March 2018

NCCOR’s 2017 Annual Report: Moving Forward on Physical Activity

March 29, 2018, NCCOR

NCCOR’s 2017 Annual Report showcases the Collaborative’s focus on physical activity throughout the year. NCCOR continues to advance physical activity research and practice by launching new tools and products, connecting and sharing information with the field, and looking ahead for emerging opportunities.

Launching new tools and products

As a central resource for researchers, NCCOR develops and updates data collections, user guides, and other tools. In 2017, NCCOR released several new tools with a special emphasis on physical activity:

• Individual Physical Activity Measures Registry User Guide
• Physical Activity Environment Measures Registry User Guide
• Youth Compendium of Physical Activities
• Health, Behavioral Design, and the Built Environment white paper

Connecting and sharing information with the field

NCCOR continued the successful Connect & Explore webinar series in 2017, convening nationally recognized experts to discuss current issues in childhood obesity research. The Collaborative also connected with the field through innovative social media activities on both Twitter and Facebook, and through various conferences, such as the American College of Sports Medicine 64^th Annual Meeting, Environmental Design Research Association 48^th Annual Conference, and The Obesity Society Annual Scientific Meeting.

Looking ahead for emerging opportunities

NCCOR will continue to pursue cross-cutting, innovative, member-led approaches to building the field of childhood obesity research in 2018, with attention on four key areas:

• Physical Activity projects related to increasing trail use among underserved youth, surveillance of youth active school transportation, and the benefits of walkability
• Greater focus on health equity, including publication in Childhood Obesity on the Childhood Obesity Declines project, which explored an alarming trend of significant disparities in the populations seeing improvements in childhood obesity prevalence
• Continuation of NCCOR’s strategic alliance with The JPB Foundation, with an emphasis on work related to the Measures Registry
• The Engaging Health Care Providers and Systems workgroup efforts on evaluating healthy weight programs

Read the full Annual Report

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Exploring Declines in Childhood Obesity in Four Communities

March 29, 2018, NCCOR

Childhood Obesity published six papers highlighting findings from the NCCOR’s Childhood Obesity Declines project. The supplement details the strategies and policies implemented in four diverse communities—Anchorage, AK; Granville County, NC; New York City, NY; and Philadelphia, PA—that experienced declines in childhood obesity prevalence from 2003 to 2011. The six articles in this supplement are described below and are available at https://nccorstg.wpengine.com/projects/obesity-declines.

• “An Effort of the National Collaborative on Childhood Obesity Research to Explore Progress in Four Communities” introduces the rationale, aims, and overall study design of COBD, which systematically studied and documented the what, how, when, and where of community-based obesity strategies in four distinct communities across the nation.
• “A Different Methodology” explains the rationale for adapting the Systematic Screening and Assessment (SSA) method for COBD to confirm obesity declines and better understand what and how policies and programs or interventions may contribute as drivers.
• “An Exploratory Study of Strategies Identified in Communities Reporting Declines” highlights the multi-level approaches in each of the jurisdictions intended to improve the nutrition and physical activity environments where children spend most of their time and supporting community context. The in-depth retrospective analysis suggests simultaneous public health messaging and multi-layered initiatives—including cross-sector partnerships and active, high-level champions—were likely important contributors to success in attaining declines in the prevalence of childhood obesity.
• “A Review of Enacted Policies” identifies co-occurring state and local level policies that were reviewed and coded by setting (i.e., early care and education also known as child care, school, and community), jurisdictional level (i.e., state or local), and policy type (i.e., legislation or regulation) and then analyzed for similarities among the types of policies enacted in the four communities.
• “Highlights of Community Strategies and Policies” examines the programs and policies implemented in the communities through the lens of a social-ecological model. This lens can clarify how multiple levels of influence operate, what assets and people are needed as change makers, and how this synergy may drive behavior and health outcomes.
• “Implications for Research and Evaluation Approaches” discusses the research and evaluation design implications of an adapted SSA method for community-based prevention efforts. The article discusses the rationale for SSA compared to other design and evaluation schemas (e.g., randomized controlled trials and cohort studies) and highlights evidence generated by this method and how that evidence can be integrated into other evaluation strategies. Guidance for future studies of community-based childhood obesity prevention is suggested.

After nearly a decade of work to reduce the prevalence of childhood obesity in the United States, NCCOR remains a leader in the field by promoting novel research and evaluation strategies. Learn more about other NCCOR initiatives at nccorstg.wpengine.com.

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Nutritional Quality of Foods Acquired by Americans: Findings From USDA’s National Household Food Acquisition and Purchase Survey

This report uses data from the U.S. Department of Agriculture’s (USDA) National Household and Food Acquisition and Purchase Survey to describe the nutritional quality of foods purchased and acquired by a nationally representative sample of Americans. It compares the nutritional quality of foods purchased and acquired by households that participate in USDA’s Supplemental Nutrition Assistance Program (SNAP) to the foods of other low-income, SNAP-nonparticipating households and those of higher income households. It also compares the nutritional quality of foods purchased and acquired by households with low access to healthy food retailers to households with better access, for the population as a whole, and for the SNAP-participating and -nonparticipating subgroups previously described. Similarly, it compares nutritional quality of foods obtained from supermarkets and other grocery retailers to foods prepared away from home at restaurants, fast-food establishments, schools, and other sources for the whole population and for defined subgroups. The report found that lower nutritional quality of household food acquisitions was associated with SNAP participation status and limited household access to healthy food retailers. More reliance on food prepared away from home was also associated with lower nutritional quality, especially for higher income households.

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Promoting Walking & Walkable Communities: Cross-Sector Recommendations from the National Physical Activity Plan Alliance

The National Physical Activity Plan Alliance (NPAPA) is a coalition of national organizations that have come together to ensure that efforts to promote physical activity in the American population will be guided by a comprehensive, evidence-based strategic plan. The recommendations outline a strategy for increasing walking in the U.S. population and are intended to support increased physical activity in all segments of the population including those with disabilities that limit their ability to walk without assistance. The document suggests a new conceptual framework with six components: policies, places, programming, cross-sector collaborations, data and monitoring, and resources and funding. The recommendations include overarching strategies for each component and a selection of supporting priority tactics. The strategies and tactics call for changes in multiple societal sectors including transportation and community planning, public health, business and industry, education, and healthcare.

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The Associations Between Sugar-Sweetened Beverage Consumption and Children’s Health: An Updated Review of the Literature

Consumption of sugar-sweetened beverages (SSBs)—which include all drinks with added sugar, such as soda, fruit drinks, and sports drinks—is strongly linked to obesity and other negative health consequences. This research review is based on a review of the literature on this topic, published in BMC Obesity (Bleich and Vercammen 2018). It examines the evidence on: 1) the health impacts of sugary beverages on children’s health (obesity, diabetes risk, dental caries, and caffeine-related effects); 2) the health impact of substituting SSBs with other drinks; and 3) the role of taste preferences in SSB consumption patterns. There is clear evidence that consumption of SSBs increases overweight and obesity risk and dental caries among children and adolescents, with emerging evidence linking SSB consumption to risk of diabetes. The vast majority of the available literature suggests that reducing SSB consumption could help improve children’s health by decreasing the risk for obesity and other negative health consequences. More research is needed related to substitution and taste preferences.

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Trends in Obesity and Severe Obesity Prevalence in US Youth and Adults by Sex and Age, 2007-2008 to 2015-2016

March 23, 2018, Journal of the American Medical Association

Obesity prevalence has been increasing since the 1980s among adults, but among youth, prevalence plateaued between 2005-2006 and 2013-2014. We analyzed trends in obesity prevalence among US youth and adults between 2007-2008 and 2015-2016 in order to determine recent changes.

Methods

The National Health and Nutrition Examination Survey (NHANES) is a cross-sectional survey with a complex, multistage probability design that represents the civilian, noninstitutionalized population with a response rate of 75.4% in 2007-2008 and 58.7% in 2015-2016. Participants 18 years or older provided written consent, youth aged 7 to 17 years provided written assent, and parental permission was obtained in writing for youth younger than 18 years. NHANES was approved by the National Center for Health Statistics research ethics review board. Standardized measurements of weight and height were obtained.

Among adults aged 20 years and older, obesity was defined as a body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) of 30 or more and severe obesity was defined as a BMI of 40 or more. Among youth aged 2 to 19 years, obesity was defined as a BMI at or above the 95th percentile of sex-specific BMI-for-age and severe obesity was defined as a BMI at or above 120% of the 95th percentile. Pregnant females were excluded.

Prevalence and 95% CIs of obesity and severe obesity were estimated overall and stratified by sex and age (2-5, 6-11, 12-19, 20-39, 40-59, and ≥60 years). Linear and quadratic trends overall and stratified by sex and age were examined in regression models with 2-year survey cycles modeled as an orthogonal polynomial and in adjusted models (including survey cycle, sex, age, race/Hispanic origin [non-Hispanic white, non-Hispanic black, Hispanic, or other], education [high school graduate or less, some college, and college graduate; education of household head for youth], and, among adults, smoking status [never, former, or current smoker]) to determine if trends could be explained by these factors. Interactions between survey cycle with sex and age were tested among youth and adults separately to supplement stratified analyses and were not significant. A 2-sided P value of .05 was used to assess statistical significance.

Statistical analyses accounted for the complex survey design, including examination sample weights, which adjusted for nonresponse and took into account loss between the screener and interview and between the interview and the examination. Analyses were conducted using R (R statistics), version 3.4.16; SAS (SAS Institute), version 9.4; and SUDAAN (RTI International), version 11.0.

Results

Data from 16,875 youth and 27,449 adults were analyzed. Among youth, obesity prevalence was 16.8% (95% CI, 14.2%-19.8%) in 2007-2008 and 18.5% (95% CI, 15.8%-21.3%) in 2015-2016. Based on the unadjusted model, there were no significant linear trends in the prevalence of obesity or severe obesity overall, by sex or age group (P range = .17 to .78). Obesity prevalence among children aged 2 to 5 years showed a quadratic trend (P = .04), decreasing from 10.1% in 2007-2008 to 8.4% in 2011-2012 and then increasing to 13.9% in 2015-2016. Adjusted overall linear and quadratic trends for obesity and severe obesity among youth aged 2 to 19 years remained nonsignificant.

Age-standardized prevalence of obesity among adults increased from 33.7% (95% CI, 31.5%-36.1%) in 2007-2008 to 39.6% (95% CI, 36.1%-43.1%) in 2015-2016 (P = .001). Prevalence increased among women, and in adults aged 40 to 59 years and 60 years or older. The observed increases in men and adults aged 20 to 39 years did not reach statistical significance. There were no significant quadratic trends. The adjusted model also showed a significant overall linear trend for obesity among adults (P < .001; data not shown).

Age-standardized prevalence of severe obesity in adults increased from 5.7% (95% CI, 4.9%-6.7%) in 2007-2008 to 7.7% (95% CI, 6.6%-8.9%) in 2015-2016 (P = .001). Prevalence increased in men, women, adults aged 20 to 39 years and 40 to 59 years. There was no significant linear trend among adults 60 years and older. There were no significant quadratic trends. The adjusted model also showed a significant overall linear trend for severe obesity (P < .001; data not shown).

Discussion

Over the most recent decade between 2007-2008 and 2015-2016, increases in obesity and severe obesity prevalence persisted among adults, whereas there were no overall significant trends among youth. Changes in demographics did not explain the observed trends. Limitations include small sample sizes in the youngest age group. Residual bias due to incomplete nonresponse adjustment is possible and may vary with changing response rates. Additional NHANES data will allow continued monitoring of trends in obesity and severe obesity prevalence among US youth and adults.

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Eating School Meals Daily is Associated with Healthier Dietary Intakes: The Healthy Communities Study

March 16, 2018, Journal of the Academy of Nutrition and Dietetics

Abstract

Background

Research on the association between school meal consumption and overall dietary intake post-Healthy Hunger-Free Kids Act implementation is limited.

Objective

This study examines the association between frequency of participating in the National School Lunch and School Breakfast Programs and children’s dietary intakes.

Design

The Healthy Communities Study was a cross-sectional observational study conducted between 2013 and 2015.

Participants and setting

US children aged 4 to 15 years (n=5,106) were included.

Main outcome measures

Dietary measures were assessed using the National Health and Nutrition Examination Survey Dietary Screener Questionnaire. Dietary intake included fruit and vegetables, fiber, whole grains, dairy, calcium, total added sugar, sugar-sweetened beverages, and energy-dense foods of minimal nutritional value.

Statistical analysis

Multivariate statistical models assessed associations between frequency of eating school breakfast or lunch (every day vs not every day) and dietary intake, adjusting for child- and community-level covariates.

Results

Children who ate school breakfast every day compared with children who ate 0 to 4 days/wk, reported consuming more fruits and vegetables (0.1 cup/day, 95% CI: 0.01, 0.1), dietary fiber (0.4 g/day, 95% CI: 0.2, 0.7), whole grains (0.1 oz/day, 95% CI: 0.05, 0.1), dairy (0.1 cup/day, 95% CI: 0.05, 0.1), and calcium (34.5 mg/day, 95% CI: 19.1, 49.9). Children who ate school lunch every day, compared with those who ate less frequently, consumed more dairy (0.1 cup/day, 95% CI: 0.1, 0.2) and calcium (32.4 mg/day, 95% CI: 18.1, 46.6). No significant associations were observed between school meal consumption and energy-dense nutrient-poor foods or added sugars.

Conclusions

Eating school breakfast and school lunch every day by US schoolchildren was associated with modestly healthier dietary intakes. These findings suggest potential nutritional benefits of regularly consuming school meals.

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A Pragmatic Controlled Trial to Prevent Childhood Obesity Within a Risk Group at Maternity and Child Health-Care Clinics: Results Up to Six Years of Age (The VACOPP Study)

February 27, 2018, BMC Pediatrics

Abstract

Background

Obesity in childhood appears often during the toddler years. The prenatal environment influences obesity risk. Maternal gestational diabetes, the child’s diet, and physical activity in the first few years have an important role in subsequent weight gain. A study was conducted to evaluate effectiveness of a primary health-care lifestyle counselling intervention in prevention of childhood obesity up to 6 years of age.

Methods

The study was a controlled pragmatic trial to prevent childhood obesity and was implemented at maternity and child health-care clinics. The participants (n = 185) were mothers at risk of gestational diabetes mellitus with their offspring born between 2008 and 2010. The prenatal intervention, started at the end of the first trimester of pregnancy, consisted of counselling on diet and physical activity by municipal health-care staff. The intervention continued at yearly appointments with a public health-nurse at child health-care clinics. The paper reports the offspring weight gain results for 2–6 years of age. Weight gain up to 6 years of age was assessed as BMI standard deviation scores (SDS) via a mixed-effect linear regression model. The proportion of children at 6 years with overweight/obesity was assessed as weight-for-height percentage and ISO-BMI. Priority was not given to power calculations, because of the study’s pragmatic nature.

Results

One hundred forty-seven children’s (control n = 76/85% and intervention n = 71/56%) weight and height scores were available for analysis at 6 years of age. There was no significant difference in weight gain or overweight/obesity proportions between the groups at 6 years of age, but the proportion of children with obesity in both groups was high (assessed as ISO-BMI 9.9% and 11.8%) relative to prevalence in this age group in Finland.

Conclusion

As the authors previously reported, the intervention-group mothers had lower prevalence of gestational diabetes mellitus, but a decrease in obesity incidence before school age among their offspring was not found. The authors believe that an effective intervention should start before conception, continuing during pregnancy and the postpartum period through the developmentally unique child’s first years.

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Obesity Could be Linked to Early Childhood Behavior

February 27, 2018, University of Waterloo

Health authorities will need to focus on more than eating habits if they are going to combat the obesity epidemic.

A study led by the University of Waterloo found it’s generally a combination of unhealthy behaviours among youth that could be the greatest predictors of whether or not young people will experience obesity issues in adulthood.

The study concluded that public health efforts focusing on obesity prevention must identify and correct poor behaviours that are often developed in early childhood.

“Adolescents with obesity often maintain their weight status into adulthood, increasing their risk of developing cardiovascular disease, diabetes, and high blood pressure,” says Rachel Laxer, who formed part of the research team while doing her PhD at Waterloo. “Public health practitioners should be targeting clusters of risky behaviours using a comprehensive and multi-pronged approach.”

“Research tells us that while calorie intake has not dramatically changed over time, habits such as exercising, smoking, drug use and alcohol consumption have,” said Laxer. “It’s increasingly important to target these risky behaviours together, and early, before they become habits.”

The study involved Ontario students in grades nine and ten, ranging from 13 to 17 years of age and participating in the COMPASS Study, a nine-year study started in 2012 that is funded by the Canadian Institute for Health Research.

Students reported risky behaviours at the beginning of the study, and their heights and weights were tracked for two additional years. Based on their reported behaviours, the teens were classified as Typical High School Athletes, Inactive High Screen-Users (“Screenagers”), Moderately Active Substance Users, or Health Conscious. The researchers found that although the four groups saw similar increases to their weight status over the years that they were followed, students in the Health Conscious group had the healthiest body weight at the beginning of the study.

“It’s important to try to improve behaviours before they become habits, which are much harder to correct,” said Laxer. “This could have important implications for public health initiatives. Intervening and modifying unhealthy behaviours earlier might have a greater impact than during adolescence. Health promotion strategies targeting higher risk youth as they enter secondary school might be the best way to prevent or delay the onset of obesity, and might have better public health outcomes over the longer term.”

The study, done in collaboration with Professor Scott Leatherdale from Waterloo, was recently published in PLOS ONE.

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Prevalence of Obesity and Severe Obesity in US Children, 1999–2016

February 26, 2018, Pediatrics

Abstract

Objectives

To provide updated prevalence data on obesity trends among US children and adolescents aged 2 to 19 years from a nationally representative sample.

Methods

We used the NHANES for years 1999 to 2016. Weight status was determined by using measured height and weight from the physical examination component of the NHANES to calculate age- and sex-specific BMI. We report the prevalence estimates of overweight and obesity (class I, class II, and class III) by 2-year NHANES cycles and compared cycles by using adjusted Wald tests and linear trends by using ordinary least squares regression.

Results

White and Asian American children have significantly lower rates of obesity than African American children, Hispanic children, or children of other races. We report a positive linear trend for all definitions of overweight and obesity among children 2–19 years old, most prominently among adolescents. Children aged 2 to 5 years showed a sharp increase in obesity prevalence from 2015 to 2016 compared with the previous cycle.

Conclusions

Despite previous reports that obesity in children and adolescents has remained stable or decreased in recent years, we found no evidence of a decline in obesity prevalence at any age. In contrast, we report a significant increase in severe obesity among children aged 2 to 5 years since the 2013–2014 cycle, a trend that continued upward for many subgroups.

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