July 2020


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NCCOR Celebrates National Parks and Recreation Month

NCCOR, July 2020

In honor of National Parks and Recreation Month, NCCOR is sharing tools and resources for childhood obesity researchers and practitioners related to getting active outdoors!

While Americans across the country are still advised to socially distance and generally stay at home, visiting parks can be a great way to get some fresh air and exercise (while wearing a mask and maintaining 6 feet of space). If you’re working on a project relating to staying active during this time, whether that be parks and recreation or physical activity in general, here are some NCCOR resources that might be helpful for you:

  • This Connect & Explore webinar featuring graduate student Tyler Prochnow shows how he used NCCOR’s Measures Registry to conduct a study on kids’ physical activity levels during the summer.
  • NCCOR’s Youth Compendium of Physical Activities provides a list of 196 common activities in which youth participate and the estimated energy cost associated with each activity. You can find the energy cost of many outdoor activities, such as walking, running, or swimming. Note: The Compendium is now available in Spanish!
  • If you’re looking for COVID-19 resources related to childhood obesity, NCCOR has compiled them here.
  • This blog from the American College of Sports Medicine explains the role of physical activity in reducing the spread of COVID-19 and reducing health disparities.
  • This dataset from the Catalogue of Surveillance Systems, called “National Survey on Recreation and the Environment,” collected data about participation in outdoor recreational activities and related behaviors and attitudes for individuals in the United States.
  • The Physical Activity Environment module series in NCCOR’s Measures Registry Learning Modules addresses why the built environment is important to physical activity and what can be gained from using existing physical activity and environment assessment tools.

To learn more about NCCOR’s resources, visit and follow us on social media @NCCOR!

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Publications & Tools

NCCOR’s Toolbox

Looking for COVID-19 resources related to childhood obesity? Find them here.

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COVID-19 School Nutrition Policy Brief

A new report from Trust for America’s Health called “Beyond School Walls: How Federal, State and Local Entities are Adapting Policies to Ensure Student Access to Healthy Meals During the COVID-19 Pandemic” reviews steps the federal and state governments have taken to ensure students’ access to healthy meals when schools are closed and what needs to be done to ensure continued meal access as all school systems face uncertainties about how to safely reopen for the 2020-2021 school year.

See the report

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Strengthening WIC’s Impact During and After the COVID 19 Pandemic

This research brief focuses on how to strengthen WIC’s impact during and after COVID-19 and summarizes the evidence of WIC’s benefits and challenges the program and participants are facing due to COVID-19. The brief suggests increasing access to telemedicine, expanding online food package ordering, in addition to steps already taken, including minimum stocking requirements and food package substitutions for added flexibility.

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Advancing Effective Obesity Communications

On September 16, 2019, the Roundtable on Obesity Solutions of the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine, held a public workshop, Advancing Effective Obesity Communications, in Washington, DC. The workshop explored effective communication of obesity-related issues by providing an overview of the current communications environment and addressing the complexity of identifying key audiences and developing targeted messages. This publication summarizes the presentations and discussions that occurred at the workshop.

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Feeding Infants and Children from Birth to 24 Months: Summarizing Existing Guidance

Feeding Infants and Children from Birth to 24 Months collects, compares, and summarizes existing recommendations on what and how to feed infants and young children from birth to 24 months of age. This report makes recommendations to stakeholders on strategies for communicating and disseminating feeding recommendations.

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Childhood Obesity Research & News

Hospital Length of Stay, Charges, and Costs Associated With a Diagnosis of Obesity in US Children and Youth, 2006-2016

National Library of Medicine, August 2020 Issue

Background: Childhood obesity is linked with adverse health outcomes and associated costs. Current information on the relationship between childhood obesity and inpatient costs is limited.

Objective: The objective of this study was to describe trends and quantify the link between childhood obesity diagnosis and hospitalization length of stay (LOS), costs, and charges.

Research design: We use the National Inpatient Sample data from 2006 to 2016.

Subjects: The sample includes hospitalizations among children aged 2-19 years. The treatment group of interest includes child hospitalizations with an obesity diagnosis.

Measures: Hospital LOS, charges, and costs associated with a diagnosis of obesity.

Results: We find increases in obesity-coded hospitalizations and associated charges and costs during 2006-2016. Obesity as a primary diagnosis is associated with a shorter hospital LOS (by 1.8 d), but higher charges and costs (by $20,879 and $6049, respectively); obesity as a secondary diagnosis is associated with a longer LOS (by 0.8 d), and higher charges and costs of hospitalizations (by $3453 and $1359, respectively). The most common primary conditions occurring with a secondary diagnosis of obesity are pregnancy conditions, mood disorders, asthma, and diabetes; the effect of a secondary diagnosis of obesity on LOS, charges, and costs holds across these conditions.

Conclusions: Childhood obesity diagnosis-related hospitalizations, charges, and costs increased substantially during 2006-2016, and obesity diagnosis is associated with higher hospitalization charges and costs. Our findings provide clinicians and policymakers with additional evidence of the economic burden of childhood obesity and further justify efforts to prevent and manage the disease.

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Nearly 60% of American Children Lack Healthy Cardiorespiratory Fitness

EurekAlert!, July 20, 2020

Nearly 60% of American children do not have healthy cardiorespiratory fitness (CRF), a key measure of physical fitness and overall health, according to “Cardiorespiratory Fitness in Youth – An Important Marker of Health,” a new Scientific Statement from the American Heart Association, published today in the Association’s flagship journal Circulation.

CRF, also referred to as aerobic fitness, refers to the body’s ability to supply oxygen to muscles during physical activity. Children with healthy CRF are more likely to live longer and be healthier as adults. Children with low or unhealthy CRF at higher risk for developing premature heart disease, type 2 diabetes (T2D) and high blood pressure at younger ages, and they are at increased risk for premature death from heart disease and stroke as adults. Children with obesity are the most likely to have poor CRF.

In addition, studies have linked better CRF in children with improved academic achievement, clearer thinking, better mental health and a higher sense of self-worth and life satisfaction, according to studies cited in the statement. Since the 1980s, studies have demonstrated a downward trend for CRF among youth both in the U.S. and internationally.

“CRF is a single measure that shows how strong the heart, lungs and blood circulation are in children. Whereas measuring body weight, blood pressure, cholesterol and blood sugar levels tell us about each of these individual risk factors, measuring CRF provides a comprehensive assessment of a child’s overall health,” said Geetha Raghuveer, M.D., M.P.H., FAHA, chair of the writing committee for the new scientific statement, a cardiologist at Children’s Mercy Hospital and professor of pediatrics at the University of Missouri, both in Kansas City, Missouri.

According to the statement, one of the biggest contributors to low CRF in children is the decline in physical activity among young people. Children play fewer physically active games and are exercising less.

Children are also more sedentary than they were in the past, although it is not clear if the sedentary time itself or the resultant lack of physical activity is correlated with lower CRF in young people. Studies (conducted prior to the COVID-19 pandemic) show that children are spending more time using their electronic devices for recreation and entertainment in addition to education needs – sedentary activities have replaced physical activity. However, a recent meta-analysis that combines the results of multiple studies found that increased sedentary time was correlated with lower levels of CRF in children, yet not among teens.

CRF in youth can be improved by spending more time doing repeated bursts of vigorous physical activity otherwise called high-intensity interval training, such as regular sprint running sessions coupled with periods of rest or low-intensity exercise. Sports that include periods of vigorous physical activity such as basketball, soccer, tennis, swimming among others should be encouraged.

“Cardiorespiratory fitness is crucial for good heart and overall health both in childhood and as children become adults,” said Raghuveer. “We’ve got to get kids moving and engaged in regular physical activity, such as in any sports they enjoy. The best activity is the activity a child or teen likes and that is sustained for a longer period. The habits they learn when they’re young will directly benefit their health as they become adults,” said Raghuveer.

However, there are many challenges for parents who may want to help children be more physically active. Social determinants of health, such as socioeconomic status and neighborhood characteristics, greatly affect children’s CRF. Studies cited in the statement have found that lower-income families tend to have children with lower or unhealthy CRF, possibly because they do not have access to safe places to exercise, play sports and be physically active. In many communities, physical education is not provided in schools, and outdoor recess opportunities have been reduced or eliminated.

In addition, many lower-income families live in food deserts, making it difficult to find or afford healthy foods, factors which contribute to obesity in young people and adults.

“Every child would benefit from CRF testing as part of a yearly physical and doing so may identify children who would benefit from lifestyle interventions that can help improve health,” said Raghuveer. Currently, CRF is not routinely measured by health care professionals, except in children with specific conditions such as congenital heart disease, asthma or cystic fibrosis. There are a wide variety of tests and protocols that can be used to measure CRF, some of which can be administered in a pediatric health care office.

The most accurate measure of CRF in children is the cardiopulmonary exercise test, which is conducted while a participant is exercising to exhaustion, typically on a treadmill or cycle ergometer (specially adapted stationary bike).

Other office-based tests include: the PWC170 test (Physical Work Capacity Corresponding to a Heart Rate of 170 beats per minute), which is conducted with a cycle ergometer; a six-minute walk test that measures the distance achieved in six minutes; however, this is only considered useful for children with already suspected low CRF; and step tests, where a participant steps up and down on a 12-inch bench in an effort to engage larger muscle mass, with a goal of 24 steps/minute for a duration of three minutes. (Step tests can be a good alternative when space is limited; they can be conducted in office settings with minimal equipment or on school bleachers for groups of children.)

Patient questionnaires to assess the level of physical activity for a child or teen tend to be unreliable and not effective for measuring CRF because they are self-reported and do not include testing.

Although the CRF tests noted above can be implemented in a pediatric health care office, many professionals don’t have enough time, space or personnel to administer the tests.

In many cases, schools provide a great avenue for CRF testing, because they widely administer the 20-meter Shuttle Run, which is an effective measure of CRF and is the most widely used CRF test in the world. During this test, a student runs between lines set 20 meters apart until a facilitator sounds a “beep.” The intervals between beeps accelerate towards the end of the test, and the student must run faster. Students are scored on the number of laps run.

Many schools also measure body mass index (BMI), weight, abdominal strength, upper-body strength and flexibility through a group of tests called Fitness Gram, which is administered in all 50 states.

The other field-based test is a run test where the participant is given a set distance or a maximum duration time and instructed to complete the test in the shortest amount of time or the greatest distance as possible during that time.

“As is current practice for immunization records that health care professionals share with schools with parental consent, schools could share CRF testing results with health care professionals. This bidirectional communication will result in health care professionals knowing more about their young patients, so interventions and counseling can begin,” said Raghuveer. “As so happens now, there are important pieces of information regarding a child’s health that are not easy to access because they are in a silo.”

“Our hope is that this statement will also inspire research into finding valid, lower-cost alternative options for traditional cardiopulmonary exercise testing to assess CRF in all children, and improved CRF tests that can be done in an office with limited space and without the need for formally trained exercise physiology personnel.”

“In the meantime, requiring physical activity for every grade level through high school would be a step in the right direction,” said Raghuveer.

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Now Available: 2020 Dietary Guidelines Advisory Committee’s Scientific Report, USDA and HHS Now Accepting Comments

U.S. Department of Health and Human Services, July 15, 2020

The 2020 Dietary Guidelines Advisory Committee has completed their review of the evidence on nutrition and health, and their Scientific Report is now available online. The final report reflects the Advisory Committee’s full examination of the evidence using three rigorous approaches: data analysis, systematic reviews, and food pattern modeling.

Submit public comments now! The period to submit comments to the report will last 30 days, opening today, July 15, 2020 and will close on August 13, 2020, 11:59pm EST.

The Scientific Report also includes advice to the United States Departments of Agriculture and Health and Human Services to consider in the development of the next edition of the Dietary Guidelines for Americans.

As part of this new public comment period, USDA and HHS will also hold a virtual meeting on Tuesday, August 11, 2020, to hear comments on the Scientific Report. Registration to present oral comments will be available on at least two weeks prior to the meeting.

USDA and HHS will consider the Advisory Committee’s Scientific Report, along with public and agency comments, as the Departments develop the 2020-2025 Dietary Guidelines for Americans.  

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Does a Child's Height Affect Their Future Risk of Obesity?

EurekAlert!, July 8, 2020

Children who are relatively tall for their age have a higher risk of developing obesity, according to a new study published in Obesity.

In the study, investigators examined the health records of 2.8 million children who were initially examined between 2 and 13 years of age. When they were re-examined an average of 4 years later (but up to 13 years later), taller children were more likely to have a higher body mass index than shorter children.

For example, among the thinnest children at the start, the prevalence of obesity at the second exam was 5-fold higher in the tallest children than in the shortest children (3.1% versus 0.6%). Among the heaviest children at the start, the respective prevalence rates of obesity were 89.5% versus 53.4%.

The association between taller height and obesity at the second exam was strongest in children who were initially examined when they were younger than 7 years old.

“As about half of this association is independent of the initial body mass index of the child, the use of height may be a simple way to more accurately classify which children will become obese,” said lead author David S. Freedman, PhD, of the Centers for Disease Control and Prevention.

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Flattening the (BMI) Curve: Timing of Child Obesity Onset and Cardiovascular Risk

Pediatrics, July 6, 2020

The worldwide prevalence and severity of childhood obesity has steadily risen over the last 50 years. Although there have been some indicators of recent stabilization, it has been suggested that we have simply reached our upper genetic limit. Whether this is true, the current prevalence is shockingly high; one-third of children aged 2 to 19 have a BMI >85th percentile, and 18.5% have a BMI >95th percentile, consequently affecting 13.7 million children in the United States and 340 million children worldwide.

It makes intuitive sense that childhood obesity is a serious health problem. However, at exactly what age obesity begins to predict future disease has proven an elusive question. The evidence is clear that (1) child obesity predicts adult obesity, (2) adult obesity predicts cardiometabolic disease and early mortality, and (3) obesity in late adolescence predicts early mortality, the majority of which is related to cardiovascular disease. But is obesity something to be concerned about in a 3-year-old?

Researchers in previous studies have demonstrated that single time-point measures of early obesity poorly predict adult outcomes. For example, in a 2016 meta-analysis of 37 studies that included child BMI data and adult endpoints, it was shown that although the association between high childhood BMI adult disease was significant, only 31% of adults with diabetes and 22% with hypertension diagnoses were overweight as children. Researchers of a 2012 systematic review of 39 studies found that the association between child BMI and adult outcomes was attenuated when adult BMI was considered. The inevitable conclusion is that child BMI is important through its impact on adult BMI rather than directly worsening health.

When repeatedly measured over time, however, other more-concerning patterns emerge. Geserick et al managed a cohort (n = 51 505) from birth through age 18 and showed that 50% of adolescents with obesity had developed it by age 5; 90% of children who had obesity by age 3 remained obese at age 18. The Project Viva cohort demonstrated that BMI acceleration after age 1 predicts excess adiposity by age 6 to 10. Smego et al showed that obesity by age 4 to 6 months predicted obesity by age 6. Although these show the persistence of obesity, what they mean for later disease has been more difficult to study.

In this issue of Pediatrics, Lycett et al evaluate 5107 Australian children at repeated time points from infancy examining BMI and cardiometabolic markers up to age 11 to 12, with 1811 children retained throughout the time period. The growth data fell into 4 relatively distinct BMI trajectories: always low, always normal, always high, and normal to high. This important and comprehensive study has 2 important implications: first, high BMI by age 2 to 3 tends to stay high, and second, normal BMI occasionally increases to high BMI, but the reverse is rarely true. Simply put, infants and toddlers with obesity are unlikely to “grow out of it.”

The question remains, “is this a problem?” Lycett et al attempted to answer this question by collecting a cardiovascular risk assessment using metabolic syndrome, carotid-femoral pulse wave velocity, and carotid intima-media thickness at age 11 to 12. They found that obesity by age 3 and being overweight by age 6 predicted metabolic syndrome at age 11. Obesity by age 6 predicted subclinical atherosclerotic changes by age 11. Most strikingly, obesity that started at 3 and persisted appeared to accumulate risk over these early years of life, and those children demonstrated significant and detectable markers of silent atherosclerotic disease by 11 years of age. An important caveat is that although the relationships were significant, the amount of variance attributable directly to child BMI was small. Even small impacts are important on a population level, but this highlights the complexity of the relationship between obesity and health.

In this study, it is definitively established that obesity by age 3 is predictive of future obesity up to early adolescence, and evidence is added that risk for cardiovascular disease accumulates the earlier children develop their obesity. The point cannot be understated: early-onset obesity is unlikely to change and, if it persists, will lead to detectable precursors of atherosclerosis by the time a child enters middle school.

Parents and primary care physicians are less likely to perceive obesity as a concern in younger children. Measuring and defining obesity in children <2 years of age is challenging. However, current predictions reveal that if we continue current patterns of watchful waiting, 57.3% of today’s children will have obesity by age 35.

Our best chance to “flatten the curve” of cardiovascular disease may be to slow down BMI increases early in life, delaying (or preventing) the onset of obesity as long as possible to minimize accumulation of risk.

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