority of television advertisements seen by or directed at children consists of unhealthy foods and beverages.


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National study on vending machines: Majority of beverage, food options unhealthy

The Center for Science in the Public Interest (CSPI), released a national study of 853 food and beverage vending machines on 260 state and local public properties. The study found that the majority of beverage vending machines were stocked with sugar-sweetened beverages (58 percent). Similarly, 85 percent of food vending machine options were considered unhealthy, with the most prevalent options including candy (32 percent) and chips (24 percent).

Overall, beverage vending machines offered a larger percentage of healthier options than food vending machines (42 percent vs. 15 percent). Food vending machine options are still overwhelmingly unhealthy, despite interest from consumers in healthier items and a growing supply of healthier options. In consideration of the percentage of healthier options in beverage machines, the authors suggest that nutritional standards requiring a 75 percent threshold are more likely to provide meaningful progress than standards requiring a 25 percent to 30 percent threshold.


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Childhood Obesity Research & News

‘Walking school bus’ powered by kids’ feet

Oct. 2, 2014, The Washington Post

By Kitson Jazynka

Fifth-grader Dominic Feder Di Toro bounds to the curb on Connecticut Avenue on a busy Monday morning, his backpack bouncing to the rhythm of his pounding feet. He glimpses the bright white walk sign beckoning from the other side of the six-lane road. He looks back at his friends. “We got it,” he tells them in an authoritative tone.

The fifth-graders bunch up, step into the crosswalk, and hustle across the street. The volume of their chatter rises above the rumble of a trash truck turning the corner, a convoy of impatient tour buses caught at the red light and the distant siren of an emergency vehicle. Dominic—or Nic, as his friends call him—and the gaggle of friends he’s walking with attend Oyster-Adams Bilingual School in Northwest Washington. Together on a “walking school bus,” these kids trek through an urban jungle every day to get to school.

“I love walking with my friends to school,” Lizey Leibovich says. “This way, we have half an hour to hang out before school. And when you get to school, you can say, ‘I just walked a mile.’ You just feel good.”

The miles add up, even though these kids have so much fun they hardly notice that they’re walking more than five miles a week or nearly 200 miles in a school year.

The walking school bus is an idea that’s gaining traction in the Washington area as a way to encourage kids to walk to school. “It’s like a carpool, except we walk,” says 10-year-old CJ Stanton, who “rides” with Nic and Lizey. “There are different little stops, and the group just keeps getting bigger and bigger with more and more kids the closer we get to school.”

At one stop, their friend Zara Escobar runs out from her apartment building. Some mornings, she grabs mints from the building’s front desk to share with her friends.

A walking school bus such as theirs involves students walking a planned route with a parent “driver” every day or even just once a month. Other versions meet at designated spots from which “riders” walk to school together. In Vienna, Va., students at Vienna Elementary participate in “Walking Wednesdays” and “Biking Fridays” each week. “Even on rainy days, the walking school bus is fun,” says Jennifer Hefferan, who works for the D.C. Department of Transportation. Part of her job is to help schools create safe routes for kids to get to school. “Splashing in puddles is fun, and walking is fun. Our feet have power.”

Walking school buses (or “walk pool” as Nic, Lizey, CJ, and Zara’s group calls it) help parents save time because they take turns supervising the walk. It also saves energy and cuts down on neighborhood traffic. Having fewer cars on the road means better air quality and less gasoline used. It also provides kids an opportunity for exercise and fun.

But there are rules, such as being on time, staying on the sidewalk, and crossing only on green lights and within the crosswalks. Nic says another rule is that “your feet should move way faster than your lips.” “But that doesn’t usually happen,” Ruthie Williams points out.

“Because Nic’s usually singing,” adds Ruthie’s twin sister, Georgie. On Oct. 8, schools around the world celebrated the fun of walking with friends and the power of pedestrians (and their feet) on International Walk to School Day.

Capitol Hill students met in Lincoln Park that day for a rally before school. Elsie Whitlow Stokes Community Freedom Public Charter School held its annual “Walk and Roll” event in which kids walked to school from a drop-off point and hiked up the steep hill that leads to the school with cheerleaders cheering along the way. Parents who drove to school that day had to pay a $1 car “tax.”

Lafayette Elementary in Washington’s Chevy Chase neighborhood organized multiple walking school buses and awarded prizes for all participants.

In Takoma Park, Md., on Walk to School Day, student walkers at Rolling Terrace Elementary carried banners and honored student safety patrols. The school hosted an outdoor assembly where police officers and community leaders talked about the importance of walking or biking and why it’s good for everyone.

“Part of Walk to School Day is about safety and encouraging parents and students to choose walking and biking over driving,” says Lucy Neher, who works as the Safe Routes to School coordinator for the city of Takoma Park. It’s also teaching pedestrian safety to walkers and teaching drivers to be more careful around pedestrians. “It wakes up kids’ minds and their senses,” she says.

It also builds what she calls “street smarts” and helps kids maintain a connection to the outdoors. Neher recalls a boy who said he felt famous on Walk to School Day.

“He thought it was a parade,” Neher says. “You might not feel famous walking to school every day, but you will feel good about yourself.” “There’s nothing about walk pool that’s not good,” says Lizey Leibovich’s mom, Meri Kolbrener, who started the “bus” that travels 1.3 miles each morning from Woodley Park to the Adams campus of Oyster-Adams Bilingual School. The “bus” runs every day unless it’s colder than 25 degrees outside or it’s pouring rain.

Kolbrener says the effort invested in setting up what she calls “walk pool” saves parents hundreds of hours throughout the school year. “It’s one of those ‘it takes a village’ moments where the parents are taking care of each other’s kids one morning a week,” she says. Here’s Kolbrener’s advice for how families can start their own walking school bus:

  • Create a route that participants agree on.
  • Insist that the kids take responsibility for getting to the bus on time. If a kid is late, he or she will have to catch up.
  • Keep the bus schedule strict, but allow changes if necessary.
  • Use technology: Collect every parent’s cell phone number so you can communicate easily.


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Me eat vegetable: Cookie Monster wants kids to snack healthier

Oct. 4, 2014, The Guardian

By Sarah Shemkus

Cookie Monster wants your children to cut down on his namesake treats and start snacking on baby carrots and clementines instead. Sesame Workshop, the nonprofit behind the children’s TV show, and the Produce Marketing Association (PMA) have partnered to create Eat Brighter, an initiative aimed at curbing childhood obesity. Sunkist, one of the country’s largest citrus brands, joined the effort in late October, launching a line of navel oranges and mandarins in Sesame Street-themed packaging.

“We are particularly excited to be a part of this initiative with PMA and Sesame Workshop because it offers our industry the opportunity to join together to, hopefully, spur greater change than any one of our companies could affect on their own,” said Kevin Fiori, vice president of sales and marketing for Sunkist.

The goal of the initiative is to compete with producers of cookies and chips by deploying the same marketing strategies these foods use. Sesame Workshop will license characters such as Big Bird, Elmo, and Cookie Monster to fruit and vegetable suppliers free of charge for two years. Such deals would usually be worth millions of dollars to Sesame Workshop, according to Todd Putnam, chief commercial officer of Bolthouse Farms, another produce supplier signed up to use the Sesame Street brand on its packaging. He is also on the task force that designed the program.

“We know that telling people to eat healthier does not work, but inspiring them emotively and using some of the tactics of the junk food industry … is a much more successful strategy,” said Putnam. The initiative was announced in October 2013 and the first products hit the shelves earlier this year. In the late spring, East Coast Fresh, a produce packager and distributor in Maryland, introduced pre-cut fruits and vegetables labeled with Sesame Street characters. Bolthouse Farms will be launching Eat Brighter-branded baby carrots in January 2015.

So far, about 25 companies have signed the licensing agreement to use Sesame Street branding on their products.

“We have applications coming in every day now,” said Meg Miller, spokeswoman for PMA. “The program is really picking up speed.”

There is strong evidence that the marketing of food to children is effective, though questions remain as to whether these strategies will work as well for fruits and vegetables as they do for chips and cookies.

“The best evidence we have that it’s working is that companies spend $1.6 billion every year on food marketing to children,” said Jennifer Harris, director of marketing initiatives at Yale University’s Rudd Center for Food Policy & Obesity.

The science seems to back up these marketing practices. A 2009 study at Yale found that exposure to food advertising during television viewing makes children eat up to 45 percent more snack food compared to children who did not watch ads. Harris also points to other research that has shown that branding food makes children believe it tastes better. The use of characters in marketing has been shown to increase the appeal of fruits and vegetables and junk food alike.

However, using character-based marketing to encourage fruit and vegetable consumption may be more challenging than using similar tactics to promote sugary and salty snacks. Although studies have indicated the character branding works on both produce and less healthy snacks, that effect was not as strong for the healthier foods, she said.

“Kids are not born liking the taste of vegetables,” she said. “I believe it would be much more difficult to market healthier food to kids.”

Putnam is confident that obstacle can be overcome, he said, pointing to research that suggests children can adapt to new foods in as few as five exposures.

For some critics, however, the question of whether the initiative will be effective is secondary to whether these tactics should be used at all.

Children already live in an advertising-saturated world, argues Josh Golin, associate director of the Boston-based Campaign for a Commercial-Free Childhood. They do not need another campaign urging them to respond positively to characters and emotional pleas, especially when these techniques are more often used to sell unhealthy foods, he said.

“If we tell kids to eat based on what characters tell you to eat, it’s not a winning battle in the long run,” he said. “From the perspective of overall well-being, we really need to try and reverse the sway that characters have over kids.”

Brian Wilcox, a professor of psychology at the University of Nebraska at Lincoln, draws a distinction between the sort of marketing the Eat Brighter campaign employs and advertising in which characters deliver a direct pitch. Such advertising depends on young children’s inability to distinguish promotional media from entertainment or information, he noted. Including a character’s image on fruit or vegetable packaging, however, creates a positive emotional association in pursuit of a healthy behavior.

“That is a very different process and that’s much more acceptable from my standpoint,” Wilcox said. “I am willing to use the tools of marketing when they can benefit the well-being of kids.”

Putnam recognizes the concerns people might have about targeting children with commercial messages. But he argues that the health problems caused by childhood obesity are worrisome enough that all available tools should be used to combat them. Using marketing to promote healthy foods is not the only answer, he said, but is an important part of tackling the issue.

“I have a solution that I know works,” Putnam said. “It’s hard for me to say no to that.”


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High-fives, not high reps

Oct. 1 2014, The New York Times

By Mary Pilon

On a recent afternoon at the CrossFit gym in Long Island City, Queens, N.Y., 3-year-old Ella Reznik bounded toward an array of hoops and candy-colored bouncy balls, her ponytail and her mother trailing her.

Ella’s brother Adam, 4, padded along nearby on rubber black mats and inspected some metal bars bolted to the wall. The gym’s owner and coach, Michele Kelber, greeted the Rezniks and other children with a series of high-fives and smiles. Soon, class was underway: duck, duck, goose; burpees; and dangling from monkey bars.

CrossFit, the hard-core workout regimen, has a growing new demographic to court: preschoolers.

As the issue of youth fitness — from obesity to proper exercise regimens — takes on more resonance in schools and communities across the country, CrossFit Kids and other preschool fitness programs are raising questions about when and how children should start playing organized sports or hitting the gym.

The adult version of CrossFit has garnered acclaim and criticism in recent years for its high-intensity workouts and unyielding approach to exercise, with colorful language to match…While critics have questioned the quality of some instructors and have said there is insufficient research on injuries, CrossFit has dismissed those claims as its business has exploded. Today it includes devout followers at more than 10,000 gyms, worldwide, and conducts the CrossFit Games, an annual test to find “the fittest on earth.”

Physical fitness for children has become big business as gyms and workout centers continue to wind back the ages of their youngest customers. Last year, there were 460,000 children under 13 using personal trainers, according to the International Health, Racquet & Sportsclub Association, an industry trade group. That is more than triple the 140,000 who used them in 2009. Young boys and girls who used to be guided reluctantly into day care centers are now considered crucial to customer acquisition and retention.

CrossFit instructors say they are aware of the skepticism that sometimes greets their preschool efforts, and they say it is a misunderstanding. They argue that their low-key preschool classes are more akin to the tumble sessions and in-school physical education programs of the past. The emphasis for 3- to 5-year-olds, they say, is on fun.

“There is a stigma,” said Jeff Martin, a CrossFit Kids co-founder. The preschool program is “completely different,” he said.

“The goal isn’t to make the fittest 4-year-old in the world,” Martin said in a recent telephone interview. “The goal is to have a kid be physically active and physically literate so they can express athleticism in whatever sport they like. The goal is they can have a fun experience doing something physically active and buy into a physically active lifestyle.”

Martin said the idea for a preschool program arose in the early 2000s, when he noticed that the younger siblings of his elementary-, middle- and high school-age students were frustrated that they had no activity in which to participate. In 2003, he and his wife, Mikki, started CrossFit Kids, and four years later they began consulting with pediatric physical therapists on developing a program for recently potty-trained children.

In recent years it has ballooned to about 700 active preschool CrossFit Kids classes across the country.

Preschool-age CrossFit participants do not use weights. Class time is short, typically 30 minutes or less. There are basic lessons on nutrition, such as where tomatoes come from. There are no weigh-ins or flexing of muscles before a mirror. Instead, activities are done for only a few minutes at a time in short bursts followed by rests. In preschool CrossFit, dangling off hanging bars is likened to being a monkey. Squats are frog-inspired. Box jumps, plyometric leaps long beloved by elite athletes, are smaller and rebranded for children as superhero leaps.

In Long Island City, a tunnel constructed from red tumbling mats inspired comparisons to snakes and worms. Games and exercises were punctuated by water breaks and doodling. CrossFit Kids instructors are discouraged from telling children to move faster, Martin said. High-fives for effort are prevalent.

As long as that remains the case, some pediatricians said, CrossFit preschool classes can be suitable for youngsters. But some cautioned that the same criticisms leveled at CrossFit’s grown-up counterpart — that there can be great variation among the thousands of CrossFit outposts in the style and quality of trainers and regimens — may be true for preschoolers. The doctors suggested that parents would benefit from observing a class beforehand.

“CrossFit has the image of pushing people beyond their limits,” said Dr. Gregory D. Myer, director of the Human Performance Laboratory at Cincinnati Children’s Hospital Medical Center. “You want to make sure people are trained in understanding a child. Kids are likely going to have a disconnect with their ability and what they want to do.”

Dr. Lee Beers, a pediatrician with Children’s National Health System in Washington, said some of her concerns were more environmental. If a child observes behaviors exhibited by adults at a gym, such as comparing muscles or looking distressed when weighing in on a scale, that could lead to a negative body image later in life.

“You want to make sure it’s teaching lifelong healthy behaviors for the sake of being healthy and not focused on body image or weight,” she said. “Kids this age are sponges, and they pick up on everything around them.”

Shiri Reznik, Ella and Adam’s mother, said she decided to enroll her children this fall only after she had met the preschool instructors and had seen the low-intensity environment.“I see the CrossFit adults running around the neighborhood like crazy people,” Reznik said. “But once I saw this class, I saw that it was different.” She added, “If it wasn’t playful, we wouldn’t do it.”

Angela Salveo, who offers CrossFit Kids for preschoolers at her gym in Middletown, N.J., said it was often a struggle to harness the boundless energy of preschoolers. “When we practice box jumps, if the boxes are set up for an adult class, they’ll try and jump on those,” she said. “They have no fear at all.”

Costs vary by location, but children in Long Island City can register for a once- or twice-a-week “membership,” at $140 or $260 a month, said Kelber, the gym owner there.

“We climbed ropes in gym class,” Kelber said. “I don’t even know if schools have ropes anymore. The kids are mesmerized by these things.” For some parents and children, CrossFit has become an alternative to the travel teams and year-round youth sports schedules that can be so demanding. Leslie Costa, from Long Island City, said she was surprised when her older daughter, Natalie, 10, embraced CrossFit Kids after eschewing activities like ballet, gymnastics, and tennis. This fall, Costa enrolled Natalie’s 3-year-old sister, Georgia.

“I think this isn’t as intimidating for them,” she said. The class this month, which was punctuated by the occasional tear or a giggle, progressed from an obstacle course to a game of “farmers and lumberjacks,” a contest to tip over kettlebell weights onto the ground, as a lumberjack would knock over a tree. “I have strong muscles!” Ella Reznik exclaimed, tipping one over.

“It’s made for your kid to succeed in life,” Kelber said, “not to beat them down.”


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