May 2016





USDA improves nutrition quality for foods served to 4 million young children

May 10, 2016, NCCOR

Last month, the U.S. Department of Agriculture (USDA) announced an update to the meal patterns for the Child and Adult Care Food Programs (CACFP) that will strengthen the nutrition standards for foods and drinks served at family or group day care centers. CACFP provides funding to day care centers for nutritious meals feeding over 4 million young children each day. The new standards now better align with the recommendations of the Dietary Guidelines and with the nutritional quality of other programs like the National School Lunch Program and School Breakfast program. The implementation date for the new standards is set for October 1, 2017.

With more than 1 in 5 children ages 2–5 years already overweight and obese, early child care and education settings have been identified as a priority setting for obesity prevention. “This final rule marks another important step toward ensuring young children have access to the nutrition they need and develop healthy habits that will contribute to their well-being over the long term.” said the Undersecretary of Agriculture, Kevin Concannon, at the annual conference of the National Child and Adult Care Food Sponsors conference.

The new meal standards include a greater variety of fruits and vegetables, more whole grains, and less added sugar from yogurt and breakfast cereals. In addition, the meal standards consist of serving low-fat and fat-free milk and water as well as promoting breastfeeding for very young children participating in the program.

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Publications & Tools

Healthy school lunches improve kids' habits

Schools can serve healthy lunches, but whether kids will eat them is a question that has been asked often since the 2012–13 school year, when districts across the United States raised the nutritional quality of meals to meet updated national standards. Multiple studies comparing students’ eating habits before and after these changes show that the answer is clearly yes. Among the four studies that tracked the largest numbers of children, three measured the amount of food students selected and calculated the percentage eaten and discarded, and the fourth evaluated changes in the nutritional quality of the lunches kids chose.


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Cost Effectiveness of a Sugar-Sweetened Beverage Excise Tax in Philadelphia, PA

SSBs include all beverages with added caloric sweeteners. The modeled excise tax does not apply to 100% juice, milk products, or artificially-sweetened beverages. Although SSB consumption has declined in recent years, children and adults in the United States consume twice as many calories from SSBs compared to 30 years ago. Randomized trials and longitudinal studies have linked SSB consumption to excess weight gain, diabetes, and cardiovascular disease. Consumption of SSBs increases the risk of chronic diseases through its impact on BMI and other mechanisms. The Dietary Guidelines for Americans, 2015, recommends that individuals reduce SSB intake in order to manage their body weight. Drawing on the success of tobacco taxation and decades of economic research, public health experts have called for higher taxes on SSBs and documented their likely impact. In 2009, the IOM recommended that local governments implement tax strategies in order to reduce consumption of “calorie-dense, nutrient-poor foods,” emphasizing SSBs as an appropriate target for taxation.


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Childhood Obesity Research & News

Prevalence of obesity and severe obesity in U.S. children 1999–2004

April 25, 2016, Obesity



Provide the most recent data on the prevalence of obesity and severe obesity among U.S. children and adolescents aged 2–19 years.


The National Health and Nutrition Examination Survey, 1999–2014, was used. Weight status was defined using measured height and weight and standard definitions as follows: overweight as ≥85th percentile for age- and sex-specific BMI; class I obesity as ≥95th percentile; class II obesity as ≥120 of the 95th percentile, or BMI ≥35; and class III obesity as ≥140% of the 95th percentile, or BMI ≥40. This study reports the prevalence of obesity by 2-year National Health and Nutrition Examination Survey cycle and Wald tests comparing the 2011–2012 cycle with the 2013–2014 cycle, as well as the linear trend from 1999–2014. Multivariable logistic regression models estimated odds ratios for differences by each 2-year cycle.


In 2013–2014, 17.4% of children met criteria for class I obesity, including 6.3% for class II and 2.4% for class III, none statistically different than 2011–2012. A clear, statistically significant increase in all classes of obesity continued from 1999–2014.


There is no evidence of a decline in obesity prevalence in any age group, despite substantial clinical and policy efforts targeting the issue.


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Are we making progress in the prevention and control of childhood obesity? It all depends on how you look at it

April 25, 2016, Obesity

By William H. Dietz

The paper by Skinner, Perrin, and Skelton in this issue of Obesity suggests that the prevalence of childhood obesity increased in all age groups between 1999 and 2014, despite clinical and policy efforts to contain the epidemic. The data considered by Skinner et al. were derived from the National Health and Examination Survey (NHANES), which collects data in 2-year increments. The NHANES obesity data used by Skinner et al. reprise data published in an issue brief by the National Center for Health Statistics. However, in the issue brief, Ogden et al. concluded that the prevalence of obesity in 2- to 19-year-old children and adolescents did not change significantly between 2003–2004 and 2011–2012, and that the prevalence in 2- to 5-year-old children decreased from 13.9% to 8.4% over the same time period. In 2013 to 2014, the prevalence in 2- to 5-year-old children was 9.4%, indicating that the decrease observed in 2011–2012 was not an aberration.

The difference in the interpretation of these findings depends on what year is chosen to anchor the analysis. Skinner et al. anchored their analysis with 1999–2000 data whereas Ogden et al. based theirs on 2003–2004 data. Although the two studies appear contradictory, neither analysis is incorrect—it all depends on whether you start with the 1999–2000 or 2003–2004 data. This observation suggests that reliance on NHANES data alone does not provide conclusive information on the state of the epidemic and indicates that we need to broaden our inquiry. The declines in the prevalence of obesity in 2- to 5-year-old children observed in NHANES between 2003–2004 and 2013–2014 are supported by data from the Pediatric Nutrition Surveillance System (PedNSS) which showed significant declines in the prevalence of obesity among 2- to 4-year-old children in 18 states. An important difference between NHANES and PedNSS is that the NHANES sample size for each 2-year survey was 850–900 children whereas the PedNSS state samples ranged from 8,200–260,000 per state, depending on the state size. Declines in the prevalence of obesity among varying groups of children and adolescents have also been documented in a number of states and municipalities. Furthermore, the declines in the consumption of sugary drinks, fast food, and pizza observed over the past decade would lead us to expect a plateau in the prevalence of obesity in 2- to 19-year-old youth, as well as declines among younger children in whom the caloric gap necessary to return prevalence levels to those of the 1970s is so small. The net effect of these observations makes it hard to agree with the conclusion of Skinner et al. that “There is no evidence of a decline in obesity prevalence in any age group, despite substantial clinical and policy efforts targeting the issue.”

The biggest concern raised by Skinner et al. is their documentation of the increasing prevalence of severe childhood obesity (BMI ≥120% of the 95th percentile). Severe obesity in 2013–2014 appeared substantially more prevalent in black and Hispanic children and adolescents. Their data suggest that over 4.5 million children and adolescents have severe obesity. As the authors point out, and as Hall et al. indicate, the magnitude of the decreases in net daily energy intake necessary for children and adolescents with obesity to achieve a healthy weight is considerably greater than the caloric deficits accomplished by policy or environmental changes. Although the Task Force for Clinical Preventive Services concluded that medium- to high-intensity (≥26 h) comprehensive behavioral interventions were associated with short-term improvements in weight, translation of these recommendations into a standard of care has not yet been accomplished. Data from the Agency for Healthcare Research and Quality indicate that in 2010 there were approximately 125,000 primary care pediatricians and family practitioners in the United States, which suggests that the average primary care practice may include almost 50 pediatric patients with severe obesity. The effective delivery of aggressive obesity treatment would require that every primary care practice would need a weight control program. However, most primary care physicians are poorly prepared to treat obesity, and who should deliver care, how care should be delivered, what outcomes are paid for, and how to effectively link clinical and community services are uncertain. Policy efforts to prevent childhood obesity must continue. However, the substantial contribution of severe childhood obesity to the costly burden of severe obesity in adults emphasizes the urgency with which we must develop and validate a reimbursable standard of care for severe obesity in children and adolescents.

“It’s not currently recommended to measure BMI in children under the age of 2, but we say it should be because we now know it predicts obesity risk later,” says Dr. Smego. “Pediatricians can identify high-risk infants with BMI above the 85th percentile and focus additional counseling and education regarding healthy lifestyles toward the families of these children. Our hope in using this tool is that we can prevent obesity in early childhood.”


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Plateau but no decline: Child Obesity Rates remain steady

April 26, 2016, The Salt

When it comes to reversing the obesity epidemic, there have been glimmers of hope that the United States might be making headway, especially with young children.

For instance, back in 2013, the Centers for Disease Control and Prevention documented declines in obesity rates among low-income preschoolers in many states. And case studies in cities including Kearney, NE; Vance, NC; and New York, NY, have reported progress, too.

But a new study published in Obesity concludes that—though the prevalence of obesity among U.S. children has plateaued in recent years—there is no indication of a national decline.

“If you look at the long-term from 1999–2014, we see a pretty consistent increase in obesity across all-aged children,” says study author Asheley Cockrell Skinner, a researcher at the Duke Clinical Research Institute at Duke University. And she points to a continued increase in the rate of severe, or morbid, obesity among teens, which rose from 6% in 1999 to about 10% in 2014.

According to the study, which is based on NHANES data—a nationally representative survey and study on nutrition and health—33 % of children between the ages of 2 and 19 are overweight, and 17% are obese. Skinner says the estimates are reliable, in part because of the way the data is collected. Health professionals weigh and measure the kids who participate in the study, so researchers are not relying on self-reports from parents.

The study echoes findings from last November, when the CDC released numbers pointing to the stubborn rate of obesity among U.S. adults.

Skinner says she hopes these findings don’t overshadow the success stories out there. Certainly, there are many promising efforts aimed at helping people make healthier choices. There’s also more attention on preventing obesity among primary care doctors and pediatricians.

“If we take a multi-pronged approach, we may start to see some declines,” says Skinner. But so far, she says these messages—and public health interventions aimed at helping—”are not reaching everybody.”

Experts say a multi-pronged approach is needed to reverse the epidemic, and there are many efforts underway that show promise in nudging Americans’ lifestyle choices in a healthier direction.

As we’ve reported, there’s been an increase in the number of moms breastfeeding their infants as the results of support programs in hospitals nationwide. These efforts may lower the risk of obesity. And the overhaul of school lunch has shown promise in promoting better eating habits.

And municipalities, health providers and employers across the country have introduced all sorts of initiatives to encourage healthier lifestyles. Some doctors are even prescribing fruits and vegetables for their patients.

Also, as we reported back in 2013, pediatricians say they’re much more assertive about obesity-prevention efforts than they were a decade ago. “It used to be a very awkward, embarrassing conversation to have [with overweight families],” Dr. Margaret Desler, a pediatrician with Kaiser Permanente, told us in 2013.

But that’s changing. Desler told us she charted kids’ body mass indexes, or BMIs, at every visit and talked with patients and their families about their eating and exercise habits. “It just opens up communication lines,” Desler said.

So there are lots of efforts underway aimed at getting people to think anew about their daily habits. As Dr. Tom Robinson at Stanford University told us in 2013, “small changes can magnify into large improvements in health” over time.


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FDA Issues Final Guidance on Menu Labeling

April 29, 2016

The U.S. Food and Drug Administration (FDA) announced today the publication of its final guidance for industry, “A Labeling Guide for Restaurants and Retail Establishments Selling Away-From-Home Foods – Part II (Menu Labeling Requirements in Accordance with 21 CFR 101.11).” The guidance is an important resource to help businesses comply with the menu labeling final rule. FDA guidance documents describe FDA’s interpretation of our policy on a regulatory issue. The draft guidance was announced in the Federal Register on September 16, 2015.

The FDA intends to begin enforcing the menu labeling final rule one year from the date that the Notice of Availability (NOA) is published in the Federal Register. The NOA for the guidance is expected to be published in early May 2016.

This guidance responds to many frequently asked questions that the agency has received to date. It differs from the draft guidance by providing additional examples and new or revised questions and answers on topics such as covered establishments, alcoholic beverages, catered events, mobile vendors, grab-and-go items, and record keeping requirements.

The FDA is committed to working flexibly and cooperatively with establishments covered by the menu labeling final rule and to providing educational and technical assistance for state, local, and tribal regulatory partners to support consistent compliance nationwide. After release of the guidance, the agency will continue to conduct webinars and will hold menu labeling workshops that focus on specific stakeholder needs. The FDA will announce more information about these workshops at a later date. Covered establishments can send questions on menu labeling requirements to


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Toronto looking to ban 'unhealthy' food ads aimed at kids

April 26, 2016, Metro News Toronto

The city of Toronto wants to put kids on an advertising diet.

The board of health voted Monday to seek federal support to ban commercial advertising to children aged 16 and under, in part to protect them from being exposed to unhealthy eating habits.

The vote follows recommendations from the city’s Medical Officer of Health, who in a recent report noted the rise of obesity levels among children. According to the report, 29% of students in Grades 7–12 in Toronto are either overweight or obese.

The report also notes only one in eight students is eating enough fruit and vegetables, while one in five students eat sugar-sweetened beverages and salty munchies more than three times a day.
Lesley James, health policy analyst for Heart and Stroke Foundation, thinks that kids’ bad eating habits are related to what they’re seeing in the media. “Children are being bombarded with commercials about unhealthy food and beverages,” she said.

The foundation has teamed up with Childhood Obesity Foundation to form a national coalition to sound the alarm about the danger of marketing junk food to kids.

Board of health chair Joe Mihevc said Toronto could learn from Quebec, where restrictions have existed since the 1980s preventing child-targeted food advertising has been restricted since the 1980s.
“When children go to watch Saturday morning cartoons and it’s full of sugary-eating advertising, you have to ask if that’s appropriate,” he said. The city of Toronto wants to put kids on an advertising diet.


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