April 2023

New Commentary from NCCOR: National Collaborative on Childhood Obesity Research Efforts to Advance Childhood Obesity Research: Progress and Next Steps

NCCOR, April 2023

NCCOR recently published a commentary titled “National Collaborative on Childhood Obesity Research Efforts to Advance Childhood Obesity Research: Progress and Next Steps” in the American Journal of Preventive Medicine. The paper celebrates a decade of NCCOR’s landmark tools—the Catalogue of Surveillance Systems and the Measures Registry—and  advancements in childhood obesity research.

NCCOR was formed in 2008 to accelerate progress in childhood obesity research. At the time, researchers sought to understand rising childhood obesity rates but lacked knowledge of available data sets and measures suitable for studying childhood obesity. NCCOR responded by creating the Catalogue of Surveillance Systems and the Measures Registry in 2011. The Catalogue provides one-stop access to publicly available data sets. The Measures Registry contains a searchable database of validated measures in the four domains of childhood obesity research (individual diet, food environment, individual physical activity, and physical activity environment). These tools helped innovate the field of childhood obesity research and led to a rapid expansion of scientific progress.

The commentary explores this history and describes how the Catalogue and Registry have evolved since their initial development. The Catalogue now includes more systems relevant to schools, communities, and racial and ethnic minorities. The Registry contains more measures for rural environments, Spanish language speakers, and populations under two. NCCOR also created three training tools, known as the Measures Registry Resource Suite, to help advance the field. The User Guides explain how to select measures for childhood obesity, while the Learning Modules guide students, faculty, and those newer to research and evaluation in diet and physical activity. Finally, the Decision Tree offers guidance on when to apply, adapt, or develop a measure for different populations.

The commentary concludes by stating the Catalogue and Registry are tools worthy of celebration after a decade of use. Still, more work is needed to optimize the use of appropriate measures and to increase access to data for surveillance, evaluation, and public health action. For more information, including how academicians, students, and researchers have used the tools, visit the NCCOR website at www.nccor.org.

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NCCOR Toolbox: Popular NCCOR Webinar Now Available Online

On March 28, 2023, NCCOR hosted a Connect & Explore webinar based on the new , “Clinical Practice Guidelines for Evaluation and Treatment of Children and Adolescents with Obesity.” The lead authors discussed the development process of the key recommendations included in the first clinical practice guidelines released by the American Academy of Pediatrics. The guideline aims to inform pediatricians and other pediatric allied health care professionals about the standard of care for evaluating and treating children with overweight and obesity and related comorbidities. It promotes an approach that considers the child’s health status, family system, community context, and resources for treatment to create the best evidence-based treatment plan. The guideline is based on a comprehensive evidence review of controlled and comparative effectiveness trials and high-quality longitudinal and epidemiologic studies. In addition, the webinar included an overview of the new “CDC Extended BMI-for-age Growth Charts,” which extended the BMI percentiles based on data for children and adolescents with obesity. Visit the webinar webpage on the NCCOR website to view the recording and access the slides.

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Dietary Quality by Food Source and Demographics in the United States, 1977–2018

March 2023, U.S. Department of Agriculture

Food prepared away from home (FAFH) has become a mainstay in U.S. consumers’ diets, accounting for more than 50 percent of total food expenditures since 2009 and more than 30 percent of total food energy intake since 2011. This report analyzes data from nationally representative food consumption surveys conducted between 1977 and 2018 to examine U.S. consumers’ dietary quality relative to the Federal dietary guidance and how this varies by food source. The food sources this report examines include food at home, food purchased at restaurants, food purchased at fast-food establishments, food obtained at school among K–12 school and daycare children, and other food obtained away from home. Dietary quality is measured by nutrient and food-group density (i.e., intake amount per 1,000 calories) for 12 nutrients and 35 food groups. All analyses are conducted for individuals aged 2 and above, both as a group and subdivided by demographics. In general, U.S. consumers make more nutritious choices when grocery shopping for foods than when obtaining food from commercial eating establishments. Compared with FAFH, food at home (FAH) is denser in under consumed nutrients and food groups—e.g., fiber, iron, whole grains, fruits, dairy, and dark green vegetables—and lower in the density of overconsumed nutrients and food groups, including saturated fats, sodium, and refined grains. However, FAH has more added sugars in addition to a lower intake of seafood and most types of vegetables. In recent years, school foods have differed from other FAFH consumption due to a lower density of saturated fats and a higher density of whole grain, fiber, and fruit.

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The Reach of School Breakfast and Lunch During the 2021–2022 School Year

March 2023, Food Research & Action Center

The 2021–2022 school year marked the return for nearly all students to in person learning after schools across the country had moved to virtual and hybrid learning models in response to the pandemic. As students transitioned back, the nutritious breakfasts and lunches served during the school day continued to be a critical support for millions of families. This reliable source of nutrition was especially important at a time when food insecurity rates remained high, and inflation was at historic levels, even as the height of the COVID-19 pandemic passed.1 An extension of the nationwide waivers issued in response to the pandemic allowed schools to serve meals to all students at no charge through the Seamless Summer Option (SSO), while receiving the higher Summer Food Service Program (SFSP) reimbursement for each meal served. This gave students access to much-needed school breakfasts and lunches to help ensure that they were in class well-nourished and ready to learn. It also significantly reduced the administrative burden on school nutrition departments, eliminated school meal debt, and better supported school nutrition departments in the face of rising food costs and ongoing supply chain disruptions.

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Why We Need a More Equitable Food Marketing Environment

February 2023, State of Childhood Obesity

Food marketing is something everyone is exposed to every day—especially kids. Companies use TV ads, youth-directed packaging, outdoor signs, and sponsorships to promote products, as well as digital marketing via social media campaigns, in-game marketing, and paid promotions from influencers to target kids directly. Food marketing is even in online educational resources for kids.

We rarely stop to think about it, but we should. The power of food marketing cannot be understated: it influences attitudes, preferences, and consumption; it reaches the youngest of ages; and it targets specific audiences, making exposure to unhealthy food promotion greater for some than others. In my 10+ years studying the amount and frequency with which people are exposed to food marketing, particularly children, and the poor nutrition of the products promoted, I’ve learned that we need substantial change in order for children to live longer, healthier lives in a more equitable food environment.

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Tools for More Accurate Obesity Risk Assessment Based on Sex, Ethnicity

March 23, 2023, EurekAlert!

For decades, health care practitioners have used body mass index (BMI) as an indicator of a person’s health. But this equation only considers height and weight, and may not capture an accurate picture of a person’s risk for obesity-related diseases, like heart disease, diabetes, and certain cancers.

Jacob Earp, assistant professor of kinesiology in the College of Agriculture, Health and Natural Resources, recently published papers in the International Journal of Environmental Research and Public Health and Nutrition, Metabolism and Cardiovascular Diseases that include a series of equations that add simple circumference measurements to better predict how a person’s fat is distributed within their body and accounts for known differences in ethnicity and sex.

Scientists have known for years that having more adipose tissue, or fat, around the middle of your body, in the abdominal cavity is a greater health risk than having fat in other parts of the body.

“There is clear evidence that fat located in certain places, mainly in the visceral cavity, is really the fat that increases most of your metabolic risk,” Earp says.

Additionally, fat distribution looks different between different ethnic populations and between women and men. This fact influences which interventions work best for different groups.

To generate their equations, Earp’s team looked at data from 12,000 full-body DXA scans logged in the National Health Nutrition Examination Survey.

One significant finding was that Hispanic individuals are at a higher risk of poor fat distribution and its associated diseases.

Additionally, they found that men who are commonly classified as being either underweight or obese using BMI had unhealthier adipose tissue distribution than normally believed, and the opposite was true for women.

“On the high end, women still had higher abdominal fat in general because as that body mass index or waist circumference increases, abdominal adiposity increased, but we actually found that the distribution gets worse in men,” Earp says. “For women, as they got to those higher levels of obesity, they were better able to distribute that fat in a healthier fashion.”

Earp says he hopes these equations can serve as a tool for physicians and researchers who can input simple measurements of a patient’s height, weight, and waist and hip circumference to get a sense of how that patient’s fat is distributed based on their sex and ethnicity.

This will help physicians assess a patient’s risk of obesity-related conditions more accurately than using BMI which may mislabel people and recommend inappropriate lifestyle interventions.

“It’s our hope that these equations can be used to identify people who are misclassified based on BMI alone,” Earp says.

For example, someone may have a high weight and be flagged as obese, but their weight is due to muscle and bone mass and their fat distribution is actually very healthy. By contrast, someone with a lower weight would not be labeled as at-risk but they may have high abdominal fat.

Earp’s group is also working with recently obtained data from the UConn Center on Aging and the Pepper Center to study fat distribution within muscles. In this study they only looked at fat beneath the skin and stored in around the hips. But as people age, fat within muscle becomes a significant concern.

The next steps for this research are looking at how to adapt the equations to populations with chronic illnesses like diabetes and COPD which create atypical fat distribution.

“We know the obesity crisis is something we’ll be facing for years to come. These tools help us better address a major health issue across a broad range of Americans,” says Earp.

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Risk of Overweight and Obesity in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: A Systematic Review and Meta-Analysis

March 23, 2023, Childhood Obesity

This study was performed to explore the association between attention-deficit/hyperactivity disorder (ADHD) and the risk of overweight/obesity in both children and adolescents. The PubMed, Web of Science, and Cochrane Library databases were searched for relevant studies published before July 12, 2022. Studies with data for calculating the odds ratio (OR) of childhood overweight/obesity and ADHD were included. The literature value was assessed by the cross-sectional evaluation criteria proposed by the Agency for Healthcare Research and Quality (AHRQ). All analyses were conducted using StataSE 11 and RevMan 5.3 software with random-effects models. This review included a total of 16 studies covering 14,981 cases and 128,916 controls. According to the meta-analysis, children with ADHD had a significant risk for co-occurring overweight and obesity [OR 1.56; 95% confidence intervals (CI) 1.32–1.85], especially boys (OR 1.45; 95% CI 1.10–1.90), people in Asia (OR 3.25; 95% CI 1.70–6.21) and Europe (OR 1.85; 95% CI 1.61–2.12), and patients not using medication (OR 1.54; 95% CI 1.22–1.94). ADHD has a significant association with overweight and obesity in both children and adolescents, which may be altered by factors such as geography, gender, and medication use. Timely treatment should be provided to children and adolescents diagnosed with ADHD to inhibit the emergence of overweight and obesity.

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USDA Announces New Investments in School Meals to Support Healthy Kids

March 22, 2023, U.S. Department of Agriculture

Today, U.S. Department of Agriculture announced several actions to expand support for and access to the school meal programs, including awarding $50 million in grants that will increase collaboration between schools, food producers and suppliers, and other partners to develop nutritious, appetizing school meals for kids. The department also announced $10 million in grants for schools to expand nutrition education, as well as a proposed regulatory change to give more schools the option to provide healthy school meals to all students at no cost.

These forward-thinking, innovative actions were all highlighted by Agriculture Secretary Tom Vilsack at an event at Maplewood Elementary in Greeley, Colo. where he spoke with school and district leaders about how these USDA actions will benefit their communities.

“The Biden-Harris Administration believes that a healthier future for our country starts with our children,” said Vilsack. “Continuing to make school meals healthier and available to more students are some of the best ways we can help our children thrive early in life.”

As part of the USDA’s Healthy Meals Incentives Initiative, Vilsack announced that the department is awarding $50 million to the following organizations to manage the School Food System Transformation Challenge Sub-Grants:

• Boise State University
• Chef Ann Foundation
• Full Plates Full Potential
• Illinois Public Health Institute

These grants will foster innovation in the school food marketplace to get a wider variety of healthy, appealing foods into the marketplace and onto kids’ lunch trays. Schools and other eligible organizations can apply for the challenge sub-grants later this year and are encouraged to check the USDA’s Healthy Meals Incentives website for updates.

“USDA is taking a holistic approach to supporting school meal programs, which includes strengthening the food supply chain that supports them,” said Stacy Dean, deputy under secretary for Food, Nutrition, and Consumer Services. “We’re hopeful that these grants will accelerate and expand innovation in the school food marketplace, so that schools – and ultimately our children – have better access to healthier food products.”

Also today, USDA opened applications for up to $10 million in Fiscal Year 2023 Team Nutrition Grants, which support nutrition education for school-aged children. The grants will extend nutrition education efforts beyond the cafeteria, incorporating it into all parts of the school day and even enrichment activities outside of school. The resources also support another component of the Healthy Meals Incentives Initiative by helping school districts introduce additional nutritious menu options, and eventually qualify for a Recognition Award.

Secretary Vilsack also announced that the department is proposing a change that would give more schools the option to provide healthy school meals to all students at no cost. The rule would expand the number of schools eligible to opt into the Community Eligibility Provision, also known as CEP, which could result in more children receiving tasty, nutritious school meals.

“Many schools and even some entire states have successfully provided free meals to all their students,” said Vilsack. “We applaud their leadership in nourishing children and hope this proposed change will make it possible for more schools and states to follow suit.”

While the proposed rule does not increase federal funds for school meals, President Biden’s 2024 budget requests an additional $15 billion over 10 years to support schools participating in CEP and reach 9 million more children. Vilsack added, “Together, these actions are one of many efforts the Biden-Harris Administration and USDA are taking to ensure the federal government, states, and local schools are working together to support child health.”

FNS encourages all interested parties to comment on the CEP proposed rule during the 45-day comment period that begins tomorrow.

Today’s announcements are part of USDA’s ongoing efforts to support schools and strengthen school meals to improve children’s health. They also build on commitments made in the Biden-Harris Administration’s National Strategy on Hunger, Nutrition, and Health:

• The expansion of CEP advances a pathway for healthy school meals to more students at no cost.
• The School Food System Transformation Challenge Grants unite the public and private sector in expanding healthier food options in the K-12 school food marketplace.
• The Team Nutrition Grants help schools expand nutrition education to students and introduce healthier food options into their meals.

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Built Environment Strongest Predictor of Adolescent Obesity, Related Health Behaviors

March 21, 2023, EurekAlert!

New research shows that the built environment, not social and economic environments, is a strong predictor of adolescents’ body mass index (BMI), overweight and obesity status, and eating behaviors, according to a new study in Obesity, The Obesity Society’s (TOS) flagship journal. This study provides the first quasi-experimental empirical evidence of these environments on adolescents’ BMI, overweight, obesity and related behaviors.

“Our research suggests that strategies for addressing childhood and adolescent obesity should focus on improving built environments more comprehensively,” said Maria J. Prados, PhD, Center for Economic and Social Research, University of Southern California Dornsife College of Letters, Arts and Sciences, Los Angeles, Calif. Prados is the corresponding author of the study.

Childhood and adolescent obesity have been identified as one of the most serious health issues of the 21st century. “Adolescents represent an important target for potential health policy interventions because they are at an age when their health behaviors, preferences and interactions with the environments are evolving,” Prados explained.

Literature reviews assessing the influence of environments on childhood obesity suggest that the majority of existing evidence has come from observational studies. These studies often have found somewhat varying results with respect to whether environments matter and for whom.

Studies that are suited to address causality, such as the Moving to Opportunity housing experiment and other quasi- and natural experiment studies, have not directly or simultaneously assessed the independent roles of built, social and economic environments on obesity. Instead, they have either focused only on a narrow set of environmental characteristics such as supermarkets, restaurants and peers or examined the effects of place as a whole. Moreover, these well-designed studies have primarily been among adults.

These new findings, said Prados, “add a new dimension to the growing evidence that place matters by applying a more comprehensive approach to characterizing environments.”

Previous research by the study’s authors utilized a natural experiment, the plausibly exogenous assignment of military service members and adolescents in their families to different places to assess place effects on obesity and obesity-related behaviors. This work assessed the role of a narrow set of environmental factors such as neighborhood physical activity opportunities or food environment or assessed the combined influence of the environment as a whole showing that adolescents whose military parents were assigned to counties with higher obesity rates were more likely to present with overweight or obesity. The current study builds on the previous work by using the same natural experiment to simultaneously assess the role of built, social and economic environments in adolescent obesity and related behaviors. This experiment relies on the routine assignment of military personnel (and their families) to different installations based on the needs of the Army.

Researchers analyzed data from the Military Teenagers Environments, Exercise and Nutrition Study, a co-hort study of adolescents in military families. Data was collected on adolescents’ BMI, overweight, obesity and self-reported diet and exercise. Forty-eight percent of the analysis sample (1,111 adolescents) was female, with an age range of 12 to 14 years old and 41% of participants being non-Hispanic White, 22% non-Hispanic Black, 23% Hispanic and 14% other. Three indices for the built, social and economic environments characterized 35 county-level environments based on 19 indicators. Significant heterogeneity existed in the two measures of exposure to the civilian environment: 61% of families had been assigned to the military installations for more than 2 years and 54% were not living on military bases but in the surrounding community.

Results revealed that exposure to higher (i.e., more healthful) built environment index scores for more than 2 years were associated with lower probability of obesity, and lower overweight or obesity status, but not with BMI z scores. All else equal, after more than 2 years of exposure, the likelihood of adolescent obesity is estimated to be 3.6 percentage points higher in a county with a built environment index at the 25th percentile relative to a county at the 75th percentile of the built environment distribution. Results were similar for adolescents not living on military bases. More advantageous built environments were also associated with lower consumption of unhealthy foods but not with physical activity. Social and economic environments were not associated with any outcomes.

“An interesting finding is that it was specifically the built environment that mattered – features like how close the adolescent lives to fast-food restaurants versus park and recreation facilities. Less important were the social and economic environmental factors like crime, social support, household income, household education – and while very important for adolescents’ health, these factors were not directly tied to obesity risk or eating behaviors in this study, and these factors are also harder to modify. The built environment, on the other hand, can be improved with policy change and economic investment like incentivizing grocery stores to come to food deserts, limiting fast-food outlets near school zones, enacting complete street policies to ensure pedestrians and cyclists are safe on the road, supporting municipalities to build more safe playgrounds and parks, and enacting joint use agreements so families can access public facilities like school fields and courts on the weekend,” said Amanda Staiano, PhD, associate professor, Louisiana State University’s Pennington Biomedical Research Center. Staiano was not associated with the research.

Staiano added that “while the recent release of the American Academy of Pediatric’s clinical practice guidelines reminds us that evidence-based treatment is a critical tool in our fight against childhood obesity, putting concerted effort into improving the built environment is also essential both for obesity prevention and to assist those families who have obesity and are trying to develop healthier habits. Improving the built environment will require input and action from many stakeholders – urban planners, elected officials, research scientists, concerned community members – to create healthier spaces for our kids to play, learn and live.”

The study’s authors add that further research is needed to understand whether social and economic environments may be more consequential among adolescents and adults in civilian populations.

Other authors of the study include Ashlesha Datar, Center for Economic and Social Research, University of Southern California Dornsife College of Letters, Arts and Sciences, Los Angeles, Calif., and Nancy Nicosia, Rand Corp., Boston, Mass.

The study, titled “Impact of Built, Social and Economic Environments on Adolescent Obesity and Related Health Behaviors,” will be published in the April 2023 print issue.

Research reported in this study was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health under award number R01DK111169.

The authors declared no conflicts of interest.

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