October 2020

NCCOR Releases New White Paper: Advancing Measurement for High-Risk Populations and Communities Related to Childhood Obesity

NCCOR, October 28, 2020

This month, NCCOR released the second white paper based on a series of workshops on advancing measurement for childhood obesity. The white paper, titled “Advancing Measurement for High-Risk Populations and Communities Related to Childhood Obesity” describes the workshop held on September 23-24, 2019. The workshop series was funded by The JPB Foundation.

Leading research and practice experts were convened to (1) illustrate current challenges, needs, and gaps in measurement for high-risk populations, and (2) discuss current practices used to adapt existing measures and develop new measures for high-risk populations.

This whitepaper highlights recommendations for actionable steps to address short-term (1-3 years) and medium-term (3-5 years) measurement needs in these areas. Recommendations included: (1) To develop new, and adapt existing, measures for high-risk groups, (2) To develop methods and guidance to accommodate the need to balance standardization against tailoring, (3) To support efforts to ensure that measures and their implementation reflect cultural competence and cultural humility, and (4) To develop ways to share current work to improve learning and leverage existing research and implementation practices. The white paper can be accessed on the NCCOR website at www.nccor.org/measurement-workshop-series/.

The first white paper is also available on the NCCOR website. The third paper will be available by the end of the year. In addition, NCCOR plans to publish a synthesis of findings and recommendations from the three workshops in the scientific literature. It is anticipated that priority areas from these workshops will advance development of improved measures that can be used across a range of research, surveillance, and intervention activities related to diet, physical activity, and childhood obesity by addressing the many levels of influences, such as social determinants that impact the onset and progression of childhood obesity.

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New from NCCOR! Measures for Children at High-Risk for Obesity: Choosing Whether to Apply, Adapt, or Develop a Measure

NCCOR, October 28, 2020

This month, NCCOR  released a resource to bolster measurement of children at high-risk for obesity. “High-risk populations” are children and families residing in communities where the risk of obesity and related comorbidities may be highest. Factors related to high-risk for obesity include an individual’s race and ethnicity, education, income, urbanicity, region of the country, and disability status and exposure to health hindering policies, social conditions, and environments such as economic or neighborhood disadvantage.

This new resource, titled Measures for Children at High Risk For Obesity: Choosing Whether to Apply, Adapt, or Develop A Measure, includes three parts: (1) a decision tree, (2) five real case studies, and (3) a resource list. It was developed based on  findings from a recent review of the Measures Registry, Identification of Measurement Needs to Prevent Childhood Obesity in High-Risk Populations and Environments, published in the American Journal of Preventive Medicine, in addition to recommendations from a 2019 workshop, Advancing Measurement for High-Risk Populations and Communities Related to Childhood Obesity, which are described in a recently published whitepaper.

The Measures for Children at High Risk For Obesity decision tree walks researchers and practitioners through a series of 10 prompts to help users determine whether to develop, adapt, or apply a measure for use in a high-risk population. Examples of questions include: 1) Do you have a research question and is it important to the community? 2) Has this measure been validated in your population of interest? and 3) Does it need to be adapted?

To accompany the decision tree, five case studies were developed to exemplify different scenarios and to describe the rationale for choosing one of the three approaches. These scenarios include: how to involve community members and stakeholders in research, how to determine whether two populations are meaningfully different, and how to apply, adapt, and develop a measure for your research population. The complimentary resource list compiles more than 40 resources including guides for adapting articles, exemplary articles, measurement tools, and frameworks.

The resource aligns with NCCOR’s efforts to improve the ability of childhood obesity researchers and program evaluators to conduct research and program evaluation with special attention to high-risk populations and communities. By creating this resource for the field, NCCOR hopes that the number of measures appropriate for populations at a high-risk for obesity increase beyond current levels.

Learn more about other NCCOR initiatives at www.nccor.org

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NCCOR’s Toolbox

Whether you are a researcher, a public health practitioner, clinician, or any professional or student with an interest in researching or evaluating weight-related outcomes, NCCOR’s new “A Guide to Methods for Assessing Childhood Obesity” will help you understand the most common adiposity assessment methods and which one is most appropriate for your particular objective. Check it out!

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Prioritizing Children’s Health During the Pandemic

Explore interactive data, read stories about how communities are responding to the pandemic, and find expert insights about promising strategies for helping all kids grow up healthy, from the Robert Wood Johnson Foundation.

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School and University Nutrition

This collection of school and university nutrition articles from Elsevier is available for free through November 30, 2020.

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Nutrition Education is Helping Low-Income Families Eat Healthier

Civil Eats, October 20, 2020

In addition to math and reading lessons, many third graders in Alabama’s low-income communities learn about nutrition from animated characters like Shining Rainbow, who loves colorful vegetables, and Muscle Max, who eats plenty of lean protein. The students also take the “Vow of the Warrior” in their classrooms. “I will enter into the quest for health, strength, and wisdom. I will try new fruits and vegetables,” the vow begins.

It’s all part of a state SNAP-Ed curriculum called Body Quest, which applies what Sondra Parmer, the administrator of SNAP-Ed programs for the Alabama Cooperative Extension System, calls “multilevel intervention” —and it turns out it has had a significant impact on children and families since its launch in 2010.

Most people are familiar with SNAP (Supplemental Nutrition Assistance Program) benefits, which help address food insecurity among vulnerable populations. SNAP-Ed is a companion program that provides comprehensive nutrition education to many of the same families, who may be struggling to put together healthy meals on a limited budget.

“When we look at the data for the program, we can say with certainty—because we’re comparing a treatment and a control group—that because of Body Quest, these kids are eating better,” said Parmer.

Now, a new study has aggregated data across eight states in the Southeast to evaluate the broader impact of programs like these for the first time. Published in the Journal of Nutritional Science at the end of September, the study found adults and children in SNAP-Ed programs are more likely to make a number of positive behavior changes, including eating more fruit and vegetables.

And while the data is from 2017, the results come at a time when advocates say helping food-insecure families eat well is more important than ever. Since the pandemic began, millions of Americans have lost their jobs and joined the ranks of those struggling to feed their families, prompting various calls for an increase in SNAP benefits. One analysis found nearly a quarter of American households faced food insecurity during the pandemic, more than double the number that did before COVID-19. In households with children, food insecurity tripled.

In the face of hunger, prioritizing healthy eating is even harder, especially in low-income communities where few nutritious foods are even available. And those communities have long suffered higher rates of diet-related diseases such as diabetes.

Those statistics now also point to risk factors for COVID-19. “COVID has really highlighted the impact of underlying conditions like heart disease, diabetes, high blood pressure, and obesity,” said Tracy Fox, a nutritionist by training who has been working on federal nutrition and nutrition education policy for more than 20 years. “They have such a significant impact on whether or not you get COVID and how well you handle it.”

Based on the study results, then, SNAP-Ed may be one effective tool to help people in low-income communities eat more of the foods that prevent diet-related diseases and the devastating impact of COVID-19.

How Does SNAP-Ed Work?

The entire SNAP program is funded by the farm bill; about 95 percent of the money goes directly to SNAP benefits, and the small remaining slice includes funding for SNAP-Ed. While states began to operate the education program as far back as 1998, it transformed during the Obama administration to focus on evidence-based projects and emphasize community and public health approaches to nutrition education.

The U.S. Department of Agriculture (USDA) distributes annual funds to states, which then administer the educational programs through cooperative extension services at land-grant universities, public health departments, and nonprofits. In 2020, the USDA distributed $441 million for the program. (Because SNAP-Ed funding is distributed entirely separately from benefits themselves, calls to raise benefits would not affect SNAP-Ed.)

The programs aim to educate SNAP recipients, but there is a lot of flexibility in terms of what each program looks like.

They include direct education programs such as lessons and cooking classes, and social marketing campaigns to disseminate messages about healthy eating. And in recent years, there has been emphasis placed on the implementation of policy, systems, and environmental (PSE) changes—or long-term shifts that make healthy choices easier. For example, a school might ban soda and other sugary beverages (policy), install new water-bottle-filling fountains with promotional posters nearby (environment), and make a plan to stock vending machines with healthier alternatives (systems).

In Alabama, the Body Quest program includes direct education in the form of classroom nutrition lessons as well as many PSE changes, such as lunchroom posters with animated characters encouraging healthy choices and school wellness committees that create action plans to make school environments healthier. For example, at a school in Conecuh County, the committee identified a need for daily physical activity breaks, and the SNAP-Ed educator trained teachers in how to conduct them.

Body Quest is just “one cog in the wheel” when it comes to SNAP-Ed programs in the state, Parmer noted. Educators also plant and maintain teaching gardens, teach food bank clients how to cook with produce they are unfamiliar with, and more.

Evidence of Impacts

The flexibility given to each state to craft programs that meet the needs of its unique communities is one of SNAP-Ed’s biggest strengths, Fox said. But it also makes collecting consistent data and evaluating that data in a uniform way difficult.

To undertake the research, the Public Health Institute created a working group with representatives from SNAP-Ed agencies in eight states: Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee.

“We selected the common indicators, and then we came up with a plan on how to gather that information from everyone,” explained Amy DeLisio, the director of the Center for Wellness and Nutrition at the Public Health Institute and a co-author of the study. The 25 participating agencies used pre- and post-tests with SNAP-Ed participants, and then re-coded the results to match standardized indicators.

Results showed participants ate about a third of a cup of more fruit and a quarter of a cup more vegetables per day than they had before participating in the programs. And while that little bump might not sound significant, experts said it’s more meaningful than it may appear.

“It may seem like a very small amount of fruits and vegetables on your plate,” said Julia McCarthy, interim deputy director at the Laurie M. Tisch Center for Food, Education and Policy, but it is a significant increase, especially given most Americans fall far short of meeting dietary guidelines in this realm. Furthermore, “behavior change is slow and hard to come by,” she said.

Researchers also found that individuals in the study reported that they were more likely to increase the variety of produce in their diets, drink more water and fewer sugary beverages, and read nutrition labels while shopping.

The study was limited by the lack of a control group, DeLisio said. But “in general, [the data] is showing SNAP-Ed works,” she concluded.

McCarthy said she was excited to find more than 700 policy, system, and environmental changes being used within the SNAP-Ed programs they analyzed, which she thought pointed to the fact that changing people’s environments is a crucial component of nutrition education.

“You can’t teach people how to eat well without healthy foods, just like you can’t teach people how to read without books,” she added.

And the fact that the study aggregated data across states in the entire Southeast region, Fox said, made it much more impactful and interesting. “You have higher numbers reporting, and therefore you have a little more confidence in the data . . . and what they’re showing,” she said. “I think it’s a really good model for other regions, hopefully, to use.”

Timely Information

All the experts said the study was a starting point for more research that needs to be done across the country. But at this moment in time, the results are especially meaningful.

“There are a lot of Americans who have lost their jobs and are now in poverty, and they might not know how to stretch their food dollars or select healthier foods on a budget,” DeLisio said. “It’s relevant to that new population.”

SNAP-Ed programs have also been affected by the pandemic in significant ways, since most are facilitated in person. Some programs have moved online, while some educators have had to pause their efforts entirely.

The USDA has so far denied state requests for waivers that would allow SNAP-Ed educators to temporarily participate in hunger relief efforts that don’t directly include nutrition education. Fox has been working with groups who are asking Congress to step in to allow that flexibility, and while a draft of the second HEROES Act did include language to allow for that, the legislation is still a work in progress and negotiations are currently stalled.

Regardless of what the future brings, DeLisio said she believes the data supports ongoing funding for SNAP-Ed. McCarthy echoed that sentiment, emphasizing the “unnecessary division” that has often existed between hunger and nutrition work.

“Families want to feed their members healthy, delicious food, and any sort of food insecurity efforts that don’t consider nutrition are not going far enough,” she said. “COVID-19 has exposed just how vulnerable diet-related diseases have made us. Healthy eating has to be a top priority.”

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Extra Pounds May Raise Risk of Severe Covid-19

New York Times, October 10, 2020

Obese Americans are more likely to become dangerously ill if they are infected with the new coronavirus. Now public health officials are warning that a much broader segment of the population also may be at risk: even moderately excess weight may increase the odds of severe disease.

The warning, reported by the Centers for Disease Control and Prevention this week, may have serious implications for Americans. While about 40 percent of U.S. adults are obese, another 32 percent are simply overweight, among the highest rates of obesity and overweight in the world.

By the new calculus, nearly three-quarters of Americans may be at increased risk of severe Covid-19 if infected with the coronavirus.

“It’s important to make sure the public and individuals are aware of this potential risk,” said Dr. Brook Belay, a medical officer at the C.D.C.

“The message is to strive to make healthy changes on a daily basis, through healthy food choices, choices about physical activity, and getting sufficient sleep.”

Other medical conditions for which there is limited or mixed evidence of increased Covid-19 severity include asthma, cerebrovascular disease and cystic fibrosis, the C.D.C. said. Medical conditions clearly shown to increase the risk of Covid-19 include cancer, chronic kidney disease, heart disease and sickle cell disease, among others.

Overweight and obesity are defined by a person’s body mass index, a ratio of an individual’s weight and height. People with a B.M.I. between 18.5 and 24.9 are considered to be of healthy weight; the overweight zone ranges from a B.M.I. of 25 through 29, and obesity starts at a B.M.I. of 30.

Someone who is 5 feet 9 inches and weighs 125 to 168 pounds is in the healthy range, for example; above that, the individual is overweight, and at 203 pounds or higher, is obese.

“This greatly expands the risk to a pretty big chunk of the U.S. population,” Barry M. Popkin, a professor of nutrition at the University of North Carolina at Chapel Hill, said of the C.D.C.’s new advice.

In a recent review of 75 studies published in August, Dr. Popkin found that obese people were twice as likely to be hospitalized with Covid-19, compared with those who were overweight or of healthy weight, and nearly twice as likely to wind up in intensive care.

Dr. Popkin and his colleagues were unable to pinpoint the risk of being merely overweight, because so few studies have examined that variable.

Doctors observed early on in the pandemic that excess weight appeared to pose an extra risk to patients. But since obesity is often accompanied by other medical problems, it took some time for researchers to learn whether excess fat, in and of itself, was the culprit. Many studies now indicate that it may be, at least in some patients.

Adipose tissue — the fat accumulated by the body — is itself biologically active, causing metabolic changes and abnormalities. Adipose promotes a state of chronic low-grade inflammation in the body, even without an infection.

In addition, abdominal obesity — which is more common in men — may cause compression of the diaphragm, lungs and chest cavity, restricting breathing and making it more difficult to clear pneumonia and other respiratory infections.

The C.D.C. based its warning on a small number of studies that successfully differentiated between overweight and obesity, including a paper on risk factors for severe Covid-19 among patients in the United Kingdom and a report analyzing the outcomes of more than 500 patients hospitalized in March and April at Downstate Health Sciences University in Brooklyn.

Among those patients, 43 percent were obese, 30 percent overweight and 27 percent of healthy weight. After adjusting for age, diabetes and other such factors, the researchers found that patients who were overweight or obese were at increased risk for requiring mechanical assistance with breathing and were more likely to die. The paper was published in July in the International Journal of Obesity.

Surprisingly, the risk of being overweight was even greater than that linked to obesity. Overweight patients were 40 percent more likely to die than healthy-weight patients, while obese patients were at 30 percent greater risk, compared with the healthy-weight patients.

The findings clearly demonstrated an increased risk of severe Covid-19 in anyone with a B.M.I. of 25 or above, according to the authors of the study, Dr. Mohamed Rami Nakeshbandi, an assistant professor of infectious diseases at SUNY Downstate Health Science University, and Rohan Maini, a medical student.

But while obesity increased the risk of death for men, it did not do so for women, they noted. (Other studies have also reported this disparity.)

The British study examined lifestyle risk factors among 387,109 men and women, 760 of whom had Covid-19. People with the virus who were overweight were roughly 30 percent more likely to be hospitalized than those of healthy weight; those who were obese were about twice as likely, compared with healthy-weight individuals.

The study, published in July in the journal Brain, Behavior and Immunity, also looked at factors like smoking, alcohol consumption and levels of physical activity, and concluded that moderate exercise reduced the odds that an infected person would be hospitalized.

“Socially distanced physical activity may be a good intervention,” said Mark Hamer, a professor of sports and exercise medicine at University College London and an author of the paper, said in an email. “It gives immune protection, and also helps with weight loss.”

Physical activity, which has been extensively studied, can reduce the risk of developing chronic conditions linked to excess weight, like diabetes and high blood pressure. But it won’t entirely eliminate the risk of impaired immune function and heightened inflammation, Dr. Popkin cautioned.

“Overweight is quite different than other diseases in terms of inflammation,” he said. “The fat tissue are inflamed for a long period of time, and it affects immune function more over time. It is a continuous insult.”

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Prevalence of Overweight and Obesity Among Children Enrolled in Head Start, 2012-2018

American Journal of Health Promotion

Purpose:

Determine prevalence of overweight and obesity as reported in Head Start Program Information Reports.

Design:

Serial cross-sectional census reports from 2012–2018.

Setting:

Head Start programs countrywide, aggregated from program level to state and national level.

Subjects:

Population of children enrolled in Head Start with reported weight status data.

Measures:

Prevalence of overweight (body mass index [BMI] ≥85th percentile to <95th percentile) and obesity (BMI ≥95th percentile).

Analysis:

Used descriptive statistics to present the prevalence of overweight and obesity by state. Performed unadjusted regression analysis to examine annual trends or average annual changes in prevalence.

Results:

In 2018, the prevalence of overweight was 13.7% (range: 8.9% in Alabama to 20.4% in Alaska). The prevalence of obesity was 16.6% (range: 12.5% in South Carolina to 27.1% in Alaska). In the unadjusted regression model, 34 states and the District of Columbia did not have a linear trend significantly different from zero. There was a statistically significant positive trend in obesity prevalence for 13 states and a negative trend for 3 states.

Conclusion:

The prevalence of obesity and overweight in Head Start children remained stable but continues to be high. Head Start reports may be an additional source of surveillance data to understand obesity prevalence in low-income young children.

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Studies Begin to Untangle Obesity’s Role in Covid-19

New York Times, September 29, 2020

In early April, Edna McCloud woke up to find her hands tied to her hospital bed.

She had spent the past four days on a ventilator in a hospital in St. Louis County, Mo., thrashing and kicking under sedation as she battled a severe case of Covid-19.

“They told me, ‘You were a real fighter down there,’” recalled Ms. McCloud, a 68-year-old African-American retiree with a history of diabetes and heart problems. She weighed close to 300 pounds when she caught the coronavirus, which ravaged her lungs and kidneys. Nearly six months later, she feels proud to have pulled through the worst. “They said people with the conditions I have, normally, this goes the other way,” she said.

As rates of obesity continue to climb in the United States, its role in Covid-19 is a thorny scientific question. A flurry of recent studies has shown that people with extra weight are more susceptible than others to severe bouts of disease. And experiments in animals and human cells have demonstrated how excess fat can disrupt the immune system.

But the relationship between obesity and Covid-19 is complex, and many mysteries remain. Excess weight tends to go hand in hand with other medical conditions, like high blood pressure and diabetes, which may by themselves make it harder to fight Covid-19. Obesity also disproportionately affects people who identify as Black or Latino — groups at much higher risk than others of contracting and dying from Covid-19, in large part because of exposure at their workplaces, limited access to medical care and other inequities tied to systemic racism. And people with extra weight must grapple with persistent stigma about their appearance and health, even from doctors, further imperiling their prognosis.

“A new pandemic is now laying itself on top of an ongoing epidemic,” said Dr. Christy Richardson, an endocrinologist at SSM Health in Missouri. Regarding obesity’s effects on infectious disease, she said, “We are still learning, but it’s not difficult to understand how the body can become overwhelmed.”

The correlations between Covid-19 and obesity are worrisome. In one report published last month, researchers found that people with obesity who caught the coronavirus were more than twice as likely to end up in the hospital and nearly 50 percent more likely to die of Covid-19. Another study, which has not yet been peer-reviewed, showed that among nearly 17,000 hospitalized Covid-19 patients in the United States, more than 77 percent had excess weight or obesity.

Similar links were unmasked during the H1N1 flu pandemic of 2009, when researchers began to notice that infected people with obesity were more likely to wind up in the hospital and to die. Flu vaccines administered in subsequent years performed poorly in individuals with extra weight, who fell ill more often than their peers even after getting their shots.

“Obesity resets human physiology,” said Dr. Anne Dixon, a pulmonologist at the University of Vermont Medical Center who studies how excess weight can affect respiratory conditions like asthma. “People who are very obese are living on sort of a precarious position. This is not just cosmetic.”

Experts said part of obesity’s threat is mechanical: Large amounts of fat, for instance, can compress the lower parts of the lungs, making it harder for them to expand when people breathe in. The blood of people with obesity also seems to be more prone to clotting, plugging up delicate vessels throughout the body and starving tissues of oxygen.

Fat, or adipose tissue, can also send out hormones and other signals that make nearby cells go haywire. “Adipose tissue is very active,” said Rebekah Honce, a virologist at St. Jude Children’s Research Hospital in Tennessee and an author on a recent review describing how metabolism intersects with immunity. “It’s not a dormant tissue.”

One of fat’s most potent effects appears to involve quelling the body’s initial immune response to the virus, allowing the pathogen to spread unchecked.

Eventually, the body’s immune soldiers get their act together. But this delayed assault might do more harm than good: When late-arriving immune cells and molecules finally rouse themselves into action, they go berserk, driving uncontrolled bouts of inflammation throughout the body.

These aberrant early responses can have severe long-term consequences as well, said Melinda Beck, who studies how nutrition affects immunity at the University of North Carolina at Chapel Hill. The constant inflammation, she said, can wear away at the immune system’s ability to generate a long-lived population of “memory” cells, which store intelligence about past encounters with pathogens.

Similar trends have been noted in the immune systems of elderly patients, who also struggle to marshal effective defenses against pathogens. When obesity enters the picture, Dr. Beck said, some of the immune cells found in 30-year-old people “look like those of an 80-year-old.”

These problems could have a big impact on the first coronavirus vaccines, Dr. Beck said. If the immune systems of people with obesity are more prone to pathogen amnesia, then they may need different dosages of a vaccine. Some products might not work at all in people carrying extra weight.

But little attention has been paid to these risks in ongoing vaccine trials. When asked if they were testing the effects of weight on vaccine effectiveness, representatives from Novavax and AstraZeneca, two of the leaders among companies in the race for a coronavirus vaccine, said there were no public plans to investigate the issue. Representatives from their competitors Moderna and Pfizer did not respond to repeated requests for comment.

Johnson & Johnson, whose coronavirus vaccine candidate entered late-stage clinical trials this month, is enrolling people with obesity, according to a company spokesman, Jake Sargent. The company “will have the opportunity to evaluate this question during development,” he said.

Like many other conditions that can exacerbate Covid-19, excess weight does not have a quick fix — especially in areas where access to healthy food and opportunities for exercise are vastly uneven among communities.

“If we don’t address these social underpinnings, I think we’ll continue to see a recurrence of what is happening now,” said Dr. Jennifer Woo Baidal, a pediatric weight management specialist at Columbia University.

In her neighborhood in St. Louis County, where there have been more than 23,000 cases of the coronavirus since March, Ms. McCloud has struggled to find fresh, affordable produce at her local grocery store. Availability has plummeted further since the start of the pandemic, she said, and what little is on the shelves is often on the verge of rotting.

“I have to cook it right away, or it starts to turn,” she said.

Ms. McCloud will sometimes travel a bit further to buy salad mixes or leeks — a favorite that adds zing to her meals. But the closest store with any variety is an inconvenient car ride away. She estimates that since contracting Covid-19, she has lost 20 or 30 pounds. She wants to keep her weight down, she said, but her circumstances have made that hard, and “it has only gotten worse since the pandemic started.”

A few months after Ms. McCloud got sick, her younger sister, Elaine Franklin, 62, began to experience terrible headaches. When she spoke to family members, they asked why she sounded so out of breath. “My son said, ‘Mama, you need to go to urgent care,’” Ms. Franklin recalled. A test soon revealed that she, too, had caught the coronavirus.

Ms. Franklin’s case of Covid-19 was more moderate than her sister’s. But she still deteriorated quickly, to the point where she could no longer reach the bathroom without assistance. “I was so weak, I couldn’t balance myself,” she said.

Her physical symptoms haven’t been the only hardship. Ms. Franklin, who is overweight, said she had been irritated by incessant messaging in news reports blaming illnesses like hers on excess fat.

“The way they were saying it is that because you’re obese and didn’t take care of yourself, you’ll get this disease,” Ms. Franklin said. “I feel like that was unfair.”

Even medical professionals show bias when caring for patients with excess weight, said Dr. Benjamin Singer, a pulmonologist at the University of Michigan and an author on a recent review of obesity’s influence on immunity. Studies have shown that doctors tend to be more dismissive of patients with obesity and may brush off worrisome symptoms as irrelevant side effects of their weight. Drug dosages and diagnostic machines are also often incompatible with patients carrying excess weight, making it difficult to tailor treatments. Such interactions can be a powerful disincentive to some of the people who most need care.

“These are not easy conversations,” said Dr. Kanakadurga Singer, a pediatric endocrinologist at the University of Michigan. (She and Dr. Benjamin Singer are married.) Not everyone who weighs more than average is unwell, she said. “It’s more than just the numbers, and it’s not just the weight we should focus on.”

In St. Louis County, Ms. McCloud and Ms. Franklin have recovered well, though both sisters still grapple with lingering symptoms. Ms. McCloud has occasional fatigue and an intermittent cough. “I can’t talk like I did before,” she said. Ms. Franklin’s headaches never disappeared, and her mind now feels constantly clouded by a fog.

Both women have worried about their sons, who also developed Covid-19. Chris McCloud, a teacher, was like his mother put on a ventilator, and spent several weeks in the hospital shortly before Ms. McCloud fell ill. He was overweight as well.

Ms. Franklin suspects she might have contracted the coronavirus from her son Darren Catching, who most likely caught it from a former co-worker. He had recently lost a large amount of weight, Ms. Franklin said, and was not hospitalized either, instead recovering at home.

In July, when she was infected, she sought medical attention twice. She had lupus, an autoimmune disease, and worried that she wouldn’t be able to fight off the virus. Thoughts of friends and acquaintances who had died from Covid-19 rushed through her head.

But both times, Ms. Franklin was sent home — first from an urgent care facility, and then from a hospital emergency room.

She managed to heal on her own, she said. Still, she wonders if her weariness and brain fog might have been prevented by more attentive clinical care. “I’m not a doctor or anything,” she said. “But if I had been in the hospital, maybe it would have been better.”

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Reframing the Early Childhood Prevention Through an Equitable Nurturing Approach

Maternal and Child Nutrition, September 20, 2020

High‐quality mother–child interactions during the first 2,000 days, from conception to age 5 years, are considered crucial for preventing obesity development during early life stages. However, mother–child dyads interact within and are influenced by broader socio‐ecological contexts involved in shaping child development outcomes, including nutrition. Hence, the coexistence of both undernutrition and obesity has been noted in inequitable social conditions, with drivers of undernutrition and overnutrition in children sharing common elements, such as poverty and food insecurity. To date, a holistic life‐course approach to childhood obesity prevention that includes an equitable developmental perspective has not emerged. The World Health Organization (WHO) Nurturing Care Framework provides the foundation for reframing the narrative to understand childhood obesity through the lens of an equitable nurturing care approach to child development from a life‐course perspective. In this perspective, we outline our rationale for reframing the childhood narrative by integrating an equitable nurturing care approach to childhood obesity prevention. Four key elements of reframing the narrative include: (a) extending the focus from the current 1,000 to 2,000 days (conception to 5 years); (b) highlighting the importance of nurturing mutually responsive child‐caregiver connections to age 5; (c) recognition of racism and related stressors, not solely race/ethnicity, as part of adverse child experiences and social determinants of obesity; and (d) addressing equity by codesigning interventions with socially marginalized families and communities. An equitable, asset‐based engagement of families and communities could drive the transformation of policies, systems and social conditions to prevent childhood obesity.

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