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Evidence suggests that sweetened beverage taxes reduce taxed beverage purchases, but few studies have used individual-level data to assess whether these taxes affect purchases of nontaxed foods, beverages, and alcohol. Additionally, research has not examined whether sweetened beverage taxes influence restaurant purchases.We assessed changes in individuals' purchases of taxed beverage types; low-calorie/low-added-sugar nontaxed beverages; high-calorie/high-added-sugar nontaxed beverages, foods, and alcohol; and beverages from restaurants following implementation of the 1.5 cent-per-ounce Philadelphia sweetened beverage tax.A longitudinal cohort of adult sugar-sweetened beverage consumers in Philadelphia (n = 306; 67% female; mean age: 43.9 years) and Baltimore (n = 297; comparison city without a beverage tax; 58% female; mean age: 41.7 years) submitted all food and beverage receipts during 2-week periods at baseline and at 3, 6, and 12 months posttax. Difference-in-differences analyses compared changes in purchases from pre- to posttax in Philadelphia to changes in Baltimore.Purchases of taxed juice drinks [ratio of incidence rate ratios (RIRR) = 0.62; 95% CI, 0.42-0.91], but not other taxed beverage types, decreased in Philadelphia compared to Baltimore following the tax. Analyses did not find changes in purchases of low-calorie/low-added-sugar nontaxed beverages, such as water or milk. Additionally, analyses did not find increases in purchases of most high-calorie/high-added-sugar nontaxed products, including alcohol, juice, candy, sweet snacks, salty snacks, and desserts. Purchases of beverage concentrates increased in Philadelphia (RIRR = 2.22; 95% CI, 1.39-3.54).In this difference-in-differences analysis, the Philadelphia beverage tax was associated with reduced purchases of taxed juice drinks. Purchases of beverage concentrates increased after the tax, but no increases were observed for other high-calorie/high-added-sugar nontaxed foods, beverages, or alcohol.

In January 2017 Philadelphia, Pennsylvania, implemented an excise tax of 1.5 cents per ounce on beverages sweetened with sugar or artificial sweeteners. Small independent stores are an important ye...

Background: Cardiovascular and respiratory diseases, predominantly due to tobacco use, are the leading causes of death among individuals with serious and persistent mental illness. However, many psychiatric health facilities do not routinely treat tobacco use disorder. The purpose of the current study was to examine the impact of implementing a tobacco-free policy in inpatient psychiatric health facilities in a large, urban setting on behavioral problems, treatment access, and tobacco treatment. Methods: Data on seclusion and restraint incidents, voluntary commitment at admission for each hospitalization episode, and nicotine replacement therapy (NRT) prescriptions were collected through secondary analysis of Medicaid administrative records from baseline in January 2015 ( n = 8983) to follow-up in December 2016 ( n = 9685) at 14 inpatient psychiatric health facilities. Results: There were no significant changes from baseline to follow-up in odds of seclusion and restraint incidents or voluntary admission status. There was a significant increase in the odds of NRT prescriptions at both 30 and 180 days post discharge (odds ratio [OR] range = 1.58–2.09, P Conclusions: In a large, urban setting among Medicaid enrollees, implementation of a tobacco-free policy in inpatient psychiatric health facilities had no negative impact on behavioral problems or treatment access and improved access to NRT, although overall NRT use remained low. This study challenges perceptions among some providers that addressing tobacco use disorder will negatively impact treatment outcomes in individuals with serious mental illness. These findings support tobacco-free policies in psychiatric health facilities and the role of psychiatric health providers in treating tobacco use in this population, which is at high risk for tobacco-related mortality.

Objectives. To evaluate changes in licensed tobacco retailers and retailer density 5 years before and 3 years after novel tobacco retailer licensing regulations were implemented in a large, urban area. Methods. We used administrative tobacco license data (n = 23 806 licenses, 2012–2019) to calculate (1) annual retailer density by district (n = 18), (2) density by district and school income status, and (3) retailers within 500 feet of schools (n = 673) before and after regulations. Results. Observed tobacco retailer density declined by 20.3% (from 1.97 to 1.57 per 1000 daytime residents) 3 years after regulation implementation. Regression results showed a decline in the trend of retailers per 1000 daytime population (b = −0.19; 95% confidence interval[CI] = −0.23, −0.14) that was modestly but significantly greater in low-income districts (interaction b = −0.18; 95% CI = −0.25, −0.11) and a 12% decline in the rates of retailers near schools (rate ratio = 0.88; 95% CI = 0.85, 0.92) following implementation of the regulations. We did not observe similar density changes in comparable cities. Conclusions. Tobacco retailer licensing strategies can be an effective policy approach to reduce the availability of tobacco and tobacco marketing, lessen socioeconomic disparities in tobacco retailer density, and decrease the number of tobacco outlets near schools.

INTRODUCTION: It is unclear if changes in beverage price and sales following beverage tax implementation can be sustained long term. This study aims to quantify changes in beverage prices and sales in large retailers 2 years after implementation of the 1.5 cents-per-ounce Philadelphia beverage tax. METHODS: Data on price and volume sales of beverages and potential food substitutes were collected from 109 supermarkets, 45 mass merchandisers, and 350 pharmacies in Philadelphia, Baltimore (control), and Pennsylvania ZIP codes bordering Philadelphia (to investigate potential cross-border shopping for tax avoidance). Difference-in-differences analyses compared beverage prices and volume sales in the year before tax implementation (2016) to 2 years after (2018). Data were analyzed in 2020–2021. RESULTS: Difference-in-differences analyses found that, after tax implementation, taxed beverage prices in Philadelphia increased by 1.02 cents per ounce (95% CI=0.94, 1.11; 68% pass-through) and taxed beverage volume sales in stores decreased by 50% (95% CI=36%, 61%). After accounting for cross-border shopping, taxed beverage volume sales decreased in Philadelphia by 35% in 2018. Volume sales of nontaxed beverages did not change post-tax (difference-in-differences=4%, 95% CI= −3%, 12%). Volume sales of nontaxed beverage concentrates increased on average by 34% (95% CI=19%, 51%), but there was no evidence of substitution to high-calorie foods. CONCLUSIONS: There was a large reduction in taxed beverage volume sales 2 years after Philadelphia tax implementation, even after accounting for cross-border shopping. Increases in nontaxed beverage concentrate sales likely partially offset this decline, but there was no evidence of post-tax food substitution.

Purpose: To evaluate changes in compliance with a smoke-free outdoor seating policy before and after passage of a local regulation in 2015, which reinterpreted Philadelphia’s Clean Indoor Air Worker Protection Law to include outdoor seating areas of food or beverage establishments. Design: Natural experiment. Setting: Philadelphia, Pennsylvania. Sample: Food or beverage establishments (N = 108). Establishments were comprised of sit-down restaurants, cafes, quick-service restaurants, and bars. Measures: Presence of outdoor smoking and smoking-related litter on a given day were measured as binary variables. A geographic information system–based survey developed for this study was used to collect observational data. Analysis: Logistic regressions were used to determine the change in odds of observing outdoor smoking and smoking-related litter on a given day from baseline (preregulation) to follow-up (postregulation). Results: Compliance with smoke-free outdoor seating increased from 84.5% to 95.4% after passage and implementation of the regulation. Results showed a significant 75% decrease (odds ratio [OR]: = 0.25, 95% confidence interval [CI]: 0.08-0.67) in odds of outdoor smoking and a slight decrease in smoking-related litter (OR: 0.81, 95% CI: 0.39-1.65) at follow-up in establishments overall. However, at baseline, bars had higher odds of outdoor smoking (OR: 2.68, 95% CI: 0.57-12.72) and smoking-related litter (OR: 4.09, 95% CI:, 1.87-9.49) compared to sit-down restaurants. Conclusion: Results suggest there is high compliance with low-cost, low-burden, smoke-free outdoor seating policy and that enforcement is best targeted toward bars.

Key Points Question How has the 2017 Philadelphia beverage tax factored into longer-term changes in beverage prices and purchases in independent food retail stores based on observational data? Findings This cross-sectional study found that, 2 years after tax implementation, price audits of stores showed 137% of the tax was passed through to prices and bag checks indicated a 42% decline in volume of taxed beverages purchased in Philadelphia compared with Baltimore. Total calories purchased from beverages and high-sugar foods declined, suggesting food substitution did not offset beverage declines. Meaning These findings suggest a city-level beverage excise tax was associated with persistent declines in purchases of sweetened drinks and calories from sugar in independent stores., This cross-sectional study assesses the association of a sweetened beverage tax imposed by the city of Philadelphia, Pennsylvania, with price changes on beverages in small independent retail stores and examines changes in purchases of sweetened beverages and high-sugar foods after implementation of the tax., Importance The relationship between a sweetened beverage tax and changes in the prices and purchases of beverages and high-sugar food is understudied in the long term and in small independent food retail stores where sugar-sweetened beverages are among the most commonly purchased items. Objective To examine whether a 1.5 cent-per-fluid-ounce excise tax on sugar- and artificially sweetened beverages Philadelphia, Pennsylvania, was associated with sustained changes in beverage prices and purchases, as well as calories purchased from beverages and high-sugar foods, over 2 years at small independent stores. Design, Setting, and Participants This cross-sectional study used a difference-in-differences approach to compare changes in beverage prices and purchases of beverages and high-sugar foods (candy, sweet snacks) at independent stores in Philadelphia and Baltimore, Maryland (a nontaxed control) before and 2 years after tax implementation, which occurred on January 1, 2017. Price comparisons were also made to independent stores in Philadelphia’s neighboring counties. Main Outcomes and Measures Changes in mean price (measured in cents per fluid ounce) of taxed and nontaxed beverages, mean fluid ounces purchased of taxed and nontaxed beverages, and mean total calories purchased from beverages and high-sugar foods. Results Compared with Baltimore independent stores, taxed beverage prices in Philadelphia increased 2.06 cents per fluid ounce (95% CI, 1.75 to 2.38 cents per fluid ounce; P

We explored the role that exogenous and endogenous competitors for attention play in infants' abilities to encode and retain information over a 6-month period. Sixty-six children visited the laboratory at 15 months, and 32 returned for a second visit at 21 months. Children observed models of conventional- relation and enabling-relation action sequences. Half the children were distracted by a "Mister Monkey" mechanical toy during the conventional-relation sequence, while the other half was distracted during the enabling-relation sequence. The Early Childhood Behavior Questionnaire indexed endogenous factors at both ages. Immediate postmodel production of target actions indexed encoding efficiency, and 6-month production of target actions indexed long-term recall. The exogenous distracter impacted encoding efficiency (i.e., immediate recall), but not long-term recall. Endogenous factors (i.e., temperament) were primarily associated with long-term recall. Of special interest was our finding that endogenous factors, especially surgency, moderated the effect of the exogenous distracter. It appears that when learning conventional-relation sequences in the presence of exogenous distracters, surgency mobilizes attentional resources toward the learning objective; however, when learning enabling-relation sequences under the same conditions, surgency either boosts the saliency of the distracters or boosts children's susceptibility to them.

In January 2017 Philadelphia, Pennsylvania, implemented an excise tax of 1.5 cents per ounce on beverages sweetened with sugar or artificial sweeteners. Small independent stores are an important yet understudied setting. They are visited frequently in urban and low-income areas, and sugary beverages are among the most commonly purchased items in them. We compared changes in beverage prices and purchases before and twelve months after tax implementation at small independent stores in Philadelphia and an untaxed control city, Baltimore, Maryland. Our sample included 134 stores with price data and 4,584 customer purchases. Compared with Baltimore, Philadelphia experienced significantly greater increases in the price of taxed beverages (1.81 cents per ounce, or 120.4 percent of the tax) and significantly larger declines in the volume of taxed beverages sold (5.76 ounces, or 38.9 percent) after tax implementation. Beverage excise taxes may be an effective policy tool for decreasing the purchase of sweetened drinks in small independent stores, particularly among populations at higher risk for sugar-sweetened beverage consumption.

Objective Although the tracking of BMI levels from childhood to adulthood has been examined, there is little information on the within-person variability of BMI. Methods Longitudinal data from 11,591 schoolchildren, 3,096 of whom were reexamined as adults, were used to explore the tracking and variability of BMI levels. This article focuses on changes in age-adjusted levels of BMI. Results There was strong tracking of BMI levels. The correlation of adjusted BMI levels was r = 0.88, and 78% of children with severe obesity at one examination had severe obesity at the next examination (mean interval, 2.7 years). Further, an increase in adjusted BMI from +5 kg/m2 (above the median) to + 10 increased the risk for adult BMI ≥ 40 by 2.7-fold. However, BMI levels among children and adolescents were variable. Over a 9- to 15-month interval, the SD of adjusted BMI change was 0.9 kg/m2 , and 0.7% of children had an absolute change ≥ 3.5. This variability was associated with the interval between examinations and with the initial BMI. Conclusions Despite the high degree of tracking of BMI, annual changes of 3.5 kg/m2 or more are plausible. Knowledge of this variability is important when following a child over time.

Introduction Previous interventions to increase water access and consumption have focused on school settings, have shown mixed results on sugar-sweetened beverage (SSB) consumption, and have rarely addressed tap water safety. Our randomized controlled trial examined how improving access and appeal of water in recreation centers in low-income neighborhoods affected counts of SSBs carried by youth attending summer camp. Methods Recreation centers (N = 28) matched on their characteristics were randomly assigned to control or intervention groups. Intervention centers received a new water fountain with a bottle filler (hydration station), water testing services, reusable water bottles, and water promotion and education training and materials. Primary outcomes were 1-year changes in center-level average daily gallons of water from fountains and hydration stations (flowmeter readings). Secondary outcomes were counts of SSBs observed, use of bottled water and reusable water bottles, staff SSB consumption, and hydration station maintenance. Results Results showed increased water use (b = 8.6, 95% CI, 4.2-13.0) and reusable bottle counts (b = 10.2, 95% CI, 4.2-16.1) in intervention centers compared with control centers. No change occurred in youth carrying SSBs at camp, but center staff's past 30-day SSB consumption frequency decreased (b = -34.8, 95% CI, -67.7 to -1.9). Intervention sites had marginally lower odds of maintenance problems (OR = 0.09; 95% CI, 0.004-0.76, P = .06) than control sites. Conclusion Although providing hydration stations along with water testing, reusable water bottles, education, and promotion increased water consumption among youth at recreation centers, it had no effect on the number of SSBs observed during camp. Future strategies to increase water consumption should also address reducing SSB intake.

Introduction Evidence suggests real-world beverage taxes reduce sweetened beverage purchases, but it is unknown if consumers consequently increase food or alcohol purchases. This study examines whether Philadelphia's 1.5 cents/ounce beverage tax was associated with substitution to 3 kinds of hypothesized substitutes: snacks, nontaxed beverage concentrates, and alcohol. Methods Using commercial retail sales data and a difference-in-differences approach, analyses compared logged volume and dollar sales of snacks and beverage concentrates between 2016 (pretax) and 2017 (post-tax) at chain food retail stores in Philadelphia (n=180) and Baltimore (nontaxed control city; n=60), and logged volume and dollar sales of wine and spirits at liquor stores in Philadelphia (n=44) and nearby Pennsylvania counties (alternate control; n=66). Additional food analyses examined change in logged volume sales of hypothesized products compared to control products (other foods). Analyses were conducted in 2020. Results Across store types, analyses showed no statistically significant increases in logged volume or dollar sales of snacks or spirits in Philadelphia stores compared to control sites (decreased, ranging from −10% to 0%). Supermarket analyses showed substitution to nontaxed beverage concentrates (27% increase in volume, 36% increase relative to other food) but remained a relatively small percentage of overall beverage dollar sales (12% at baseline, 15% at post). Conclusions At the population level, there is no evidence that Philadelphia's decline in taxed beverage purchases is offset by increases in snacks or spirits purchasing, but there is evidence of substitution to beverage concentrates in supermarkets. Future studies should explore individual-level purchasing changes.

Background Few longitudinal studies examine the response to beverage taxes, especially among regular sugar-sweetened beverage (SSB) consumers. Objective This study aimed to examine changes in objectively measured beverage purchases associated with the Philadelphia beverage tax on sugar-sweetened and artificially sweetened beverages. Methods A longitudinal quasi-experiment was conducted with adult sugar-sweetened beverage (SSB) consumers in Philadelphia (n = 306) and Baltimore (n = 297; a nontaxed comparison city). From 2016 to 2017 participants submitted all food and beverage receipts during a 2-wk period at: baseline (pretax) and 3, 6, and 12 mo posttax (91.0% retention; data analyzed in 2019). Linear mixed effects models were used to assess the difference-in-differences in total purchased ounces (fl oz) of taxed beverages in a 2-wk period in Philadelphia compared with Baltimore. Secondary analyses: 1) excluded weeks that contained major holidays at baseline and 12 mo (42% of measured weeks at baseline and 12 mo) because policy implementation timing necessitated data collection during holidays when SSB demand may be more inelastic, and 2) aggregated posttax time points to address serial correlation and low power. Results There were no statistically significant changes in purchased ounces of taxed beverages in Philadelphia compared with Baltimore in the primary analysis. After excluding holiday purchasing, the tax was associated with statistically significant reductions of taxed beverage purchases at 3 and 6 mo (-157.1 ounces, 95% CI: -310.1, -4.1 and -175.1 ounces, 95% CI: -328.0, -22.3, respectively) but not 12 mo. Analyses aggregating all 6 wk of posttax time points showed statistically significant reductions (-203.7 ounces, 95% CI: -399.6, -7.8). Conclusions A sweetened beverage tax was not associated with reduced taxed beverage purchases among SSB consumers 12 mo posttax in the full sample. Both secondary analyses excluding holiday purchasing or aggregating posttax time periods found reductions in taxed beverage purchases ranging from -4.9 to -12.5 ounces per day. Larger longitudinal studies are needed to further understand tax effects.

IMPORTANCE: Policy makers have implemented beverage taxes to generate revenue and reduce consumption of sweetened drinks. In January 2017, Philadelphia, Pennsylvania, became the second US city to implement a beverage excise tax (1.5 cents per ounce). OBJECTIVES: To compare changes in beverage prices and sales following the implementation of the tax in Philadelphia compared with Baltimore, Maryland (a control city without a tax) and to assess potential cross-border shopping to avoid the tax in neighboring zip codes. DESIGN, SETTING, AND PARTICIPANTS: This study used a difference-in-differences approach and analyzed sales data to compare changes between January 1, 2016, before the tax, and December 31, 2017, after the tax. Differences by store type, beverage sweetener status, and beverage size were examined. The commercial retailer sales data included large chain store sales in Philadelphia, Baltimore, and the Pennsylvania zip codes bordering Philadelphia. These data reflect approximately 25% of the ounces of taxed beverages sold in Philadelphia. EXPOSURES: Philadelphia’s tax on sugar-sweetened and artificially sweetened beverages. MAIN OUTCOMES AND MEASURES: Change in taxed beverage prices and volume sales. RESULTS: A total of 291 stores (54 supermarkets, 20 mass merchandise stores, 217 pharmacies) were analyzed. The mean price per ounce of taxed beverages in Philadelphia increased from 5.43 cents in 2016 to 6.24 cents in 2017 at supermarkets; from 5.28 cents to 6.24 cents at mass merchandise stores, and from 6.60 cents to 8.28 cents at pharmacies. The mean price per ounce in Baltimore increased from 5.33 cents in 2016 to 5.50 cents in 2017 at supermarkets, from 6.34 cents to 6.52 cents at mass merchandise stores, and from 6.76 cents to 6.93 cents at pharmacies. The mean per-ounce difference in price between the 2 cities was 0.65 cents (95% CI, 0.60 cents-0.69 cents; P

Background Although it is a common practice to estimate dietary intake using three random 24-hour dietary recalls, some studies have suggested up to nine may be necessary to reliably estimate usual intake in youth. Given the resulting increase in resources and participant burden, more research is needed to determine whether this method is reliable, particularly in African-American youth at increased risk for obesity and other chronic diseases. Objective This study estimated the reliability with which 24-hour dietary recalls measure energy, fat, fruit, and vegetable intake in African-American youth and examined how reliability changes as a function of the number of recalls. Design This study used cross-sectional data collection across three studies. Participants/setting Participants were African-American youth (n=456, mean±standard deviation age 13.28±1.86 years, 64% were girls, mean±standard deviation body mass index [calculated as kg/m 2 ] 31.45±7.94) who completed random 24-hour dietary recalls (67% completed three) conducted by research assistants using the Automated Self-Administered 24-Hour recall system (n=258) or registered dietitian nutritionists using the Nutrition Data System for Research (n=198). Main outcome measures/statistical analyses Estimates provided by multilevel models were used to calculate the proportion of variance accounted for between individuals and the reliability of means within individuals as a function of the number of recalls. Results Reliability estimates for assessing dietary outcomes using one to three recalls ranged from 11% to 62%. To achieve 80% reliability, the following number of recalls would need to be conducted: 8 for energy intake, 13 for fat intake, 21 to 32 for fruit intake, and 21 to 25 for vegetable intake. Conclusions The common practice of assessing dietary intake with three recalls does so with low reliability in African-American youth. Until more objective methods for reliably estimating usual intake are developed, researchers who choose to use 24-hour dietary recalls are encouraged to include estimates of the measure's reliability in a priori power calculations for improved decision making regarding the number of observations and/or sample size.

Objective Previous research has not investigated the role of prescription medication in sleep-obesity associations despite the fact that 56% of U.S. adults take at least one prescription medication. Methods Data from n = 16,622 adults in the National Health and Nutrition Examination Survey (2007-2012) were used to examine how the association between obesity and self-reported sleep duration varied by total number of prescription medications used in the past 30 days and by select classes of prescription medications including anxiolytics/sedatives/hypnotics, antidepressants, sleep aids, anticonvulsants, thyroid agents, and metabolic agents. Results Logistic regression analyses showed a significant inverse linear association of sleep duration and obesity, regardless of the total number of prescription medications individuals were taking. Each additional hour of sleep was associated with a 10% decrease in the odds of obesity. Results suggest that increased sleep duration is associated with lower odds of having obesity overall, even for long-duration sleepers (≥9 h), and this association does not differ for those taking antidepressants, thyroid agents, metabolic agents, and multiple prescription medications. Conclusions The relationship between sleep duration and obesity was similar among all prescription medication users and nonusers. The potential for a nonlinear association between sleep duration and obesity may be important to examine in some specific prescription medication classes.

Objectives Possible adverse economic impacts of sweetened drink taxes are a key concern for numerous stakeholders. This study examined changes in unemployment benefit claims filings in Philadelphia compared to its neighboring counties two years prior to and 14 months post implementation of a 1.5 cents per ounce excise tax on sugar- and artificially-sweetened beverages. Methods Data were obtained from the Pennsylvania Department of Labor. Interrupted time series analysis was used to determine if there was a change in new monthly unemployment claims filings post-tax implementation in Philadelphia compared to surrounding counties in supermarkets, select potentially affected industries, and in total claims filings across all industries combined. Results Results showed there were no statistically significant changes to unemployment claims in Philadelphia compared to neighboring counties for supermarkets (s = -9.45, 95% CI = -98.11, 79.22), soft drink manufacturers (s = -0.13, 95% CI = -9.13, 8.88), across other potentially affected industries (s = 9.16, 95% CI = -488.29, 506.60), or across all industries (s = -445.85, 95% CI = -4272.39, 3380.68) following implementation of the beverage tax. Unemployment declined similarly in Philadelphia compared to surrounding counties. Conclusions Public reports of increased unemployment within the first year following the implementation of the Philadelphia beverage tax are not supported by this analysis. Future work should examine employment outcomes and include longer follow-up periods.

Introduction Improving children's tap water intake and reducing sugar-sweetened beverage (SSB) consumption is beneficial for health and health equity, particularly in low-income communities and communities of color. Existing community level interventions to improve the intake of tap water have predominantly occurred in schools and have focused on promoting water consumption in cafeterias during lunch or snack periods. Methods The “Hydrate Philly” intervention was developed to target multiple environmental and social factors to improve tap water consumption in community recreation centers in low-income communities: replacing old and unappealing water fountains with appealing water-bottle-filling “hydration stations”, conducting water safety testing and publicizing results, disseminating reusable water bottles, promoting tap water, and discouraging SSB consumption. Efficacy of the intervention will be tested through a group-randomized controlled trial (n = 28 centers) of the intervention's impact on center-level water fountain/station use as measured by flow meters during a youth summer camp program primarily for children aged 6–12 years. Intervention impact on the primary outcome (use of drinking water sources) will be examined with a difference-in-differences approach using an ordinary least squares regression model for analysis at the center level. Secondary outcomes include SSBs brought to summer camp, reusable and single-use bottled water use, program trash, and recreation center staff SSB consumption. Discussion Multilevel approaches are needed to increase tap water intake and decrease SSB consumption among low-income and minority youth beyond school and meal settings. The current study describes the Hydrate Philly intervention, the study design, and baseline characteristics of recreation centers participating in the study. ClinicalTrials.gov Registration: #NCT03637465

Introduction Policymakers are interested in requiring chain restaurants to display sodium warning labels on menus to reduce sodium consumption. This study examined the influence of label design on consumers’ hypothetical choices, meal perceptions, and knowledge. Study design Four sequential, randomized, controlled online experiments were conducted. Setting/participants Across all 4 experiments, 10,412 sociodemographically diverse participants were recruited online through Survey Sampling International and Amazon Mechanical Turk. Intervention Participants were randomized to view restaurant menus with either no sodium label (control) or 1 of 13 sodium warning labels that varied the text (e.g., “sodium warning” versus “high sodium”), icons (e.g., stop sign), and colors (red/black) used. Participants placed a hypothetical meal order and rated restaurant meal perceptions. Data were collected and analyzed in 2016–2019. Main outcome measures The primary outcome was sodium content of hypothetical restaurant choices. Secondary outcomes included restaurant meal perceptions and sodium knowledge. Results In Experiments 1–3, all warning labels reduced average sodium ordered across both restaurants (by 19–81 mg) versus controls, with some of the largest reductions from traffic light and stop sign labels, but results were not statistically significant. In a larger, preregistered replication (Experiment 4) testing traffic light and red stop sign labels versus control, traffic light and red stop sign labels significantly reduced average sodium ordered across both restaurants (−68 mg, p=0.002 and −46 mg, p=0.049, respectively). Warnings also significantly increased participants’ knowledge of sodium content and perceived health risks associated with high-sodium meals compared with no label. Conclusions Traffic light and red stop sign warning labels significantly reduced sodium ordered compared with a control. Warning labels also increased knowledge about high sodium content in restaurant meals. Designs with warning text are likely to improve consumer understanding.

Perna, FM, Coa, K, Troiano, RP, Lawman, HG, Wang, C-Y, Li, Y, Moser, RP, Ciccolo, JT, Comstock, BA, and Kraemer, WJ. Muscular grip strength estimates of the U.S. population from the National Health and Nutrition Examination Survey 2011–12. J Strength Cond Res 30(3): 867–874, 2016—The purposes of this study were to use the National Health and Nutrition Examination Study (2011–12) data to determine nationally representative combined handgrip strength ranges and percentile information by sex and age group, examine trends in strength across age by sex, and to determine the relative proportion of children and adults falling into established health benefit zones (HBZ). Results indicate that mean strength was greater among men than women and increased linearly for children and in a quadratic fashion among adults for both sexes. Grip strength peaked in the 30- to 39-year age group for both men (216.4 lbs) and women (136.5 lbs) with subsequent age groups showing gradual decline, p < 0.0001. Relative and absolute increases in grip strength were greater for men than for women, but relative decrease from peak strength was less among women than men. Although absolute strength was greater among men than women, HBZ data indicated that a higher percentage of men than women overall and at each age group fell into the needs improvement zone, with differences particularly pronounced during adolescence and older adulthood. These data provide the first nationally representative population estimates of combined handgrip strength and percentile information from childhood through senescence and suggest consideration of HBZ information in conjunction with grip strength to improve surveillance data interpretation and intervention planning.

Objective Although the tracking of BMI levels from childhood to adulthood has been examined, there is little information on the within-person variability of BMI. Methods We used longitudinal data from 11,591 schoolchildren, 3096 of whom were reexamined as adults, to explore the tracking and variability of BMI levels. We focus on changes in age-adjusted levels of BMI. Results There was strong tracking of BMI levels. The correlation of adjusted BMI levels was r=0.88 and 78% of children with severe obesity at one examination had severe obesity at the next examination (mean interval, 2.7 years). Further, an increase in adjusted BMI from +5 kg/m2 (above the median) to +10 increased the risk for adult BMI ≥ 40 by 2.7-fold. However, BMI levels among children and adolescents were variable. Over a 9- to 15-month interval, the SD of adjusted BMI change was 0.9 kg/m2 and 0.7% of children had an absolute change ≥ 3.5. This variability was associated with the interval between examinations and with the initial BMI. Conclusions Despite the high degree of tracking of BMI, annual changes of 3.5 kg/m2 or more are plausible. Knowledge of this variability is important when following a child over time.

IntroductionTo examine the prevalence and patterns of tobacco purchases at low-income, urban corner stores.MethodsData on tobacco products and other purchases were collected through direct observation of customers’ purchases (n=6369) at 120 urban corner stores in Philadelphia, Pennsylvania, from April to September 2012.ResultsOverall 13% of corner store purchases included tobacco products. The majority (61%) of tobacco purchases did not include any other products, and 5.1% of all purchases from corner stores included a food or beverage and tobacco product. Approximately 24% of tobacco purchases were for lower-cost tobacco products such as cigars and cigarillos, and nearly 5% of tobacco purchases were an illegal purchase of a single, unpackaged tobacco product that is not intended for individual sale (ie, loosies). There was no difference in the average amount spent on food or beverages when purchased with (US$2.55, 95% CI: 2.21 to 2.88) or without (US$2.55, 95% CI: 2.48 to 2.63) tobacco products.ConclusionsIn low-income, urban corner store settings, 87% of purchases did not include tobacco; most tobacco purchases did not include the sale of non-tobacco items and spending on non-tobacco items was similar whether or not tobacco was purchased. These findings can help inform retail-level tobacco sales decisions, such as voluntary discontinuation of tobacco products or future public health policies that target tobacco sales. The results challenge prevailing assumptions that tobacco sales are associated with sales of other products in corner stores, such as food and beverages.

The “Positive Action for Today’s Health” (PATH) trial tested an environmental intervention to increase walking in underserved communities. Three matched communities were randomized to a police-patrolled walking plus social marketing, a police-patrolled walking-only, or a no-walking intervention. The 24-month intervention addressed safety and access for physical activity (PA) and utilized social marketing to enhance environmental supports for PA. African-Americans (N = 434; 62 % females; aged 51 ± 16 years) provided accelerometry and psychosocial measures at baseline and 12, 18, and 24 months. Walking attendance and trail use were obtained over 24 months. There were no significant differences across communities over 24 months for moderate-to-vigorous PA. Walking attendance in the social marketing community showed an increase from 40 to 400 walkers per month at 9 months and sustained ~200 walkers per month through 24 months. No change in attendance was observed in the walking-only community. Findings support integrating social marketing strategies to increase walking in underserved African-Americans (ClinicalTrials.gov #NCT01025726).

Objectives Recent cross-sectional data indicate the rates of childhood obesity are plateauing. Few large-scale longitudinal data sets exist, particularly in low-income and minority youth. The purpose of this study was to describe longitudinal changes in relative weight among a large sample of low-income, minority youth over 1 year. Methods Participants were students from 56 schools in urban, low-income environments. There were 17,727 first- to sixth-graders (64% African–American, 52% male) assessed at baseline, and 13,305 youth (75.1%) were reassessed 1 year later at follow-up. Measured height and weight were used to assess categorical (overweight, obesity, severe obesity) and continuous (BMI, percentile, z-score) measures of relative weight. Results Longitudinal data showed that over 1 year, BMI percentile (95% CI.64-–0.32, P

ObjectiveCorner stores, also known as bodegas, are prevalent in low-income urban areas and primarily stock high-energy foods and beverages. Little is known about individual-level purchases in these locations. The purpose of the present study was to assess corner store purchases (items, nutritional characteristics and amount spent) made by children, adolescents and adults in a low-income urban environment.DesignEvaluation staff used 9238 intercept surveys to directly examine food and beverage purchases.SettingIntercepts were collected at 192 corner stores in Philadelphia, PA, USA.SubjectsParticipants were adult, adolescent and child corner store shoppers.ResultsAmong the 9238 intercept surveys, there were 20 244 items. On average, at each corner store visit, consumers purchased 2·2 (sd 2·1) items (1·3 (sd 2·0) foods and 0·9 (sd 0·9) beverages) that cost $US 2·74 (sd $US 3·52) and contained 2786·5 (sd 4454·2) kJ (666·0 (sd 1064·6) kcal). Whether the data were examined as a percentage of total items purchased or as a percentage of intercepts, the most common corner store purchases were beverages, chips, prepared food items, pastries and candy. Beverage purchases occurred during 65·9 % of intercepts and accounted for 39·2 % of all items. Regular soda was the most popular beverage purchase. Corner store purchases averaged 66·2 g of sugar, 921·1 mg of sodium and 2·5 g of fibre per intercept. Compared with children and adolescents, adults spent the most money and purchased the most energy.ConclusionsUrban corner store shoppers spent almost $US 3·00 for over 2700 kJ (650 kcal) per store visit. Obesity prevention efforts may benefit from including interventions aimed at changing corner store food environments in low-income, urban areas.

This study examined imputational modeling effects of spatial proximity and social factors of walking in African American adults.Models were compared that examined relationships between household proximity to a walking trail and social factors in determining walking status.Participants (N=133; 66% female; mean age=55 years) were recruited to a police-supported walking and social marketing intervention. Bayesian modeling was used to identify predictors of walking at 12 months.Sensitivity analysis using different imputation approaches, and spatial contextual effects, were compared. All the imputation methods showed social life and income were significant predictors of walking, however, the complete data approach was the best model indicating Age (1.04, 95% OR: 1.00, 1.08), Social Life (0.83, 95% OR: 0.69, 0.98) and Income$10,000 (0.10, 95% OR: 0.01, 0.97) were all predictors of walking.The complete data approach was the best model of predictors of walking in African Americans.

We explored the role that exogenous and endogenous competitors for attention play in infants' abilities to encode and retain information over a 6-month period. Sixty-six children visited the laboratory at 15 months, and 32 returned for a second visit at 21 months. Children observed models of conventional- relation and enabling-relation action sequences. Half the children were distracted by a "Mister Monkey" mechanical toy during the conventional-relation sequence, while the other half was distracted during the enabling-relation sequence. The Early Childhood Behavior Questionnaire indexed endogenous factors at both ages. Immediate postmodel production of target actions indexed encoding efficiency, and 6-month production of target actions indexed long-term recall. The exogenous distracter impacted encoding efficiency (i.e., immediate recall), but not long-term recall. Endogenous factors (i.e., temperament) were primarily associated with long-term recall. Of special interest was our finding that endogenous factors, especially surgency, moderated the effect of the exogenous distracter. It appears that when learning conventional-relation sequences in the presence of exogenous distracters, surgency mobilizes attentional resources toward the learning objective; however, when learning enabling-relation sequences under the same conditions, surgency either boosts the saliency of the distracters or boosts children's susceptibility to them.

Background:Previous research suggests motivation, enjoyment, and self-efficacy may be important psycho-social factors for understanding physical activity (PA) in youth. While previous studies have shown mixed results, emerging evidence indicates relationships between psychosocial factors and PA may be stronger in boys than girls. This study expands on previous research by examining in the effects of motivation, enjoyment, and self-efficacy on PA in underserved adolescents (low income, ethnic minorities) boys and girls. Based on previous literature, it was hypothesized the effects of motivation, enjoyment, and self-efficacy on moderate-to-vigorous PA (MVPA) would be stronger in boys than in girls.Methods:Baseline cross-sectional data were obtained from a randomized, school-based trial (Active by Choice Today; ACT) in underserved 6th graders (N = 771 girls, 651 boys). Intrapersonal variables for PA were assessed via self-report and confirmatory factor analyses were conducted for each predictor. MVPA was assessed with 7-day accelerometry estimates.Results:Multivariate regression analyses stratified by sex demonstrated a significant positive main effect of self-efficacy and motivation on MVPA for girls. Boys also showed a positive trend for the effect of motivation on MVPA.Conclusions:The results from this study suggest motivation and self-efficacy should be better integrated to facilitate the development of more effective interventions for increasing PA in underserved adolescents.

Ethnic minorities and lower-income adults have among the highest rates of obesity and lowest levels of regular physical activity (PA). The Positive Action for Today's Health (PATH) trial compares three communities that are randomly assigned to different levels of an environmental intervention to improve safety and access for walking in low income communities.Three communities matched on census tract information (crime, PA, ethnic minorities, and income) were randomized to receive either: an intervention that combines a police-patrolled-walking program with social marketing strategies to promote PA, a police-patrolled-walking only intervention, or no-walking intervention (general health education only). Measures include PA (7-day accelerometer estimates), body composition, blood pressure, psychosocial measures, and perceptions of safety and access for PA at baseline, 6, 12, 18, and 24 months.The police-patrolled walking plus social marketing intervention targets increasing safety (training community leaders as walking captains, hiring off-duty police officers to patrol the walking trail, and containing stray dogs), increasing access for PA (marking a walking route), and utilizes a social marketing campaign that targets psychosocial and environmental mediators for increasing PA. MAIN HYPOTHESES/OUTCOMES: It is hypothesized that the police-patrolled walking plus social marketing intervention will result in greater increases in moderate-to-vigorous PA as compared to the police-patrolled-walking only or the general health intervention after 12 months and that this effect will be maintained at 18 and 24 months.Implications of this community-based trial are discussed.

Objective Previous research indicates that body mass index (BMI) and sex are important factors in understanding physical activity (PA) levels. The present study examined the influence of BMI on psychosocial variables (self-efficacy, social support) and PA in underserved (ethnic minority, low income) boys in comparison with girls. Methods Participants (N = 669; 56% girls; 74% African American) were recruited from the "Active by Choice Today" trial. Main outcome measures BMI ʐ score was calculated from objectively collected height and weight data, and PA was assessed with 7-day accelerometry estimates. Self-report questionnaires were used to measure self-efficacy and social support (family, peers) for PA. Results A 3-way interaction between BMI z score, sex, and family support on PA was shown such that family support was positively associated with PA in normal-weight but not overweight or obese boys, and was not associated with PA in girls. Self-efficacy had the largest effect size related to PA in comparison with the other psychosocial variables studied. Conclusions Self-efficacy was found to be an important variable related to PA in underserved youth. Future studies should evaluate possible barriers to PA in girls, and overweight youth, to provide more effective family support strategies for underserved adolescents' PA.

This study assessed the prevalence and consistency of high values of weight, height, and BMI considered to be biologically implausible (BIV) using cut points proposed by WHO among 8.8 million low-income children (13.7 million observations).Cross-sectional and longitudinal analyses were performed among 2- to 4-year-olds who were examined from 2008 through 2011.Overall, 2.7% of the body size measurements were classified as BIVs; 95% of these BIVs were very high. Among the subset of children (3.6 million) examined more than once, most of those who initially had a high weight or BMI BIV also had a high BIV at the second examination; odds ratios were250. Based on several alternative classifications of BIVs, the current cut points likely underestimate the prevalence of obesity by about 1%.Many of the extremely high values of body size currently flagged as BIVs are unlikely to be errors. Increasing the z-score cut points or using a percentage of the maximum values in the National Health and Nutrition Examination Survey, could improve the balance between removing probable errors and retaining those that are likely correct.

INTRODUCTION: Although decline in muscle mass and quality and resulting declines in muscle strength are associated with aging, more research is needed in general populations to assess the utility of handgrip strength as an indicator of muscle strength and cardiovascular disease risk. METHODS: Data from 4,221 participants aged ≥20 years in the 2011–2012 cycle of National Health and Nutrition Examination Survey were analyzed during 2014–2015. Standing isometric relative handgrip strength (calculated as maximal absolute handgrip strength from both hands divided by BMI) was used to predict cardiovascular biomarkers, including blood pressure (measured systolic and diastolic blood pressure); serum lipids (total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides); and plasma insulin and glucose. RESULTS: Results from regression analyses showed that higher relative grip strength was significantly associated with lower systolic blood pressure, triglycerides, and plasma insulin and glucose, and higher high-density lipoprotein cholesterol in male and female participants (p

The availability of epidemiologic data on childhood obesity has increased in response to public health concerns regarding childhood obesity trends. For example, researchers in several nations have begun to collect school surveillance data to monitor the prevalence of childhood obesity (1–5). Data quality can be variable (6), and researchers investigating obesity must address how to identify biologically implausible values (BIVs) in anthropometric data (height, weight, body mass index (BMI)). This may be of particular concern because height and weight measurements often are collected in non–research settings such as schools and when summarizing very high BMI values. In addition, a unique set of criteria may be needed for longitudinal studies to address biologically implausible change over time, such as weight loss/gain and shrinking/large height changes. The methodological process of identifying BIVs, 1 possible source of measurement error, has not been explored, and researchers have utilized a variety of methods that have not been compared or evaluated. It is not yet known how different methods for the identification of BIVs may affect study results or how often the issue of BIVs is addressed in large epidemiologic studies. Appropriate identification of BIVs will help to minimize measurement error, particularly data-recording and -entry errors, which may otherwise be more difficult to identify (6). Therefore, the current study aimed 1) to track how often large epidemiologic studies in youth address the issue of BIVs, 2) to review available methods for addressing cross-sectional and longitudinal BIVs in youth anthropometric data, and 3) to apply each unique set of BIV criteria to a large longitudinal data set from Get Healthy Philly of low-income minority youth and compare the effects on weight status and BIV prevalence estimates.

Popular methods for analyzing accelerometer data often use a single physical activity outcome variable such as average-weekly or total physical activity. These approaches limit the types of research questions that can be answered and fail to utilize the detailed, time-specific information available from accelerometers. This study proposes the use of multilevel modeling, which tested intervention effects at specific time periods.The motivating example was the Active by Choice Today trial. Simulations were used to test whether the application of time-specific hypotheses about when physical activity intervention treatment effects were expected to occur (e.g., after-school hours) increased power to detect effects compared to traditional methods.Six simulation conditions were tested: (1) no treatment effects (to test the type 1 error rate), (2) time-specific effects, but no traditionally-tested effects, (3) traditionally-tested effects, but no time-specific effects, and (4) combinations of traditional and time-specific effects in 3 proportions.Results showed the proposed multilevel approach demonstrated appropriate type 1 error rates and increased power to detect treatment effects during hypothesized times by 31-38 percentage points compared to traditional approaches. This was consistent across varying proportions of traditional versus time-specific effects, and there was no loss of power using the multilevel approach when only traditional effects were present.The current study showed potential advantages of testing time-specific hypotheses about intervention effects using a multilevel time-specific approach. This approach may show intervention effects when traditional approaches do not. Future research should explore the application of this additional analytic tool for accelerometer physical activity estimates.

Objectives The purpose of this study was to assess one-year changes in corner store purchases (nutritional characteristics, amount spent) of children, adolescents, and adults in a low-income urban environment before and after implementing an environmental intervention to increase the availability of healthier products. Methods Corner store owners were provided tools (trainings, signage, refrigeration) to increase the promotion and availability of several healthy foods. Based on the degree of support provided, stores were classified as “basic” or “high-intensity” intervention stores. Data on purchases and their nutrient content were gathered (n = 8671 at baseline, n = 5949 at follow-up) through customer purchase assessment interviews and direct observation outside of 192 corner stores in Philadelphia from March 2011 to August 2012. Results At baseline, shoppers spent $2.81 ± 3.52 for 643 ± 1065 kcal. Energy, select nutrients, and the total amount spent did not significantly change in the overall sample from baseline to follow-up. Similarly, there was no effect on energy and nutrient content when comparing changes over time between basic and high-intensity stores. Conclusions There were no significant changes in the energy or nutrient content of corner store purchases one year after implementation of environmental changes to increase the availability of healthier products.

Background Evidence to support differential health impacts of sedentary behavior (SB), light physical activity (LPA), and moderate-to-vigorous physical activity (MVPA) is building. However, few studies have examined individual, social, and environmental supports across the full range of sedentary and physical activities, including key influences such as self-efficacy, parenting factors, and home and neighborhood resources. This may be particularly important in underserved (low-income, minority), overweight/obese adolescents due to the social and environmental challenges (lack of resources, etc.) associated with increasing MVPA. This study evaluated a range of bioecological factors including individual (self-efficacy), parental (parental support, monitoring, limit-setting, and nurturance), and environmental (perceived home resources for PA and neighborhood support for PA) predictors of SB, LPA and MVPA in overweight/obese adolescents. Methods Overweight/obese and predominantly minority adolescents and caregivers (n = 181) completed measures in 2010 in the US including surveys assessing self-efficacy for PA, parenting variables related to PA and home and neighborhood supports for PA. Outcomes included 7-day accelerometer estimates of SB, LPA, and MVPA. Results Regression analyses showed parental social support and neighborhood support were significantly associated with LPA. No significant associations were found for SB or MVPA. Conclusions Results emphasized the importance of examining a range of sedentary and PA intensities and highlighted the role of parental and neighborhood social supports for LPA. These results have important implications that suggest that health promotion efforts should target social and environmental supports for increasing LPA in youth who are overweight/obese.

Objective This study examined weight status as a moderator of the relationship between motivation (controlled, autonomous, regulatory), emotional social support (parents, peers) and moderate-to-vigorous physical activity (MVPA) in underserved adolescents (ethnic minority, low-income). Methods Participants from the Active by Choice Today Trial (n ¼ 1,416; 54% girls, 73% African American, 52% overweight/obese) completed baseline measures, including height and weight, psychosocial surveys, and 7-day accelerometry estimates. Weight status was defined by body mass index z-score (zBMI). Results Weight status moderated the effects of controlled, autonomous, and regulatory motivation on MVPA, such that these variables were more strongly associated with MVPA in adolescents with lower versus higher zBMI scores. Conclusions A better understanding of why motivation is not related to MVPA in underserved youth with a higher weight status is needed. Future pediatric obesity treatment in underserved youth may need to move beyond motivation into environmental factors associated with long-term behavior change.

Previous research has shown that social contextual factors are important in understanding physical activity (PA) behavior, although little is known about how these factors may relate to PA, especially in underserved adolescents (low income, minorities). This study examined how motivation may differentially mediate the relationship of two social contextual variables (i.e., peer and parent social support) and moderate-to-vigorous PA (MVPA).Baseline data (n = 1421 sixth graders, 54% female, 72% African American) from the Active by Choice Today (ACT) trial in underserved adolescents were analyzed. Motivation was examined as a mediator of the relationships between peer social support, parent social support, and MVPA (measured by 7-day accelerometer estimates).Motivation and peer but not parent support were significantly related to MVPA overall. Significant mediation effects were found indicating motivation partially mediated the relation between peer social support and MVPA and to a lesser degree parent support and MVPA.These findings provide support for the importance of social contextual influences, especially peer social support, on underserved adolescents' PA and motivation for PA.

The lack of sufficient physical activity among youth is a major health concern nationally (Miller & Silverstein, 2007). Only 8% of adolescents are meeting the national guidelines of engaging in 60 minutes a day of moderate-to-vigorous physical activity (PA; Troiano et al., 2008). Youth of low socioeconomic status (SES) and African-Americans in particular, engage in less physical activity than their non-minority counterparts (Wilson et al., 2011) and there is a scarce amount of studies that have tested mediation to understand PA in these populations (Wilson & Kitzman-Ulrich, 2008). Previous research also shows that girls engage in fewer minutes of PA daily than boys (Trost et al., 2002). Interventions to increase PA are therefore crucial, and continuing to research possible underlying mechanisms could advance the field. Mediation models may help investigators specify mechanisms that are effective in the delivery of PA interventions (Wilson, 2009). Social Cognitive Theory (Bandura, 1989) suggests that strong social support networks increase an individual’s self-efficacy (SE) to overcome barriers to being physically active. Parent influence especially constitutes a major source of social support throughout a child’s lifespan. According to socialization theory, parent influence has an effect on a youth’s competency to engage in a specific behavior such as increasing PA (Bois, Sarrazin, Brustad, Trouilloud, & Cury, 2005; Eccles & Harold, 1991). Empirical research (van Suijs, McMinn, & Griffin, 2007) also supports the important role of parents and family on increasing PA in youth. In an intervention for mothers with young children that emphasized social support and overcoming barriers to PA, SE mediated PA behavior change (Miller, Trost, & Brown, 2002). An intervention emphasizing parent support also mediated the relationship on adolescent PA through SE (Haerens et al., 2008). Taken together, these studies support investigating further how parent socialization of adolescent PA may be mediated through SE. Parents can provide emotional social support for engaging in PA through providing encouragement and they can provide instrumental social support through offering tangible support such as transportation to PA events (Barrera, 1986). Previous research has shown that parent emotional and instrumental social support are positively associated with PA in youth (Duncan, Duncan, & Strycker, 2005; Heitzler, Martin, Duke, & Huhman, 2006). In a recent review by Beets and colleagues (2010) parent social support was also shown to be consistently positively associated with adolescent PA. However, further research is needed to understand what mechanisms may explain how parent social support influences PA in youth specifically. SE for overcoming barriers to PA has been shown to be a significant mediator between PA interventions and adolescent PA engagement (Haerens et al., 2008). Past cross-sectional (Motl, Dishman, Saunders, Dowda, & Pate, 2007) and longitudinal studies (Shields et al., 2008) support the role of SE as a mediator between family social influences (including support) and adolescent PA, though some researchers have shown inconsistent effects (Wu & Pender, 2002). Given the inconsistent evidence further research is needed to expand understanding of mechanisms, especially among underserved youth who are at high risk for inactivity. Few studies have examined sex differences in understanding the role of SE and different types of social support in relation to PA. Wu and colleagues (2003) examined SE as a mediator between social influences (parent and peer emotional support, modeling, norms) and adolescent PA, and found the pathway between peer social influences and adolescent SE to be stronger for boys than girls, whereas the pathway between SE and PA was similar for boys and girls. Parent social influences were not related to PA directly or indirectly through SE. Other research shows that SE relates stronger to boys’ PA than girls’ PA (DiLorenzo, Stucky-Ropp, Vander Wal, & Gotham, 1998) and that girls report more barriers to being physically active than boys (Cardon et al., 2005). Given these sex difference in SE and PA, it is important to better understand how boys and girls may differ in the types of social support that may influence their daily regulation and self-efficacy for engaging in PA. Boys and girls also may demonstrate different preferences for certain types of social support. For example, Belle (1987) reports that social relationships of females are more dyadic, exclusive, intimate and self-disclosing than those of males. This preference for verbal discussion and support may be indicative of emotional social support having a more important role for girls than boys, due to the differences in socialization of sex roles. Choquet and colleagues (2008) found that a lack of general parent emotional support was associated with a high risk for drug use among girls but not boys. Another study demonstrated that under stress, boys showed less physiological arousal with instrumental social support compared to emotional social support, but not for girls (Wilson, Kliewer, Bayer et al, 1999). This suggests that boys tend to react more negatively to emotional social support than girls. Findings from past studies have been mixed regarding which type of social support is more strongly related to adolescent PA in boys as compared to girls. One study showed that family emotional social support was positively associated with PA for boys, but not for girls (McGuire et al., 2002). This contradicts a study among adolescent females, showing that family encouragement was significantly related to girls’ PA (Springer et al., 2006). Clearly, more studies are needed that investigate how specific types of social support may influence PA differentially in boys versus girls. Results from another study demonstrated that mothers’ logistical support (e.g. transportation) and fathers’ explicit modeling were positively associated with girls’ PA (Davison, Cutting, & Birch, 2003). Other investigators found that parent transportation to sports activities was significantly related to girls’ and boys’ PA, but this relationship was stronger in girls (Hoefer, McKenzie, Sallis, Marshall, & Conway, 2001). Taken together these studies suggest that there may be sex differences in the relation between parent social support and adolescent PA, though there are inconsistencies. Examining the role of indirect effects may help clarify these discrepancies. The present study expands on past research by investigating the unique contribution of instrumental and emotional social support on adolescent PA. In particular, this study examined boys and girls separately to clarify potential differences in direct and indirect relationships between social support, SE and adolescent PA. A recent review (Gustafson & Rhodes, 2006) noted that few previous studies have used objective measures of PA, therefore the present study’s use of accelerometry is a major strength. Furthermore, little is known about minority populations and PA (Van der Host, Paw, Twisk, & Van Mechelen, 2007). De Bourdeaudhuij and Sallis (2002) suggested that more studies are necessary to gain a consensus on the role that different types of social support have on promoting PA among minority groups. Based on previous research, it was hypothesized that adolescent SE for overcoming barriers would account for the relationship between parent social support (emotional and instrumental) and adolescent PA across boys and girls. In addition, given that boys and girls are socialized to seek out and respond differentially to emotional and instrumental support, it was hypothesized that emotional social support would have stronger direct and indirect effects on PA for girls than boys and that instrumental social support would have stronger direct and indirect effects on PA for boys than girls. Furthermore, given previous empirical findings it was hypothesized that the relationship between SE and PA would be stronger in boys than girls.

Disparities in the prevalence of obesity in youth place minority and low socioeconomic status youth at increased risk for the development of chronic disease, such as metabolic syndrome and type 2 diabetes. Contributing factors to the increases in obesity include a decline in positive health behaviors, such as making healthy dietary choices, engaging in physical activity, and limiting sedentary behaviors. Family and physical environmental contextual factors related to health behaviors are increasingly the focus of health behavior interventions in line with the bioecological model that encourages a system-focused perspective on understanding health behavior influences. Physical environmental characteristics, such as home and neighborhood characteristics and resources, provide the tangible means to support health behaviors and are important contextual variables to consider that may increase intervention effectiveness. Therefore, the current review seeks to highlight the importance of investigating influences of behavior beyond individual characteristics in understanding factors related to the risk of developing metabolic syndrome and type 2 diabetes in youth at high risk for developing chronic disease. The current study reviews the non-intervention literature on family and physical environmental factors related to health behaviors (i.e., diet, physical activity, and sedentary behavior) in youth who are considered to be at-risk for developing metabolic syndrome and type 2 diabetes. Results on 38 published articles of diet, physical activity, and sedentary behaviors showed support for the role of parenting and physical environmental factors, particularly parental monitoring and neighborhood context, such as social cohesion, as they relate to health behaviors in high-risk youth. Implications and recommendations for future research are discussed.

Few studies have examined environmental, home, and parental supports for physical activity in underserved adolescents (low income, ethnic minority). Given the increasing incidence of obesity in minority adolescents, it is important to better understand ecologic determinants of physical activity in these youth. This study used an ecologic model to evaluate the significance of neighborhood, home, and parental supports for physical activity on moderate-to-vigorous (MV) physical activity in underserved adolescents.The study was a secondary data analysis of a randomized controlled school-based trial "Active by Choice Today" (ACT) for increasing physical activity in underserved sixth-graders. Schools were matched on school size, percentage minorities, percentage entitled to free or reduced-price lunch, and urban or rural setting prior to randomization. This study used a randomly selected sample of parents (n=280) from the intervention and control schools whose adolescent was enrolled in the larger trial.A total of 679 6th-grade students (mean age=11.4 years, 70% African-American, 76% free or reduced-price lunch, 52% female) participated in the larger trial. Parents of 280 youth were contacted to participate in a telephone survey and 198 (71%) took part in the study.The ACT trial was designed to test the efficacy of a 17-week (1 academic year) motivational plus behavioral skills intervention versus comparison after-school programs on increasing physical activity. A telephone survey was developed and was administered within 6 months after the trial began on parents of 198 adolescents from the ACT randomized school-based trial during 2005-2007.The primary outcome measure was adolescent MVPA based on 7-day accelerometry estimates from baseline to mid-intervention. The data were analyzed in 2010-2011 and included both parent and adolescent self-reports of environmental, home, and family supports for physical activity.Regression analyses indicated a significant effect of parental and neighborhood supports for physical activity on adolescent MVPA. Adolescents who perceived higher (vs lower) levels of parental support for physical activity engaged in more minutes of MVPA (B=3.01, SE=1.38, p0.05) at mid-intervention. Adolescents who lived in neighborhoods with more (vs fewer) supports for physical activity (parks, lighting), also engaged in more minutes MVPA (B=4.27, SE=2.15, p0.05).Support from parents and neighborhood quality are both associated with increased physical activity in underserved adolescents.

National studies indicate that the increasing rate of childhood obesity is a major public health problem and that prevalence rates of obesity among youth have more than tripled in the last three decades (Levi, Vinter, Laurent, & Segal, 2008; Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). Reports indicate that 34.2% of adolescents and 39.5% of African American adolescents are overweight or obese (Ogden et al., 2010). In addition, recent estimates indicate that 50–92% of youth do not meet the national guidelines for engaging in regular physical activity (PA) and PA declines by 50% between the elementary and middle school years (Nader et al., 2008; Troiano et al., 2008; U.S. Department of Health and Human Services, 2008). High levels of obesity have been found to be especially problematic among minority and low-income youth who have less access to safe PA opportunities, and who have lessfamily support for participating in PA (Molnar, Gortmaker, Bull, & Buka, 2004; Pettit, Laird, Bates, & Dodge, 1997). Few studies have examined the effects of school-based interventions on increasing PA in underserved adolescent populations such as low income, ethnic minorities (Bayne-Smith, Fardy, Magel, Schmitz, & Agin, 2004; Coleman, Tiller, Sanchez, et al., 2005; McKenzie et al., 2004; Robinson et al., 2003; Story et al., 2003). In general school-based interventions have had little or only modest effects on increasing PA and have resulted in little to no change in PA outside of school settings (Baranowski, Anderson, & Carmark, 1998; Gortmaker et al., 1999; Kelder, Perry, & Klepp, 1989; Killen et al., 1988; Saunders et al., 2006; van Sluijs, McMinn, & Griffin, 2007). Where comprehensive school-based interventions have typically included common behavior modification components including self-monitoring of PA, goal setting, and behavioral skills training, little attention has been given to involving youth in developing program ideas and PA choices that may enhance more intrinsic motivation, and thus, increase the likelihood of continued engagement in PA. Previous studies have provided evidence for the importance of choice and self-initiated behavior change on increasing intrinsic motivation for engaging in PA (Ferrer-Caja & Weiss, 2000; Thompson & Wankel, 1980; Wilson et al., 2005), but large scale randomized trials have not tested motivational and behavioral skills interventions specifically in low-income, ethnic minority adolescents (Wilson, 2009; Wilson et al., 2002; Wilson et al., 2005). The ACT intervention integrated principles from Self-Determination Theory (Deci, Koestner, & Ryan, 1999; Ryan & Deci, 2000) and Social Cognitive Theory (Bandura, 1989, 2004). Self-Determination Theory (SDT) proposes that behavior changes that are motivated by intrinsic factors such as novel, enjoyable, self-driven, and satisfying experiences will be sustained over time. In the ACT intervention elements from SDT targeted the social environmental during the after-school program for enhancing autonomy (choice), fun, belongingness (engagement), and competence (challenges emphasizing non- competitive play) for PA (Wilson et al., 2006; Wilson et al., 2009). SCT theory assumes that individual-cognitive factors, environmental events, and behavior are interacting and reciprocal determinants of each other. Thus, both cognitive and social factors were integrated into the development of a behavioral skills component of the ACT intervention for increasing PA. The ACT intervention specifically targeted development of behavioral skills (communication, reciprocity of social support, group goal setting, and behavioral competence) for increasing PA outside of program days. In addition, the ACT after-school program social environment (autonomy, choice, participation, belongingness, fun, enjoyment, support) was designed to have a positive impact on cognitive mediators (self-confidence, perceived competence) and motivational orientation (intrinsic motivation, commitment, positive self-concept) to promote longterm PA behavior (Wilson et al., 2009, 2006, 2008). The primary aim of this study was to determine the efficacy of the motivational and behavioral skills ACT intervention (vs. a control program– general health education) on increasing PA at 2-weeks postintervention (primary outcome) and at midintervention (intermediate outcome) in underserved adolescents.

Rates of overweight in youth have reached epidemic proportions and are associated with adverse health outcomes. Family-based programs have been widely used to treat overweight in youth. However, few programs incorporate a theoretical framework for studying a family systems approach in relation to youth health behavior change. Therefore, this review provides a family systems theory framework for evaluating family-level variables in weight loss, physical activity, and dietary approaches in youth. Studies were reviewed and effect sizes were calculated for interventions that manipulated the family system, including components that targeted parenting styles, parenting skills, or family functioning, or which had novel approaches for including the family. Twenty-one weight loss interventions were identified, and 25 interventions related to physical activity and/or diet were identified. Overall, family-based treatment programs that incorporated training for authoritative parenting styles, parenting skills, or child management, and family functioning had positive effects on youth weight loss. Programs to improve physical activity and dietary behaviors that targeted the family system also demonstrated improvements in youth health behaviors; however, direct effects of parent-targeted programming is not clear. Both treatment and prevention programs would benefit from evaluating family functioning and parenting styles as possible mediators of intervention outcomes. Recommendations are provided to guide the development of future family-based obesity prevention and treatment programs for youth.

Background Despite their increased use, no studies have examined the validity of Actical accelerometry cut points for moderate physical activity (PA) in underserved (low-income, high-crime), minority populations. The high rates of chronic disease and physical inactivity in these populations likely impact the measurement of PA. There is growing concern that traditionally defined cut points may be too high for older or inactive adults. The present study aimed to determine the self-selected pace associated with instructions to “walk for exercise” and the corresponding accelerometry estimates (e.g., Actical counts/minute) for underserved, African American adults. Method Fifty one participants (61% women) had a mean age of 60.1 (SD = 9.9) and a mean body mass index of 30.5 kg/m2 (SD = 6.0). They performed one seated task, one standing task, and three walking tasks: “strolling”; “walking for exercise”; and “walking in an emergency.” Results The average pace for strolling, walking for exercise, and walking in an emergency were 1.62 miles per hour (mph; SD = .51), 2.51 mph (SD = .53), and 2.86 mph (SD = .58), respectively. The average Actical counts/minute for the five activities were: 4 (SD = 15), 16 (SD = 29), 751 (SD = 591), 2006 (SD = 1095), and 2617 (SD = 1169), respectively. Regression analyses showed that the predicted counts/minute for a pace of 2.0 mph (which is used as the criterion for moderate exercise in this study) was 1075 counts/minute (SEM = 73). Conclusions The cut point associated with subjectively determined moderate PA is similar to those previously published for older adults and extends the use of adjusted cut points to African American populations. These results indicate that accurate cut points can be obtained using this innovative methodology.

Objective This study assessed the prevalence and consistency of high values of weight, height, and BMI considered to be biologically implausible (BIV) using cut points proposed by WHO among 8.8 million low-income children (13.7 million observations). Methods Cross-sectional and longitudinal analyses were performed among 2- to 4-year-olds who were examined from 2008 through 2011. Results Overall, 2.7% of the body size measurements were classified as BIVs; 95% of these BIVs were very high. Among the subset of children (3.6 million) examined more than once, most of those who initially had a high weight or BMI BIV also had a high BIV at the second examination; odds ratios were >250. Based on several alternative classifications of BIVs, the current cut points likely underestimate the prevalence of obesity by about 1%. Conclusions Many of the extremely high values of body size currently flagged as BIVs are unlikely to be errors. Increasing the z-score cut points or using a percentage of the maximum values in the National Health and Nutrition Examination Survey, could improve the balance between removing probable errors and retaining those that are likely correct.