December 2016





2016 NCCOR Year in Review

December 29, 2016, NCCOR

In 2016, NCCOR worked to expand its reach, connecting with new audiences to accelerate progress in reducing childhood obesity. NCCOR continued to work with non-health partners through its work on behavioral design, engaged healthcare providers and systems that work in childhood obesity prevention, and learned from retailers that collaborate with researchers to promote healthy options. The refresh of the NCCOR website at the end of the year allowed NCCOR to more effectively communicate research, products, and webinars. Through member meetings, workshops, conferences, Connect & Explore webinars, and other workgroup activities, NCCOR collaborated with 150 external experts.

Workshops. NCCOR hosted two workshops in the fields of behavioral design and healthy retail in 2016. The behavioral design workshop brought together a multidisciplinary range of experts to work toward applying behavioral design principles to healthier living, specifically as they pertain to healthy eating and active living. NCCOR members are working on refining a white paper on these principles to be released early next year. In addition, the Moving from Test Market to All Markets: Translating Food Purchasing Research into Evidence-based Strategies to Improve the Purchase of Healthier Items workshop brought together researchers, practitioners, and retailers working via the Supplemental Nutrition Assistance Program-Education Program (SNAP-Ed) and other public and private programs that promote healthy food purchasing by low-income consumers. This workshop allowed this group of experts to learn how they can work together to promote healthy food in the retail setting.

Conferences. NCCOR attended the Society for Behavioral Medicine (SBM) 37th Annual Meeting in Washington, DC and the American Public Health Association’s 144th Annual Meeting in Denver, CO. NCCOR livestreamed three SBM panel sessions via the Connect & Explore webinar series. The panels offered exclusive access to presentations from internationally renowned scholars, exploring high-impact childhood obesity strategies from around the world, including scalable physical activity interventions in Latin America; sugar-sweetened beverage taxes in Mexico, South America, and the United States; and approaches to eliminating health disparities among U.S. and international populations disproportionately affected by obesity.

Connect & Explore Webinars. 2016 was a monumental year for the Connect & Explore webinar series. In addition to the three special sessions at SBM, NCCOR hosted a record number of eight Connect & Explore Webinars. This year Connect & Explore highlighted topics ranging from Health Care Community Collaborations, the SNAP-Ed Evaluation Framework, Assessing the Prevalence and Trends in Obesity, Declines in Childhood Obesity, and School Wellness Policies. Through these topics NCCOR expanded its audience to hospitals, insurers and payers, health care providers, SNAP-Ed implementing agencies, and school wellness coordinators. Overall, more than 3,500 people registered for this year’s webinars.

Looking Forward. In 2017, NCCOR will continue to support researchers and practitioners with tools that help build the capacity for research and surveillance to accelerate progress to reduce childhood obesity. Stay tuned for the release of the four domain-specific Measures Registry User Guides and the Youth Compendium of Physical Activity in early 2017.

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Publications & Tools

The Pros and Cons of Taxing Sweetened Beverages Based on Sugar Content

The amount of added sugar in sweetened drinks varies greatly. If policymakers decide to use taxes on sweetened beverages to discourage consumption of added sugar, they should therefore consider basing those taxes on the amount of sugar drinks contain rather than their volume. In this report, we analyze the potential policy benefits of taxing sugar content; document how content-based taxes have been used to discourage consumption of sugar, alcohol, and tobacco; and examine the legal and practical challenges of implementing such taxes at the federal, state, and local level. We conclude that taxing based on the amount of added sugar a drink contains, either by taxing sugar content directly or by levying higher volume taxes on drinks with more sugar, is feasible in many jurisdictions and reduces sugar consumption more effectively than comparable taxes on drink volume. Broad-based volume or sales taxes on all soft drinks, however, raise revenue more efficiently. Federal, state, and local policymakers thus face trade-offs between using sweetened-beverage taxes to raise revenue and to discourage consumption of added sugars.

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500 Cities: Local data for better health

The 500 Cities project is a collaboration between CDC, the Robert Wood Johnson Foundation, and the CDC Foundation. The purpose of the 500 Cities project is to provide city- and census tract-level small area estimates for chronic disease risk factors, health outcomes, and clinical preventive service use for the largest 500 cities in the United States. These small area estimates allow cities and local health departments to better understand the burden and geographic distribution of health-related variables in their jurisdictions, and help them plan public health interventions

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USDA Boosts Healthy Food Access, Sets New Standards for SNAP Retailers

Final Rule Balances Concerns Raised by Retailers While Still Improving Access to Healthy Food Choices for SNAP Participants

U.S. Department of Agriculture (USDA) Secretary Tom Vilsack today announced final changes to increase access to healthy food choices for participants in the Supplemental Nutrition Assistance Program (SNAP). The provisions in this rule require SNAP authorized retail establishments to offer a larger inventory and variety of healthy food options.

“This final rule balances the need to improve the healthy staple foods available for purchase at participating stores, while maintaining food access for SNAP recipients in underserved rural and urban areas,” said Vilsack. “We received many helpful comments on the proposed rule and have modified the final rule in important ways to ensure that these dual goals are met. I am confident that this rule will ensure the retailers that participate in SNAP offer a variety of healthy foods for purchase and that SNAP recipients will continue to have access to the stores they need to be able to purchase food.”

The final rule provides long overdue updates to SNAP retailer eligibility criteria. Previously, a retailer could be authorized to participate in the program with a minimum inventory of 12 items. Now, the number of required food items is expanded to a minimum of 84. These changes are in keeping with the primary purpose of the program.

USDA extended the comment period for the proposed rule to ensure all interested parties had the opportunity to bring their voice to the final rule, and made significant changes to respond to those comments. The final rule announced today incorporates feedback from over 1,200 comments received and ensures the new standards will balance commenters’ concerns.

In particular, in the final rule multiple ingredient foods will continue to count towards retailer eligibility. In addition, the existing regulatory requirement that specifies the threshold of hot and cold prepared foods sold that makes a location an ineligible restaurant (rather than an eligible SNAP retailer) is far more flexible than in the proposed rule. Now the requirement is nearly the same as the requirement that has been in place for some time with only a modest change to account for foods heated and consumed on site after purchase.

Changes to the definition of accessory foods ensure that stores are not able to participate in SNAP by selling primarily snack foods. At the same time, the definition of variety has been expanded to make it easier for stores to meet the new requirements mandated by the Agricultural Act of 2014, and the number of each variety of staple food items retailers must have in stock has been halved as compared to the proposed rule from six to three.

USDA has taken many steps in the last several years to strengthen SNAP and increase access to healthy foods. Recently, USDA sought retailer volunteers for a two-year, nationwide pilot to enable SNAP participants to purchase their groceries online. USDA also provided funding to incentivize participants in SNAP to purchase more healthy fruits and vegetables through the Food Insecurity Nutrition Incentive Program, increased farmers market participation in SNAP to improve access to fresh and nutritious food, and announced a purchase and delivery pilot, which is designed for non-profits and government entities to improve access to groceries solely for homebound elderly and disabled SNAP participants.

As the nation’s first line of defense against hunger, SNAP helps put food on the table for millions of low income families and individuals every month and is critical in the fight against hunger. SNAP is a vital supplement to the monthly food budgets of about 45 million low-income individuals. Nearly half of SNAP participants are children, 10 percent are elderly and more than 40 percent of recipients live in households with earnings. SNAP plays an important role in reducing both poverty and food insecurity in the United States—especially among children. SNAP is an effective and efficient health intervention for low-income families with a positive impact on children beginning before birth and lasting beyond childhood years, improving health, education, and economic outcomes.

Read the final rule

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Pew and RWJF: Schools Report Growing Success With Healthier Menus

School food service directors are using a mix of strategies—three, on average—to encourage students to eat healthy meals and snacks, and many see few or no remaining challenges to implementing updated breakfast and lunch nutrition standards. The findings come from a new report from the Kids’ Safe and Healthful Foods Project, a collaboration between The Pew Charitable Trusts and the Robert Wood Johnson Foundation.

Based on a nationally representative survey of food service directors, the report, School Meal Programs Innovate to Improve Student Nutrition, sheds light on which approaches have been most effective during the multiyear transition to healthier food and drink standards issued by the U.S. Department of Agriculture since 2011. A panel of school nutrition professionals, whose programs are successfully serving healthy meals and snacks, reviewed the survey results and provided additional insights on effective approaches to implementing updated nutrition rules. The research finds that:

  • Near the end of the 2014-15 school year, 6 in 10 directors said they faced few or no ongoing obstacles to meeting updated breakfast requirements; 4 in 10 said the same about the lunch guidelines.
  • For breakfast and lunch, the most commonly cited challenges were two rules that took effect in school year 2014-15: tighter limits on weekly average sodium content and a requirement that any food counted as a grain serving be made from at least 50 percent whole grains.
  • 9 in 10 directors adopted at least one practice to raise children’s fruit and vegetable consumption. For example, almost two-thirds of directors who increased the use of salad bars said that kids ate more produce as a result.
  • Respondents said that holding taste tests with students and redistributing uneaten, sealed foods were among the most effective ways to reduce waste, but only 44 percent and 38 percent of programs, respectively, used these strategies.
  • Directors whose programs prepared more foods from scratch and increased the use of salad bars were more likely to report that student participation rose or was unchanged from SY 2011-12 to 2014-15. Conversely, declines in participation were seen most often by directors who purchased more commercially prepared foods or decreased menu options.
  • Equipment and labor costs were the most frequently reported financial concerns (38 percent and 33 percent, respectively).
  • 84 percent of program directors reported rising or stable combined revenue (meal reimbursements plus snack and beverage sales) in the past year. More than half (54 percent) of districts saw higher combined revenue in school year 2014-15 compared with a year earlier. Almost a third (30 percent) said total revenue remained level.

“Thousands of districts have emerged from this transition, and many more can see light at the end of the tunnel,” said Stephanie Scarmo, of the Kids’ Safe and Healthful Foods Project. “Successful meal programs have made continuous innovation and collaboration with students their guiding principles, and they’ve worked to improve not just cafeteria menus but what schoolchildren are taught about food, with help from principals, teachers, and parents.”

Food service directors reported uneven progress toward district-wide compliance with the Smart Snacks in School nutrition standards, which govern items sold in cafeteria a la carte lines, vending machines, snack bars, and at fundraisers. In 2013, the USDA issued an interim final Smart Snacks rule that districts were to implement by school year 2014-15. Two-thirds of respondents said that all food and beverages sold by their departments met the standards by the deadline. But only 2 in 10 reported that the same was true for products sold by other departments and school groups. The panel of nutrition professionals suggested that achieving full compliance with the rule would involve greater cooperation between school staff and state child nutrition agencies, as well as support from the broader education community.

“Change doesn’t happen overnight,” said Rodney Taylor, director of food and nutrition services for Fairfax County Public Schools in Virginia and a panel participant. “I always tell my staff: ‘Bug them nicely. Don’t go away. Don’t give up on an idea because this teacher or that parent said no.’ Success requires constantly asking, ‘How do we get better at what we do?’”

The report offers lessons from the panelists’ experiences and recommendations to help states, districts, families, and communities enhance meal programs’ success in implementing updated nutrition standards and encouraging healthy eating among students.

Read the full report

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Childhood Obesity Research & News

Study Tied to Food Industry Tries to Discredit Sugar Guidelines

December 19, 2016, The New York Times

A prominent medical journal on Monday published a scathing attack on global health advice to eat less sugar. Warnings to cut sugar, the study argued, are based on weak evidence and cannot be trusted.

But the review, published in The Annals of Internal Medicine, quickly elicited sharp criticism from public health experts because the authors have ties to the food and sugar industries.

The review was paid for by the International Life Sciences Institute, a scientific group that is based in Washington, D.C., and is funded by multinational food and agrochemical companies including Coca-Cola, General Mills, Hershey’s, Kellogg’s, Kraft Foods and Monsanto. One of the authors is a member of the scientific advisory board of Tate & Lyle, one of the world’s largest suppliers of high-fructose corn syrup.

Critics say the medical journal review is the latest in a series of efforts by the food industry to shape global nutrition advice by supporting prominent academics who question the role of junk food and sugary drinks in causing obesity, Type 2 diabetes and other health problems.

A report in September showed that those efforts began in the 1960s when the sugar industry paid scientists to cast doubt on the link between sugar and heart disease and promote saturated fat as the culprit instead. More recently, The New York Times found that Coca-Cola had been funding scientists who played down the connection between sugary drinks and obesity. And The Associated Press reported in June that food companies paid for studies that claimed candy-eating children weigh less.

Some experts said the Annals review appeared to be an attempt by the industry to undermine sugar guidelines from the World Health Organization and other health groups that urge children and adults to consume fewer products with added sugar, such as soft drinks, candy and sweetened cereals. The paper, they say, is reminiscent of tactics once used by the tobacco industry, which for decades enlisted scientists to become “merchants of doubt” about the health hazards of smoking.

“This comes right out of the tobacco industry’s playbook: cast doubt on the science,” said Marion Nestle, a professor of nutrition, food studies and public health at New York University who studies conflicts of interest in nutrition research. “This is a classic example of how industry funding biases opinion. It’s shameful.”

But the scientists behind the paper said more scrutiny of sugar guidelines was needed. The researchers reviewed guidelines issued by the W.H.O. and eight other agencies around the world and said the case against sugar was based on “low-quality” evidence.

“The conclusion of our paper is a very simple one,” said Bradley C. Johnston, a professor of clinical epidemiology at the University of Toronto and McMaster University and the lead author of the new paper. “We hope that the results from this review can be used to promote improvement in the development of trustworthy guidelines on sugar intake.”

Dr. Johnston said he recognized that his paper would be criticized because of its ties to industry funding. But he said he hoped people would not “throw the baby out with the bathwater” by dismissing the conclusion that sugar guidelines should be developed with greater rigor. He also emphasized that he was not suggesting that people eat more sugar. The review article, he said, questions specific recommendations about sugar but “should not be used to justify higher intake of sugary foods and beverages.”

The industry-funded review comes as health authorities around the world are increasingly taking steps to curb the amount of sugar people consume. Last year, the W.H.O. said adults and children should restrict their intake of sugar from most foods — other than fruit, vegetables and milk — to 10 percent of their daily calories. The W.H.O. said it relied on the latest scientific evidence, which showed that adults and children consuming a lot of sugar were more likely to gain weight or become obese.

Roshaunda Frazier, left, shopped for Vitaminwater with her cousin Bettye Harper in Brooklyn. Health groups have urged people to consume fewer sugary drinks. Credit Dave Sanders for The New York Times

In the United States, the Food and Drug Administration has promised new labeling rules that require food companies to disclose added sugars. Recently, six local governments approved taxes on soft drinks. And in Britain, the health agency Public Health England called for strict limits on daily sugar intake.

The Annals review gave poor ratings to all of the sugar guidelines it evaluated, saying the quality of the evidence they were based on was “low to very low.” It said that the guidelines were generally not transparent about how the recommendations were reached and that most of them failed to include disclosures about potential conflicts of interest among their authors.

But Barry Popkin, a professor of nutrition at the University of North Carolina at Chapel Hill, said he was stunned that the paper was even published at all because its authors “ignored the hundreds of randomized controlled trials” that have documented the harms of sugar.

“They ignored the real data, created false scores, and somehow got through a peer review system that I cannot understand,” he said. “It is quite astounding.”

Dr. Christine Laine, editor in chief of The Annals of Internal Medicine, defended the journal’s decision to publish the industry-funded review. She said in an interview that the journal made decisions based on the quality of the research, not the source of funding.

“We thought that this was something that our readers would be interested in, and we thought the methods of the systematic review were high quality,” Dr. Laine said. “We decided to go ahead and publish it despite the fact that we’re completely aware that the funding source has a relationship with the food and beverage industry.”

Dr. Dean Schillinger, chief of the University of California, San Francisco, division of general internal medicine at San Francisco General Hospital, said that it was fine to question the quality of nutrition guidelines and to hold them to high standards but that in this case, the researchers and their financial backers had an obvious agenda.

“They’re hijacking the scientific process in a disingenuous way to sow doubt and jeopardize public health,” Dr. Schillinger said.

Dr. Schillinger, who co-wrote an accompanying editorial criticizing the methodology of the Annals review, disclosed that he had served as a paid expert for the City of San Francisco last year when it was sued by the beverage industry for requiring warning labels on soft drink advertisements.

Other experts agreed with the study’s point that more rigor was needed in issuing nutrition guidelines but said the current guidelines should go much further.

Dariush Mozaffarian, a cardiologist and the dean of the Friedman School of Nutrition Science and Policy at Tufts University, who has served as a peer reviewer on the sugar guidelines issued by the W.H.O. and the American Heart Association, said there was strong scientific evidence that sugar contributed to adverse health conditions like weight gain and Type 2 diabetes.

But, he said, most guidelines that urge people to limit sugar say nothing about reducing refined starches, even though studies suggest that both are equally harmful.

“It’s unfair to single out sugar and not starch,” he said. “I would like to see recommendations to limit both sugar and starch. But that’s half the calories in the food supply.”

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Children with higher genetic risk for obesity respond more strongly to fast food ads

December 19, 2016, EurekaAlert

Dartmouth researchers have found that children with a genetic risk for obesity had greater activity in brain reward centers when watching fast food commercials, which could help us to understand why some children are more likely to overeat. The study is the first-of-its kind to examine how a key obesity gene influences brain response to food advertisements and other cues to eat. The findings are published in the Proceedings of the National Academy of Sciences.

“By examining the still-developing brain and its reward-related structures, our findings help explain why children who are genetically at-risk for obesity may be prone to over-eating unhealthy foods,” says first author, Kristina M. Rapuano, a graduate student in the Brain Imaging Lab in the department of Psychological and Brain Sciences at Dartmouth College.

Television food advertisements were used for this study to better approximate how the brain responds to food cues in the real-world, as most studies to date have shown only still images of food. Seventy-eight children ages nine to 12 years old, watched a children’s television show in an MRI scanner. To simulate the experience of watching television from home, the show included 12 minutes of commercial breaks– half were advertisements for fast food and the other half for non-food items. Children were also evaluated on their genetic risk for obesity based on the fat-mass and obesity-associated (FTO) gene, which strongly predicts obesity across the lifespan. The nucleus accumbens, a region in the brain commonly associated with reward craving, was not only physically larger in children with the obesity-risk FTO genotype compared to genetically low-risk children but also showed a stronger craving response to the food commercials.

“About one-third of commercials children see on network television are food advertisements, and each one is a prompt to eat,” says senior author, Diane Gilbert-Diamond, assistant professor of Epidemiology at Dartmouth’s Geisel School of Medicine and member of the Norris Cotton Cancer Center. “We know from our prior work that children with this same genetic obesity risk factor are more likely to overeat after watching food advertisements on TV, even when they are not hungry. The brain scans suggest that these children may be especially vulnerable to food cues, and that limiting food advertisement exposure could be an effective way to combat child obesity.”

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What’s Being Served for Dinner? An Exploratory Investigation of the Associations between the Healthfulness of Family Meals and Child Dietary Intake

December 2016, Journal of the Academy of Nutrition and Dietetics



Little is known about the healthfulness of foods offered at family meals or the relationship between the food’s healthfulness and child overall dietary intake.


This exploratory study uses a newly developed Healthfulness of Meal Index to examine the association between the healthfulness of foods served at family dinners and child dietary intake.


Direct observational, cross-sectional study.


Primarily low-income, minority families (n=120) video recorded 8 days of family dinners and completed a corresponding meal screener. Dietary recalls were completed on the target child (6 to 12 years old). The Healthfulness of Meal Index was used to measure meal healthfulness and included component scores for whole fruit, 100% juice, vegetables, dark green vegetables, dairy, protein, added sugars, and high-sodium foods.

Main outcome measures

Child dietary intake measured by three 24-hour dietary recalls.

Statistical analyses performed

Linear regression models estimated the association between the healthfulness of foods served at dinner meals and overall child HEI.


The majority of coded meals included foods from protein and high-sodium components; more than half included foods from dairy and vegetable components. Nearly half of the meals had an added-sugar component food (eg, soda or dessert). Few meals served foods from fruit, 100% juice, or dark green vegetable components. Many components served at family dinner meals were significantly associated with child daily intake of those same foods (ie, dark green vegetable, non−dark green vegetables, dairy, and added sugars). The Healthfulness of Meal Index total score was significantly associated with child HEI score.


This study represents the first report of a new methodology to collect data of foods served at family dinners. Results indicated a significant association between the majority of components served at family dinner meals and child overall dietary intake. Validation of the Healthfulness of Meal Index and video-recorded family meal methodology is needed to strengthen these research methods for use in future studies.

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Percentage of Youth Meeting Federal Fruit and Vegetable Intake Recommendations, Youth Risk Behavior Surveillance System, United States and 33 States, 2013

December 2016, Journal of the Academy of Nutrition and Dietetics



National- and state-level self-reported frequency of fruit and vegetable (F/V) consumption is available for high school students from the Centers for Disease Control and Prevention’s Youth Risk Behavior Surveillance System (YRBSS). YRBSS monitors priority health-risk behaviors among a nationally representative sample of US high school students and representative samples of students in states and selected large urban school districts. However, YRBSS measures intake in times per day and not the cup equivalents that national goals use, which limits interpretation.


To help states track youth progress, scoring algorithms were developed from external data and applied to 2013 YRBSS data to estimate the percentages of high school students in the nation and 33 states meeting the US Department of Agriculture’s Food Patterns F/V intake recommendations.


Twenty-four–hour dietary recalls were used from the 2007-2010 National Health and Nutrition Examination Survey to fit sex-specific models for 14- to 18-year-olds that estimate probabilities of meeting recommendations as a function of reported frequency of consumption and race/ethnicity, adjusting for day-to-day dietary variation. Model regression parameters were then applied to national cross-sectional YRBSS data (n=12,829) and to data from the 33 states (n=141,006) that had complete F/V data to estimate percentages meeting recommendations.


Based on the prediction equations, 8.5% of high school students nationwide met fruit recommendations (95% CI 4.9% to 12.1%) and 2.1% met vegetable recommendations (95% CI 0.0% to 8.1%). State estimates ranged from 5.3% in Nebraska and Missouri to 8.9% in Florida for fruit and 1.0% in New Jersey, North Dakota, and South Carolina to 3.3% in New Mexico for vegetables.


This method provides a new tool for states to track youth progress toward meeting dietary recommendations and indicates that a high percentage of youth in all states examined have low intakes of F/V.

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