August 2018

NCCOR is Highlighting Multidisciplinary Partnerships to Celebrate National Childhood Obesity Awareness Month 2018!

August 30, 2018, NCCOR

In recognition of National Childhood Obesity Awareness Month (NCOAM), NCCOR is highlighting how multidisciplinary partnerships can accelerate progress in reducing childhood obesity.

Earlier this year, NCCOR published two papers in the American Journal of Preventive Medicine describing how the NCCOR partnership has transformed the field of childhood obesity prevention. The first paper, “Developing A Partnership for Change: The National Collaborative on Childhood Obesity Research,” highlights the formation, structure, and operations of NCCOR and discusses benefits of using a collaborative model to address health problems. The companion paper, “A National Collaborative for Building the Field of Childhood Obesity Research,” details several principles for successful partnerships and how NCCOR used these principles to make significant contributions to build the field of research, evaluation, and surveillance for childhood obesity prevention and management.

This month, NCCOR is releasing a new fact sheet that introduces the steps for building a public health collaborative using NCCOR as a case study. This fact sheet is meant to be used not only by childhood obesity researchers and practitioners but anyone working on complex public health problems.

Over the past ten years, NCCOR members have worked with individuals across a wide array of sectors to positively impact the field of childhood obesity research. These multidisciplinary partnerships are highlighted in some of our projects:

• Health, Behavioral Design, and the Built Environment: This workgroup was created to understand an important gap in the knowledge—how do specific aspects of the built environment influence healthy living? NCCOR members invited a multidisciplinary group of experts, including architects, psychologists, physicians, planners, and childhood obesity researchers to derive ways of applying behavioral design principles to foster active living and healthy eating. This work was first developed into a white paper, and this week, a book chapter entitled, Behavioral Design as an Emerging Theory for Dietary Behavior Change, was published in Food and Public Health. Stay tuned for an upcoming NCCOR Connect & Explore on this topic in October!
• Engaging Health Care Providers and Systems in Obesity Prevention: Since 2015, NCCOR members have been partnering with physicians, researchers, health insurance companies, and hospital systems to understand the relationships between communities and clinical settings that address obesity preventions. Currently, the workgroup is planning an online learning collaborative to engage participants in the development of an evaluation framework for community-based, childhood healthy weight programs.
• Increasing Opportunities for Trail Use to Promote Physical Activity and Health Among Underserved Youth: NCCOR members are working together with scientists, public health advisors, nutritionists, transportation planners, community planners, and landscape architects to review the literature on trail use to promote physical activity and health among underserved youth. Two reviews are currently being conducted to identify effective, promising, and emerging interventions and programs for increasing trail use among underserved youth.

Connect with us! How are you working in multidisciplinary partnerships to reduce childhood obesity? Follow us on Twitter and Facebook and let us know! #NCOAM

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NCCOR Publishes Chapter: Behavioral Design as an Emerging Theory for Dietary Behavior Change

August 30, 2018, NCCOR

On August 30, the National Collaborative on Childhood Obesity Research (NCCOR) published a chapter in Food and Public Health—a book published by Oxford University Press and edited by Allison Karpyn, PhD—titled “Behavioral Design as an Emerging Theory for Dietary Behavior Change.”

The chapter, excerpted from a larger NCCOR white paper, explains how theories of behavior and design, and relevant fields of application (e.g., nutrition, physical activity) intersect to form a more comprehensive understanding of how theory and practice connect. The chapter specifically focuses on enabling the development of behavioral design applications to the built and natural environments.

Food and Public Health introduces more than 100 years of food-focused regulation, policy, and education. The book highlights the interwoven nature of the U.S. food system and its effect on traditional diets globally. It also discusses food insecurity and its influence on hunger and obesity.

Learn more about NCCOR’s health, behavioral design, and the built environment work here. The book can be purchased here.

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USDA Economic Research Service Releases Estimates of Average Prices for Fruits and Vegetables

ERS estimated average prices for over 150 commonly consumed fresh and processed fruits and vegetables. Reported estimates include each product’s average retail price per pound and per edible cup equivalent (the unit of measurement for Federal recommendations for fruit and vegetable consumption). For many fruits and vegetables, a 1-cup equivalent equals the weight of enough edible food to fill a measuring cup. ERS calculated average prices at retail stores using 2013 and 2016 retail scanner data from Information Resources, Inc. (IRI). A selection of retail establishments—grocery stores, supermarkets, supercenters, convenience stores, drug stores, and liquor stores—across the U.S. provides IRI with weekly retail sales data (revenue and quantity).

ERS reports average prices per edible cup equivalent to inform policymakers and nutritionists about how much money it costs Americans to eat a sufficient quantity and variety of fruits and vegetables. Every five years the Departments of Agriculture and Health and Human Services release a new version of the Dietary Guidelines for Americans with information about how individuals can achieve a healthy diet. However, the average American falls short in meeting these recommendations. Many people consume too many calories from refined grains, solid fats, and added sugars, and do not eat enough whole grains, fruits, and vegetables.

Are food prices a barrier to eating a healthy diet? ERS research using this data set shows that, in 2013, it was possible for a person on a 2,000-calorie diet to eat a sufficient quantity and variety of fruits and vegetables for about $2.10 to $2.60 per day. The report also illustrates the variety of fruits and vegetables affordable to a family on a limited budget. See: The Cost of Satisfying Fruit and Vegetable Recommendations in the Dietary Guidelines

ERS fruit and vegetable prices are updated periodically to coincide with the release of each new version of the Dietary Guidelines for Americans. When generating estimates using 2013 and 2016 data, ERS researchers priced similar fruit and vegetable products during both years. However, because of different methods for coding the underlying IRI data, the entry of new products into the market, the exit of old products from the market, and other factors, the data are not suitable for making year-to-year comparisons. These data should not be used for making inferences about price changes over time.

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CDC Publishes 2018 Breastfeeding Report Card

In the United States, most infants (83.2%) start out breastfeeding, but many stop earlier than recommended, according to the 2018 Breastfeeding Report Card released by the Centers for Disease Control and Prevention (CDC).

For most infants, good nutrition starts with breastfeeding exclusively for about the first 6 months of life, as recommended by the American Academy of Pediatrics. Although nearly 6 in 10 (57.6 %) babies are still breastfeeding at 6 months of age, only 1 in 4 (24.9%) are breastfeeding exclusively.

To track the nation’s breastfeeding progress, the CDC’s Division of Nutrition, Physical Activity, and Obesity (DNPAO) uses data from CDC’s National Immunization Survey (NIS). These data allow us to measure whether we are meeting the nation’s breastfeeding targets, as outlined in Healthy People 2020. Currently, the nation is meeting 5 of the 8 Healthy People 2020 breastfeeding objectives.

Among infants born in 2015:

• More than 4 out of 5 (83.2%) started out breastfeeding.
• Almost half (46.9%) were exclusively breastfeeding at 3 months old.
• More than one-third (35.9%) of infants were breastfeeding at 12 months old.

In addition:

• More than 1 in 4 babies are now born in facilities that provide recommended maternity care practices for breastfeeding mothers and their babies.
• Almost half (49%) of employers provide work site lactation support programs.

For the first time, the Breastfeeding Report Card includes data for Guam and the U.S. Virgin Islands.

Many hospitals are making strides to implement maternity care practices that support breastfeeding.

Facilities designated through the World Health Organization/UNICEF Baby-Friendly Hospital Initiative (“Baby-Friendly” facilities) are those that provide recommended care for lactating mothers and babies. The percentage of live births occurring in “Baby-Friendly” facilities increased from less than 2% in 2008 to 26.1% in 2018, which is currently about 1 million births. This increase shows improved maternity care practices that support mothers and infants.

All sectors of society can play a role in improving the health of families by supporting breastfeeding. To reach their breastfeeding goals, mothers need continuity of care through consistent, collaborative, and high-quality breastfeeding services and support.

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CDC Releases New BE Active Campaign Resources

CDC’s BE Active: Connecting Routes + Destinations campaign shares new resources for implementing the Community Preventive Services Task Force built environment recommendations to increase physical activity. State and local health departments, public health professionals, and community organizations working on ways to increase physical activity can use the Real World Examples, Implementation Resource Guide, Visual Guide, and new slides and talking points to guide their implementation process as they aim to build more activity-friendly communities.

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How Healthy is the American Diet? The Healthy Eating Index Helps Determine the Answer

August 23, 2018, Elsevier

Dietary risk factors are among the key contributors to mortality and morbidity in the United States and globally, and there is increasing emphasis on understanding the influence of total diet quality and overall dietary patterns rather than single aspects of what we eat and drink. In order to evaluate the quality of what people eat and drink, researchers often rely on recommendations such as the Dietary Guidelines for Americans (DGA). In the latest issue of the Journal of the Academy of Nutrition and Dietetics, leading nutrition experts describe and evaluate the latest version of the Healthy Eating Index (HEI), which has been issued to correspond to the 2015-2020 Dietary Guidelines for Americans.

The DGA are updated every five years, leading to changes in emphasis and quantification, as the evidence on healthy eating evolves over time. Likewise, a new HEI is issued to correspond to each new edition of the DGA and to reflect these changes. The HEI is a measure of diet quality, independent of quantity, that can be used at various levels of the food stream, including the national food supply, the community food environment (e.g., foods available at a school or a fast food menu), and food intakes among the population.

The HEI score can be used to evaluate how healthy the American diet is in relation to federal dietary guidance. It has been applied by researchers to describe diet quality among the US population, as well as population subgroups such as Mexican Americans, children, and cancer survivors. It has also been used to evaluate the quality of food offerings across the food stream, including the US food supply, restaurant menus, grocery store circulars, and Federal food distribution programs.

“Tracking quality at these different levels is critical since we are increasingly recognizing the power of the food environment on eating behavior. That is, individuals cannot be expected to make healthy choices if those options are not readily available in the home, at work, at school, and in the community,” comments Jill Reedy, PhD, MPH, RD, Program Director at the Risk Factor Assessment Branch, Epidemiology and Genomics Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA, and co-author of the papers in this issue.

The latest HEI was developed through a collaboration between researchers at the National Cancer Institute (NCI) and the United States Department of Agriculture’s (USDA) Center for Nutrition Policy and Promotion (CNPP). A trio of papers in this special issue introduce the new HEI and describe differences compared to the 2010 and 2005 editions, evaluate the properties of the HEI-2015 for assessing dietary quality, and discuss its applications.

Update

The first paper outlines the steps taken to update the most recent version of the HEI and prepare an HEI-2015 scoring system to reflect compliance with the 2015-2020 DGA food and nutrient recommendations. “The Dietary Guidelines for Americans evolve incrementally over time based on scientific evidence, and updates to the HEI are designed to capture that evolution,” explains Susan M. Krebs-Smith, PhD, MPH, Risk Factor Assessment Branch, Epidemiology and Genomics Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, National Institutes of Health, Bethesda MD, USA.

The 2015 edition has 13 components, each reflecting an important aspect of diet quality as per the DGA. Dr. Krebs-Smith and colleagues describe each of the HEI-2015’s constituent food and nutrient categories, as well as its 100-point scoring system, including referent standards for each component of the total score. Since the 2005 version, the HEI has been based on densities (e.g., amounts per 1000 kcal), rather than absolute amounts, and relies on a common set of standards that are applicable across individuals and settings. Notable differences compared to the previous edition are that saturated fat and added sugars are each separately tracked, and excessive alcohol contribution to energy is not captured separately. This new version also incorporates modifications to the scoring procedures for legumes.

Evaluation

In the second paper, Jill Reedy, PhD, MPH, RD, and colleagues report on testing of the index’s validity and reliability. Known high-quality sample menus from a variety of organizations such as the National Heart, Lung, and Blood Institute (Dietary Approaches to Stop Hypertension [DASH] diet), US Department of Agriculture (USDA), Harvard Medical School (Healthy Eating Guide), and the American Heart Association (AHA) (No-Fad Diet) were scored using the HEI standards. These menus all achieved high scores, ranging from 88 to 100 points.

At the next level of testing, data from the Centers for Disease Control and Prevention’s National Health and Nutrition Examination Survey (NHANES) were used to compare HEI-2015 scores across population subgroups to examine if meaningful differences could be detected. Average HEI-2015 scores and ranges demonstrated reasonable variation across the subgroups examined, including groups differentiated by age, gender, and smoking status. Results suggested that the index reflects the many dimensions of dietary guidance. As a final assessment, datasets from the NIH-AARP Diet and Health Study were examined and showed that individuals in the highest quintiles of HEI-2015 scores had a 13-23 percent decreased risk of all-cause, cancer, and cardiovascular disease mortality.

“These analyses demonstrated evidence supportive of validity and reliability for the HEI-2015, as has been shown in earlier work with the HEI-2005 and HEI-2010,” notes Dr. Reedy. “However, limitations in the HEI as well as those inherent to dietary intake data more broadly should be considered in any application of the index.”

Applications

The third paper examines potential applications of the HEI-2015 in surveillance, epidemiology, and community intervention research. Lead investigator Sharon I. Kirkpatrick, PhD, MHSc, RD, Associate Professor, School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada, and colleagues outline approaches to calculating scores and review their suitability for research questions related to monitoring eating patterns, understanding associations between eating patterns and health/disease, and evaluating dietary interventions.

The focus of this paper is on the use of the HEI for cases in which dietary intake data are available for characterizing diet quality for groups of individuals sampled from the population. Further development of methods for calculating the HEI for individuals will help advance our knowledge on diet quality. “The use of the most appropriate approach to calculating HEI scores for a given purpose can help build a stronger literature on the influence of dietary quality on health and disease risk, helping to inform future policies and programs to support health,” comments Dr. Kirkpatrick.

In an accompanying editorial, Barbara Millen, DrPH, MPH, RD, FADA, Millennium Prevention, Inc., and Boston Nutrition Foundation, Inc., Westwood, MA, USA, and Chairman of the 2015 Dietary Guidelines Advisory Committee, points out the growing use of web and mobile platforms and apps in clinical and community settings for purposes such as diet and exercise behavior monitoring. She forecasts a bright future for integrating new methods of nutritional risk assessment, such as the HEI-2015, with advanced analytics and innovative web and mobile technologies.

According to Dr. Millen, “The evidence base is stronger than ever before linking the ‘total diet’ – its dietary patterns, nutrient density, and overall quality – to health promotion and disease prevention across the human life span. The work of these investigators will hopefully inspire other researchers and nutrition professionals to utilize the HEI-2015 broadly and establish other evidence-based innovations that fully embrace the 2015-2020 DGA’s five cornerstone guidelines, and advance research and practice in clinical, public health and consumer settings.”

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Girls with Obesity Have Increased Risk of Depression

August 10, 2018, Reuters

Obese girls are more likely to develop depression during childhood and adolescence than their peers who weigh less, a research review suggests.

Compared to girls at a healthy weight, girls with obesity were 44 percent more likely to have depression or to be diagnosed with it in the future, the analysis of 22 studies with a total of almost 144,000 participants found.

Just being overweight rather than obese, however, didn’t appear to influence the risk of depression for girls, and there wasn’t any association between weight and depression in boys.

The smaller studies included in the analysis were not controlled experiments designed to prove whether or how obesity might cause depression, or the role that gender might play. But it’s possible boys and girls might have different perceptions about body image that at least partially explain the results, said lead author Dr. Shailen Sutaria of Imperial College London in the UK.

“While a number of factors may be involved, clearly there are additional social pressures on girls to be a certain body shape, perpetuated and amplified though social media,” Sutaria said by email.

Girls who experience body dissatisfaction may develop symptoms of depression as a result, Sutaria added. But overweight or obese boys might think differently about their size.

“Boys may find it desirable to be larger as this reflects strength and dominance, traits that are likely to be desirable during childhood,” Sutaria said.

Globally, more than 40 million children are overweight or obese by the time they’re 5 years old, according to the World Health Organization.

Depression is also a leading cause of reduced quality of life for children, impacting school performance, friendships and the risk of substance use and other risky behaviors, researchers note in the Archives of Disease in Childhood.

While previous research has linked childhood obesity to an increased risk of depression, results have been mixed and the estimated excess risk has ranged from as low as 4 percent to as high as 64 percent, researchers note.

In the current analysis, children were 14 years old on average and almost 16 percent were obese. Slightly more than one in 10 obese children were depressed.

Girls who experience body dissatisfaction may develop symptoms of depression as a result, Sutaria added. But overweight or obese boys might think differently about their size.

“Boys may find it desirable to be larger as this reflects strength and dominance, traits that are likely to be desirable during childhood,” Sutaria said.

Globally, more than 40 million children are overweight or obese by the time they’re 5 years old, according to the World Health Organization.

Depression is also a leading cause of reduced quality of life for children, impacting school performance, friendships and the risk of substance use and other risky behaviors, researchers note in the Archives of Disease in Childhood.

While previous research has linked childhood obesity to an increased risk of depression, results have been mixed and the estimated excess risk has ranged from as low as 4 percent to as high as 64 percent, researchers note.

In the current analysis, children were 14 years old on average and almost 16 percent were obese. Slightly more than one in 10 obese children were depressed.

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Effect of a Behavioral Intervention for Underserved Preschool-Age Children on Change in Body Mass Index a Randomized Clinical Trial

August 7, 2018, JAMA

Abstract

Importance

Prevention of obesity during childhood is critical for children in underserved populations, for whom obesity prevalence and risk of chronic disease are highest.

Objective

To test the effect of a multicomponent behavioral intervention on child body mass index (BMI, calculated as weight in kilograms divided by height in meters squared) growth trajectories over 36 months among preschool-age children at risk for obesity.

Design, Setting, and Participants

A randomized clinical trial assigned 610 parent-child pairs from underserved communities in Nashville, Tennessee, to a 36-month intervention targeting health behaviors or a school-readiness control. Eligible children were between ages 3 and 5 years and at risk for obesity but not yet obese. Enrollment occurred from August 2012 to May 2014; 36-month follow-up occurred from October 2015 to June 2017.

Interventions

The intervention (n = 304 pairs) was a 36-month family-based, community-centered program, consisting of 12 weekly skills-building sessions, followed by monthly coaching telephone calls for 9 months, and a 24-month sustainability phase providing cues to action. The control (n = 306 pairs) consisted of 6 school-readiness sessions delivered over the 36-month study, conducted by the Nashville Public Library.

Main Outcomes and Measures

The primary outcome was child BMI trajectory over 36 months. Seven prespecified secondary outcomes included parent-reported child dietary intake and community center use. The Benjamini-Hochberg procedure corrected for multiple comparisons.

Results

Participants were predominantly Latino (91.4%). At baseline, the mean (SD) child age was 4.3 (0.9) years; 51.9% were female. Household income was below $25 000 for 56.7% of families. Retention was 90.2%. At 36 months, the mean (SD) child BMI was 17.8 (2.2) in the intervention group and 17.8 (2.1) in the control group. No significant difference existed in the primary outcome of BMI trajectory over 36 months (P = .39). The intervention group children had a lower mean caloric intake (1227 kcal/d) compared with control group children (1323 kcal/d) (adjusted difference, −99.4 kcal [95% CI, −160.7 to −38.0]; corrected P = .003). Intervention group parents used community centers with their children more than control group parents (56.8% in intervention; 44.4% in control) (risk ratio, 1.29 [95% CI, 1.08 to 1.53]; corrected P = .006).

Conclusions and Relevance

A 36-month multicomponent behavioral intervention did not change BMI trajectory among underserved preschool-age children in Nashville, Tennessee, compared with a control program. Whether there would be effectiveness for other types of behavioral interventions or implementation in other cities would require further research.

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Intervention for First-Time Moms and Their Infants Improves Child Weight Through Age

August 7, 2018, NIH

An intervention designed to help first-time mothers effectively respond to their infant’s cues for hunger, sleep, feeding, and other infant behaviors significantly improved the body mass index (BMI) z-scores of the child through age 3 years compared with the control group. Results of the study, call Intervention Nurses Start Infants Growing on Health Trajectories (INSIGHT), published August 7 online in JAMA.

Funded by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), a component of the National Institutes of Health (NIH), INSIGHT randomly assigned first-time mothers and their infants into two groups to determine if an intervention in “responsive parenting” delivered during infancy and early childhood promoted healthy weight gain leading to improved  body mass index (BMI) z-scores through age 3 compared to a control group who did not receive the responsive parenting intervention. The 279 mothers who participated were an average of 28 years old, mostly white, married, well-educated, and privately insured, although INSIGHT researchers aimed for a racially and economically diverse study population. Overall, retention over three years was 83 percent.

First-time mothers assigned to the “responsive parenting” group were educated on how to respond to their infant’s needs across four behaviors: feeding, sleep, interactive play, and emotional regulation. Responsive parenting encourages parents to interact with their child in a way that is appropriate for their age, prompt, and meets the child’s needs. This group also learned such strategies as how to put infants to bed drowsy, but awake and avoid feeding infants to sleep; anticipate and respond to infants waking up at night; when to introduce solid foods; how to use growth charts; and how to limit sedentary time.

The control group received a home safety intervention. Both groups received four home visits from a research nurse during infancy, followed by annual research center visits at 1, 2, and 3 years old.

“Educating first-time mothers about responsive parenting practices can promote healthy weight gain,” said Voula Osganian, M.D., Ph.D., M.P.H., director of NIDDK’s pediatric clinical obesity program. “By helping parents to understand how to respond to their infant’s cues when drowsy, sleeping, fussy and alert, we can help them to instill healthy behaviors in the child during a critical period of development.”

The INSIGHT study found that, after completing the three-year study, children in the responsive parenting group had a lower average BMI z-score than those in the control group. There were significantly lower rates of overweight or obesity in the responsive parenting compared to control group at age 2 years, and these differences were still favorable but not statistically significant at age 3 years.

At age 3 years, in the responsive parenting group, 11.2 percent of children were overweight, compared to 19.8 percent in the control group. Further, only 2.6 percent of children in the responsive group were considered obese, whereas, 7.8 percent were considered obese in the control group.

“The effects of the INSIGHT intervention appeared early and were sustained through age 3, something that had not been achieved before,” said Ian M. Paul, M.D., M Sc., professor of pediatrics and public health sciences at Penn State Health Milton S. Hershey Medical Center, who led the study with co-principal investigator Leann Birch, Ph.D., of the University of Georgia, Athens. “Although INSIGHT participants were primarily white and of higher socioeconomic status, we believe components of the intervention can be successfully implemented in more diverse and lower income populations, and this is currently being studied,” added Paul.

Previous reports from the INSIGHT study demonstrated that a responsive parenting intervention reduced rapid weight gain during the first six months after birth and overweight status at age 1 year,  promoted developmentally appropriate infant sleep-related behaviors and sleep duration, and was associated with healthier dietary patterns at 9 months of age.

Obesity affects 13.9 percent of children ages 2 to 5 years. Children who have obesity are at increased risk for developing type 2 diabetes, heart disease, high blood pressure, asthma and other serious health problems in early childhood and later in life.

“Infancy is a critical period for parents and health care providers to intervene and promote healthy behaviors, and INSIGHT results show us a way to do this effectively,” said NIDDK Director Griffin P. Rodgers, M.D., M.A.C.P. “These important findings help us better understand the important role that infancy and early childhood play in developing healthy habits and preventing obesity.”

The INSIGHT study (NCT01167270) was conducted at the Penn State Milton S. Hershey Medical Center in Hershey, Pennsylvania, and supported through NIDDK grant R01DK088244 and NIH’s National Center for Advancing Translational Sciences grant UL1TR000127.

The NIDDK, part of the NIH, conducts and supports basic and clinical research and research training on some of the most common, severe, and disabling conditions affecting Americans. The Institute’s research interests include: diabetes and other endocrine and metabolic diseases; digestive diseases, nutrition, and obesity; and kidney, urologic, and hematologic diseases. For more information, visit www.niddk.nih.gov.

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Sedentary Behaviors in Today’s Youth: Approaches to the Prevention and Management of Childhood Obesity: A Scientific Statement From the American Heart Association

August 6, 2018, American Heart Association

Abstract

This scientific statement is about sedentary behavior and its relationship to obesity and other cardiometabolic outcomes in youth. A deleterious effect of sedentary behavior on cardiometabolic health is most notable for screen-based behaviors and adiposity; however, this relation is less apparent for other cardiometabolic outcomes or when sedentary time is measured with objective movement counters or position monitors. Increasing trends of screen time are concerning; the portability of screen-based devices and abundant access to unlimited programming and online content may be leading to new patterns of consumption that are exposing youth to multiple pathways harmful to cardiometabolic health. This American Heart Association scientific statement provides an updated perspective on sedentary behaviors specific to modern youth and their impact on cardiometabolic health and obesity. As we reflect on implications for practice, research, and policy, what emerges is the importance of understanding the context in which sedentary behaviors occur. There is also a need to capture the nature of sedentary behavior more accurately, both quantitatively and qualitatively, especially with respect to recreational screen-based devices. Further evidence is required to better inform public health interventions and to establish detailed quantitative guidelines on specific sedentary behaviors in youth. In the meantime, we suggest that televisions and other recreational screen-based devices be removed from bedrooms and absent during meal times. Daily device-free social interactions and outdoor play should be encouraged. In addition, parents/guardians should be supported to devise and enforce appropriate screen time regulations and to model healthy screen-based behaviors.

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