February 2021

New Update to NCCOR’s Measures Registry

NCCOR recently conducted an update of the Measures Registry and added over 250 new articles and 136 new measures! The Registry is used by researchers, practitioners, and students to answer research and evaluation questions related to four domains of childhood obesity research: individual diet, food environment, individual physical activity, and physical activity environment. 

The Measures Registry is a searchable database of more than 1,500 articles and 200 discrete measures. The purpose of the Measures Registry is to standardize use of common measures and research methods across childhood obesity research at the individual, community, and population levels.  

New to the Registry are over 70 measures for children age 0-5, including over 15 new measures specifically for birth-24 months. There are also measures in over 25 languages, more than 25 measures in Spanish, and 49 measures tested in populations at high risk for obesity.  

To accompany the Registry, NCCOR’s Measures Registry Resource Suite includes Learning Modules, which are ideal for users newer to research and evaluation, or those who need a refresher on key research concepts. The Learning Modules walk users through measurement selection on their own time through 5- to 15-minute modules in the four major domains of childhood obesity research. In addition to the Learning Modules, the Measures Registry User Guides are a great resource for those seeking detailed instructions on how to find the best measure for their work. This project was funded by the JPB Foundation.

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New! Increasing the Health and Physical Activity of Youth from Under-Resourced Communities through Trail Programs Brief

This month, NCCOR released a new program brief titled “Increasing the Health and Physical Activity of Youth from Under-Resourced Communities through Trail Programs.” The brief is based on a review of gray literature sources (e.g., websites, government or organizational reports, success stories) to identify programs promoting trail use among youth that are accompanied by process or outcome evaluation data. We identified nine U.S.-based programs promoting trail use among youth. The programs include a variety of programs on walking and hiking, overnight camping, and biking on trails. This resource is geared towards public health practitioners as it identifies strengths including programs’ reach and scalability, focus on under-resourced communities, and evaluations and outlines future considerations for improving programs and youth trail use in general. 

This brief complements a scientific review NCCOR published in the International Journal of Environmental Research and Public Health. The scientific review identified evaluated programs and policies that effectively promote and increase the use of trails among youth, especially those from under-resourced neighborhoods and communities. These communities are often predominantly made up of residents from diverse racial, ethnic, and cultural backgrounds. 

One of NCCOR’s major goals is to address health disparities related to nutrition, physical activity, and obesity. This brief was supported by NCCOR members from the Centers for Disease Control and Prevention, National Institutes of Health, and United States Department of Agriculture Forest Service, in collaboration with staff from the Federal Highway Administration, to explore the use of trails by youth as a health-enhancing behavior to engage in outdoor recreational physical activity. 

For more information on the Increasing Opportunities for Trail Use to Promote Physical Activity and Health Among Underserved Youth workgroup, visit  www.nccor.org/physical-activity/trail-use. 

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NCCOR Toolbox

The Childhood Obesity Evidence Base (COEB) Project aligns with NCCOR’s efforts to identify and evaluate practical and sustainable interventions as well as facilitate the ability of childhood obesity researchers and program evaluators to conduct research and program evaluation. Join us for an upcoming webinar about this project! 

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Healthy Food Service Guidelines: An Impactful Strategy for Promoting Health in Institutions

Various public and private institutions purchase, serve, and sell food to specific populations. Such institutions include schools, universities, healthcare facilities, shelters, correctional facilities, and agencies that provide free meals to people with low-incomes. These entities are a consistent source of food for millions of people in the United States, and some disproportionately serve populations that experience inequitable access to healthy food. They hold significant purchasing power that could be better leveraged to support healthy eating. Implementing healthy food service guidelines is an evidence-based strategy to improve the food environment in these settings. A growing body of research from schools, hospitals, public facilities, and congregate meal sites demonstrates that food service guidelines can lead to positive changes in the food environment, diet quality, and chronic disease risk factors. They also appear to be financially neutral or favorable. 

Read the article 

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Screen & Intervene: A Toolkit for Pediatricians to Address Food Insecurity

Food insecurity — the limited or uncertain access to enough food — is a critical child health issue that impacts millions of infants, children, youth, and families in all communities across the U.S. Children of all ages who live in households with food insecurity, even at the least severe levels of food insecurity, are likely to be sick more often, recover from illness more slowly, and be hospitalized more frequently. Unfortunately, 1 in 7 U.S. children lives in a household experiencing food insecurity. These levels have only deepened during the COVID-19 pandemic. Black and Hispanic/Latino households with children continue to face disproportionately high rates of food insecurity before and during the pandemic. 

See the toolkit 

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Building the Evidence Base by Testing Innovative Strategies to Reduce Food Insecurity in the United States: Findings from the Evaluation of Demonstration Projects to End Childhood Hunger

This supplement is supported by the U.S. Department of Agriculture, Food and Nutrition Service. 

Read the supplement 

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Journal of Healthy Eating and Active Living

The Journal of Healthy Eating and Active Living published its inaugural issue on December 21, 2020. 

See the full issue 

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Impact of the COVID-19 Pandemic on Childhood Obesity

February 2021, StateOfChildhoodObesity.org

The American Academy of Pediatrics has  reported  that nearly 2.3 million children in the United States have tested positive for coronavirus since the start of the pandemic. In addition to the health impacts of COVID-19 itself, there is evidence that COVID-19 can be connected to other diseases as well, including obesity. The Centers for Disease Control and Prevention lists obesity as one underlying risk factor for severe consequences from COVID-19. 

Early evidence is also beginning to show that COVID-19, and the economic consequences of the pandemic, may be increasing the risk for obesity. Factors such as limited access to affordable, healthy food, fewer places or chances to be physically active, or uncertain access to healthy school meals, can increase a child’s risk for obesity. 

To get a better understanding of how COVID-19 might ultimately impact childhood obesity rates in the future, we spoke with Drs. Punam Ohri-Vachaspati of Arizona State University and Lindsey Turner of Boise State University. 

Prior to the pandemic, what impact does school attendance have on a child’s risk for obesity? 

Dr. Lindsey Turner: There’s a fair amount of evidence accumulating that school can reduce the risk for obesity.  That’s most likely because of the structure and predictability of school days, as well as access to healthy school meals, physical education, and other supports for students. There’s also some good evidence to suggest that for lower-income students who eat meals at school, those meals are associated with a lower risk of obesity. So ensuring that students continue to be able to access healthy meals at school is important. 

Dr. Punam Ohri-Vachaspati: Prior to this very unusual school year, the vast majority of school-going children in the U.S. have had access to healthy school breakfast and lunch, and maybe a healthy snack. Nutritional standards were updated for these meals nearly a decade ago, and there is evidence that those changes may have contributed to healthier weight among school-age children, especially those from families with low incomes. School attendance also provides opportunities for physical activity—either through activities in school or through active commuting to school such as biking or walking—which are associated with healthier weight outcomes in children. There is emerging evidence that elementary school-age children gain weight at a rapid rate when the school is out during summer. So, as Lindsey noted too, schools can reduce the risk for obesity among children.   

With so many kids out of school much more than normal in 2020-21, what do we know about how some of the policy responses (e.g., school meal waivers, Pandemic EBT, etc.) may have impacted risk for obesity?  

LT: Pandemic EBT (P-EBT) was put into place to allow the families of students who most relied on access to free or reduced-priced meals at school to be able to replace those meals with items purchased locally from supermarkets or other locations. The quick availability of this program from USDA was necessary to address skyrocketing rates of food insecurity early in the pandemic. In addition, USDA allowed all schools waivers for flexibility in how and where meals are served, and allowed schools to offer free meals. That rapid response was crucial to meet the needs of children and families nationwide. 

POV: Some of our early assessments have shown that parents find the P-EBT benefits very useful. These benefits need to continue until children are back in schools on a regular basis and have the ability to access school meals. The school meal waivers have allowed schools and communities to offer much needed school meals to children during COVID-19 school closures. Parents find the access to these free meals critical, but there have still been challenges related to limited hours and location of meal distribution sites, lack of feasible delivery options, as well as families running out of meals before the next pickup day. We need innovations in program delivery to meet the needs of parents (re)-entering the workforce while their children are still not attending school on a regular basis. With growing food insecurity rates, these benefits are extremely helpful for families in need. 

What kind of questions do we need to study to better understand the connection between COVID-19 and childhood obesity?  

LT: There are a lot of important questions on this topic. While pre-existing obesity can lead to more severe consequences of COVID-19, it’s likely that the circumstances caused by the pandemic will also increase the prevalence of obesity. I say this because for many students there are fewer options for them to be physically active if they are not in school regularly during the week, and there are probably also dietary consequences from changes in where students eat and what they are eating. It will be important to study the behaviors that combine to increase risk for overweight– that is, physical activity, sedentary time, and dietary intake. Changes in any one of these are likely to increase the risk of childhood obesity, and the pandemic has impacted all three types of behavior. 

POV: There is growing evidence that food and physical activity environments where children live can impact their health. For example, in our recent work we showed that over time, having additional convenience stores in a child’s neighborhood had a negative impact on their weight status. During extended school closures, children are much more likely to go to these kinds of stores in their neighborhoods, so we need to investigate if the negative impacts of these features get exacerbated when schools are closed for extended periods. Another concern is shifts in household purchasing behaviors during this time. Especially early in the pandemic, it was difficult for families to find healthy, affordable foods regularly, making them more likely to purchase processed and packaged foods. The absence of school meals in a child’s day or the change in composition (because of much needed waivers) of meals offered during the pandemic are areas that need examination. 

Similarly, on the physical activity front, when children are not in school they are not participating in the structured physical education or walking / biking to school.  Absence of these options, especially among children living in communities that are not safe from traffic or crime and/or do not have access to safe public parks, sidewalks, or other features that can promote physical activity, has the potential to result in unhealthy outcomes. Are children living in walkable communities or close to safe public parks protected from some of the negative impacts of pandemic school closures on physical activity and weight? PhD, Director of Initiative for Healthy Schools at Boise State University 

Are there policy changes that have been put in place because of the pandemic that you think ought to be maintained even without the pandemic? Are there things that are working well now that we should keep doing?  

LT: I think it’s going to be very important to learn more about school meal delivery during the pandemic, because this is an area where so many changes were made rapidly by incredibly committed and creative school nutrition professionals. With the changes in school nutrition programs, it’s possible that some changes—such as making all meals free—might be worth keeping after the pandemic is over. 

POV: At the outset of the pandemic the school food systems were challenged to deliver free meals to all children and they did a remarkable job organizing and delivering these meals. These programs were implemented on a very short time scale. The lessons learned from this experience can be instrumental in exploring universal free meals for children or expanding eligibility criteria—we know school meal participation rates are higher among those who receive free and reduced-price meals. On the flip side, waivers relaxed some of the nutritional requirements for school meals—these waivers were critical to ensure children were fed during the uncertain times. However, when we return to the post-pandemic era, it is important to ensure that the advances made on the nutritional quality of school meals are reinstated and further improved.  

At the end of the day, what does the research tell you about the impact COVID-19 is likely to have on childhood obesity rates?  

LT: The pandemic has definitely shone a bright light on the crucial role that schools play in supporting healthy behaviors among children and adolescents. The pandemic has also reduced opportunities for physical activity even outside of school times, in terms of sports and play time outdoors. With so many families dealing with financial challenges due to the pandemic, the connection between food insecurity, unhealthy eating habits, and obesity, have become even more evident. Finding ways to support the health of children year-round—whether during a pandemic or not—must be a priority for our nation. 

POV: COVID-19 is likely to affect obesity rates in children in a significant way. Absence of regular school attendance over extended periods is a major concern. Schools play a critical role in keeping our children healthy by providing a structure that includes provision of healthy meals and opportunities of physical activity as well as limits to sedentary time. In addition to school closures, the pandemic created environments, whether because of lockdowns or public health measures, that may be more conducive to unhealthy behaviors in children. Social distancing prevented children from being physically active and increased sedentary time. Parents’ shopping patterns changed—less frequent trips and increased reliance on non-perishable foods. Disruptions in the food supply chain meant changes in what was available in stores. Loss of jobs and disruptions in income increased food insecurity rates—all impacting households with children disproportionately. Children and their families most certainly need support now and will continue to do so over time—this is necessary to protect children from long-term negative impacts of the pandemic.   

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School-Based Gardening, Cooking and Nutrition Intervention Increased Vegetable Intake but Did Not Reduce BMI: Texas Sprouts - A Cluster Randomized Controlled Trial

January 23, 2021, International Journal of Behavioral Nutrition and Physical Activity

Background 

Although school garden programs have been shown to improve dietary behaviors, there has not been a cluster-randomized controlled trial (RCT) conducted to examine the effects of school garden programs on obesity or other health outcomes. The goal of this study was to evaluate the effects of a one-year school-based gardening, nutrition, and cooking intervention (called Texas Sprouts) on dietary intake, obesity outcomes, and blood pressure in elementary school children. 

Methods 

This study was a school-based cluster RCT with 16 elementary schools that were randomly assigned to either the Texas Sprouts intervention (n = 8 schools) or to control (delayed intervention, n = 8 schools). The intervention was one school year long (9 months) and consisted of: a) Garden Leadership Committee formation; b) a 0.25-acre outdoor teaching garden; c) 18 student gardening, nutrition, and cooking lessons taught by trained educators throughout the school-year; and d) nine monthly parent lessons. The delayed intervention was implemented the following academic year and received the same protocol as the intervention arm. Child outcomes measured were anthropometrics (i.e., BMI parameters, waist circumference, and body fat percentage via bioelectrical impedance), blood pressure, and dietary intake (i.e., vegetable, fruit, and sugar sweetened beverages) via survey. Data were analyzed with complete cases and with imputations at random. Generalized weighted linear mixed models were used to test the intervention effects and to account for clustering effect of sampling by school. 

Results 

A total of 3,135 children were enrolled in the study (intervention n = 1412, 45%). Average age was 9.2 years, 64% Hispanic, 47% male, and 69% eligible for free and reduced lunch. The intervention compared to control resulted in increased vegetable intake (+ 0.48 vs. + 0.04 frequency/day,  p = 0.02). There were no effects of the intervention compared to control on fruit intake, sugar sweetened beverages, any of the obesity measures or blood pressure. 

Conclusion 

While this school-based gardening, nutrition, and cooking program did not reduce obesity markers or blood pressure, it did result in increased vegetable intake. It is possible that a longer and more sustained effect of increased vegetable intake is needed to lead to reductions in obesity markers and blood pressure. 

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The Complexities of Family Mealtimes in the 21st Century: A Latent Profile Analysis

February 1, 2021, Appetite

Abstract 

The goal of the present study was to characterize more than 500 families regarding family mealtime organization patterns. Family profiles were developed based on patterns detected across a set of sociological and psychological variables. Latent profile analyses indicated three distinct subgroups of families: Food Secure and Organized (55% of the sample), Very Low Food Security and Disorganized (27%), and Low Food Security and Organized (18%). Examination of group membership correlates revealed significant differences related to family mealtime behaviors and food preparation strategies, but not food shopping location or areas of requested change around family mealtimes. Findings highlight homogenous subgroups of families on the basis of co-occurring psychological and sociological factors pertinent to family mealtimes, with those families possessing the highest levels of risk in multiple domains also reporting family mealtime organization patterns associated with less healthy eating. Findings provide a snapshot into the organization, and complexities, of family meals for the American family today, highlighting the need for researchers and practitioners interested in promoting healthy food intake within American families to consider both psychological and sociological factors that influence family mealtime organization. 

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Mobile Game that Uses Implicit Learning Improved Children's Short-Term Food Choices

February 10, 2021, EurekAlert!

Rates of overweight and obesity in children are rising around the world, with serious long-term consequences for health and health care costs. In prior research, video and mobile games have helped children eat healthier and exercise more. A new study examined how Indian 10- and 11-year-olds’ food choices were affected by playing a pediatric dietary mobile game that uses implicit learning–educating players without making them aware of the lessons through innovations in neurocognitive training and immersive technology. The study found that the game significantly improved children’s food choices immediately after play. 

The study was conducted by researchers at Carnegie Mellon University (CMU), Hofstra University, Johns Hopkins University Center for Communication Programs (CCP), FriendsLearn, The Mithra Trust, Mind in Motion, the Center for Communication and Change – India (CCC-I), and Seethapathy Clinic and Hospital. The randomized controlled trial was designed and conducted by researchers from CCC-I and CCP and the data modeling and analytics were led by CMU. The study appears in JMIR mHealth and uHealth. 

“While many factors contribute to overweight and obesity, dietary decisions are a leading cause,” explains Rema Padman, trustees professor of management science and healthcare informatics at CMU’s Heinz College, who led the study. “Video games that are perceived by children as a fun activity rather than a learning tool present a great opportunity to change children’s health behaviors by delivering relevant knowledge implicitly. We are studying such gamified interventions as ‘digital vaccine’ candidates that have the potential to influence lifestyle behavior changes and lead to better health outcomes.” (Digital vaccines are a subcategory of digital therapeutics, which are evidence-based, prevention approaches that use digital technologies, such as gamified applications delivered via mobile devices, to encourage positive behavior.) 

Most video games for children use explicit education strategies, such as providing answers, feedback, instructions, or suggestions to players. This study examined how an action video game called fooya!, which uses implicit learning to promote healthy eating and physical activity in children, affected actual food choices. In the game, an avatar fights robots that represent unhealthy foods, and the avatar’s speed and body shape vary in response to the type of food it eats. 

Evidence of the effects of games that use implicit education strategies on pediatric healthy eating is limited. Using data about the clicks made by players as they played fooya!, researchers analyzed the relationship between patterns of game play and behavioral outcomes related to dietary health. 

The study involved 104 children ages 10 and 11 years from three schools in Chennai, India. The children were randomly assigned to a treatment group that played fooya! or a control group that played a board game that did not feature dietary education. Children played the games for 20 minutes each in two sessions. After playing, they were shown three pairs of healthy and unhealthy food items from three categories–drinks (water and a carbonated soft drink), savory snacks (cashews and potato chips), and sweet snacks (raisins and a chocolate bar)–and asked to choose two items to eat. 

Children who played fooya! were more likely to choose healthy foods immediately after playing the game, the study found. Children’s food choices were not influenced by how many levels of the game they played, as previous research on this topic has found, but by food facts children read while playing the game: Reading more facts about healthy foods was associated with healthier food choices, while reading more facts about unhealthy foods was associated with more unhealthy food choices, a finding the authors called counterintuitive. Nonetheless, children searched for more food facts about healthy food than about unhealthy food, which drove the overall positive effect of playing the game. 

“This finding will also influence how we communicate to children about healthy food choices for behavior change,” says Uttara Bharath Kumar, technical advisor for social and behavior change at CCP. “It is consistent with what we know from behavioral science that fear and negative communication do not work as well as positive messaging and promoting self-efficacy–the notion that ‘you can do it!’” 

“Nutrition and lifestyle are at the root of lifelong risk of noncommunicable and infectious diseases,” explains Bhargav Sri Prakash, founder & CEO of FriendsLearn, the life science and health technology company that serves as the research translation and innovation partner of the Digital Vaccine Project at CMU. “These findings indicate the potential for societal impact by developing rigorous evidence-based science for ‘digital vaccines’ based on neurocognitive computing and analytics. As we build a platform of scalable, rich, game-like, engaging experiences, we aim to protect the health of children and families through science.” 

Among the limitations of the study, the authors note, are its small size, homogeneous groups of children, and short-term food choices, limiting the generalizability of the findings. Longitudinal studies on this subject can help determine longer-term effects, the authors suggest. 

“By examining the complex interactions between game-playing patterns and health behaviors, our findings can inform the design and use of more effective mobile games for improving children’s dietary health,” notes Yi-Chin Kato-Lin, assistant professor of information systems and business analytics at Hofstra University, who collaborated on the study. “For example, video game designers may want to limit the display of unhealthy foods in their games.” 

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Prediction of Childhood Obesity from Nationwide Health Records

February 10, 2021, The Journal of Pediatrics

Objective 

To evaluate body mass index (BMI) acceleration patterns in children and to develop a prediction model targeted to identify children at high risk for obesity prior to the critical time-window in which the largest increase in BMI percentile occurs 

Study design 

We analyzed electronic health records of children from Israel’s largest healthcare provider from 2002 to 2018. Data included demographics, anthropometric measurements, medications, diagnoses, and laboratory tests of children and their families. Obesity was defined as BMI ≥95th percentile for age and sex. To identify the time-window in which the largest annual increases in BMI z-score occurs during early childhood, we first analyzed childhood BMI acceleration patterns among 417,915 adolescents. Next, we devised a model targeted to identify children at high risk prior to this time-window, predicting obesity at 5-6 years of age based on data from the first 2 years of life of 132,262 children. 

Results 

Retrospective BMI analysis revealed that among obese adolescents, the greatest acceleration in BMI z-score occurred between 2-4 years of age. Our model, validated temporally and geographically, accurately predicted obesity at 5-6 years old (auROC of 0.803). Discrimination results on subpopulations demonstrated its robustness across the pediatric population. The model’s most influential predictors included anthropometric measurements of the child and family. Other impactful predictors included ancestry and pregnancy glucose. 

Conclusions 

Rapid rise in the prevalence of childhood obesity warrant the development of better prevention strategies. Our model may allow an accurate identification of children at high risk of obesity. 

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