November 2020


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New from NCCOR: A Review on Improving Access to and Use of Trails Among Youth in Under-Resourced Communities

New from NCCOR: A Review on Improving Access To and Use of Trails Among Youth in Under-Resourced Communities

The National Collaborative on Childhood Obesity Research (NCCOR) recently published Identification of Effective Programs to Improve Access to and Use of Trails among Youth from Under-Resourced Communities: A Review in the International Journal of Environmental Research and Public Health.

One of NCCOR’s major goals is to address health disparities related to nutrition, physical activity, and obesity. This review 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 underuse of trails by youth as a health-enhancing behavior to engage in outdoor recreational physical activity. Low levels of trail use are pronounced among youth from under-resourced, low income neighborhoods including racial and ethnic minority groups, who may benefit greatly from the physical, mental/emotional, and social benefits of trail use.

The primary aim of this review paper was to identify programs and policies that effectively promote and increase the use of trails among youth, especially those from under-resourced neighborhoods or communities. Three additional goals of the review included identifying (1) correlates of physical activity/trail use and features of transportation systems or built environment and land use destinations that may inform and support the planning and implementation of programs to promote trail use among youth, (2) benefits associated with trail use, and (3) barriers to trail use.

Importantly, no studies were located that evaluated programs designed to promote and increase trail use among youth. Thus, this new research publication vividly highlights the lack of scientific evidence that addresses the underrepresentation of trail use by youth from under-resourced communities. Correlates of physical activity with transportation systems (e.g., trail access, road traffic congestion related to safe active travel, lack of sidewalks, proximity to trails, access to transportation), destinations (e.g., park availability and access, park improvements, greenspaces), or both routes and destinations (e.g., perceptions of safety, lighting) were identified. These correlates may support the planning and implementation of community programs to increase trail use among youth and greater program participation by connecting trails or routes to such future destinations. A benefit to trail use is an increase in physical activity behavior. One study also found that access to more greenspace was associated with better health-related quality of life and self-esteem among children. Barriers to trail use included costs, crime, lack of transportation, lack of role models using trails, and institutional discrimination.

A companion brief based on a review of programs and practices related to trails use among youth from under-resourced communities or neighborhoods will soon be published at

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Publications & Tools

NCCOR’s Toolbox

Check out this new decision tree that walks researchers and practitioners through a series of 10 questions regarding whether to develop, adapt, or apply an instrument to use in high-risk populations.

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The Double Burden of Malnutrition: Priority Actions on Ending Childhood Obesity

This publication from the World Health Organization provides regional and country data on the double burden of malnutrition, and particularly on childhood overweight and obesity, highlights the need for an integrated approach to address overweight and obesity through integration into existing programmes while supporting the improvement of food environments.

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Boosting Active Transportation Through Regional Transportation Plans

This new fact sheet lays out success stories, best practices, and resources for anyone looking to ensure a region-wide commitment to safer, more convenient streets for biking and walking.

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Childhood Obesity Research & News

Home-Visiting Program Shows Promise of Reducing Risk of Obesity Among Native American Children

November 9, 2020, EurekAlert!

Lessons on healthy feeding practices delivered to young mothers through a brief home-visiting intervention put Native American infants on a healthier growth trajectory, lowering their risks for obesity, according to a study from researchers at the Johns Hopkins Center for American Indian Health at the Bloomberg School of Public Health.

Prior research suggests that adult obesity, which is linked to heart disease and diabetes, can be programmed early in life. Native Americans have particularly high rates of obesity starting in childhood–it is estimated that more than one-third of Native American 2- to 5-year-olds are overweight or obese.

In the study, published November 9 in JAMA Pediatrics, Native American home visitors delivered six 45-minute nutrition lessons to mothers of infants on the Navajo Nation. The intervention, conducted when infants were 3 to 6 months old, taught mothers to adopt optimal feeding practices for their babies, including avoiding sugar-sweetened beverages.

The researchers found that on average the 68 mothers in the home-visiting program had better feeding practices and their babies had healthier weights during the first year of life, compared to the same sized control group.

“This is the first home-visiting intervention, tested through a randomized controlled trial, designed in partnership with Native American communities that targets obesity in the first year of life with positive impacts on healthy growth,” says study first author Summer Rosenstock, PhD, an assistant scientist in the Bloomberg School’s Department of International Health and a member of the Center for American Indian Health at the Bloomberg School.

The program, known as Family Spirit Nurture, is a six-lesson curriculum built on a federally endorsed home-visiting program designed by the Center for American Indian Health to improve maternal and child outcomes for Native American families.

“Native American children suffer the highest rates of early childhood obesity in the U.S.,” says study co-author Leonela Nelson, a Navajo tribal member and program supervisor for the Center for American Indian Health at the research site on the Navajo Nation in Shiprock, NM. “The Family Spirit Nurture program showed that local Native home visitors working to educate and support moms can have positive effects on infant feeding and growth during the first year of life.”

In the study, the Native American family health coaches delivered the Family Spirit Nurture intervention to 68 mothers on the Navajo Nation in Shiprock, New Mexico, and surrounding communities, while their infants were between 3 and 6 months old. A control group of 66 mothers in the same community received, during the same age interval for their infants, three lessons on injury prevention under the original Family Spirit home-visiting program.

The researchers found that the Family Spirit Nurture intervention helped mothers in the intervention group score significantly higher on measures of responsive feeding–the practice of reading and responding to babies’ cues for hunger. “It is important that parents don’t use food to soothe babies when they are fussing for sleep, a diaper change, or other discomforts besides hunger,” says Rosenstock.

Similarly, mothers in the intervention group reported significantly less feeding of sugar-sweetened beverages to their children at 9 and 12 months of age, compared to control group mothers.

The researchers also analyzed data from medical charts on the infants’ weights and other vital measures from birth to 12 months and found that infants in the intervention group, compared to those in the control group, had healthier weights on average for their height, age, and sex up to 12 months of age–according to a measure called the standardized body-mass index, or zBMI. In addition, at 12 months, infants in the control group on average were above the threshold for overweight, according to their zBMI measures, while intervention infants were not.

For Rosenstock and her colleagues, the results from this initial study suggest that the Family Spirit Nurture intervention, implemented by Native American home visitors, may be an effective strategy in Native American communities for improving mothers’ infant feeding practices and supporting infants’ healthier growth trajectories. They note that other Family Spirit interventions, not relating to childhood obesity, are already accepted and conducted in more than 130 tribal communities across 21 states, providing a platform to disseminate this new six-lesson module.

“The home visitors incorporate cultural teachings and practices into the lessons to support moms’ connectedness to their Native culture. Connections to our culture promote further well-being,” says Nelson.

The researchers continue to investigate how well interventions like the one tested in this study can reduce childhood obesity, through age 2.

“There is evidence that the first 24 months of life is a really critical time period to intervene to put infants on healthier growth trajectories and reduce their long-term risk for obesity,” Rosenstock says.

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Here’s How Many Georgia Youth Are Obese, According to New Report

November 9, 2020, Atlanta Journal-Constitution

The 2020 State of Childhood Obesity report was released last month and it reveals where all 50 states — including Georgia — rank percentage-wise when it comes to youth and obesity.

This year’s report notes that nationally, 15.5% of youth ages 10 to 17 are obese. The Centers for Disease Control and Prevention defines obesity “as a BMI at or above the 95th percentile for children and teens of the same age and sex.” BMI, or Body mass index, is a measure to determine childhood obesity or overweight.

“Childhood obesity remains an epidemic in this country,” Jamie Bussel, senior program officer at the Robert Wood Johnson Foundation who leads the Foundation’s efforts to prevent childhood obesity said in a press release. “The COVID-19 pandemic and ongoing economic recession have worsened many of the broader factors we know contribute to obesity, including poverty and health disparities. We must confront these current crises in ways that also support long-term health and equity for all children and families in the United States.”

The findings showed disparities in income and race when it comes to obesity rates.

Youth in households with an income under the federal poverty level had a 21.5 % rate of obesity, which is over double the 8.8 % of youth in households that earn at least 400% of the federal poverty level.

Non-Hispanic Asian children had the lowest obesity rate at 5.9% in 2018-2019. That was followed by non-Hispanic white children and non-Hispanic multiple race children, which had 11.7% and 14.7%, respectively. Hispanic, non-Hispanic Black, non-Hispanic American Indian/Alaska Native, and non-Hispanic Native Hawaiian/Other Pacific Islander children had notably higher obesity rates at 20.7%, 22.9%, 28.5% and 39.8% respectively.

While Kentucky had the highest overall youth obesity rate at 23.8% and Utah had the lowest at 9.6%, Georgia youth landed in the middle at 14.9%. Nationally, Georgia ranked at No. 24 among all 50 states and Washington D.C., reported.

Among the recommendations suggested in the report for additional changes to promote health and prevent childhood obesity are increasing the maximum SNAP benefit level by at least 15% per participant for the span of the economic downturn related to COVID-19 and the Department of Agriculture supporting states in using existing waivers to serve free meals to all students through the 2020-2021 school year.

“SNAP, WIC, and school meals all have proven benefits for children and families,” Bussel said. “Given the unprecedented circumstances families are facing, we must make sure that they reach everyone who is eligible. Doing so will help make sure children and families can stay healthy during this pandemic, and likely reduce the risk for obesity in the long term.”

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Researchers Uncover Health Disparities in Childhood Obesity and Access to Treatments

October 28, 2020, EurekAlert!

The use of bariatric surgery to treat severe obesity in adolescents, and the racial disparities in access to that treatment, were analyzed in a retrospective study published in Annals of Surgery by researchers at The University of Texas Health Science Center at Houston (UTHealth).

Nearly 19% of children and adolescents in the U.S. are obese. Because many obese children become obese adults, childhood obesity can be linked to mortality and morbidity in adulthood, making it one of the leading causes of death in the U.S. Ethnic minority groups have the highest rates of severe obesity in the country.

“It’s no surprise that childhood obesity has been a challenge in this country from both a public health and clinical standpoint for decades,” said Sarah Messiah, PhD, MPH, lead author of the study and professor of epidemiology, human genetics, and environmental sciences at UTHealth School of Public Health in Dallas. “What is most alarming is that over the past five to 10 years, we have seen an increase in those who have severe obesity. This group of patients is growing at three times the pace of adolescents who are obese.”

Pediatricians often suggest lifestyle modifications such as changes in diet to reduce calorie intake and increased physical activity. However, dietary and behavioral changes alone have not been proven to be successful in treating children and adolescents with severe obesity.

Messiah and other researchers suggested in the paper that bariatric surgery, commonly known as weight loss surgery, in combination with lifestyle changes, could be the best option for treating severely obese adolescents.

“The American Academy of Pediatrics supports the use of bariatric surgery in adolescents because evidence shows that it works and is safe. Pharmaceutical treatment options are very limited and have mixed results, and unfortunately for those who are already severely obese, lifestyle changes won’t be enough,” Messiah said.

Bariatric surgery is a minimally invasive surgery that alters the stomach or intestines to help obese patients lose weight.

By obtaining data from the American Society for Metabolic and Bariatric Surgery, researchers found that although obese adolescents are turning to weight loss surgery as a way to lose a significant amount of weight, many of those who are severely obese, especially Hispanic and Black adolescents, are not being offered that treatment option.

“There is a big disconnect between those who are getting the surgery and those who need it. Research has shown that this is a safe and effective way to help these children get their life on track, but the issue is bariatric surgery is not being utilized to treat obesity among ethnic minority groups,” Messiah said.

According to the study, more than 10% of Hispanic and Black youth suffer from severe obesity in the U.S., yet their rates of completing weight loss surgery are well below that of white youth. Data used by researchers show that in 2018, 68.5% of youth who completed bariatric surgery were white, versus 18.5% Hispanic and 15.5% Black youth.

“More pediatricians need to refer these patients to surgeons if they are a good candidate to help get their patients on a healthier path,” Messiah said.

Although bariatric surgery is an invasive treatment option, and perhaps not an agreeable weight loss solution for many youth and their families, Messiah says it is an evidence-based safe option. “Research shows that readmission into hospitals post-surgery due to any complications is low. Out of surgeries performed between 2017 and 2018, only 3.4% of youth patients were readmitted to the hospital,” Messiah said.

Despite potential risks, Messiah said adolescents face diabetes, heart disease, asthma, high blood pressure, and psychological issues including anxiety, depression, and low self-esteem that studies have found are associated with severe obesity in youth.

Most recently, studies have shown that both adult and pediatric patients with obesity are at a high risk of severe illness or death if they were to contract COVID-19.

“The bottom line is, most adolescents will not lose the weight on their own, and utilizing bariatric surgery is a safe and effective way to help treat this problem before it is too late,” Messiah said. “We need to start intervening earlier so that they can enter adulthood healthier.”

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Are ‘Kidfluencers’ Making Our Kids Fat?

October 26, 2020, New York Times

Parents beware: Many YouTube channels that are wildly popular with young children are targeting them with thinly veiled ads for sugary beverages and junk food.

That is the conclusion of a new study published on Monday in the journal Pediatrics. The authors of the study analyzed over 400 YouTube videos featuring so-called kid influencers — children with large social media followings who star in videos that show them excitedly reviewing toys, unwrapping presents and playing games. The study found that videos in this genre, which attract millions of young followers and rack up billions of views, were awash in endorsements and product placements for brands like McDonald’s, Carl’s Jr., Hershey’s, Chuck E. Cheese and Taco Bell.

About 90 percent of the foods featured in the YouTube videos were unhealthy items like milkshakes, French fries, soft drinks and cheeseburgers emblazoned with fast food logos. The researchers said their findings were concerning because YouTube is a popular destination for toddlers and adolescents. Roughly 80 percent of parents with children 11 years old or younger say they let their children watch YouTube, and 35 percent say their children watch it regularly.

A spokeswoman for YouTube, citing the age requirement on its terms of service, said the company has “invested significantly in the creation of the YouTube Kids app, a destination made specifically for kids to explore their imagination and curiosity on a range of topics, such as healthy habits.” She added, “We don’t allow paid promotional content on YouTube Kids and have clear guidelines which restrict categories like food and beverage from advertising on the app.”

Young children are particularly susceptible to marketing. Studies show that children are unable to distinguish between commercials and cartoons until they are 8 or 9 years old, and they are more likely to prefer unhealthy foods and beverages after seeing advertisements for them.

Experts say it is not just an advertising issue but a public health concern. Childhood obesity rates have skyrocketed in recent years: Nearly 20 percent of American children between the ages of 2 and 19 are obese, up from 5.5 percent in the mid 1970s. Studies have found strong links between junk food marketing and childhood obesity, and experts say that children are now at even greater risk during a pandemic that has led to school closures, lockdowns and increased screen time and sedentary behavior. The new findings suggest that parents should be especially wary of how children are being targeted by food companies on social media.

“The way these branded products are integrated in everyday life in these videos is pretty creative and unbelievable,” said Marie Bragg, an author of the study and an assistant professor of public health and nutrition at the New York University School of Global Public Health. “It’s a stealthy and powerful way of getting these unhealthy products in front of kids’ eyeballs.”

Dr. Bragg was prompted to study the phenomenon after one of her co-authors, Amaal Alruwaily, noticed her young nieces and nephews obsessively watching YouTube videos of “kidfluencers” like Ryan Kaji, the 9-year-old star of Ryan’s World, a YouTube channel with 27 million subscribers, formerly named Ryan ToysReview. The channel, run by Ryan’s parents, features thousands of videos of him excitedly reviewing new toys and games, doing science experiments and going on fun trips to stores and arcades.

Children’s channels like Ryan’s World — which are frequently paid to promote a wide range of products, including toys, video games and food — are among the highest grossing channels on YouTube, raking in millions of dollars from ads, sponsored content, endorsements and more. According to Forbes, Ryan earned $26 million last year, making him the top YouTube earner of 2019. Among the brands he has been paid to promote are Chuck E. Cheese, Walmart, Hasbro, Lunchables and Hardee’s and Carl’s Jr., the fast food chains. One of his most popular videos shows him pretending to be a cashier at McDonald’s. In it, he wears a hat with the McDonald’s logo, serves plastic Chicken McNuggets, cheeseburgers and French fries to one of his toys, and then eats a McDonald’s Happy Meal. The video has been viewed about 95 million times.

“It looks like a normal child playing with their normal games, but as a researcher who studies childhood obesity, the branded products really stood out to me,” Dr. Bragg said. “When you watch these videos and the kids are pretending to bake things in the kitchen or unwrapping presents, it looks relatable. But really it’s just an incredibly diverse landscape of promotion for these unhealthy products.”

In a statement, Sunlight Entertainment, the production company for Ryan’s World, said the channel “cares deeply about the well-being of our viewers and their health and safety is a top priority for us. As such, we strictly follow all platforms terms of service, as well as any guidelines set forth by the FTC and laws and regulations at the federal, state, and local levels.”

The statement said that Ryan’s World welcomed the findings of the new study, adding: “As we continue to evolve our content we look forward to ways we might work together in the future to benefit the health and safety of our audience.”

Other popular children’s channels on YouTube show child influencers doing taste tests with Oreo cookies, Pop Tarts and Ben & Jerry’s ice cream or sitting in toy cars and ordering fast food at drive-throughs for Taco Bell, McDonald’s, Burger King, KFC and other chains. “This is basically a dream for advertisers,” said Dr. Bragg. “These kids are celebrities, and we know from other rigorous studies that younger kids prefer products that are endorsed by celebrities.”

To document the extent of the phenomenon, Dr. Bragg and her colleagues identified five of the top kid influencers on YouTube, including Ryan, and analyzed 418 of their most popular videos. They found that food or beverages were featured in those videos 271 times, and 90 percent of them were “unhealthy branded items.” Some of the brands featured most frequently were McDonald’s, Hershey’s, Skittles, Oreo, Coca-Cola, Kinder and Dairy Queen. The videos featuring junk food have collectively been viewed more than a billion times.

The researchers could not always tell which products the influencers were paid to promote, in part because sponsorships are not always clearly disclosed. The Federal Trade Commission has said that influencers should “clearly and conspicuously” disclose their financial relationships with brands whose products they endorse on social media. But critics say the policy is rarely enforced, and that influencers often ignore it.

McDonald’s USA said in a statement that it “does not partner with kid influencers under the age of 12 for paid content across any social media channels, including YouTube, and we did not pay or partner with any of the influencers identified in this study. We are committed to responsibly marketing to children.”

Last year, several senators called on the F.T.C. to investigate Ryan’s World and accused the channel of running commercials for Carl’s Jr. without disclosing that they were ads. The Council of Better Business Bureaus, an industry regulatory group, also found that Ryan’s World featured sponsored content from advertisers without proper disclosures. And a year ago the watchdog group Truth in Advertising filed a complaint with the F.T.C. accusing the channel of deceiving children through “sponsored videos that often have the look and feel of organic content.”

In March, Senators Edward J. Markey of Massachusetts and Richard Blumenthal of Connecticut introduced legislation to protect children from potentially harmful content online. Among other things, the bill would limit what they called “manipulative” advertising, such as influencer marketing aimed at children, and prohibit websites from recommending content that involves nicotine, tobacco or alcohol to children and teenagers.

The F.T.C. has long forbidden certain advertising tactics on children’s television, such as “host selling,” in which characters or hosts sell products in commercials that air during their programs. Critics say the agency could apply the same rules to children’s programs on the internet but so far has chosen not to.

“It’s beyond absurd that you couldn’t do this on Nickelodeon or ABC but you can do this on YouTube just because the laws were written before we had an internet,” said Josh Golin, the executive director of the Campaign for a Commercial-Free Childhood, an advocacy group.

“These videos are incredibly powerful,” he said. “Very busy parents may take a look at them and think that it’s just a cute kid talking enthusiastically about some product and not realize that it’s often part of a deliberate strategy to get their children excited about toys, or in the case of this study, unhealthy food.”

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Obesity Medicine Association Announces Major Updates to Its Pediatric Obesity Algorithm

October 19, 2020, EurekAlert!

The Obesity Medicine Association (OMA) today announced the immediate availability of the 2020-2022 Pediatric Obesity Algorithm, which includes new information for clinicians such as specific considerations for special populations, nutritional recommendations for patients with obesity and adiposity-related diseases, and advanced therapies for pediatric obesity.

“Childhood obesity, particularly in the midst of the coronavirus pandemic, presents a serious public health threat,” said Suzanne Cuda, MD, FAAP, FOMA, and Co-Author of the Pediatric Obesity Algorithm. “Treatment for childhood obesity requires a specialized understanding of a patient’s family and cultural background as well as medical and psychological expertise. OMA’s Pediatric Obesity Algorithm educates clinicians and helps them implement these kinds of evidence-based practices.”

The OMA Pediatric Obesity Algorithm guidelines are a clinical tool to help health care professionals make informed decisions when treating obesity in children. The resource provides age-specific treatment recommendations and approaches for clinicians who are treating patients with obesity or referring them to childhood obesity specialists. Contents of the OMA Pediatric Obesity Algorithm include:

  • Overall management goals
  • Epigenetics
  • Assessment
  • Obesity as a disease
  • Differential diagnosis
  • Review of symptoms
  • Diagnostic work-up
  • Physical exam
  • Nutritional recommendations and management
  • Activity recommendations
  • Comorbidities
  • Pharmacology
  • Medication-related weight gain

Originally released in 2016, the OMA Pediatric Obesity Algorithm was developed by practicing pediatricians and clinicians who treat obesity in infants, children and adolescents. Every two years, the OMA Pediatric Obesity Algorithm undergoes a rigorous review by a committee that represents a diverse range of clinicians, allied health professionals, clinical researchers and academicians, in order to reflect a multidisciplinary and balanced group of experts in obesity science, evaluation and treatment. All contents in the OMA Pediatric Obesity Algorithm are based upon scientific evidence, supported by medical literature and derived from clinical experiences.

“The science and clinical management of obesity is ever-evolving,” said Dr. Cuda. “To ensure clinicians are equipped with the latest scientific evidence, medical literature and clinical experience to inform their treatment recommendations, OMA utilizes its diverse network of professionals and resources to update the Pediatric Obesity Algorithm so it is as timely and applicable as possible.”

The 2020-2022 OMA Pediatric Obesity Algorithm is available in print, a keyword-friendly, searchable ebook format and a presentation PowerPoint format. To learn more, visit

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