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OBJECTIVES: To examine changes in intake of foods and beverages with added sugars during the COVID-19 pandemic among US adults to understand groups at risk for decreasing dietary quality. METHODS: We used SummerStyles data collected in June 2020 (3,916 US adults, ≥18 y). The outcome was the reported frequency of 1) consuming more unhealthy snacks and desserts including chips, cookies, and ice cream and 2) drinking more sugary drinks like regular soda, fruit drinks, sports/energy drinks, sweetened coffee/teas during the COVID-19 pandemic. Responses were categorized as Never/Rarely, Sometimes, or Often/Always. Exposure variables were sociodemographics, currently having children (

Purpose: Characteristics of parents who purchased kids’ meals, reasons for the purchase, and desire for healthy options were examined. Design: Quantitative, cross-sectional study. Setting: National. Participants: The SummerStyles survey data of 1147 parents (≥18 years). Measures: Self-reported outcome variables were purchase of kids’ meals (yes/no), reasons for the purchase (13 choices), and desire for healthy options (yes/no). Analysis: We used multivariable logistic regression to estimate odds ratios (ORs) for purchasing kids’ meals based on parental sociodemographic and behavioral characteristics. Results: Over half (51%) of parents reported purchasing kids’ meals in the past month. The adjusted OR of purchasing kids’ meals were significantly higher among younger parents (OR = 3.44 vs ≥50 years) and among parents who consumed sugar-sweetened beverages (SSBs) daily (OR = 2.70 vs none). No differences were found for race/ethnicity, income, and education. Parents who purchased kids’ meals reported that the top 3 reasons for purchase were (1) because their children asked for kids’ meals, (2) habit, and (3) offering of healthier sides such as fruits or fruit cups. Thirty-seven percent of parents who did not purchase kids’ meals expressed willingness to purchase kids’ meals if healthy options were available; this willingness was highest among younger parents (47%; P < .05). Conclusions: Kids’ meal purchases were somewhat common. Our findings on characteristics of parents who frequently bought kids’ meals (ie, younger parents and SSB consumers), common reasons for purchasing kids’ meals, and willingness to buy healthier kids’ meal can be used to inform intervention efforts to improve quality of kids’ meals.

Childhood obesity is associated with negative health consequences in childhood (1) that continue into adulthood (2), putting adults at risk for type 2 diabetes, cardiovascular disease, and certain cancers (1). Obesity disproportionately affects children from low-income families (3). Through a collaboration with the United States Department of Agriculture (USDA), CDC has begun to use data from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Participants and Program Characteristics (WIC PC) to replace the Pediatric Nutrition Surveillance System (PedNSS) (4,5) for obesity surveillance among young children from low-income families. CDC examined trends in obesity prevalence during 2000-2014 among WIC participants aged 2-4 years using WIC PC data. Overall obesity prevalence increased from 14.0% in 2000 to 15.5% in 2004 and 15.9% in 2010, and then decreased to 14.5% in 2014. During 2010-2014, the prevalence of obesity decreased significantly overall, among non-Hispanic whites, non-Hispanic blacks, Hispanics, American Indian/Alaska Natives and Asians/Pacific Islanders, and among 34 (61%) of the 56 WIC state agencies in states, the District of Columbia, and U.S. territories. Despite these declines, the obesity prevalence among children aged 2-4 years in WIC remains high compared with the national prevalence of 8.9% among children aged 2-5 years in 2011-2014. Continued initiatives to work with parents and other stakeholders to promote healthy pregnancies, breastfeeding, quality nutrition, and physical activity for young children in multiple settings are needed to ensure healthy child development.

Purpose: This study examined associations between sugar-sweetened beverage (SSB) intake and acculturation among a sample representing civilian noninstitutionalized U.S. adults. Design: Quantitative, cross-sectional study. Setting: National. Subjects: The 2010 National Health Interview Survey data for 17,142 Hispanics and U.S.-born non-Hispanic whites (≥18 years). Measures: The outcome variable was daily SSB intake (nondiet soda, fruit drinks, sports drinks, energy drinks, and sweetened coffee/tea drinks). Exposure variables were Hispanic ethnicity and proxies of acculturation (language of interview, birthplace, and years living in the United States). Analysis: We used multivariate logistic regression to estimate adjusted odds ratios (ORs) for the exposure variables associated with drinking SSB ≥1 time/d after controlling for covariates. Results: The adjusted odds of drinking SSB ≥1 time/d was significantly higher among Hispanics who completed the interview in Spanish (OR = 1.65) than U.S.-born non-Hispanic whites. Compared with those who lived in the United States for Conclusion: The acculturation process is complex and these findings contribute to identifying important subpopulations that may benefit from targeted intervention to reduce SSB intake.

OBJECTIVES: High intake of added sugars increases risk of obesity, hypertension, dyslipidemia, and cardiovascular disease. State-specific data is lacking. We therefore examined estimated dietary intake of added sugars (tsp/day) by state and factors associated with its intake among US adults. METHODS: We used pooled data from 2010 and 2015 National Health Interview Surveys (n = 52,279). The outcome variable was added sugars intake from foods and beverages, calculated by using NCI's scoring algorithm to convert dietary screener frequency responses to estimates of dietary added sugars intake (tsp/day). The explanatory variables were age, sex, race/ethnicity, education, marital status, annual household income, metropolitan/nonmetropolitan status, and census region. We used descriptive statistics to estimate mean added sugars intake and multiple linear regression to estimate significant differences in the mean intake by category of explanatory variable. RESULTS: Overall, estimated mean dietary intake of added sugars was 17.0 tsp/day among US adults, ranging from 14.8 tsp/day in Alaska to 21.2 tsp/day in Kentucky. We found statistically higher added sugars intake with adults age 18–24 years vs. age ≥60, males vs. females, non-Hispanic blacks and Hispanics vs. non-Hispanic whites, those not married vs. married, education

We examined associations between sugar-sweetened beverage (SSB) intake - a chronic disease risk factor - and characteristics of 75,029 adults (≥18 y) in 9 states by using 2016 Behavioral Risk Factor Surveillance System (BRFSS) data. We used multinomial logistic regression to estimate adjusted odds ratios for SSB intake categorized as none (reference), fewer than 1 time per day, and 1 or more times per day, by sociodemographic and behavioral characteristics. Overall, 32.1% of respondents drank SSBs 1 or more times per day. We found higher odds for 1 or more times per day among younger respondents, men, Hispanic and non-Hispanic black respondents, current smokers, respondents residing in nonmetropolitan counties, employed respondents, and those with less than high school education, obesity, and no physical activity. Our findings can inform the targeting of efforts to reduce SSB consumption.

State agencies play a critical role in providing school districts with guidance and technical assistance on school nutrition issues, including food and beverage marketing practices. We examined associations between state-level guidance and the policies and practices in school districts regarding food and beverage marketing and promotion. State policy guidance was positively associated with districts prohibiting advertisements for junk food or fast food restaurants on school property. Technical assistance from states was negatively associated with 2 district practices to restrict marketing of unhealthy foods and beverages, but positively associated with 1 practice to promote healthy options. These findings may help inform the guidance that states provide to school districts and help identify which districts may need additional assistance to address marketing and promotion practices.

Background Frequent intake of sugar-sweetened beverages (SSB) decreases diet quality and is associated with adverse health outcomes. Objective We examined associations between status of actively trying to eat a healthy diet and SSB intake among a convenience sample of Hispanic adults. Study Design, Settings, Participants This cross-sectional study used 2015 Estilos data including a convenience sample of 1,000 Hispanic adults (≥ 18 years) from an online panel survey (conducted in Spanish and English). Measurable Outcome/Analysis The outcome variable was SSB intake (regular soda, sweetened coffee/tea drink, sports/energy drink, and fruit drink). The exposure variable was agreement on actively trying to eat a healthy diet (disagree, neither, or agree). Covariates included sociodemographic and acculturation variables, and weight status. We used chi-square tests and logistic regression analyses to examine the associations between actively trying to eat a healthy diet and SSB intake. Results Overall, 71.3% of Hispanics agreed that they were actively trying to eat a healthy diet and 17.4% neither disagreed nor agreed. The prevalence of SSB intake ≥ one time/day was the highest among those who neither disagreed nor agreed (94.3%), followed by agreed (89.9%) and disagreed (89.4%). In the crude models, the odds of consuming sweetened coffee/tea drink ≥ one time/day was greater among those who agreed (OR = 1.65) than those who disagreed, and the odds of consuming sports/energy drink ≥ one time/day was lower among who neither disagreed nor agreed (OR = 0.51) than those who disagreed. However, after controlling for covariates, these associations were no longer significant. Conclusion Daily SSB intake among a convenience sample of Hispanics was high regardless whether or not they are actively trying to eat a healthy diet. Intention alone may not be adequate for Hispanic adults to change their behaviors. Beverage may be a topic for additional consideration when seeking to promote healthful dietary behaviors among Hispanics. Funding CDC.

Summary Background Understanding state/territorial trends in obesity by race/ethnicity helps focus resources on populations at risk. Objective This study aimed to examine trends in obesity prevalence among low-income, preschool-aged children from 2008 through 2011 in U.S. states and territories by race/ethnicity. Methods We used measured weight and height records of 11.1 million children aged 2–4 years who participated in federally funded health and nutrition programmes in 40 states, the District of Columbia and two U.S. territories. We used logistic regression to examine obesity prevalence trends, controlling for age and sex. Results From 2008 through 2011, the aggregated obesity prevalence declined among all racial/ethnic groups (decreased by 0.4–0.9%) except American Indians/Alaska Natives (AI/ANs); the largest decrease was among Asians/Pacific Islanders (A/PIs). Declines were significant among non-Hispanic whites in 14 states, non-Hispanic blacks in seven states/territories, Hispanics in 13 states, A/PIs in five states and AI/ANs in one state. Increases were significant among non-Hispanic whites in four states, non-Hispanic blacks in three states, Hispanics in two states and A/PIs in one state. The majority of the states/territories had no change in obesity prevalence. Conclusions Our findings indicate slight reductions in obesity prevalence and variations in obesity trends, but disparities exist for some states and racial/ethnic groups.

There is growing interest in the use of physical activity and nutrition environmental measures by both researchers and practitioners. Built environment assessment methods and tools range from simple to complex and encompass perceived, observed, and geographic data collection. Even though challenges in tool selection and use may exist for non-researchers, there are opportunities to incorporate these measures into practice. The aims of this paper are to (1) describe examples of built environment assessment methods and tools in the practice context; (2) present case studies that outline successful approaches for the use of built environment assessment tools and data among practitioners; and (3) make recommendations for both research and practice. As part of the Built Environment Assessment Training Think Tank meeting in July 2013, experts who work with community partners gathered to provide input on conceptualizing recommendations for collecting and analyzing built environment data in practice and research. The methods were summarized in terms of perceived environment measures, observational measures, and geographic measures for physical activity and food environment assessment. Challenges are outlined and case study examples of successful use of assessments in practice are described. Built environment assessment tools and measures are important outside the research setting. There is a need for improved collaboration between research and practice in forming partnerships for developing tools, collecting and analyzing data, and using the results to work toward positive environmental changes.

Most U.S. youth fail to eat the recommended amount of fruits and vegetables (FV) however many consume too many calories as added sugars and solid fats, often as snacks. The aim of this study was to assess factors associated with serving FV as snacks and with meals using parent-child dyads. A cross-sectional sample of U.S. children aged 9 to 18, and their caregiver/parent (n=1522) were part of a Consumer Panel of households for the 2008 YouthStyles mail survey. Chi-square test of independence and multivariable logistic regression were used to assess associations between serving patterns of FV as snacks with variations in serving patterns, and covariates including dietary habits. Most parents (72%) reported serving FV at meals and as snacks. Fruit was most frequently served as a snack during the day (52%) and vegetables were most frequently served as a snack during the day (22%) but rarely in the morning. Significant differences in child FV intake existed among FV as a snack serving patterns by parents. Compared to children whose parents served FV only at meals, children whose parents reported serving FV as snacks in addition to meals were significantly more likely to have consumed FV the day before (using a previous day screener), P0.05. Contributing to the growing collection of literature describing parent-child dyad dietary behaviors, these findings suggest promoting FV access and intake throughout the day, not only at meals, by including serving as snacks, may increase FV intake among older children and adolescents.

Introduction More than 42 million people in the United States are food insecure. Although some health care entities are addressing food insecurity among patients because of associations with disease risk and management, little is known about the components of these initiatives. Methods The Systematic Screening and Assessment Method was used to conduct a landscape assessment of US health care entity-based programs that screen patients for food insecurity and connect them with food resources. A network of food insecurity researchers, experts, and practitioners identified 57 programs, 22 of which met the inclusion criteria of being health care entities that 1) screen patients for food insecurity, 2) link patients to food resources, and 3) target patients including adults aged 50 years or older (a focus of this assessment). Data on key features of each program were abstracted from documentation and telephone interviews. Results Most programs (n = 13) focus on patients with chronic disease, and most (n = 12) partner with food banks. Common interventions include referrals to or a list of food resources (n = 19), case managers who navigate patients to resources (n = 15), assistance with federal benefit applications (n = 14), patient education and skill building (n = 13), and distribution of fruit and vegetable vouchers redeemable at farmers markets (n = 8). Most programs (n = 14) routinely screen all patients. Conclusion The programs reviewed use various strategies to screen patients, including older adults, for food insecurity and to connect them to food resources. Research is needed on program effectiveness in improving patient outcomes. Such evidence can be used to inform the investments of potential stakeholders, including health care entities, community organizations, and insurers.

The 2015-2020 Dietary Guidelines for Americans recommend that Americans consume more fruits and vegetables as part of an overall dietary pattern to reduce the risk for diet-related chronic diseases such as cardiovascular disease, type 2 diabetes, some cancers, and obesity (1). Adults should consume 1.5-2.0 cup equivalents of fruits and 2.0-3.0 cups of vegetables per day.* Overall, few adults in each state met intake recommendations according to 2013 Behavioral Risk Factor Surveillance System (BRFSS) data; however, sociodemographic characteristics known to be associated with fruit and vegetable consumption were not examined (2). CDC used data from the 2015 BRFSS to update the 2013 report and to estimate the percentage of each state's population meeting intake recommendations by age, sex, race/ethnicity, and income-to-poverty ratio (IPR) for the 50 states and District of Columbia (DC). Overall, 12.2% of adults met fruit recommendations ranging from 7.3% in West Virginia to 15.5% in DC, and 9.3% met vegetable recommendations, ranging from 5.8% in West Virginia to 12.0% in Alaska. Intake was low across all socioeconomic groups. Overall, the prevalence of meeting the fruit intake recommendation was highest among women (15.1%), adults aged 31-50 years (13.8%), and Hispanics (15.7%); the prevalence of meeting the vegetable intake recommendation was highest among women (10.9%), adults aged ≥51 years (10.9%), and persons in the highest income group (11.4%). Evidence-based strategies that address barriers to fruit and vegetable consumption such as cost or limited availability could improve consumption and help prevent diet-related chronic disease.

BMI z-scores (BMIz) based on the Centers for Disease Control and Prevention (CDC) growth charts among children do not accurately characterise BMI levels among children with very high BMIs. These limitations may be particularly relevant in longitudinal and intervention studies, as the large changes in the L (normality) and S (dispersion) parameters with age can influence BMIz.To compare longitudinal changes in BMIz with BMI expressed as a percentage of the 95th percentile (%BMIp95) and a modified z-score calculated as log(BMI/M)/S.A total of 45 414 2-4-year-olds with severe obesity (%BMIp95 ≥ 120).Changes in very high BMIz levels differed from the other metrics. Among severely obese 2-year-old girls, for example, the mean BMIz decreased by 0.6 SD between examinations, but there were only small changes in BMIp95 and modified BMIz. Some 2-year-old girls had BMIz decreases of1 SD, even though they had large increases in BMI, %BMIp95 and modified BMIz.Among children with severe obesity, BMIz changes may be due to differences in the transformations used to estimate levels of BMIz rather than to changes in body size. The BMIs of these children could be expressed relative to the 95th percentile or as modified z-scores.

Electronic information technology standards facilitate high-quality, uniform collection of data for improved delivery and measurement of health care services. Electronic information standards also aid information exchange between secure systems that link health care and public health for better coordination of patient care and better-informed population health improvement activities. We developed international data standards for healthy weight that provide common definitions for electronic information technology. The standards capture healthy weight data on the "ABCDs" of a visit to a health care provider that addresses initial obesity prevention and care: assessment, behaviors, continuity, identify resources, and set goals. The process of creating healthy weight standards consisted of identifying needs and priorities, developing and harmonizing standards, testing the exchange of data messages, and demonstrating use-cases. Healthy weight products include 2 message standards, 5 use-cases, 31 LOINC (Logical Observation Identifiers Names and Codes) question codes, 7 healthy weight value sets, 15 public-private engagements with health information technology implementers, and 2 technical guides. A logic model and action steps outline activities toward better data capture, interoperable systems, and information use. Sharing experiences and leveraging this work in the context of broader priorities can inform the development of electronic information standards for similar core conditions and guide strategic activities in electronic systems.

Purpose: This study examined associations between knowledge of sugar-sweetened beverage (SSB)-related health conditions and SSB intake among US adults. Design: Quantitative, cross-sectional study. Subject: The 2014 SummerStyles survey data for 4163 US adults (≥18 years) were used. Measures: The outcome measure was frequency of SSB intake (regular soda, fruit drinks, sports or energy drinks, sweetened coffee/tea drinks). Exposure measures were knowledge of 6 SSB-related health conditions: weight gain, diabetes, cavities, high cholesterol, heart disease, and hypertension. Analysis: Six logistic regression models were used to estimate adjusted odds ratios (ORs) for consuming SSBs ≥2 times/d according to knowledge of SSB-related health conditions. Results: Overall, 37.8% of adults reported consuming SSBs ≥2 times/d. Although most adults identified that weight gain (80.2%), diabetes (73.6%), and cavities (71.8%) are related to drinking SSBs, fewer adults identified high cholesterol (24.1%), heart disease (31.5%), and hypertension (33.0%) as being related to drinking SSBs. Crude analyses indicated that lower SSB intake was significantly associated with knowledge of the associations between SSBs and weight gain, diabetes, cavities, and heart disease. However, after adjustment for covariates, only lack of knowledge of the association between heart disease and SSBs was significantly associated with consuming SSBs ≥2 times/d (OR = 1.29) than non-SSB consumers. Conclusions: The finding that knowledge of SSB-related health conditions, in general, was not associated with high SSB intake suggests that knowledge on SSB-related health conditions alone may not be sufficient for adult behavior change.

Objective To examine the associations among several body mass index (BMI) metrics ( z -scores, percent of the 95th percentile (%BMI p95 ) and BMI minus 95th percentile (ΔBMI p95 ) as calculated in the growth charts from the Centers for Disease Control and Prevention (CDC). It is known that the widely used BMI z -scores (BMIz) and percentiles calculated from the growth charts can differ substantially from those that directly observed in the data for BMIs above the 97th percentile ( z = 1.88). Study design Cross-sectional analyses of 8.7 million 2- to 4-year-old children who were examined from 2008 through 2011 in the CDC's Pediatric Nutrition Surveillance System. Results Because of the transformation used to calculate z -scores, the theoretical maximum BMIz varied by >3-fold across ages. This results in the conversion of very high BMIs into a narrow range of z -scores that varied by sex and age. Among children with severe obesity, levels of BMIz were only moderately correlated (r ~ 0.5) with %BMI p95 and ΔBMI p95 . Among these children with severe obesity, BMIz levels could differ by more than 1 SD among children who had very similar levels of BMI, %BMI p95 and ΔBMI p95 due to differences in age or sex. Conclusions The effective upper limit of BMIz values calculated from the CDC growth charts, which varies by sex and age, strongly influences the calculation of z -scores for children with severe obesity. Expressing these very high BMIs relative to the CDC 95th percentile, either as a difference or percentage, would be preferable to using BMI-for-age, particularly when assessing the effectiveness of interventions.

OBJECTIVES: To describe the prevalence and secular trends of high weight-for-length among infants (ages, 3–23 months) in the biennial US Department of Agriculture Women, Infants, and Children Program and Participants Characteristic (WIC-PC) Survey from 2000 through 2014 (n = 16 927 120). METHODS: Weight-for-length was considered to be “high” if it was ≥2 SDs above the sex- and age-specific median in the World Health Organization growth standards. Poisson regression was used to calculate adjusted prevalence ratios. RESULTS: The overall prevalence of high weight-for-length increased from 13.4% in 2000 to 14.5% in 2004, remained constant until 2010, and then decreased by >2 percentage points (to 12.3%) through 2014. The prevalence of high weight-for-length was associated with sex (higher among boys), race-ethnicity (highest among American Indians/Alaskan Natives), and with both age (positive) and family income (inverse). The secular trends, however, were fairly similar within categories of these variables. From 2010 to 2014, the prevalence of high weight-for-length decreased in 40 states and 3 (of 5) US territories, with the largest decreases seen in Puerto Rico (−9 percentage points) and Kentucky (−7 percentage points), and the largest increase (+2 percentage points) seen in West Virginia. CONCLUSIONS: Although the current results cannot be considered representative of infants in the populations, the prevalence of a high weight-for-length has decreased among infants in WIC-PC since 2010. These decreases were similar across categories of most characteristics, but there were substantial differences across jurisdictions, possibly reflecting differences in policy and local programs that target maternal and infant health.

Because there is limited information on associations between health-related knowledge and sugar-sweetened beverage (SSB) intake, our cross-sectional study examined this question using the 2010 HealthStyles Survey data for 3,926 adults (aged ≥18 years). Multivariable logistic regression analysis was used to estimate the adjusted odds ratios and 95% CIs for drinking SSBs ≥2 times per day. About 31% of adults consumed SSBs ≥1 time per day, with 20% doing so ≥2 times per day. About eight of 10 adults agreed that drinking SSBs can contribute to weight gain, yet, eight of 10 adults in this study did not know the actual kilocalorie content of a 24-oz fountain soda. After controlling for age, sex, race/ethnicity, education level, annual household income, and geographic region, the odds for drinking SSBs ≥2 times per day were significantly higher among adults who neither agreed nor disagreed (ie, were neutral) that drinking SSBs can contribute to weight gain (odds ratio 1.61, 95% CI 1.15 to 2.25 vs agree); however, knowledge about the energy content of regular soda was not associated with SSB intake. Our finding that knowledge about the adverse effects of SSB intake is significantly associated with SSB intake among adults suggests that health education regarding the potential contribution of excess energy intake from SSBs to weight gain could contribute to lowered consumption and lower rates of obesity. Although knowledge about the kilocalorie content of regular soda was unrelated to SSB intake, health education on the kilocalorie content of SSBs may still be beneficial because most adults did not know the actual kilocalorie content of SSBs. Longitudinal studies are needed to explore associations between knowledge about energy provided by SSBs and SSB intake.

OBJECTIVES: Frequent sugar-sweetened beverage (SSB) intake is associated with weight gain and type 2 diabetes. There are limited data describing SSB intake among women of reproductive age (WRA). We described SSB intake patterns among pregnant and non-pregnant WRA, and identified characteristics associated with daily SSB intake. METHODS: Using 2017 Behavioral Risk Factor Surveillance System data, we analyzed self-reported SSB intake for 392 pregnant and 11,321 non-pregnant WRA (18–49 years). SSB intake (regular soda, fruit drinks, sweet tea, and sports/energy drinks) was measured in an optional module used by the District of Columbia and 12 states (AK, AZ, AR, DE, HI, IA, NY, NC, OH, VT, WV, WI). Multivariable logistic regression models were used to estimate adjusted odds ratios (aOR) for daily (≥1 time/day) SSB intake (ref

[Author Affiliation]Heidi M. Blanck. Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.Janet L. Collins. Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA.Address correspondence to: Heidi M. Blanck, PhD, Branch Chief, Obesity Prevention and Control Branch, Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Highway, F77, Atlanta, GA 30341, E-mail: hcb3@cdc.govChildhood obesity is a serious national health problem with 17% of American youth living with obesity.1 In 2010, the Patient Protection and Affordable Care Act (ACA) appropriated $25 million for a 4-year community-based study to determine whether an integrated model of primary care and public health services can improve underserved children's risk factors for obesity. In response, the CDC established the Childhood Obesity Research Demonstration (CORD) to meet the requirements of the ACA and address the call by expert groups for comprehensive, multilevel, multisetting approaches to prevent and reduce childhood obesity.2 This commentary introduces the nine articles in this issue that describe the research collaboration funded by the CDC.Obesity-related health behaviors, such as nutrition and physical activity, are shaped by multiple sources of influence and environments, including the home, early care and education, school, healthcare, and other community settings. Therefore, a host of setting stakeholders who influence these settings, including government, education, the private setting, nonprofit organizations, and families, have a role to play in creating healthier communities. CORD will add to the limited research available on comprehensive, community-wide models for childhood obesity prevention. A recent comparative effectiveness review of the peer-reviewed childhood obesity prevention literature in developed countries found there is a need for more studies that include results from interventions occurring in multiple settings.3 The systematic review found a very limited number of articles with multiple settings and only one community-based, multiple-setting, early childhood obesity prevention study that measured weight and had at least 1 year of follow-up.4 In school-aged youth in the United States, Shape Up Somerville has been novel in its results of reducing BMI over 2 years through a community-based participatory research approach that met the community's interests and strengths and interventions that could be included into existing "platforms" (schools, afterschool, and community).5The collection of articles in this supplement to Childhood Obesity describes how CORD builds on each community's existing work, uses its stakeholders' perspectives of problems and feasible solutions, and leverages state and local infrastructure in three states: Imperial County, California; Fitchburg and New Bedford, Massachusetts; and Austin and Houston, Texas. Each of the three demonstration sites serves children ages 2-12 years and their families in communities with high childhood obesity rates.While we wait for final evaluation data from each of the demonstration sites, we are learning about novel ways that public health and primary care can work together to embed healthy eating and active living in the daily routines of children and families. CORD is increasing healthy eating and active living opportunities for young children and their families by supporting change at the individual, system, and community levels. Interventions in each setting include those reviewed and described by Foltz and colleagues on population-based research and practice-tested strategies for improving obesity-related behaviors. …

This study documented the prevalence of active screen time (i.e., screen time that includes active games, exercise or dance videos, or TV exercise programs) and identified characteristics associated with it among youth 9-18 years of age.This cross-sectional study was conducted on a convenience sample of 1,165 youth using the 2009 Styles Surveys; data were weighted to approximate the Current Population Survey. We calculated descriptive statistics and conducted multivariable logistic regression to identify characteristics associated with active screen time by estimating adjusted odds ratio (aOR) and 95 percent confidence intervals (CIs).The sample comprised 51.4 percent boys, and almost 60 percent were non-Hispanic white. The prevalence of active screen time ≥1 hour/day was 31.2 percent on a typical school day and 41.6 percent on a typical weekend day. Logistic regression revealed youth with physical activity of 3-5 days/week had higher odds of active screen time ≥1 hour/day compared with youth with no physical activity (aOR school day=2.8, 95 percent CI 1.5-5.2; aOR weekend day=2.3, 95 percent CI 1.4-3.9). Certain characteristics (i.e., sex, age group, race/ethnicity, income, and sedentary screen time) were significantly associated with active screen time ≥1 hour/day, but associations were inconsistent for school and weekend days.Three in 10 youth are engaging in at least 1 hour of active screen time on school days, and about 4 in 10 youth are engaging in at least one hour on weekend days. Understanding the use of active screen time and associated characteristics are important for developing interventions addressing screen time and physical activity.

Sales of sports and energy drinks have increased dramatically, but there is limited information on regular consumers of sports and energy drinks. Characteristics associated with sports and energy drink intake were examined among a sample representing the civilian noninstitutionalized US adult population. The 2010 National Health Interview Survey data for 25,492 adults (18 years of age or older; 48% males) were used. Nationwide, 31.3% of adults were sports and energy drink consumers during the past 7 days, with 21.5% consuming sports and energy drinks one or more times per week and 11.5% consuming sports and energy drinks three or more times per week. Based on multivariable logistic regression, younger adults, males, non-Hispanic blacks and Hispanics, not-married individuals, adults with higher family income, those who lived in the South or West, adults who engaged in leisure-time physical activity, current smokers, and individuals whose satisfaction with their social activities/relationships was excellent had significantly higher odds for drinking sports and energy drinks one or more times per week. In this model, the factor most strongly associated with weekly sports and energy drink consumption was age (odds ratio [OR]=10.70 for 18- to 24-year-olds, OR=6.40 for 25- to 39-year-olds, OR=3.17 for 40- to 59-year-olds vs 60 years or older). Lower odds for consuming sports and energy drinks one or more times per week were associated with other/multiracial (OR=0.80 vs non-Hispanic white) and obesity (OR=0.87 vs underweight/normal weight). Separate modeling of the association between other beverage intake and sports and energy drink intake showed that higher intake of regular soda, sweetened coffee/tea drinks, fruit drinks, milk, 100% fruit juice, and alcohol were significantly associated with greater odds for drinking sports and energy drinks one or more times per week. These findings can help medical care providers and public health officials identify adults most in need of encouragement to reduce sports and energy drink intake and increase healthier beverage intake.

School attendance can impact academic performance. Childhood obesity-related physical and psychosocial consequences are potentially associated with school absenteeism. Thus, we examined the association between school absenteeism attributed to illness or injury and obesity among adolescents aged 12-17 years.We used a weighted sample of 3,470 U.S. adolescents from the 2009 National Health Interview Survey. School absenteeism was measured from the parent-reported number of sick days taken in the preceding 12 months. Body mass index was calculated from parent-reported weight and height. Weight status was classified based on the sex-specific body mass index-for-age percentile defined by the CDC growth charts. Poisson regression was conducted to examine the association between school absenteeism and weight status, controlling for selected sociodemographic characteristics and disease status.The mean number of annual sick days was 3.9 days overall; 3.4 days among normal-weight, 4.4 days among overweight, and 4.5 days among obese adolescents. Obese adolescents had a higher proportion of missing ≥4 days of school per year than adolescents of normal weight. Our multivariate analyses found that compared with adolescents of normal weight, overweight and obese adolescents had greater than one-third more sick days annually (rate ratio = 1.36 for overweight and 1.37 for obese adolescents).Overweight and obese adolescents had 36% and 37% more sick days, respectively, than adolescents of normal weight. The results suggest another potential aspect of obesity prevention and reduction efforts among children and families is to improve children's school attendance.

Objective: A recent, cross-sectional analysis of adults found that the hip circumference divided by height1.5 minus 18 (the body adiposity index, BAI) was strongly correlated (r = 0.79) with percent body fat determined by dual energy X-ray absorptiometry. The BAI was proposed as a more accurate index of body fatness than BMI. We examined whether BAI was more strongly related, than was BMI and waist circumference, to skinfold thicknesses and levels of various risk factors for coronary heart disease. Design and Methods: Cross-sectional analyses of adults (n = 14,263 for skinfold thickness; n=6291 for fasting lipid levels) in the National Health and Nutrition Examination Survey (NHANES) III, 1988-1994. Results: As compared with BMI and waist circumference, we found that BAI was less strongly associated with the skinfold sum and with risk factor levels. For example, correlations with the skinfold sum were r = 0.79 (BMI) vs. r = 0.70 (BAI) among men, and r = 0.86 (BMI) vs. r = 0.79 (BAI) among women; p < 0.001 for the difference between each pair of correlations. An overall index of the 7 risk factors was also more strongly associated with BMI and waist circumference than BAI in analyses stratified by sex, race-ethnicity and age. Multivariable analyses indicated that if BMI was known, BAI provided little additional information on risk factor levels. Conclusions: Based on the observed associations with risk factor levels and skinfold thicknesses, we conclude that BAI is unlikely to be a better index of adiposity than BMI.

Limited research shows an inconclusive association between soda intake and asthma, potentially attributable to certain preservatives in sodas. This cross-sectional study examined the association between regular (nondiet)-soda intake and current asthma among a nationally representative sample of high school students. Analysis was based on the 2009 national Youth Risk Behavior Survey and included 15,960 students (grades 9 through 12) with data for both regular-soda intake and current asthma status. The outcome measure was current asthma (ie, told by doctor/nurse that they had asthma and still have asthma). The main exposure variable was regular-soda intake (ie, drank a can/bottle/glass of soda during the 7 days before the survey). Multivariable logistic regression was used to estimate the adjusted odds ratios for regular-soda intake with current asthma after controlling for age, sex, race/ethnicity, weight status, and current cigarette use. Overall, 10.8% of students had current asthma. In addition, 9.7% of students who did not drink regular soda had current asthma, and 14.7% of students who drank regular soda three or more times per day had current asthma. Compared with those who did not drink regular soda, odds of having current asthma were higher among students who drank regular soda two times per day (adjusted odds ratio=1.28; 95% CI 1.02 to 1.62) and three or more times per day (adjusted odds ratio=1.64; 95% CI 1.25 to 2.16). The association between high regular-soda intake and current asthma suggests efforts to reduce regular-soda intake among youth might have benefits beyond improving diet quality. However, this association needs additional research, such as a longitudinal examination.

Sugar-sweetened beverage (SSB) intake among U.S. adults is associated with obesity and type 2 diabetes. An association between SSB intake and asthma has been shown among U.S. children and Australian adults, but scant published information exists for U.S. adults. We examined associations between SSB intake and current asthma among U.S. adults, and the role of obesity in this association.We analyzed 2013 Behavioral Risk Factor Surveillance System data for 146,990 adults (≥18years) from 23 states and the District of Columbia. We used multivariable logistic regression to estimate associations between current asthma and frequency (none,1 time/day, once/day, ≥2 times/day) of SSB intake (soda, fruit drink, sweet tea, and sports/energy drink). SSB intake was measured using two questions. Covariates included age, sex, race/ethnicity, education, and smoking. Obesity, based on self-reported height and weight, was assessed as an effect modifier.Overall, 9.1% of adults reported current asthma: 8.5% of adults who did not consume SSBs had current asthma vs 12.1% of adults who consumed SSBs ≥2 times/day. There was no difference in asthma prevalence with SSB intake1 time/day (8.7%) or once/day (8.7%). Among non-obese adults, the odds of having current asthma were higher among those who consumed SSBs ≥2 times/day (aOR=1.66, 95%CI=1.39, 1.99) than non-SSB consumers. However, SSB intake frequency was not associated with asthma among obese adults.Frequent SSB consumption was associated with asthma among non-obese adults. Research on asthma prevention should further consider the potential adverse effects of high SSB intake among U.S. adults.

The National Cancer Institute developed the Family Life, Activity, Sun, Health, and Eating (FLASHE) Study to examine multiple cancer preventive behaviors within parent–adolescent dyads. The purpose of creating FLASHE was to enable the examination of physical activity, diet, and other cancer preventive behaviors and potential correlates among parent–adolescent dyads. FLASHE surveys were developed from a process involving: literature reviews, scientific input from experts in the field, cognitive testing, and usability testing. This cross-sectional, web-based study of parents and their adolescent children (aged 12–17 years) was administered between April and October 2014. The nationwide sample consisted of 1,573 parent–adolescent dyads (1,699 parents and 1,581 adolescents) who returned all FLASHE surveys. FLASHE assessed parent and adolescent reports of several intrapersonal and interpersonal domains (including psychosocial variables, parenting, and the community and home environments). On a subset of example FLASHE items across these domains, responses of parents and adolescents within the same dyads were positively and significantly correlated (r =0.32–0.63). Analyses were run in 2015–2016. FLASHE data present multiple opportunities for studying research questions among individuals or dyads, including the ability to examine similarity between parents and adolescents on many constructs relevant to cancer preventive behaviors. FLASHE data are publicly available for researchers and practitioners to help advance research on cancer preventive health behaviors.

The 2015-2020 Dietary Guidelines for Americans recommend that the daily intake of calories from added sugars not exceed 10% of total calories. Sugar-sweetened beverages (SSBs) are significant sources of added sugars in the diet of U.S. adults and account for approximately one third of added sugar consumption. Among adults, frequent (i.e., at least once a day) SSB intake is associated with adverse health consequences, including obesity, type 2 diabetes, and cardiovascular disease. According to the 2009-2010 National Health and Nutrition Examination Survey (NHANES), an in-person and phone follow-up survey, 50.6% of U.S. adults consumed at least one SSB on a given day. In addition, SSB intake varies by geographical regions: the prevalence of daily SSB intake was higher among U.S. adults living in the Northeast (68.4%) and South (66.7%) than among persons living in the Midwest (58.8%). In 2013, the Behavioral Risk Factor Surveillance System (BRFSS), a telephone survey, revised the SSB two-item optional module to retain the first question on regular soda and expand the second question to include more types of SSBs than just fruit drinks. Using 2013 BRFSS data, self-reported SSB (i.e., regular soda, fruit drinks, sweet tea, and sports or energy drinks) intake among adults (aged ≥18 years) was assessed in 23 states and the District of Columbia (DC). The overall age-adjusted prevalence of SSB intake ≥1 time per day was 30.1% and ranged from 18.0% in Vermont to 47.5% in Mississippi. Overall, at least once daily SSB intake was most prevalent among adults aged 18-24 years (43.3%), men (34.1%), non-Hispanic blacks (blacks) (39.9%), unemployed adults (34.4%), and persons with less than a high school education (42.4%). States can use the data for program evaluation and monitoring trends, and information on disparities in SSB consumption could be used to create targeted intervention efforts to reduce SSB consumption.

Few studies take into account the influence of family size on household resources when assessing income disparities in fruit and vegetable (F/V) consumption. Poverty income ratio (PIR) is a measure that utilizes both reported income and household size. We sought to examine state-specific disparities in meeting Healthy People 2010 objectives for F/V consumption by percent PIR. This analysis included 353,005 adults in 54 states and territories reporting data to the 2009 Behavioral Risk Factor Surveillance System in the United States. Percent PIR was calculated using the midpoint of self-reported income range and family size. The prevalences consuming at least two fruits and at least three vegetables per day were examined by percent PIR (130% [greatest poverty], 130% to200%, 200% to400%, and ≥ 400% [least poverty]). The percent of adults consuming vegetables at least three times daily was significantly lower (21.3%) among those living at greatest poverty (130% PIR) compared with 30.7% among those with least poverty (≥ 400% PIR). Daily consumption of vegetables at least three times was significantly lower among those with greatest poverty in a majority of states and territories surveyed (43 of 54). The overall percent of adults consuming fruits at least 2 times daily was also lower among those living at greatest vs least poverty, but the difference was smaller (32.0% vs 34.2%), with 14 states reporting a difference that was significantly lower among those with greatest poverty. Our study revealed that in 2009 a significantly lower proportion of US adults living at greatest poverty consumed fruits at least two times daily or vegetables at least three times daily compared with those with the least poverty, with greater disparity in vegetable intake. Policy and environmental strategies for increased affordability, access, availability, and point-of-decision information are approaches that may help disparate households purchase and consume F/V.

Background Fruit and vegetable (F/V) intake assessment tools that are valid, reliable, brief, and easy to administer and code are vital to the field of public health nutrition. Objective To evaluate three short F/V intake screeners (ie, a 2-item serving tool, a 2-item cup tool, and a 16-item F/V intake screener) among adults using multiple 24-hour dietary recalls (24-hour recalls) as the reference instrument and evaluate test–retest reliability of the screeners across a 2- to 3-week time period. Design Validity and reliability study. Participants/setting Two hundred forty-four adults for the validity study and 335 adults for test–retest reliability. Statistical analyses performed Median values for F/V intakes were calculated for the screeners and 24-hour recalls. The Wilcoxon signed rank test was used to compare screeners with the 24-hour recalls. Deattenuated Pearson correlations were reported for validity and intraclass correlation coefficient used for reliability. Results The estimated median daily servings/cups of F/V for the 2-item serving screener was lower, for the 2-item cup screener was equivalent for men but higher for women, and for the 16-item F/V intake screener were about the same when compared with 24-hour recall values. The deattenuated correlations comparing the 24-hour recalls with the screeners were positive but weak for the 2-item serving screener, and were positive and moderate in strength for the 2-item cup and 16-item F/V intake screeners. The test–retest intraclass correlation coefficients were all positive and fairly strong for all of the screeners. Conclusions Although dietary screeners offer a more cost-effective, less burdensome way to obtain gross estimates to rank individuals with regard to F/V intake, these methods are not recommended for assessing precise intake levels.

Let's go to the park today! this familiar phrase is heard routinely throughout the year in many U. s. households. Access to parks, trails, open spaces, and recreational facilities not only provides increased opportunities for children and adults to play and be physi - cally active, but these venues also influence other behaviors. As the health and wellbeing of our children are impacted by the daily environment in which they live, learn, and play, the use of parks and other recreation spaces as a healthful venue is important to consider in a comprehensive view of childhood and family obesity prevention. this article briefly summarizes some of the obesity- related benefits of parks across the local, state, and national park systems and highlights specific initiatives as examples of the com - mitment by park agencies to benefit the public's health and play a role in obesity and chronic disease prevention.

A redesigned food insecurity question that measured food stress was included in the 2009 Behavioral Risk Factor Surveillance System in the Social Context optional module. The objective of our study was to examine the association between food stress and obesity using this question as a surrogate for food insecurity. Our analytic sample included 66,553 adults from 12 states. Food insecurity was determined by response (always/usually/sometimes) to the question,“Howoften in the past 12 months would you say you were worried or stressed about having enough money to buy nutritious meals?” T tests were used to compare prevalence differences between groups, and logistic regression was used to examine the association between food insecurity and obesity. Among the 12 states, the prevalence of obesity was 27.1% overall, 25.2% among food secure adults, and 35.1% among food insecure adults. Food insecure adults had 32% increased odds of being obese compared to food secure adults. Compared with food secure adults, food insecure adults had significantly higher prevalence of obesity in the following population subgroups: adults ages ≥30 years, women, non- Hispanic whites, non-Hispanic blacks, adults with some college education or a college degree, a household income of

Childhood obesity is a major threat to individual health and society overall. Policies that support healthier food and beverage choices have been endorsed by many decision makers. These policies may reach a large proportion of the population or in some circumstances aim to reduce nutrition disparities to ensure health equity. The Nutrition and Obesity Policy Research and Evaluation Network (NOPREN) evaluates policy as a tool to improve food and beverage environments where Americans live, work, play, and learn. The network aspires to address research and evaluation gaps related to relevant policies, create standardized research tools, and help build the evidence base of effective policy solutions for childhood obesity prevention with a focus on reach, equity, cost effectiveness, and sustainability.

With obesity affecting approximately 12.5 million American youth, population-level interventions are indicated to help support healthy behaviors. The purpose of this review is to provide a summary of population-level intervention strategies and specific intervention examples that illustrate ways to help prevent and control obesity in children through improving nutrition and physical activity behaviors. Information is summarized within the settings where children live, learn, and play (early care and education, school, community, health care, home). Intervention strategies are activities or changes intended to promote healthful behaviors in children. They were identified from (a) systematic reviews; (b) evidence- and expert consensus–based recommendations, guidelines, or standards from nongovernmental or federal agencies; and finally (c) peer-reviewed synthesis reviews. Intervention examples illustrate how at least one of the strategies was used in a particular setting. To identify interventions examples, we considered (a) peer-reviewed literature as well as (b) additional sources with research-tested and practice-based initiatives. Researchers and practitioners may use this review as they set priorities and promote integration across settings and to find research- and practice-tested intervention examples that can be replicated in their communities for childhood obesity prevention.

Individual interventions to increase fruit and vegetable (FV 159 introduced (65 enacted in the healthier food retail topic area), respectively. Other topics included general access and affordability, food system support, and food policy councils. Legislation increased over time; 6 bills were introduced in 2001 (3 enacted), and 138 were introduced in 2009 (31 enacted). Policy surveillance of a food system approach to supporting F&V allows stakeholders from many fields to understand policy approaches to improving health and potential cobenefits of these policies. This article not subject to U.S. copyright law.

Importance Severe obesity in childhood is associated with negative health consequences. A previous study examined trends in severe obesity among preschool-aged children in low-income families during 1998 to 2010. No recent trends have been reported. Objective To examine trends in severe obesity by age, sex, and race/ethnicity among enrollees in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) aged 2 to 4 years during 2000 to 2014. Design, Setting, and Participants Serial cross-sectional data from 22.6 million young children enrolled in WIC from 50 states, the District of Columbia, and 5 US territories from 2000 to 2014. Data analysis was conducted from February 16, 2017, to March 9, 2017. Main Outcomes and Measures Prevalence of severe obesity. Severe obesity was defined as a sex-specific body mass index-for-age 120% or more of the 95th percentile on the 2000 Centers for Disease Control and Prevention growth charts. Children’s weights and heights were measured. Children whose sex, weight, height, or body mass index was missing or biologically implausible were excluded. Results The prevalence of severe obesity was 1.96% in 2014. During 2000 to 2004, the prevalence increased significantly overall from 1.80% to 2.11% (adjusted prevalence difference [APD], 0.26%) and among all the age, sex, and racial/ethnic groups except for Asian/Pacific Islander (APD, 0.05%-0.54% across groups with increases). The largest relative increase occurred in children aged 4 years (adjusted prevalence ratio [APR], 1.21) and non-Hispanic white (APR, 1.22) and American Indian/Alaska Native children (APR, 1.19). During 2004 to 2010, the prevalence decreased significantly overall (APD, −0.05%), among boys, children aged 2 and 3 years, and non-Hispanic black and Asian/Pacific Islander children (APD, −0.05% to −0.18%). During 2010 to 2014, the prevalence decreased significantly overall from 2.12% to 1.96% (APD, −0.14%) and among all demographic groups (APD, −0.04% to −0.30% across groups). The largest relative decrease occurred in children aged 2 years (APR, 0.88) and Hispanic (APR, 0.92), American Indian/Alaska Native (APR, 0.89), and Asian/Pacific Islander (APR, 0.87) children. Conclusions and Relevance This study provides updated prevalence and trends of severe obesity among young children enrolled in WIC and reports recent modest declines in severe obesity in all subgroups. Ongoing surveillance can assess whether declines continue into the future among low-income children.

Objective: To determine associations between changes in obesity and vigorous physical activity (PA) status and depressive symptoms in a cohort aged 51 to 61 years at baseline. Method: Two waves (1992, 1998) of Health and Retirement Study data were used to divide participants into four obesity and four vigorous PA status categories based on change in or maintenance of their 1992 status in 1998. Depressive symptoms were defined as the upper quintile score (women ≥ 4, men ≥ 3) on the eight-item Center for Epidemiologic Studies—Depression Scale. Logistic regression determined adjusted odds ratios for depressive symptoms associated with obesity and vigorous PA status. Results: Among men, no significant associations were found. Among women, decreasing from high vigorous PA status and maintenance of obese status were independently associated with increased odds for depressive symptoms in 1998. Discussion: The findings illustrate the importance of examining gender differences in studies of risk factors for depression.

One contributing factor to the obesity epidemic is the large portion sizes served in restaurants. However, no study has looked at the parents' desire for smaller-portioned meals for their children at restaurants in the U.S. This study examined parents' preference for restaurants to offer smaller, lower-priced child portions for their children and reasons for the preference. Multivariable logistic regression was used to estimate adjusted odds ratios (ORs) for the association between preference for child portions and variables on parental sociodemographic characteristics and weight status. About 70% of parents said they would prefer that restaurants offer smaller, lower-priced child portions of all menu offerings. The adjusted odds of preferring child portions were significantly higher among Hispanic parents (OR, 1.95 vs. non-Hispanic whites) but significantly lower among parents with lower education (≤ high school, OR, 0.64; some college, OR, 0.69 vs. college graduate) and parents residing in the Midwest or West (Midwest, OR, 0.61; West, OR, 0.58 vs. South). The most common reason for preferring child portions of all meals was “wanting my child to eat healthier foods that are not offered on the children's menu” (72%). These findings can be used to encourage restaurants and other venues to consider offering child portions of healthier menu items.

PURPOSE: Widespread changes in the health care system including payment reform and new delivery models create opportunity for engaging healthcare payers to improve health and control healthcare costs. For high burden and impact conditions, such as child obesity, with evidence based interventions for prevention and treatment, public health can play a role in accelerating evidence to action. The US Preventive Services Task Force (USPSTF) has given a grade B recommendation for child and adolescent obesity: 1) screen all children aged 6-18 years for obesity, and …

Objectives To estimate the prevalence of obese patients advised by health professionals about weight loss and weight loss strategies. Methods A national sample of 1873 obese adults (body mass index ≥ 30 kg/m 2 , ≥ 18 years) was surveyed. Multivariable linear regression was used to determine characteristics associated with receiving weight loss advice, and advice on diet and physical activity. Linear regression was used to evaluate characteristics associated with how much weight loss was advised. Results Among obese adults visiting a physician (past 12 months), 39.0% reported being advised to lose weight. Men had lower odds of being advised to lose weight. Adults 40–49 years of age, reporting fair/poor health, and chronic diseases had greater odds of being advised to lose weight compared to referent groups. Among adults receiving advice on amount of weight to lose, a mean 20.9% total body weight reduction was recommended. Of those advised to lose weight, 64.2% were told to change their diet, 85.7% to increase physical activity, and 58.5% to use both strategies. Conclusions Obese adults should be advised by health professionals more frequently about weight loss and the use of caloric reduction and increased physical activity as the recommended weight loss strategy.

The Michigan Long-Term PBB Study was established following exposure to polybrominated biphenyls (PBBs) in the early 1970s. Serum samples from cohort members were analyzed for PBB during 1976–1993. More than 20 years following this industrial incident, some participants still had measurable serum PBB concentration levels. Thus, there is continuing interest in understanding the elimination of PBB from the body. In the present study, we estimated serum PBB decay and investigated the effects of covariates on serum PBB decay rates among 406 female cohort members. We developed a decay model using a general linear mixed model, which attributes unique intercept and slope estimates for each individual while borrowing information across individuals for predicting these quantities. Age at exposure and body mass index (BMI) at the initial measurement were time-independent covariates. Time since exposure, smoking history, pregnancy status, and breast-feeding status were time-dependent covariates. Higher BMI was associated with a slower decay rate; smokers had a faster decay rate than nonsmokers; and increasing age at exposure was marginally associated with a slower decay rate. Our results suggest a faster serum PBB decay rate for women who breast-fed during the interval between serum PBB measurements. To evaluate the predictive performance of our modeling approach, we compared the results from this model with those from a previously developed ordinary least squares (OLS) two-stage decay model. The mixed-effects decay model predicted the observed serum PBB concentration levels significantly better than the OLS two-stage decay model (mixed-effects model, r=0.93; OLS two-stage model, r=0.86; P

Background As policy strategies are rapidly being developed to address childhood overweight, a system was developed to systematically and reliably classify state policies related to the school nutrition environment. This study describes the development process, the inter-rater reliability to code state policies enacted as of December 2003, and the variability in state policies related to the school nutrition environment. Methods The development of the School Nutrition Environment State Policy Classification System (SNESPCS) included a comprehensive review of published literature, reports from government and nongovernmental sources, input from an expert panel, and select experts. Baseline statutes and regulations for each of the 50 states and the District of Columbia were retrieved from Westlaw (data retrieved in 2005–2006 and analyzed in 2006) and pilot testing of the system was conducted. Results SNESPCS included 11 policy areas that relate to a range of environmental and surveillance domains. At baseline, states had no (advertising/promotion and preferential pricing) or modest (school meal environment, reimbursable school meals, coordinating or advisory councils, body mass index screening) activities in many of the policy areas. As of 2003, 60% of the states had policies related to the sale of foods in school that compete with the school meal program. Conclusions Evaluation of policies that affect the school-nutrition environment is in its earliest stage. SNESPCS provides a mechanism for assessing variation in state policies that can be incorporated in an evaluation framework aimed at elucidating the impact of state policies on the school environment, social norms, and children’s dietary behaviors in schools.

Accidental contamination of livestock in Michigan in 1973 with polybrominated biphenyls (PBBs) led to the establishment of a registry of exposed individuals in 1976. At the time of enrollment, serum was collected and analyzed for PBBs and polychlorinated biphenyls, PCBs. In 1997, women aged 18 years or older and active in the registry were invited to participate in a telephone interview about their health. Using generalized estimating equations to account for correlated outcomes within the same woman, we assessed the risk of spontaneous abortion among 529 women with 1344 potentially exposed pregnancies. PBB and PCB exposure were not associated with risk of spontaneous abortion after adjusting for maternal age at conception, age at menarche, and prior infertility. Compared to pregnancies with PBB exposure below the limit of detection, those with levels above 2.9 ppb had a non-significant reduced odds of spontaneous abortion (adjusted OR=0.73; 95% CI= 0.47-1.13). Compared to pregnancies with PCB exposure below the limit of detection, those with levels above 6.5 ppb had little difference in risk (adjusted OR=0.91; 95% CI= 0.59-1.41). Maternal age at conception above 34 years was significantly associated with elevated risk of spontaneous abortion (OR=2.46; 95% CI= 1.10-5.49). The effect of prior infertility was of borderline significance (OR=1.52; 95% CI= 0.98-2.38). Older age at menarche was associated with decreased risk of spontaneous abortion (adjusted OR=0.58; 95% CI: 0.38-0.89, comparing menarche at 12-13 with menarche

Understanding the influence of maternal exposures on gestational age and birth weight is essential given that pre-term and/or low birth weight infants are at risk for increased mortality and morbidity. We performed a retrospective analysis of a cohort exposed to polybrominated biphenyls (PBB) through accidental contamination of cattle feed and polychlorinated biphenyls (PCB) through residual contamination in the geographic region. Our study population consisted of 444 mothers and their 899 infants born between 1975 and 1997. Using restricted maximum likelihood estimation, no significant association was found between estimated maternal serum PBB at conception or enrollment PCB levels and gestational age or infant birth weight in unadjusted models or in models that adjusted for maternal age, smoking, parity, infant gender, and decade of birth. For enrollment maternal serum PBB, no association was observed for gestational age. However, a negative association with high levels of enrollment maternal serum PBB and birth weight was suggested. We also examined the birth weight and gestational age among offspring of women with the highest (10%) PBB or PCB exposure, and observed no significant association. Because brominated compounds are currently used in consumer products and therefore, are increasingly prevalent in the environment, additional research is needed to better understand the potential relationship between in utero exposure to brominated compounds and adverse health outcomes.

The purpose was to assess the prevalence and correlates of complementary and alternative medicine use for weight control.A list-assisted random-digit-dialed telephone survey of adults was conducted in the fall of 2002 (n = 11,211). The focus of the study was complementary and alternative medicine (CAM) use, other than dietary supplements, in the previous 12 months.The sample of respondents was drawn from the total noninstitutionalized U.S. adult population residing in telephone-equipped locations.The sampling procedures were designed to obtain adequate representation of Hispanic and non-Hispanic black respondents. Data from the total sample of 11,211 were weighted to achieve an estimate of the U.S. population. Analyses focused on 372 people who had used CAM within the previous 12 months.Of the total, 3.3% (n = 372) had used a CAM therapy in the previous 12 months. Higher adjusted odds ratios for CAM use were found among respondents who were exercising for weight control; using a lower carbohydrate, higher protein diet; using a nonprescription weight-loss product(s); overweight; physically active; and not satisfied with one's body (adjusted for age, race, gender, education, and city size). The most often used therapies were yoga (57.4%), meditation (8.2%), acupuncture (7.7%), massage (7.5%), and Eastern martial arts (5.9%). CAM users used CAM therapies on their own (62.6%), in a group setting (26.8%) or with a CAM practitioner (10.6%).The use of CAM therapies other than dietary supplements for weight loss was relatively low. The most popular therapy was yoga, and the majority of CAM users used CAM therapies on their own. Persons who had used other weight loss methods had greater odds for using CAM in the previous 12 months, suggesting that CAM use is often added to other weight-loss strategies.

Background Reducing added sugars intake is one of the Healthy People 2020 objectives. High added sugars intake may be associated with adverse health consequences. Objective This cross-sectional study identified sociodemographic and behavioral characteristics associated with added sugars intake among US adults (18 years and older) using the 2010 National Health Interview Survey data (n=24,967). Methods The outcome variable was added sugars intake from foods and beverages using scoring algorithms to convert dietary screener frequency responses on nine items to estimates of individual dietary intake of added sugars in teaspoons per day. Added sugars intake was categorized into tertiles (lowest, middle, highest) stratified by sex. The explanatory variables were sociodemographic and behavioral characteristics. Multinomial logistic regression was used to estimate the adjusted odds ratios for the highest and middle tertile added sugars intake groups as compared with the lowest tertile group. Results Estimated median added sugars intake was 17.6 tsp/d for men and 11.7 tsp/d for women. For men and women, those who had significantly greater odds for being in the highest tertile of added sugars intake (men: ≥22.0 tsp/d; women: ≥14.6 tsp/d) were younger, less educated, had lower income, were less physically active, were current smokers, and were former or current infrequent/light drinkers, whereas non-Hispanic other/multiracial and those living in the West had significantly lower odds for being in the highest tertile of added sugars intake. Different patterns were found by sex. Non-Hispanic black men had lower odds for being in the highest tertile of added sugars intake, whereas non-Hispanic black women had greater odds for being in the highest tertile. Conclusions One in three men consumed ≥22.0 tsp added sugars and one in three women consumed ≥14.6 tsp added sugars daily. Higher added sugars intake was associated with various sociodemographic and behavioral characteristics; this information can inform efforts to design programs and policies specific to high-intake populations.