August 2016





SNAP-Ed Evaluation Framework Connect & Explore: A Two-Part Webinar Series

August 11, 2016, NCCOR

States and organizations are implementing comprehensive nutrition education and obesity prevention programs around the country as one approach to address the rise in childhood obesity. The Healthy, Hunger-Free Kids Act of 2010 stipulates that changes in policies, systems, and environments (PSEs) are to be layered with direct nutrition education and social marketing to enable, promote, and support healthy behaviors among low-income people and their communities. Supplemental Nutrition Assistance Program-Education (SNAP-Ed), the nutrition education and obesity prevention arm of the SNAP, aims to increase the likelihood that SNAP-Ed eligible households will make healthy diet and physical activity choices within a limited budget.

To establish a mechanism to evaluate program effectiveness and report results to funders, NCCOR, in partnership with the U.S. Department of Agriculture’s Food and Nutrition Service (FNS), the Association of SNAP Nutrition Education Administrators (ASNNA), and more than 28 states, contributed and developed the Supplemental Nutrition Assistance Program Education (SNAP‐Ed) Evaluation Framework: Nutrition, Physical Activity, and Obesity Prevention Indicators.

Join us on Thursday, August 18, and September 8, at 3 p.m. ET. for a two-part Connect & Explore webinar series on the SNAP-Ed Evaluation Framework and Interpretive Guide.

August 18: “SNAP-Ed Evaluation Framework: Measuring Success in Low-Income Nutrition Education and Obesity Prevention Programs” will explore how to use the framework to evaluate nutrition education and obesity prevention programs. Guest speakers include:

  • Andrew Naja-Riese, MSPH, Chief, Program Integrity Branch, Supplemental Nutrition Assistance Program, Food and Nutrition Service, Western Regional Office, U.S. Department of Agriculture
  • Laurel Jacobs, DrPH, MPH, Lead Evaluator, Arizona SNAP-Ed, The University of Arizona, and Theresa Le Gros, MA, Evaluator, Arizona SNAP-Ed, The University of Arizona

September 8: “SNAP-Ed Evaluation Framework: Strategies and Tools for Measuring the Priority Indicators” will highlight the seven SNAP-Ed priority indicators from the Evaluation Framework. Guest speakers include:

  • Jean Butel, MPH, Junior Researcher, RNECE-PSE Milestone 5 Project Manager and CHL Intervention Coordinator, College of Tropical Agriculture and Human Resources, University of Hawaiʻi at Mānoa
  • Lauren Whetstone, PhD, Project Scientist, Nutrition Education and Obesity Prevention Unit, Nutrition Policy Institute, University of California Agriculture and Natural Resources
  • Heidi LeBlanc MS, CFCS, Food $ense Director, Utah State University

You must register to receive webinar access. The event is free, but attendance is limited, so tell a colleague and register today!

Please consider sharing this information on your social networks using the hashtag #ConnectExplore. We will live-tweet the event, so be sure to follow the conversation at @NCCOR. For those who cannot attend, the webinar will be recorded and archived on

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Publications & Tools

Final Rule: National School Lunch Program and School Breakfast Program: Nutrition Standards for All Foods Sold in School as Required by the HHFKA of 2010

This rule adopts as final, with some modifications, the National School Lunch Program and School Breakfast Program regulations set forth in the interim final rule published in the Federal Register on June 28, 2013. The requirements addressed in this rule conform to the provisions in the Healthy, Hunger-Free Kids Act of 2010 regarding nutrition standards for all foods sold in schools, other than food sold under the lunch and breakfast programs. Most provisions of this final rule were implemented on July 1, 2014, a full year subsequent to publication of the interim final rule. This was in compliance with section 208 of the Healthy, Hunger-Free Kids Act of 2010, which required that State and local educational agencies have at least one full school year from the date of publication of the interim final rule to implement the competitive food provisions.

View Final Rule

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State Quality Rating and Improvement Systems: Strategies to Support Healthy Eating and Physical Activity Practices in Early Care and Education Settings

In the early 2000s, states began developing Quality Rating and Improvement Systems (QRIS) as a structural approach to improve the quality of Early Care and Education (ECE) programs. QRIS are voluntary or required systems designed to reach large numbers of ECE providers, particularly those serving lower-income children receiving child-care subsidies. The topics covered by QRIS (e.g., curriculum, workforce development, health and safety) vary by state. This study aimed to learn about strategies to promote healthy eating, breastfeeding, physical activity, and limit screen time (referred to as “HEPA”) in state QRIS implementation. The purpose of this report is to provide data, recommendations, and case study examples to state-level administrators and stakeholders on how to more effectively use QRIS as a lever for change in childhood obesity prevention. It also identifies opportunities for continued research to advance childhood obesity prevention in ECE settings. This report summarizes information learned from 24 states that have identified practices related to HEPA they want to promote via the state QRIS. Case studies from seven states (Arizona, Georgia, Idaho, Indiana, New Jersey, Oklahoma, and Wisconsin) highlight strategies to support ECE providers’ childhood obesity prevention efforts.

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Assessing Prevalence and Trends in Obesity: Navigating the Evidence

Accurate and meaningful estimates of prevalence and trends are fundamental to describing and understanding the scope of obesity. Policy makers, program planners, and other stakeholders search for and use reports relevant to their population(s) of interest to inform decision making. Interpreting and appropriately applying information derived from such reports, however, is challenging because of inconsistencies in methodologies and presentation that exist in the literature.

View Report in Brief

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Childhood Obesity Research & News

Research Aims to Fight Childhood Obesity through Family Approach

Tuesday, July 26, 2016, University of Rochester Medical Center Newsroom

UR Medicine’s Golisano Children’s Hospital is joining several other universities on one of the largest family-based childhood obesity studies ever conducted.

Working with the University of Buffalo, Washington University in St. Louis, and Nationwide Children’s Hospital at Ohio State University, the study will discern the effectiveness of a treatment program that teaches both a child and their parents how to change their behaviors and attitudes regarding food, exercise, and stressful situations. This method deviates from traditional efforts that emphasize patient education.

The treatment program will be integrated into the primary care setting, potentially allowing the intervention to be widely adopted by pediatricians and family physicians. The study is supported by $9.6 million from the National Institutes of Health, of which Rochester will receive $1.5 million.

“At least 4 percent of children and teens have what is considered severe obesity,” said Stephen Cook, M.D., associate professor of Pediatrics at UR Medicine’s Golisano Children’s Hospital and the study’s lead researcher locally. “This program will help them get their weight under control through a change in mindset and by behavior change for the child and family that targets problem solving mechanisms.”

The study will involve over 600 families of children between the ages of 6 and 12. Past studies have shown that this type of behavioral approach can carry a “halo effect,” with other family members often seeing benefit as well, which researchers will track.

The intervention meets the U.S. Preventive Services Task Force recommendation for childhood obesity treatment, which means that if it is implemented broadly, it should be covered by insurers in pursuance to the Affordable Care Act.

Cook’s team will begin recruiting locally in early 2017. At least five local pediatric practices are expected to participate in addition to Strong Pediatrics: Rochester General Pediatric Associates, Elmwood Avenue Pediatrics, Long Pond Pediatrics, Panorama Pediatrics, and Genesis Pediatrics.

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Determinants and Consequences of Obesity

July 26, 2016, American Journal of Public Health

Objectives. To review the contribution of the Nurses’ Health Studies (NHS and NHS II) in addressing hypotheses regarding risk factors for and consequences of obesity.

Methods. Narrative review of the publications of the NHS and NHS II between 1976 and 2016.

Results. Long-term NHS research has shown that weight gain and being overweight or obese are important risk factors for type 2 diabetes, cardiovascular diseases, certain types of cancers, and premature death. The cohorts have elucidated the role of dietary and lifestyle factors in obesity, especially sugar-sweetened beverages, poor diet quality, physical inactivity, prolonged screen time, short sleep duration or shift work, and built environment characteristics. Genome-wide association and gene–lifestyle interaction studies have shown that genetic factors predispose individuals to obesity but that such susceptibility can be attenuated by healthy lifestyle choices. This research has contributed to evolving clinical and public health guidelines on the importance of limiting weight gain through healthy dietary and lifestyle behaviors.

Conclusions. The NHS cohorts have contributed to our understanding of the risk factors for and consequences of obesity and made a lasting impact on clinical and public health guidelines on obesity prevention.

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New study from Duke links prepregnancy obesity to infant growth

July 19, 2016, Mary Ann Liebert, Inc./Genetic Engineering News

New Rochelle, NY, July 19, 2016 — Infants born to women with a prepregnancy body mass index (BMI) in the obese range (>40) were 8% larger during the first two years of life than were those born to women with a BMI in the healthy range (18.5-24.9), based on a new study of a multiethnic group of infants in the U.S. published in Childhood Obesity, a peer-reviewed journal from Mary Ann Liebert, Inc., publishers. The article is available free on the Childhood Obesity website.

Bernard Fuemmeler, PhD, MPH and coauthors from Duke University Medical Center and Duke University, Durham, and North Carolina State University, Raleigh, NC, also reported differences in the pace of infant growth and the time to reach peak growth rate depending on the mothers’ prepregnancy BMI. The researchers further showed a link between greater maternal weight gain during pregnancy and larger infant size in the article “Association Between Prepregnancy Body Mass Index and Gestational Weight Gain with Size, Tempo, and Velocity of Infant Growth: Analysis of the Newborn Epigenetic Study Cohort.”

The article is part of a special issue on “Childhood Obesity Risk and Prevention: First 1000 Days of Life,” led by Guest Editor Elsie M. Taveras, MD, MPH, Massachusetts General Hospital for Children and Harvard Medical School, and Harvard T.H. Chan School of Public Health, Boston, MA.

“This special issue devoted to obesity risks in the first 1000 days of life brings together some of the latest research on this key issue and exemplifies the complexities,” says Childhood Obesity Editor-in-Chief Tom Baranowski, PhD, Baylor College of Medicine, Houston, TX. “Fuemmeler et al. demonstrate that both maternal prepregnancy obesity and gestational weight gain were associated with infant weight trajectories in the first 24 months of life. However, Claesson et al. and Gregory et al. report in this issue that gestational weight management programs had no effect on children’s weight. Whether the maternal-to-child weight relationships are causal or both reflect some unmeasured third variable remains to be determined. If causal, future research specifying the biological pathways of influence hopefully will lead to effective interventions. Stay tuned!”

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A simple change that could help solve one of the biggest problems facing poor people

July 15, 2016, Wonkblog, Washington Post

Middle- and upper-class city dwellers tend to live near supermarkets. But if the trek feels too far, in many cities and suburbs they can order grocery deliveries, often for a single-digit delivery fee, from services such as Instacart, Peapod and FreshDirect.

That’s not an option for the 14 percent of Americans who rely on food stamps. The Supplemental Nutrition Assistance Program’s benefits cannot be used online. That only worsens food access for poor Americans who live far from grocery stores.

And many of them do. The Agriculture Department estimates that 11.5 million poor Americans live more than one mile from a supermarket, commonly called a “food desert.” That represents 4.1 percent of the U.S. population. And 2.3 million households, or 2.2 percent overall, do not have access to a vehicle and live more than a mile from a supermarket.

As these maps demonstrate, food deserts are most common in some of the country’s poorest areas, such as the Deep South, Appalachia, and the border of New Mexico and Arizona. And they often are also in places where obesity rates are high, highlighting the fact that people who have trouble getting easy access to high quality food are often less healthy.

The Internet might provide a solution. This fall, the USDA will start recruiting online grocery delivery services to test the possibility of accepting SNAP benefits. The experiments are long overdue. Congress instructed the agency in the 2014 Farm Bill to conduct and publicly report the results of these tests by July 1, 2016, and then assess if the program should be implemented nationwide.

“We look forward to working with states to get these projects running and learn how best to bring online access to SNAP participants in an efficient and secure manner,” USDA press secretary Cathy Cochran wrote in a statement.

Ed Bolen, senior policy analyst at the Center on Budget and Policy Priorities, said that buying food can be exhausting for the poor. Those earning low wages are already pressed for time as many work multiple jobs.

A big-box supermarket, which would probably have the lowest prices, could take hours to visit by public transportation. A neighborhood grocery store could be closer but have higher prices, a sacrifice hard to accept when the average monthly food stamp allowance is $125 per month. Closest of all might be a corner store, gas station or pharmacy. That offers plenty of processed and frozen foods, but no fresh produce or meat.

“Just the litany of challenges when you’re resource scarce, when you don’t have a lot of options, can make it very difficult to go to a store that has the best selection,” Bolen said.

Access to at-home Internet is somewhat more common among the poor than access to a car — 88 percent vs. 79.6 percent. Take Mobile, Ala., where a third of residents are both below poverty level and live further than half a mile from the nearest supermarket. Ninety-one percent of those below the poverty line have Internet access, and only 76 percent have a car. The option of home-delivered groceries, assuming the Internet access is fast enough to use the websites of grocery providers, could make life less stressful.

It may also take less time to shop online than in brick-and-mortar stores, particularly when comparing prices. Today, visiting multiple stores in search of the best prices is common for SNAP households, said Kathy Edin, who studies poverty as a professor at Johns Hopkins University.

Spending food stamps online involves several barriers, beyond the USDA’s sluggishness in getting the pilots up and running. For starters, all vendors that accept SNAP benefits must meet standards that regulators have put in place to prevent food stamp fraud. And the way benefits are conferred altogether would need to be changed. SNAP transactions require entering an encrypted pin, which is not currently compatible with online credit card forms. Broadband, while common, is not universal among the poor. According to a Center for Public Integrity analysis, 2.6 percent of upper-middle-class and wealthy lack high-speed Internet, compared to 11.9 percent of the poor.

Edin said grocery companies will likely have to change, too. Currently, grocery delivery services cater to young professionals without cars or many financial concerns. Along with the slew of other apps that take care of your laundry, pets and housekeeping with the touch of a button, they were created to tend to the demands of the young and well-off.

Even when the poor have greater access to better food, research has shown that they will still not consume enough fruits and vegetables. Low-income people have concerns about what their children will eat and how long fresh food might last in refrigerators, Edin said. So, even when broccoli is the same price as pizza pockets, the poor aren’t automatically apt to buy veggies if there’s any concern that their children would refuse to eat it. That would waste a valuable fraction of their food stamp budget.

Poor people also shop shop differently than middle- and upper-class people too, for example, with routine coupon clipping. To truly better the lives of food stamp households, Edin said, grocery delivery services will have to use social media and other creative strategies to show the poor how to prepare healthy foods. “They’re going to have to learn how to market for this population in order for it to make sense,” Edin said. “Poor people do eat less healthy food when it’s cheapest.”

Major grocers such as Walmart and Kroger that provide grocery delivery services do not accept electronic benefit transfer (EBT) cards that are traditionally used to distribute food stamp benefits. The same goes for Instacart and Peapod.

Kroger spokesman Keith Dailey said in an email that the company is “watching the conversation closely,” but doesn’t have any plans to accept food stamps online. Peapod would support a USDA move to allow food stamps to be used online, said Peg Merzbacher, regional marketing vice president. Walmart and Instacart did not reply to a request for comment.

Some companies are taking a more proactive approach to the issue. In some locations, Safeway accepts EBT cards for online deliveries, but only for people with a disability. New York City-based FreshDirect, one of the first delivery services, started accepting EBT cards in the two area codes in the Bronx in 2012. A delivery driver must have a card reader to accept EBT.

Larry Scott Blackmon, vice president of public affairs for FreshDirect, said that the company hopes to expand the program and will work with the USDA to show how mail delivery for food stamp households could work.

It would take widespread involvement of the biggest players to make a true difference. In the meantime, far smaller companies are pushing for the option.

Thrive Market, an online store focused on healthy food and organic products, has been leading a coalition of health food companies pushing to make it possible for food stamp families nationwide to use their EBT cards online. After the USDA dragged its feet on launching a trial, Thrive launched an online campaign late last month to speed up the pilot program, with partners like Clif Bar & Company, the Hispanic Federation and celebrity fitness trainer Jillian Michaels.

With 300,000 paying members, Thrive, which was founded in 2014 and based in Los Angeles, ships nonperishable health foods and other home products at discounted prices while providing free memberships to low-income families for each paid one. For those low-income customers, chief executive Gunnar Lovelace said his company has made it easier to shop for natural and higher quality cleaning supplies, cereals, and oils — though it must be said many of these are more Whole Foods and less bare essentials.

Grocery delivery services have become especially popular in the past five years. This year, $33 billion will be spent on food online — about 4 percent of all money spent on food and beverages overall, according to research from financial consulting firm Cowen and Co.

Bolen, the Center on Budget expert, said it may very well be inevitable that food stamps are usable online. As the law states, food stamps are meant to allow “low-income households to obtain a more nutritious diet through normal channels of trade.”

Grocery delivery services are increasingly a normal channel. Already, Lovelace said, some of his low-income customers have to discontinue their service because they can’t use food stamps on the site.

“We don’t want to leave people behind just because they’re poor,” said Bolen, the senior policy analyst with the Center on Budget and Policy Priorities.

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Early Bedtime For Preschoolers Might Help Reduce Obesity Risk Later

July 14, 2016, National Public Radio

For parents concerned that their preschoolers may one day gain excess weight, a study published Thursday suggests one strategy for keeping the little ones on track that isn’t related to food: Tuck them in earlier.

Scientists reporting online in The Journal of Pediatrics found, in a study of not quite a thousand U.S. children, that preschoolers who got to bed by 8 p.m. were about half as likely as those who turned in after 9 p.m. to develop obesity in their teenage years.

Obesity continues to be a major health issue for children and teens in the United States, and many studies have shown that issues with sleep quality and duration can contribute to that risk, says Sarah Anderson, epidemiologist at the Ohio State University and lead author on the current research. But “there haven’t been many studies that have looked at bedtime,” Anderson says.

A child’s bedtime is an important factor to examine because it’s something a parent generally has some control over, says Lisa Medalie, director of the Pediatric Insomnia Program at the University of Chicago Medicine, whereas kids often have a fixed wakeup time because they have to get out the door in time for camp or school.

“Kids can get really fussy when you keep them up too late,” Medalie says. “If they get too fussy and get overtired, then it actually makes it harder for them to sleep.”

To find out whether preschooler bedtimes might be linked to obesity later in life, Anderson and colleagues looked back at data collected for 977 children across nine states as part of a government-funded research project called the Study of Early Child Care and Youth Development.

Researchers followed these children from birth in 1991 through their adolescent years. They recorded a range of data — everything from a child’s height and weight at different ages to a mother’s education level and attention to her child’s needs as observed through video recordings.

Importantly for Anderson’s study, when the children reached about 4.5 years old, researchers included this in the list of questions they asked mothers: “What time does your child go to bed on most weekday evenings?”

It turned out that about 25 percent of the children went to bed at 8 p.m. or earlier, half went to bed between 8 and 9 p.m., and 25 percent went to bed after 9 p.m.

Anderson and her team found that the bedtime category a child fell into was linked to his or her likelihood of being obese. When the preschoolers reached about age 15, 10 percent of the early-to-bed group, 16 percent of the middle group, and 23 percent of the late-to-bed group were obese.

Even after the researchers controlled for other factors like birthweight, socioeconomic status, ethnicity, and the mother’s weight, the preschoolers who went to bed late — after 9 p.m. — were still twice as likely to develop obesity in their teens as the early-to-bed group.

“That you can ask one question of a mother of a 4.5-year-old child and it relates to body mass index 10 years later — that’s pretty remarkable,” says Joseph Buckhalt, a pediatric sleep researcher at Auburn University.

The research hasn’t proved that later bedtimes directly cause obesity, only that there seems to be some connection between the two, the sleep scientists agree. Research on this point has only just begun.And Anderson says she recognizes that it’s not always possible to get kids to bed early. Some parents’ work schedules “don’t allow them to arrive home early enough in the evening to both spend time with the child and have an early bedtime,” she notes.

Still, Anderson says, for lots of reasons, “parents might want to consider what it would take for them to have a regular early bedtime routine for their preschool-aged child.” And aim for that.

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