April 2019

Did You Know: NCCOR’s Measures Registry Can Enhance Your Grant Proposal?

NCCOR, April 17, 2019

Are you working on an upcoming grant proposal? Consider using NCCOR’s Measures Registry to strengthen your proposal. The Measures Registry is a searchable database of diet and physical activity measures relevant to childhood obesity research. Its purpose is to standardize the use of common measures and research methods across childhood obesity research at the individual, community, and population levels. The Measures Registry also has filters that can help you reach your intended population and highlights the psychometric properties of each measure including reliability and validity.

So, how do you incorporate this into your proposal? Let’s walk through an example!

In this scenario, you are writing a proposal for a school-based obesity prevention intervention attempting to change à la carte offerings in high school cafeterias. You have decided that the primary outcome of the study is foods sold in the cafeteria using sales data from cash register receipts.

For your primary outcome, you know that you want to get sales data that can detail the food items purchased on a daily basis, but you also know that you should assess foods and beverages available in the schools before and after the intervention period as process data. However, you might be less familiar with measures of the food environment that exist related to this outcome.

In the Measures Registry, you can filter for measures of the food environment, children ages 12–18, and search for measures related to schools. Once you make those adjustments, you have 65 potential articles at your disposal. As you scan the titles, you see an inventory or checklist for “Middle School and High School A La Carte Food Environments” and a school food checklist that might be good options.

As you can see, the Registry provides easy-to-access information on how to use the measures, as well as the training and time required to implement them. It will save you time when you are working on your next proposal by allowing you to review a list of measures, including the validity and reliability properties of each.

Additionally, if you want a primer on any of the four domains of the Measures Registry, you can check out the Measures Registry User Guides, which are designed to complement the Measures Registry and provide an overview of measurement, describe general principles of measure selection, and highlight additional resources. The User Guides present case studies that walk researchers through the process of using the Measures Registry to select appropriate measures—perfect for guiding your proposal writing process.

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Toolbox

Did you know that NCCOR has held more than 27 Connect & Explore webinars with top experts in the field? If you missed any, check out the archive here for information on a wide variety of childhood obesity research topics that might relate to your research.

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A Look Back at Five Years of Progress of Voices for Healthy Kids

In 2013, the American Heart Association and the Robert Wood Johnson Foundation launched Voices for Healthy Kids, an innovative advocacy initiative with the monumental goal of reversing childhood obesity through policy change in disproportionately affected areas. This report looks at the initiative’s progress and accomplishments from the past five years.

See the report here

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The Cost-Effectiveness of Interventions for Reducing Obesity among Young Children through Healthy Eating, Physical Activity, and Screen Time

This brief compiles research conducted by the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) on interventions that impact young children. The brief provides an overview of the goals of cost-effectiveness analysis, the evidence thus far on the cost-effectiveness of different strategies to prevent obesity in the places where very young children (0- to 5-year-olds) live, learn, and play, and the evidence that is still needed for informed decision-making.

See the issue brief here

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WIC Food Package Changes: Trends in Childhood Obesity Prevalence

April 2019, AAP News and Journals Gateway

OBJECTIVES 

To evaluate the association of the 2009 changes to the US Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package and childhood obesity trends. We hypothesized that the food package change reduced obesity among children participating in WIC, a population that has been especially vulnerable to the childhood obesity epidemic.

METHODS 

We used an interrupted time-series design with repeated cross-sectional measurements of state-specific obesity prevalence among WIC-participating 2- to 4-year-old children from 2000 to 2014. We used multilevel linear regression models to estimate the trend in obesity prevalence for states before the WIC package revision and to test whether the trend in obesity prevalence changed after the 2009 WIC package revision, adjusting for changes in demographics. In a secondary analysis, we adjusted for changes in macrosomia and high prepregnancy BMI.

RESULTS 

Before the 2009 WIC food package change, the prevalence of obesity across states among 2- to 4-year-old WIC participants was increasing by 0.23 percentage points annually (95% confidence interval: 0.17 to 0.29; P < .001). After 2009, the trend was reversed (−0.34 percentage points per year; 95% confidence interval: −0.42 to −0.25; P < .001). Changes in sociodemographic and other obesity risk factors did not account for this change in the trend in obesity prevalence.

CONCLUSIONS 

The 2009 WIC food package change may have helped to reverse the rapid increase in obesity prevalence among WIC participants observed before the food package change.

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To Lower Childhood Obesity, Don't Sugarcoat the Facts About Sweet Drinks

April 9, 2019, EurekAlert!

A new study at Columbia University suggests that giving mothers plain facts about the health risks of consuming sugary drinks during pregnancy and early childhood may offer a new strategy to reduce childhood obesity.

The study was published in the journal Academic Pediatrics.

Why It’s Important

Obesity affects approximately 18 percent of children in the U.S. Recent studies show that obesity is growing fastest among young children between the ages of 2 to 5 years.

“Emerging evidence suggests that regular consumption of sugary beverages, either by the mother during pregnancy or by the child before age 2, may increase a child’s risk of obesity later in childhood,” says the study’s lead author Jennifer Woo Baidal, MD, assistant professor of pediatrics at Columbia University Vagelos College of Physicians and Surgeons.

A recent study found that sugary drinks may be marketed more heavily toward low-income children and teens.

Link Between Attitudes and Behavior

In a previous study, Woo Baidal and her team found that nearly 90 percent of parents and 66 percent of infants between 1 and 2 years old who were enrolled in a local Women, Infants, and Children (WIC) program, a nutritional supplementation program for low-income families, regularly consumed sweetened beverages. Families with more negative attitudes toward sugary beverages were less likely to drink them or give them to their infants.

“We were surprised at how many parents and infants were regularly consuming drinks with added sugar. In order to influence behavior, we needed a better understanding of the factors that influence parents’ attitudes,” Woo Baidal explains.

Clearing Up Confusion about “Healthy” Drinks

In the current study, the researchers conducted in-depth interviews with 25 of the WIC-enrolled families from the previous study. Families were asked to respond to a variety of materials from public health campaigns and other interventions, including written messages and visual aids, about the sugar content and associated health risks of sugar-sweetened drinks.

Many families were confused about which beverages are healthy, the researchers found, and were surprised to learn that many juices and flavored milks contain large amounts of sugar.

Families were more receptive toward materials–especially images and graphic warning labels–explaining the sugar content of different beverages and the health risks they pose for children. They indicated the need to include information about culturally relevant drinks and other alternatives to plain water. In contrast, families were less responsive toward materials that advised parents what to consume without giving them facts so they could make their own informed decisions.

“Parents were unreceptive to finger-wagging messages about what they should buy or drink, but most welcomed information that would help them make healthy choices for themselves and their families,” Woo Baidal says. “Although our study was small, our findings could inform broader strategies to counter the mixed messages that many low-income families get about what’s healthy and what’s not.”

What’s Next

The researchers plan to conduct a larger, randomized study to learn how different ways of presenting information about the health risks of sugary drinks affects families’ purchasing habits and consumption.

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Behavioral Research Agenda in a Multietiological Approach to Child Obesity Prevention

March 29, 2019, Childhood Obesity

Background

Serious limitations have been found in the simple energy balance model (energy in–energy out) as the single or primary biological strategy for virtually all child obesity prevention interventions. Experts have criticized it for not reflecting the likely multifactorial nature of obesity. A substantial number of other possible, even likely, causes of obesity have been identified.

Since the simple energy balance model is easy to understand and target, behavioral scientists have taken the initiative to identify factors that influence energy in and energy out, and design, implement, and evaluate behavior and/or environmental change interventions to prevent obesity accordingly. Unfortunately, most of these obesity prevention interventions have either not worked, or had small effects, not nearly enough to halt the epidemic. In the process, a serious disconnect has developed between advances in biological and in behavioral sciences in regard to obesity prevention.

Several investigators have proposed multietiological approaches to understanding obesity onset and thereby its prevention. A recent article specified infectobesity (i.e., virus-related infection), dysbiosis (imbalance in phyla in the microbiome), and dys-synchrony in circadian and circannual rhythms as three etiologies for which ample and growing evidence exists for a role in the development of obesity in children. Behavioral- and prevention-oriented scientists have had minimal involvement in the delineation of these etiologies. However, behavioral and prevention scientists can make important contributions to child obesity prevention research based on these multiple etiologies, thereby reconnecting the biological, behavioral, and prevention sciences. In general, this prevention-oriented research agenda would involve assessing the incidence of childhood obesity due to each problem, prioritizing the problems for research attention, specifying the behaviors that may be involved in the transmission or the prevention, developing models predicting the behaviors, and designing and evaluating interventions to minimize the problem, thereby preventing obesity. We briefly identify some of the research issues specific to each possible etiology to exemplify how behavioral or prevention researchers may begin to address such problems from a biobehavioral perspective.

Infectobesity

Several literature reviews and meta-analyses have indicated that infection with adenovirus 36 increases the risk of obesity for which children may be particularly susceptible. From a child obesity prevention perspective, it would be important to know how infection by adenovirus 36 occurs, for example, as an “outbreak” or “epidemic,” or the nature or process of person-to-person or environment-to-person transmission; the incidence of adenovirus 36 infection among children; the proportion of children infected who develop obesity; and the proportion of child obesity due to adenovirus 36 infection.

If we assume that not everyone who is infected becomes obese, it would be important to know the behaviors and other exposures that minimize or enhance viral infection immunity in general and resistance to adenovirus 36 in particular. Cause-specific interventions require testing to assess if they prevent transmission under controlled conditions in the laboratory, and then prevent transmission of infection in the field. For example, if adenovirus 36 infection spreads person-to-person by sneezing and coughing, then sneezing into the arm at the back of the elbow and hand washing should be useful child obesity prevention strategies. Immunity and resistance enhancing strategies also need testing, specifically in regard to adenovirus 36.

If scientists developed an adenovirus 36 vaccine, programs to promote vaccination would need to be developed. Delayed child vaccinations with existing vaccines have become common, increasing the risk of infection. Thus, behavioral programs would need to be developed and tested to minimize potential resistance and enhance vaccination rates.

Microbiome

Imbalances in the bacterial (and maybe the viral, fungal, and eukaryotic) phyla in the microbiome can lead to obesity. The microbiome begins to develop (from the mother) in the immediate postnatal period and changes substantially early in life, due, in part, to diet and physical activity influences.

In parallel with infectobesity, understanding the population prevalence of dysbiosis and determining whether this differs by age, gender, socioeconomic status, ethnic group, or other demographic grouping variables become important. For example, the microbiome may vary early in life by any, and duration of, breastfeeding, formula feeding, and introduction of complementary foods. It would be important to develop an understanding of how different aspects of the diet (e.g., dietary fiber, prebiotics, probiotics, vegetarian dietary patterns), physical activity, and other behaviors influence the microbiome. The role of processed foods in the development of obesity has tweaked public health interest. The influence of processed food on the microbiome needs further understanding. Cannabis use has been related to obesity, but its influence on the microbiome is not clear. Antibiotic use, especially in the first 2 years of life, has been shown to influence the microbiome and increase the risk of childhood obesity. Further research on the possible effects of different types of antibiotics is needed so that some drugs may be used more safely early in life. At least one study demonstrated parental resistance to the use of antibiotics in children early in life to prevent obesity. Understanding and finding ways to minimize parental resistance are important behavioral research agendas. Household disinfectantsand acid suppression or prokinetic medications also have been shown to influence the microbiome and deserve research parallel to that on antibiotics. The internal and external validity of microbiome research in humans has been challenged. These are issues that prevention and behavioral scientists have usefully addressed.

Circadian and Circannual Rhythms

The body has multiple biological clocks synchronized in the brain to be in concert with external influences. Because of this synchronization, we are able to sleep, eat, and be active during evolutionarily advantageous times. Social demands such as school and work schedules, school holidays, and social obligations can affect the timing of sleep, physical activity, and eating patterns, which may lead to dys-synchrony between behavior and the internal clocks as well as within the internal clocks. Disruptions of, or dys-synchrony among, circadian rhythms have been demonstrated to lead to obesity. The interaction of circadian misalignment and children’s circannual or seasonal rhythms in growth has also been proposed as a cause of obesity among children, accounting for the summertime increases and school year decreases in adiposity in subsets of early elementary school children.

Following the same logic, research is needed on the incidence of childhood obesity in response to circadian or circannual disruptions, specifying the behaviors that contribute most to the dys-synchrony, and generating and evaluating interventions to change these behaviors and environmental influences on obesity. Sleep duration or disturbances have not been related consistently to obesity in children, perhaps partially due to use of self-report measures. Exploring sleep within the context of indicators of circadian rhythm synchrony, for example, timing and amounts of melatonin release, using objective measures offers opportunities for testing hypotheses regarding the role of sleep in energy balance, hopefully leading to more effective behavioral interventions. Digital media at night disturbs circadian rhythms among children and ways of minimizing those effects need to be developed.

While the timing of meals has been identified as a circadian rhythm issue, the time and content of those meals (e.g., macronutrients, caffeine, alcohol), and seasonal differences in timing and content need to be understood. Once the operative nutritional factors can be identified, the role of school and family influences on chronobiology, meal content, and timing may be determined. Longitudinal analyses of interrelationships among diet, physical activity (PA), sedentary behaviors, sleep, and indicators of circadian rhythmicity are needed, including their impact on the microbiome. A more expansive research agenda in regard to summer-onset obesity in children has been suggested.

Multietiological Approach

Priority among the biological etiologies for behavioral obesity prevention research in early childhood must be established, based on their relative contribution to and severity of obesity. Subsets of children develop obesity at different ages, suggesting that identifying such subsets and determining the size of the subsets and operational etiological influences would be an important approach. Analyses of large electronic health records might be a first step in identifying the subsets.

In a multietiological approach, any particular child may be subject to influence by multiple etiologies simultaneously. It is not clear how each etiology interacts with each other or with a complex dynamic energy balance model (including neurological and hormonal influences). Diverse etiological influences on obesity may be mediated by diet, physical activity, or sedentary behaviors, reintroducing behavioral factors in the multiple etiological approach, but based on different biological models.

Interventions for each causal factor related to the development of obesity can be designed, implemented, and evaluated. For targeted groups of children (e.g., specific schools or day care centers in specific cities), the risk of obesity must be estimated for each potential etiology to apply the most likely to be effective interventions (likely multiple). These procedures need to be developed and tested.

Conclusions

We believe the above discussion delineates a substantial research agenda that holds promise of a beneficial contribution to child obesity prevention. As indicated before, we welcome submission of articles on these issues for consideration for publication in Childhood Obesity.

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Systematic Review of How Play Streets Impact Opportunities for Active Play, Physical Activity, Neighborhoods, and Communities

March 22, 2019, BMC Public Health

Background

Active play and physical activity are important for preventing childhood obesity, building healthy bones and muscles, reducing anxiety and stress, and increasing self-esteem. Unfortunately, safe and accessible play places are often lacking in under-resourced communities. Play Streets (temporary closure of streets) are an understudied intervention that provide safe places for children, adolescents, and their families to actively play. This systematic review examines how Play Streets impact opportunities for children and adolescents to engage in safe active play and physical activity, and for communities and neighborhoods. Methods for evaluating Play Streets were also examined.

Methods

A systematic literature review was conducted in Academic Search Complete, CINHAL, PsycINFO, PubMED, Web of Science, and Google Scholar. Peer-reviewed intervention studies published worldwide were included if they were published in English, through December 2017 and documented free-to-access Play Streets or other temporary spaces that incorporated a designated area for children and/or adolescents to engage in active play. Systematic data extraction documented sample, implementation, and measurement characteristics and outcomes.

Results

Of 180 reviewed abstracts, 6 studies met inclusion criteria. Studies were conducted in five different countries (n = 2 in U.S.), using mostly cross-sectional study designs (n = 4). Physical activity outcomes were measured in half of the studies; one used observational and self-report measures, and two used device-based and self-report measures. In general, Play Streets provided safe places for child play, increased sense of community, and when measured, data suggest increased physical activity overall and during Play Streets.

Conclusions

Play Streets can create safe places for children to actively play, with promise of increasing physical activity and strengthening community. Given the popularity of Play Streets and the potential impact for active play, physical activity, and community level benefits, more rigorous evaluations and systematic reporting of Play Streets’ evaluations are needed.

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