December 2019

NCCOR Year in Review: 2019

NCCOR, December 19, 2019

It’s been another busy and productive year for the National Collaborative on Childhood Obesity Research. This year, NCCOR launched brand-new resources, collaborated across agencies through workshops, disseminated information at multiple conferences, and more.

Here are some highlights of what NCCOR did in 2019:

• Enhanced the Measures Registry Resource Suite by launching the new Measures Registry Learning Modules. This tool is designed to complement the Measures Registry and Measures Registry User Guides and assists researchers and practitioners with choosing the best measures across the four domains of the Measures Registry: individual diet, food environment, individual physical activity and physical activity environment.
• Launched the NCCOR Student Hub, a new quarterly student e-newsletter, geared towards helping students maximize use of NCCOR tools for coursework and research projects.
• Held three workshops to advance new measurement methods for the field.
• Facilitated two Connect & Explore webinars: “From Purchase to Plate: Linking USDA Nutrition Data with Retail Scanner Data to Assess the Healthfulness of America’s Food-at-Home Purchases” and “Measures Registry Learning Modules: Helping You Understand Measurement Concepts and Approaches for Diet and Physical Activity.”
• Created new products for our tools and resources to make them more user-friendly for certain groups. For example, NCCOR produced a new Student Resource Guide with information on NCCOR tools and case studies to help students navigate our wealth of resources. We also created a fact sheet on the Youth Compendium geared directly towards classroom teachers and a fact sheet on how professors can incorporate the Measures Registry Resource Suite into their curricula. There is also a one-page guide on how to incorporate NCCOR tools into grant proposals.
• Engaged 55 outside experts in childhood obesity research through NCCOR meetings, workshops, and our Connect & Explore webinar series.
• Attended and shared information at eight conferences: Active Living Conference, Society of Behavioral Medicine Annual Conference, Healthy Eating Research Annual Conference, Society for Public Health Education Annual Conference, the Future of Food and Nutrition Graduate Student Research Conference, Society of Nutrition 2019, Childhood Obesity Conference 2019, and the American Public Health Association Annual Meeting.

To learn more about what NCCOR did in 2019, stay tuned for NCCOR’s 2019 Annual Report!

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NCCOR's Toolbox

Are you a graduate student? Do you work with one? Sign up for NCCOR’s new Student Hub—a quarterly e-newsletter that brings the latest childhood obesity-related tools and news to your inbox.

If you’re a student who has used NCCOR tools, e-mail us at NCCOR@fhi360.org for a chance to be featured in an upcoming webinar!

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Characteristics of Health Programs Among Secondary Schools 2018

This new report from CDC summarizes data related to health education, physical education and activity, nutrition environment and services, healthy and safe school environment (including social and emotional climate), health services, family engagement community involvement, and school health coordination.

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A Health Equity Approach to Obesity Efforts: Proceedings of a Workshop

On April 1, 2019, a workshop was convened by the Roundtable on Obesity Solutions of the National Academies of Sciences, Engineering, and Medicine in Washington, DC. The workshop explored the history of health equity issues in demographic groups that have above-average risk for obesity, and considered principles and approaches for addressing these issues as part of obesity prevention and treatment efforts. This publication was released this month.

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Less Sleep Linked to Teen Obesity, Poor Eating Habits, and Low Physical Activity

University of Minnesota, December 9, 2019

Sleep can impact an individual’s health in many ways. School of Public Health researchers were interested in how much teens sleep at night is related to their weight, eating habits and physical activity. Their findings were published in the journal Childhood Obesity.

Using survey data from approximately 2,000 Twin Cities area ninth graders in the START study, researchers found:

• 15% of the sample of ninth graders reported optimal sleep duration for adolescents (i.e., 8.5-10 hours of sleep each night);
• Nearly 30% of the study participants reported very curtailed sleep (i.e., less than 7 hours of sleep per night);
• Teens who reported shorter sleep also reported less healthful weight-related behaviors including greater consumption of sugar sweetened beverages, lesser vegetable consumption and lesser physical activity;
• The short sleepers were also less likely to report eating breakfast on school mornings;
• Shorter sleepers were more likely to be obese.

“If adolescent sleep insufficiency negatively affects diet and physical activity, this could increase kids’ risk for chronic disease,” said study lead and Associate Professor Rachel Widome. “This is especially true if lack of sleep is setting the stage for enduring, lifelong, poor, weight-related behavior patterns, and weight gain over time.”

“Given the epidemic of short sleep among teens, interventions and policies such as delaying high school start times, which can give adolescents a greater opportunity for healthy sleep, deserve prioritization,” said study co-author Kyla Wahlstrom, a senior research fellow in the College of Education and Human Development.

Widome says the next step in their research is to examine how changes in schools’ start times relate to future alterations in teens’ diet, physical activity, and weight.

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Exercise Yields Some Cardiovascular Benefits in Children with Excess Weight

EurekAlert!, December 9, 2019

Eight months of daily, afterschool physical activity in previously inactive 8- to 11-year-olds with obesity and overweight improved key measures of their cardiovascular health like good cholesterol levels, aerobic fitness and percent body fat, but didn’t improve others like arterial stiffness, an early indicator of cardiovascular risk, investigators report.

The exercise group experienced twice the improvement in measures like fitness and adiposity, or body fat, levels compared to the control group, they report in the International Journal of Obesity.

“They could do more, breathe better, their heart rates were lower when they were pushing themselves,” says Dr. Catherine “Katie” Davis, clinical health psychologist at the Georgia Prevention Institute in the Medical College of Georgia Department of Medicine and corresponding author.

The active children also experienced a surprising increase in the protective HDL cholesterol — a full five milligrams per deciliter –that likely resulted from sustained months of physical activity, the investigators say.

The children who exercised did not lose weight, reduce their BMI or waist size likely because with exercise, growing children are replacing some fat with muscle, which is a healthy response, Davis says.

She notes that focusing on weight loss is often not the right goal for children because they are growing and, in fact, may ultimately “grow into” their weight. Reducing sugar and processed foods in favor of fresh, home-cooked meals is good for children, but weight-loss diets are not necessarily helpful because children need plenty of nutrients to grow, Davis says. As an example, children in the study grew about 2 inches during the school year.

Rather gradual reductions in body fat, like that experienced by study participants who exercised, is more beneficial, the investigators say.

“They should be growing. With exercise, you can allow their body to develop in a more healthy way,” Davis says.

They theorize that a healthy diet and exercise together might more effectively address arterial stiffness, and that prevention is always the best strategy.

For the current study, the 175 boys and girls were mostly black, three quarters had obesity, and a majority had prediabetes — their glucose levels were already higher than normal, probably due to insulin resistance, a major risk factor for diabetes. Three percent were prehypertensive and 5% were already hypertensive.

All the children came to the Georgia Prevention Institute each afternoon, both groups did homework for about a half hour, had a healthy snack — but no specific nutrition education — and got redeemable points for good behavior like playing well with others, keeping their heart rate up in the exercise class, or putting away their supplies in the sedentary group.

Those in the exercise group participated in instructor-led aerobic activities like jumping rope and playing tag for 40 minutes daily and wore heart rate monitors so both they and the investigators could see how their pulse responded to the exercise. The control group also participated in instructor-led activities, but sit-down ones like crafts, music and board games.

“We were looking at cardiovascular health comprehensively but the focus was on arterial stiffness: How stiff are the big blood vessels that supply the body,” says Davis of the little-explored area of the impact of physical activity on arterial stiffness.

Investigators measured many cardiovascular health indicators before and after the course of the study, including blood pressure, insulin resistance, and blood levels of glucose, lipids and inflammation, as well as arterial stiffness. None of these were affected by exercise although the investigators expected changes in blood pressure and fitness to track with arterial stiffening.

Surprisingly, the new study found that increasing insulin resistance was the most closely associated with the unhealthy high blood velocity indicating stiff arteries, even more than blood pressure, which is thought to be the main cause of arterial stiffness. Therefore, reducing insulin resistance might be the best strategy to prevent arterial stiffness in children, Davis notes.

But contrary to what they expected, changes in fitness were not related to arterial stiffening, suggesting that poor fitness is not a direct cause of arterial stiffness, she says.

Davis notes that over time the blood vessel stiffness in children who exercised was generally holding steady, while in the children who did not exercise it was trending upward. “It looked like it was heading in the right direction,” she says.

In a follow up assessment of the children some 8 to 10 months after the study, the investigators found benefits in fitness and body fat gained by the children in the exercise arm were lost. Just like individuals with high blood pressure need to continue to take their medication, eat healthy and exercise, continued exercise is needed to maintain the gains these children experienced, Davis says.

The bottom line is that children need ready access to fun aerobic activities that encourage them to stay physically active, says Davis, a longtime proponent of ensuring these type of activities are part of the educational curriculum.

To enable activity, children need options they consider fun and not necessarily competitive. “Children need to feel encouraged to do physical activity even when they are not winning,” says Davis. That means having a variety of programs to choose from that are not targeted to only the fast or coordinated children, she says.

Investigators used painless ultrasound to measure carotid-femoral pulse wave velocity, which looks at how long it takes blood to travel through major arteries such as the aorta in the chest and abdomen, to measure arterial stiffness at the start and end of the exercise treatment.

Faster speed is worse, indicating blood vessels are less compliant, Davis says of what can become a vicious cycle of stiffer vessels driving blood pressure up which further stiffens vessels and sets a perfect stage for heart disease.

Arterial stiffness is considered an independent predictor of cardiovascular problems and death in adults. Black children tend to have stiffer arteries than their peers, and pulse wave velocity has been shown to be faster and increase more quickly in young blacks than whites. Children in the study who had more body fat or a higher BMI already had stiffer arteries than their leaner peers.

In the United States, rates of obesity among children and adolescents have more than tripled since the 1970s, affecting about 1 in 5 children, according to the Centers for Disease Control and Prevention. Factors contributing to obesity include genetics, metabolism, eating and physical activity, sleep duration and adverse childhood experiences, like family dysfunction or violence.

Obesity is a major risk factor for cardiovascular disease and both obesity and cardiovascular problems tend to have their origins in childhood, Davis says.

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Structure and Function in Cross-Sectional Work: A Cautionary Tale

JAMA Pediatrics, December 9, 2019

In this issue of JAMA Pediatrics, Laurent et al¹ extend our understanding of the associations among body mass index (BMI), brain structure (in this case cortical thickness), and executive functioning in children. Their analyses found that higher BMI in 9- to 10-year-old children was associated with lower scores on some measures of executive function and thinner cortical thickness, measured with structural magnetic resonance imaging. They observed inverse associations between BMI and cortical thickness in areas of the prefrontal cortex—a brain region key to regulating executive cognitive functions, such as attention, planning, decision-making, and problem solving. The authors also found that prefrontal cortical thickness partially mediated the association between BMI and 1 of 4 executive functioning tasks: list sorting (a measure of working memory). In this editorial, we highlight what is important about these findings while urging caution in interpretation because of the limitations of the study design and analysis and concern about perpetuating damaging weight stigma.

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Are Sugar Substitutes Good for Kids?

New York Times, December 9, 2019

Even the name, “nonnutritive sweeteners,” sounds like it was invented to avoid, well, sugarcoating the issue. We used to call them artificial sweeteners; this new term is intended to emphasize that they have no nutritional content — no vitamins, no minerals, no calories, or very few (that’s the whole point).

We evolved to like sugar and sweet tastes precisely because they signal the presence of calories — that is to say, food that our bodies can burn for energy.

Now, we are more likely to be worried about consuming too many calories — and whether our children are overdosing on sugar.

The American Academy of Pediatrics put out a policy statement in November on the place of these nonnutritive sweeteners in children’s diets, noting that there are now more of them in foods and other products on the market, and that therefore children and adolescents are consuming more of them — and this is happening in the absence of clear data about whether they help with weight control, or how they affect children’s tastes as they grow.

“First and foremost, the information we have regarding nonnutritive sweeteners and long-term safety is limited,” said Dr. Carissa Baker-Smith, the lead author of the statement, who is an associate professor of pediatric cardiology at the University of Maryland School of Medicine.

There have been scares in the past about whether certain nonnutritive sweeteners can be carcinogenic, especially in large doses, but in the literature that was reviewed for the policy statement, no such association has been demonstrated.

Allison Sylvetsky, an assistant professor in the department of exercise and nutrition science at George Washington University whose research focuses on this group of sweeteners, said that “while we know that these nonnutritive sweeteners are safe from a toxicological viewpoint, we don’t know if they’re effective for lowering calories and helping kids reduce sugar intake.”

Parents are concerned about the right nutritional balance for their children, Dr. Baker-Smith said, but also often worry more specifically about making sure that their children don’t get too much sugar, worrying about obesity, diabetes, high cholesterol. But consuming nonnutritive sweeteners has not been shown to lead to healthier weight in children, though they may have a place in a larger weight control plan.

Dr. Sylvetsky pointed to one trial published in 2012, done in children ages 6 to 12 in the Netherlands, in which some children were given sugar-sweetened drinks and others got diet beverages. In that study, in which the children were of normal weight, those who were given the diet drinks gained less weight over time than those who were given drinks sweetened with sugar; however, there was no group given unsweetened drinks for comparison.

Some studies in adults suggest it can be helpful to replace sugar-sweetened beverages with diet soda, but in the context of a more comprehensive behavioral weight loss program. “It’s not just, here’s a diet soda, drink this instead,” Dr. Sylvetsky said.

On the other hand, other research suggests that many people use the nonnutritive sweeteners and continue to consume sugar as well. In a study by Dr. Sylvetsky and her colleagues, using survey data, “kids that consumed low-calorie sweetened beverages actually had considerably higher total energy intake and added sugar intake compared to kids drinking unsweetened beverages,” she said. Their reported total calorie intakes were similar to those of the children who reported drinking sugar-sweetened drinks.

This kind of cross-sectional study shows an association but cannot possibly explain cause and effect. Maybe the kids who drink the diet beverages are also eating snack foods and fast foods — that is to say, maybe drinking a lot of diet drinks is a marker for a less healthy lifestyle overall. But there have also been concerns, some connected to animal studies, that incorporating the nonnutritive sweeteners may have some biological effects on the child’s appetite or metabolism.

We also don’t know, Dr. Sylvetsky said, how different amounts of these sweeteners may affect the young, perhaps influencing their taste preferences, or the bacterial flora in their guts. Taste preferences begin to develop in utero, reflecting substances present in the amniotic fluid, and continue to develop in infancy and after.

“There are a lot of questions that have yet to be answered with respect to early exposure,” she said.

In a 2017 article on how the perception of sweet taste develops in children, Dr. Sylvetsky and her colleagues reviewed possible mechanisms by which exposure to the nonnutritive sweeteners early in life may affect children later on, including the question of whether too much sweetness early on tends to lead children to develop unhealthy diets — and ended by concluding that much more research is needed.

Infants born to mothers who consumed diet beverages were heavier at 1 year of age than those whose mothers avoided the sweeteners in a 2016 study, Dr. Sylvetsky said — even after controlling for other factors like the mother’s weight. Nonnutritive sweeteners are also transferred to nursing infants through breast milk, she said, though at a very low concentration.

If a parent is concerned about a child’s weight, Dr. Sylvetsky said in an email, “I would encourage replacement of sugar-sweetened beverages with unsweetened alternatives such as plain water, rather than simply switching from sugar-sweetened beverages to diet beverages containing nonnutritive sweeteners. An occasional sweet beverage, whether sugar-sweetened or diet, is fine, but the focus should really be on improving the overall diet.”

“What we want to instill is not, replace sugary food with nonnutritive sweeteners, but teach healthier behaviors,” Dr. Baker-Smith said. “Exercise 150 minutes out of the week, choose vegetables at meals, and fruit, appropriate portion size, not an adult-size plate.” She doesn’t see the nonnutritive sweeteners as necessarily beneficial over the long term.

“We should go back to the way we thought about sweets a long time ago, as a treat,” Dr. Baker-Smith said. “One sweet, once a week, not every meal.” And in that context, stick to real sugar for the treats, and avoid all sweetened beverages. That’s what she tries to do for herself and her own kids, she said. “I have gone to avoiding nonnutritive sweeteners for my own family, and I want parents to make the choice for themselves.”

The other message to parents is that to make these choices, we have to read labels — and the labels don’t have enough information. Because six of the eight sweeteners approved by the Food and Drug

Administration are considered food additives, manufacturers are required only to state on the label that they are present, not to specify the quantity. Better, clearer labeling would help, she said. “This policy statement is really advocating that the F.D.A. make it clear how much nonnutritive sweetener is in each product, so parents can make informed decisions.”

These sweeteners turn up in an increasing number of places, from toothpaste to breakfast pastries. “If a product says low sugar or sugar-free, that likely means it contains a nonnutritive sweetener,” Dr. Baker-Smith said. “We have to all be aware of how much we’re taking in.”

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Elective and Nonelective Cesarean Section and Obesity Among Young Adult Male Offspring: A Swedish Population–Based Cohort Study

PLOS Medicine, December 6, 2019

Background

Previous studies have suggested that cesarean section (CS) is associated with offspring overweight and obesity. However, few studies have been able to differentiate between elective and nonelective CS, which may differ in their maternal risk profile and biological pathway. Therefore, we aimed to examine the association between differentiated forms of delivery with CS and risk of obesity in young adulthood.

Methods and findings

Using Swedish population registers, a cohort of 97,291 males born between 1982 and 1987 were followed from birth until conscription (median 18 years of age) if they conscripted before 2006. At conscription, weight and height were measured and transformed to World Health Organization categories of body mass index (BMI). Maternal and infant data were obtained from the Medical Birth Register. Associations were evaluated using multinomial and linear regressions. Furthermore, a series of sensitivity analyses were conducted, including fixed-effects regressions to account for confounders shared between full brothers. The mothers of the conscripts were on average 28.5 (standard deviation 4.9) years old at delivery and had a prepregnancy BMI of 21.9 (standard deviation 3.0), and 41.5% of the conscripts had at least one parent with university-level education.

Out of the 97,291 conscripts we observed, 4.9% were obese (BMI ≥ 30) at conscription. The prevalence of obesity varied slightly between vaginal delivery, elective CS, and nonelective CS (4.9%, 5.5%, and 5.6%, respectively), whereas BMI seemed to be consistent across modes of delivery. We found no evidence of an association between nonelective or elective CS and young adulthood obesity (relative risk ratio 0.96, confidence interval 95% 0.83–1.10, p = 0.532 and relative risk ratio 1.02, confidence interval 95% 0.88–1.18, p = 0.826, respectively) as compared with vaginal delivery after accounting for prepregnancy maternal BMI, maternal diabetes at delivery, maternal hypertension at delivery, maternal smoking, parity, parental education, maternal age at delivery, gestational age, birth weight standardized according to gestational age, and preeclampsia. We found no evidence of an association between any form of CS and overweight (BMI ≥ 25) as compared with vaginal delivery. Sibling analysis and several sensitivity analyses did not alter our findings. The main limitations of our study were that not all conscripts had available measures of anthropometry and/or important confounders (42% retained) and that our cohort only included a male population.

Conclusions

We found no evidence of an association between elective or nonelective CS and young adulthood obesity in young male conscripts when accounting for maternal and prenatal factors. This suggests that there is no clinically relevant association between CS and the development of obesity. Further large-scale studies are warranted to examine the association between differentiated forms of CS and obesity in young adult offspring.

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Click, Click, Cook: Online Grocery Shopping Leaves ‘Food Deserts’ Behind

EurekAlert!, December 2, 2019

There’s a new path out of the “food desert,” and it’s as close as the nearest Internet connection.

A Yale University analysis found that most people in “food deserts” in eight states would increase their access to healthy, nutritious food if they purchase groceries online and had the food delivered as part of the federal government’s Supplemental Nutrition Assistance Program (SNAP).

The analysis showed that online grocery delivery systems already cover about 90% of food deserts — places where access to healthy food is limited — in the eight states: Alabama, Iowa, Maryland, Nebraska, New Jersey, New York, Oregon, and Washington.

“If you live in a food desert, online grocery delivery really stands out as way to get healthy food that potentially can save your life,” said Eric Brandt, M.D., a postdoctoral research fellow in the National Clinician Scholars Program at Yale and lead author of a study published online Dec. 2 in JAMA Network Open.

Earlier this year, SNAP began a pilot program in which clients had the option of buying food via online grocery delivery services. The program was established by the 2014 Farm Bill; it may be considered for national implementation after the pilot ends in 2021.

Brandt’s inspiration for the study was a visit to an urban, East Coast neighborhood served only by small convenience stores. “I thought, ‘One of the grocery store chains must deliver here — wouldn’t that be a better option than trying to build a new brick-and-mortar store nearby or change the way local bodegas are run?’”

Brandt then learned the latest Farm Bill had just such a program.

For his study, Brandt identified food deserts in eight states by working with data from the U.S. Department of Agriculture and the U.S. Census Bureau. He also made use of a database of all stores that both sold and delivered groceries purchased online in the eight states (including department stores and big-box retailers) and also accepted orders from SNAP clients.

Brandt said the benefits of allowing SNAP families to buy healthy food online are far-reaching and wide-ranging. In the short term, they provide nutrients and nourishment that reduce obesity, boost energy, and help heal patients recovering from serious physical ailments; in the long term, they promote better eating habits and behaviors, which can lower the risk for serious illnesses.

“When I see patients who have had a heart attack, the cornerstone of their recovery is making better lifestyle choices,” Brandt said. “Part of that has to do with the environment in which they live. It really influences the outcome.”

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