July 2023


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New Research Reveals Gaps in School Recess Programs

NCCOR, July 2023

While summer vacation is in full swing, a new research paper is shedding light on the importance of school recess. Published in the Journal of School Health, the paper identifies significant gaps in how schools implement recess programs.

With the majority (76%) of children ages 6 to 17 not getting enough physical activity, recess provides a vital opportunity for students to be more active. Well-planned recess programs also help children form social connections, reduce stress, and improve their academic performance. To ensure that all students benefit from recess, the Centers for Disease Control and Prevention created evidence-based guidelines to help schools create high-quality recess programs.

The newly published paper uses data from six nationally representative surveys (available through NCCOR’s Catalogue of Surveillance Systems) to examine how closely schools adhere to the CDC guidelines. Researchers found that approximately 65-80% of elementary school children receive at least 20 minutes of daily recess. However, adherence to the CDC guidelines declines significantly by the sixth grade, and limited information is available for middle and high school students. While compliance with playground safety measures is high (90%), there are lower rates of adherence to recommendations about having recess before lunch (<50%), withholding recess as a punishment (∼50%), and training recess staff (<50%).

The authors recommend ongoing national surveillance of recess-related data to inform policies and ensure equitable access for all students.

More Information about Recess Is Available on the NCCOR Website

If you want to learn more, this project was featured during a recent  NCCOR Connect & Explore webinar, Optimizing Recess for Healthy Child Development. Access the webinar recording and slides on the NCCOR website.

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Publications & Tools

NCCOR Toolbox: NCCOR Releases Implementation Science Video Series

Learn more about implementation science in just 10 minutes with NCCOR’s new video series.

In 2022, NCCOR hosted a three hour public workshop titled “Implementation Science & Childhood Obesity: Sparking Conversations and Actions to Advance Equity,” which offered an introduction to implementation science for researchers working in childhood obesity, nutrition, and physical activity. The workshop highlighted several experts in the field and provided examples of implementation science “in action.” Speakers illustrated approaches to advance equity across the phases of pre-implementation, implementation, and sustainability for childhood obesity, nutrition, and physical activity interventions.

Now you can access highlights of the workshop, including short videos on topics ranging from equity, partnership building, and program sustainability. Access the full series on the NCCOR website.

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Food as Medicine for Pregnant People: A Landscape Analysis To Inform Future Work

The Gretchen Swanson Center for Nutrition conducted a landscape analysis of Food as Medicine (FAM) programs for pregnant people in collaboration with Share Our Strength. The landscape analysis included 36 expert interviews and a systematic review of peer-reviewed and grey literature. The report outlines six key findings from the literature and proposes six future directions for FAM programming for this important population. Access the full report on the Gretchen Swanson website.

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NIH Issues a Request for Information: Prioritization of Drug, Vaccine, and Dietary Supplement Research Needs for Pregnant, Postpartum, and Lactating Persons

The Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) invites all stakeholders to submit nominations for drug, vaccine, and dietary supplement research needs to be considered in the development of a Priority List of Drug, Vaccine, and Dietary Supplement Research Needs for Pregnant, Postpartum, and Lactating Persons. NICHD is gathering nominations for drugs prescribed for conditions specific to, or that co-occur, during pregnancy and the postpartum period, including for lactation; dietary supplements that may be used in preparation for, during, or after pregnancy; and vaccines used by pregnant or lactating persons to prevent or treat disease. Additionally, the NICHD is seeking information on factors and processes it could consider in prioritizing these nominations. Responses are due September 29, 2023. Read the full announcement online.

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Crediting Grains in Child Nutrition Programs Tip Sheets

The Crediting in the Child Nutrition Programs Tip Sheet series from USDA  provides handy references for program operators on how to credit the five meal components in the child nutrition programs. Each tip sheet provides simple, easy-to-use information for one meal component.

“Crediting Grains in the Child Nutrition Programs” is a three-part series that includes the following tip sheets:

  • Part 1: Creditable Grains in Child Nutrition Programs;
  • Part 2: Identifying Grain Products that are Whole Grain-Rich; and
  • Part 3: Program Requirements.

This series is designed for program operators as a handy and easy-to-use reference on how to credit grains and incorporate them into the meal pattern requirements.

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Childhood Obesity Research & News

Fewer Teens Now Perceive Themselves as Overweight – International Study of More than 745,000 Adolescents

July 3, 2023 | EurekAlert!

A study involving more than 745,000 adolescents from 41 countries across Europe and North America identified an increase in the amount of teenagers who underestimate their body weight.

Tracking data from 2002 to 2018, the peer-reviewed findings, published today in Child and Adolescent Obesitydemonstrate a noticeable decrease in those who overestimate their weight too.

The team of international experts, who carried out the research, warn these shifting trends in body weight perception could reduce the effectiveness of public health interventions aimed at weight reduction in young people.

“During this impressionable age, body weight perception may influence a young person’s lifestyle choices, such as the amount and types of food they eat and their exercise habits,” says lead author Doctor Anouk Geraets, from the Department of Social Sciences, at the University of Luxembourg.

“So it’s concerning that we’re seeing a trend where fewer adolescents perceive themselves as being overweight – as this could undermine ongoing efforts to tackle increasing levels of obesity in this age group. Young people who underestimate their weight and therefore do not consider themselves to be overweight may not feel they need to lose excess weight and, as a result, they may make unhealthy lifestyle choices.”

A person’s perception of their body weight may not accurately reflect their actual weight. A discrepancy in body weight perception (BWP) may either be an underestimation (where actual weight is higher than perceived weight) or an overestimation (where actual weight is lower than perceived weight).

In the present study, the researchers examined survey data from 746,121 11-, 13- and 15-year-olds from 41 countries collected at four-yearly intervals between 2002 and 2018 in the International Health Behavior in School-Aged Children (HBSC), a WHO collaborative study.

The team modeled trends in BWP among adolescents across different countries over time, making adjustments for age, gender, and family socioeconomic status. They found:

  • Underestimation of weight status increased, and overestimation of weight status decreased over time among both sexes, with stronger trends for girls.
  • Correct weight perception increased over time among girls, while it decreased among boys.
  • Changes in correct weight perception, underestimation and overestimation of weight status differed across different countries – but these changes could not be explained by an increase in country-level overweight/obesity prevalence.

The authors speculated that the observed differences between girls and boys in BWP may support the idea there are sex differences in body ideals – and that these body ideals have changed over time. Notably, the increased underestimation and decreased overestimation of weight status over time for girls may be explained by the emergence of an athletic and strong body, as a new contemporary body ideal for both sexes.

“This study has clinical and public health implications. The increase in correct weight perception and the decrease in overestimation may have a positive effect on unnecessary and unhealthy weight loss behaviors among adolescents, while the increase in underestimation might indicate the need for interventions to strengthen correct weight perception,” says lead author Doctor Anouk Geraets.

“More research is now needed to understand the factors underlying these time trends and to develop effective public health interventions.”

While the large number of participating countries is a strength of the present study – but as these only included countries in Europe, the USA and Canada, the results can’t be generalized to other regions. In addition, although steps were taken to adjust the models for certain potential confounding factors, several other factors – such as body image, dieting, changing eating patterns, or migration – may also have played a role in the observed trends over time.


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Health is Where the Home is: Study Shows Pediatrician and Family Collaboration can Address Obesity

June 26, 2023 | University of Rochester Medical Center

Small investments in staffing at pediatricians’ offices fueled success of obesity program

A new study co-authored by University of Rochester Medical Center (URMC) faculty provides evidence for a straightforward solution to addressing the rise of pediatric obesity: collaboration between families and their local pediatrician’s office.

The study, published in the Journal of the American Medical Association, was conducted in three states with children ages 6-12. Masters-level specialists with backgrounds in social work and behavioral health were recruited to work in pediatricians’ offices and lead family-based treatment programs for obesity, which focused on getting the whole family—not just the child—to participate in lifestyle changes.

The program improved weight-loss outcomes for the treated child and parent, and even extended to untreated siblings.

“It’s no surprise that the family therapy approach benefits many patients, because if it’s in the family it will likely model sustained behaviors,” said Stephen Cook, MD, MPH, associate professor of Pediatrics at URMC and a provider at UR Medicine’s Golisano Children’s Hospital. “If you get buy-in and commitment from the family you’ll see success, and this has been verified repeatedly in research.”

The randomized clinical trial enrolled 452 children with one parent in primary care practices in Buffalo and Rochester, New York, Columbus, Ohio and St. Louis, Missouri. Half of the children were randomly assigned to family-based treatment and the other half received standard care; 27.2% of the children were Black, 8.8% were Latino, and 57.1% were white.

The study found that three times as many children in the treatment group (27%) as in the usual care group (9%) had a clinically meaningful reduction in body mass index (BMI), which was associated with improved cardiometabolic outcomes, such as lower blood pressure and lipid levels and increased glucose regulation.

Children enrolled in family-based treatment lowered their BMI by an average of 6.48% more versus the control group, while their parents had a reduction of 3.97 percent and their untreated siblings who were overweight had a reduction of 5.38 percent compared to controls. The reductions among family members were related, meaning that positive changes for the child also were more likely to happen for siblings and parents in the same family.

Rochester-area practices that participated were Elmwood Pediatrics, Genesis Pediatrics, Golisano Children’s Hospital Pediatric Practice, Long Pond Pediatrics, Panorama Pediatrics, and Rochester General Pediatric Associates.

Embedded Specialists Make a Difference

The employment of masters-level specialists in pediatric practices—with backgrounds in behavioral health related fields—helped to produce these positive outcomes, according to Cook.

“We trained people who had never done this type of obesity work before and embedded them to work within the primary care practice. Having that type of integration with primary care, with specialists trained to identify both behavioral health issues and socio-economic barriers, helped us find solutions that benefitted the whole family,” he said. “I’m not aware of any published studies that show the same ripple or halo effect when you only target and treat an adult.”

Meghan Dahlman, MA, MS, interventionist and consultant for the Developmental and Behavioral Pediatrics department at URMC, served as one of these specialists and worked in several Rochester-area practices for the study. Previously a special education teacher in Victor, NY, Dahlman found that her educational and professional background helped her transition to the family-based treatment program.

“I had been using behavioral strategies in my teaching to get kids working on their daily life skills, so it was a natural fit to adapt some of these methods for obesity consulting,” she said.

During the project, embedded specialists were provided BMI and weight criteria for inclusion in the program. Specialists preemptively flagged charts and informed doctors and nurses that a particular patient was eligible for enrollment. In addition, the program placed recruitment materials in pediatric practices and in communications from these practices to patients.

Setting expectations—and securing buy-in from families—were critical for results, according to Dahlman. “It was really important to get to know a family and brief them on all aspects of the program, then get consent from both the parents and children before we engaged in any activities,” she added.

Families who participated met weekly with the specialist, either on Zoom or in person. Specialists focused on getting families to increase physical activity, reduce screen time, and engage in realistic meal planning.

“Meal planning was huge, but we acknowledge some of the limitations families deal with,” said Dahlman. “We would create weekly plans. If we knew that there was going to be a conflict like a school event or sports activity and the family was likely to grab fast food in between those activities, then we would pull up the menu during our meal planning session and come up with ideas for the healthier choices on the menu.”

Among the families Dahlman worked with, enthusiastic child participation correlated with the best results.

“Children who were energetic about joining the program helped the whole family get on board and achieve goals,” said Dahlman. “In general, when both the child and family members were committed, we had success.”

Reforms Needed to Make Model Permanent

Follow-up studies will look to build on the evidence-based success of this program, but implementing this model permanently will require changes to insurance reimbursements, as well as staffing regulations, according to Cook.

“You can provide this treatment plan by having insurance cover the services and by allowing mental health providers and counselors to be co-located in pediatric practices,” he said. “This approach will lead to early and appropriate steps to change unhealthy behaviors in a safe and effective way. This system also integrates behavioral health and aligns with advanced pediatric primary care models that New York State Medicaid is moving toward with its next waiver.”

In addition, this model could help pediatricians identify behavioral health issues early. “It’s more efficient to have specialists trained in identifying and addressing a variety of behavioral health symptoms located in the primary care home. You can address many of these issues earlier and in the context of the family. We are less likely to see worse mental, behavioral or physical health issues later in adolescence and young adulthood,” said Cook.

Cook hopes the program can also expand to include more after-hours options for families and telemedicine services to be more accommodating.  “It’s an intensive program, and it’s not for every child or family; we present that upfront so families understand the time and effort it will take. By co-locating in the pediatric office and using telemedicine we can build on the progress we’ve made by making it even more convenient for families, because we’ve seen strong evidence that family commitment will help model sustained behaviors,” he said.


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Plant-Based Food Packages Linked To Reduced BMI in Children

June 22, 2023 | Mass General Brigham

A new study led by researchers from the Mass General Brigham healthcare system suggests that taking a “food is medicine” approach could increase nutrition security for families and lead to reductions in body mass index (BMI) in children. Working together with the MGH Food Pantry, researchers from Mass General for Children and Boston Children’s Hospital examined whether providing weekly plant-based foods to families seeking food assistance during the pandemic led to weight changes among children.

The team found an association between increasing receipt of food packages and decreased BMI. The findings, published in the journal Preventing Chronic Disease, add to a growing body of evidence that providing plant-based foods could be a useful strategy to prevent childhood obesity in children from food-insecure families.

“It’s important to encourage healthy eating habits during childhood to help prevent co-morbidities associated with obesity later in life, but many families to do not have access to expensive healthy foods, such as produce,” said senior author Lauren Fiechtner, MD, MPH, Director of the Pediatric Nutrition Center at Mass General for Children and Health and Research Advisor at The Greater Boston Food Bank. “Food pantries like MGH Revere that can provide families with healthy foods are a huge help in making sure that kids have a long, healthy future and have the best cardiovascular and metabolic health possible from a young age.”

The food packages were provided by the Massachusetts General Hospital (MGH) Revere Food Pantry, a partnership between MGH and The Greater Boston Food Bank. The MGH Revere Food Pantry has provided healthy food and nutritional education to families in the greater Boston area since it opened its doors in 2020.

“For dozens of families, the MGH Revere Food Pantry was a literal lifeline during the pandemic by providing free weekly packages of healthy food for the entire household,” said study co-author Jacob Mirsky, MD, MA, DipABLM, Medical Director of the MGH Revere Food Pantry.

Food insecurity increased by 55% percent in the United States in 2020, affecting 42% of households with children. This increase was driven by a variety of factors, such as the economic impacts of the pandemic, the closure of schools, and disruption of food supply chains. As food insecurity increased, so did the prevalence of childhood obesity, rising from 19.3% to 22.4% between August 2019 and August 2020.

For families dealing with food insecurity, the challenge is usually one of food quality as much as food quantity.

“Children in families with food insecurity are frequently skipping meals or skipping food for a whole day because their family does not have enough money for food,” said Fiechtner. “One way for parents to stretch a tight food budget and make sure their children are at least eating something is to buy the cheapest foods available, which are often not nutritious and contribute to obesity and other health problems.”

To help mitigate the impacts of pandemic-related food insecurity on childhood obesity, the MGH Revere Food Pantry provided weekly plant-based food packages to families seeking food assistance. The packages contained fresh fruits and vegetables, nuts, and whole grains, and were adjusted to family size to provide enough for three meals per day for each member of the household. Between January 1, 2021, and February 1, 2022, 107 children from 93 families received weekly food packages, averaging about 27 packages per family for the whole study period.

The food packages were provided by the Massachusetts General Hospital (MGH) Revere Food Pantry, a partnership between MGH and The Greater Boston Food Bank. The MGH Revere Food Pantry has provided healthy food and nutritional education to families in the greater Boston area since it opened its doors in 2020.

“For dozens of families, the MGH Revere Food Pantry was a literal lifeline during the pandemic by providing free weekly packages of healthy food for the entire household,” said study co-author Jacob Mirsky, MD, MA, DipABLM, Medical Director of the MGH Revere Food Pantry.

The researchers examined BMI during a baseline period prior to receiving food packages and then during a follow-up period using the MGH electronic health record. At the start of the study, 57% of children in the study aged 2-18 years had a BMI at or above the 85th percentile. At follow-up, this number was reduced to 49%. The researchers also saw a decrease in BMI with each additional food family package received and estimated that children in households who received 27 weeks or more of packages may have had a BMI decrease of 1.08 kg/m2 or more.

While the study focused specifically on the pandemic, the research suggests that these findings could carry over into strategies to address broader issues of food insecurity in the future.

“There was an immediate value to providing these food packages to support families during the pandemic, but we also enabled families and children to make healthier food choices, which we know is important to introduce when children are young,” said first author Allison Wu, MD, MPH, Attending Physician in Pediatric Gastroenterology, Hepatology & Nutrition at Boston Children’s Hospital. Wu is a research collaborator and former research fellow in the Harvard-Wide Pediatric Health Services Research Program. “This kind of support is not only important for their BMI in childhood, but also in informing how they choose foods and influencing what foods their families are prepfor them to promote overall health.”

This research, as well as the MGH Revere Food Pantry, are part of a larger Mass General Brigham ‘food as medicine’ strategy. In collaboration with the 2022 White House Conference on Hunger, Nutrition, and Health, Mass General Brigham committed $8.4 million to promote nutrition equity and security, support food as medicine programs to tackle diet-related diseases, and fund food-related programming at local community-based organizations across Massachusetts.


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Light Physical Activity from Childhood Is More Effective Than MVPA In Reducing Inflammation Caused by Being Sedentary

June 16, 2023 | EurekAlert!

Increased sedentary time from childhood through young adulthood worsened low-grade inflammation in a new follow-up study. However, the results also showed that light physical activity (LPA) may completely reverse the adverse process. Moderate-to-vigorous physical activity (MVPA) did not have a similar effect. The study was conducted in collaboration between the University of Bristol in the UK, the University of Exeter in the UK, and the University of Eastern Finland, and the results were published in the Journal of Clinical Endocrinology & Metabolism.

Low-grade inflammation has been associated with several diseases throughout the lifespan, ranging from cardiovascular, metabolic, neurological, and musculoskeletal diseases to cancer. Moreover, it was recently established that low-grade inflammation may contribute to premature vascular damage in adolescents and young adults.

More than 80% of adolescents across the globe have insufficient physical activity per day as reported by the World Health Organization. It is estimated that physical inactivity will have caused 500 million cases of heart disease, obesity, diabetes, or other noncommunicable diseases by 2030, which is estimated to cost US$ 27 billion annually.

This alarming forecast regarding the morbid danger of physical inactivity necessitates urgent research on the most effective preventive approach.

The long-term role of movement behaviour, objectively measured with an accelerometer, in low-grade inflammation in the pediatric population has not been previously studied. This is due to the cost and other challenges of repeatedly measuring movement behaviour in the same cohort during growth from childhood through young adulthood, with such studies lasting more than 10 years.

The current study which used data from the University of Bristol study Children of the 90s (also known as the Avon Longitudinal Study of Parents and Children) included 792 children aged 11 years who were followed up until age 24 years, with a total follow-up time of approximately 13 years. Accelerometer measures of sedentary time, LPA, and MVPA were collected at ages 11, 15, and 24 years. High sensitivity C-reactive protein, a marker of inflammation, was repeatedly measured at ages 15, 17, and 24 years. These children also had dual-energy Xray absorptiometry measurements for total body fat mass and skeletal muscle mass, as well as fasting blood samples such as glucose, insulin, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglyceride, smoking status, socio-economic status, and family history of cardiovascular disease repeatedly measured at ages 15, 17, and 24 years.

During the 13-year follow-up, sedentary time increased from approximately 6 hours/day in childhood to 9 hours/day in young adulthood. LPA decreased from 8 hours/day to 3 hours/day while MVPA was relatively stable around 50 mins/day from childhood until young adulthood. It was observed that increased sedentary time significantly worsened inflammation, partially by raising blood pressure. Increased blood pressure explains only 8% of the relationship between sedentary time and inflammation.

LPA from childhood through young adulthood was associated with reduced inflammation, however, increasing body fat mass reduced the effect of light physical activity by 30%. MVPA from childhood was associated with reduced inflammation but increased total fat mass decreased the effect of MVPA by 80%. The significant impact of fat mass effectively neutralized the effect of MVPA on inflammation.

“We are seeing for the first time that LPA from childhood may be better than MVPA at reversing the adverse effect of sedentary time on worsening inflammation. It is rather surprising that the physiologic increase in total fat mass even in healthy-weight children remarkably blunted the effect of MVPA on lowering inflammation,” says Andrew Agbaje, a physician and clinical epidemiologist at the University of Eastern Finland.

“We have also recently reported that LPA promotes healthy hearts among adolescents better than MVPA. These findings emphasise that LPA may be an unsung hero in preventing diseases from early life, and in this regard it could be 2 – 3 times more effective than MVPA,”

“The World Health Organization has only emphasized that children and adolescents should accumulate on average 60 mins of MVPA per day and reduce sedentary time. There has been almost no guideline on engaging in LPA in the young population because data is lacking. Our recent studies are now contributing to this body of evidence. Therefore, public health experts, pediatricians, and health policymakers should encourage more participation in LPA from childhood. However, more research on the health benefits of LPA is needed to provide sufficient evidence for updating current health guidelines,” Agbaje continues.

Dr Agbaje’s research group (urFIT-child) is supported by research grants from Jenny and Antti Wihuri Foundation, the Finnish Cultural Foundation Central Fund, the Finnish Cultural Foundation North Savo Regional Fund, the Orion Research Foundation, the Aarne Koskelo Foundation, the Antti and Tyyne Soininen Foundation, the Paulo Foundation, the Yrjö Jahnsson Foundation, the Paavo Nurmi Foundation, the Finnish Foundation for Cardiovascular Research, Ida Montin Foundation, and the Foundation for Pediatric Research.


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