Erica L. Kenney

Three Interventions That Reduce Childhood Obesity Are Projected To Save More Than They Cost To Implement

Policy makers seeking to reduce childhood obesity must prioritize investment in treatment and primary prevention. We estimated the cost-effectiveness of seven interventions high on the obesity policy agenda: a sugar-sweetened beverage excise tax; elimination of the tax subsidy for advertising unhealthy food to children; restaurant menu calorie labeling; nutrition standards for school meals; nutrition standards for all other food and beverages sold in schools; improved early care and education; and increased access to adolescent bariatric surgery. We used systematic reviews and a microsimulation model of national implementation of the interventions over the period 2015-25 to estimate their impact on obesity prevalence and their cost-effectiveness for reducing the body mass index of individuals. In our model, three of the seven interventions--excise tax, elimination of the tax deduction, and nutrition standards for food and beverages sold in schools outside of meals--saved more in health care costs than they cost to implement. Each of the three interventions prevented 129,000-576,000 cases of childhood obesity in 2025. Adolescent bariatric surgery had a negligible impact on obesity prevalence. Our results highlight the importance of primary prevention for policy makers aiming to reduce childhood obesity.

Increasing Water Availability During Afterschool Snack: Evidence, Strategies, and Partnerships from a Group Randomized Trial

BACKGROUND Providing drinking water to U.S. children during school meals is a recommended health promotion strategy and part of national nutrition policy. Urban school systems have struggled with providing drinking water to children, and little is known about how to ensure that water is served, particularly in afterschool settings. PURPOSE To assess the effectiveness of an intervention designed to promote water as the beverage of choice in afterschool programs. DESIGN The Out of School Nutrition and Physical Activity Initiative (OSNAP) used a community-based collaboration and low-cost strategies to provide water after school. A group RCT was used to evaluate the intervention. Data were collected in 2010-2011 and analyzed in 2011. SETTING/PARTICIPANTS Twenty afterschool programs in Boston were randomized to intervention or control (delayed intervention). INTERVENTION Intervention sites participated in learning collaboratives focused on policy and environmental changes to increase healthy eating, drinking, and physical activity opportunities during afterschool time (materials available at www.osnap.org). Collaboration between Boston Public Schools Food and Nutrition Services, afterschool staff, and researchers established water-delivery systems to ensure children were served water during snack time. MAIN OUTCOME MEASURES Average ounces of water served to children per day was recorded by direct observation at each program at baseline and 6-month follow-up over 5 consecutive school days. Secondary measures directly observed included ounces of other beverages served, other snack components, and water-delivery system. RESULTS Participation in the intervention was associated with an increased average volume of water served (+3.6 ounces/day; p=0.01) during snack. On average, the intervention led to a daily decrease of 60.9 kcals from beverages served during snack (p=0.03). CONCLUSIONS This study indicates the OSNAP intervention, including strategies to overcome structural barriers and collaboration with key actors, can increase offerings of water during afterschool snack. OSNAP appears to be an effective strategy to provide water in afterschool settings that can be helpful in implementing new U.S. Department of Agriculture guidelines regarding water availability during lunch and afterschool snack.

Validity of a Measure to Assess the Child-Care Nutrition and Physical Activity Environment

BACKGROUND Licensed child-care centers represent an opportunity to positively influence childrens health behaviors. Valid and easy-to-use measures of the child-care environment are needed to assess the influence of environmental change on health. OBJECTIVE To develop and validate a self-administered survey to assess the nutrition and physical activity environment of child-care centers, and to identify domains that may be evaluated adequately through self-report. DESIGN A survey was developed to assess four areas related to nutrition and physical activity: center policies, practices related to the social environment, physical environment, and nutrition quality. Development involved review of the literature, existing measures, and regulations/standards as well as collaboration with a working group. The survey was pilot tested and feedback was sought from expert consultants. It was administered statewide and validated against a menu rating tool, interviews with a center director, and a direct observation tool that was developed for this study. PARTICIPANTS/SETTING Participating sites were drawn from Child and Adult Care Food Program-participating licensed Connecticut child-care centers serving 13 or more children aged 3 to 5 years. Survey responses from 146 center directors were included, as were 62 center menus, and director interviews and observational data from 33 sites. PRIMARY OUTCOMES/STATISTICAL ANALYSES: Criterion validity of the survey was assessed through percent agreement with mirroring items in the additional measures. Healthy and unhealthy food scores were calculated for menu and survey tools, and Pearson correlations were computed. RESULTS Percent agreement with criterion outcomes ranged from 39% to 97%, with 61% of items achieving agreement ≥80%. Agreement was highest for nutrition and policy domains, and lowest for physical activity and barriers to promoting health. Correlations between food scores across measures were moderate. CONCLUSIONS The self-report survey demonstrated adequate criterion validity. We make recommendations for improving validity of low-agreement items and for the use of more labor-intensive evaluation procedures for domains not adequately assessed through self-report.

Prevalence of Inadequate Hydration Among US Children and Disparities by Gender and Race/Ethnicity: National Health and Nutrition Examination Survey, 2009–2012

OBJECTIVES We evaluated the hydration status of US children and adolescents. METHODS The sample included 4134 participants aged 6 to 19 years in the National Health and Nutrition Examination Survey from 2009 to 2012. We calculated mean urine osmolality and the proportion with inadequate hydration (urine osmolality > 800 mOsm/kg). We calculated multivariable regression models to estimate the associations between demographic factors, beverage intake, and hydration status. RESULTS The prevalence of inadequate hydration was 54.5%. Significantly higher urine osmolality was observed among boys (+92.0 mOsm/kg; 95% confidence interval [CI] = 69.5, 114.6), non-Hispanic Blacks (+67.6 mOsm/kg; 95% CI = 31.5, 103.6), and younger children (+28.5 mOsm/kg; 95% CI = 8.1, 48.9) compared with girls, Whites, and older children, respectively. Boys (OR = 1.76; 95% CI = 1.49, 2.07) and non-Hispanic Blacks (odds ratio [OR] = 1.34; 95% CI = 1.04, 1.74) were also at significantly higher risk for inadequate hydration. An 8-fluid-ounce daily increase in water intake was associated with a significantly lower risk of inadequate hydration (OR = 0.96; 95% CI = 0.93, 0.98). CONCLUSIONS Future research should explore drivers of gender and racial/ethnic disparities and solutions for improving hydration status.

The Wellness Child Care Assessment Tool: A Measure to Assess the Quality of Written Nutrition and Physical Activity Policies

BACKGROUND There is a growing interest in studying the influence of child-care center policies on the health of preschool-aged children. OBJECTIVE To develop a reliable and valid instrument to quantitatively evaluate the quality of written nutrition and physical activity policies at child-care centers. DESIGN Reliability and validation study. A 65-item measure was created to evaluate five areas of child-care center policies: nutrition education, nutrition standards for foods and beverages, promoting healthy eating in the child-care setting, physical activity, and communication and evaluation. The total scale and each subscale were scored on comprehensiveness and strength. SETTING Analyses were conducted on 94 independent policies from Connecticut child-care centers participating in the Child and Adult Care Food Program. STATISTICAL ANALYSES PERFORMED Intraclass correlation coefficient was calculated to measure inter-rater reliability, and Cronbachs α was used to estimate internal consistency. To test construct validity, t tests were used to assess differences in scores between Head Start and non-Head Start centers and between National Association for the Education of Young Children-accredited and nonaccredited centers. RESULTS Inter-rater reliability was high for total comprehensiveness and strength scores (intraclass correlation coefficient=0.98 and 0.94, respectively) and subscale scores (intraclass correlation coefficient=0.84 to 0.99). Subscales were adequately internally reliable (Cronbachs α=.53 to .83). Comprehensiveness and strength scores were higher for Head Start centers than non-Head Start centers across most domains and higher for National Association for the Education of Young Children-accredited centers than nonaccredited centers across some but not all domains, providing evidence of construct validity. CONCLUSIONS This instrument provides a standardized method to analyze and compare the comprehensiveness and strength of written nutrition and physical activity policies in child-care centers.

United States Adolescents' Television, Computer, Videogame, Smartphone, and Tablet Use: Associations with Sugary Drinks, Sleep, Physical Activity, and Obesity

Objective To quantify the relationships between youth use of television (TV) and other screen devices, including smartphones and tablets, and obesity risk factors. Study design TV and other screen device use, including smartphones, tablets, computers, and/or videogames, was self‐reported by a nationally representative, cross‐sectional sample of 24 800 US high school students (2013‐2015 Youth Risk Behavior Surveys). Students also reported on health behaviors including sugar‐sweetened beverage (SSB) intake, physical activity, sleep, and weight and height. Sex‐stratified logistic regression models, adjusting for the sampling design, estimated associations between TV and other screen device use and SSB intake, physical activity, sleep, and obesity. Results Approximately 20% of participants used other screen devices for ≥5 hours daily. Watching TV ≥5 hours daily was associated with daily SSB consumption (aOR = 2.72, 95% CI: 2.23, 3.32) and obesity (aOR = 1.78, 95% CI: 1.40, 2.27). Using other screen devices ≥5 hours daily was associated with daily SSB consumption (aOR = 1.98, 95% CI: 1.69, 2.32), inadequate physical activity (aOR = 1.94, 95% CI: 1.69, 2.25), and inadequate sleep (aOR = 1.79, 95% CI: 1.54, 2.08). Conclusions Using smartphones, tablets, computers, and videogames is associated with several obesity risk factors. Although further study is needed, families should be encouraged to limit both TV viewing and newer screen devices.

Promoting Physical Activity With the Out of School Nutrition and Physical Activity (OSNAP) Initiative: A Cluster-Randomized Controlled Trial

IMPORTANCE Millions of children attend after-school programs in the United States. Increasing physical activity levels of program participants could have a broad effect on childrens health. OBJECTIVE To test the effectiveness of the Out of School Nutrition and Physical Activity (OSNAP) Initiative in increasing childrens physical activity levels in existing after-school programs. DESIGN, SETTING, AND PARTICIPANTS Cluster-randomized controlled trial with matched program pairs. Baseline data were collected September 27 through November 12, 2010, with follow-up data collected April 25 through May 27, 2011. The dates of our analysis were March 11, 2014, through August 18, 2015. The setting was 20 after-school programs in Boston, Massachusetts. All children 5 to 12 years old in participating programs were eligible for study inclusion. INTERVENTIONS Ten programs participated in a series of three 3-hour learning collaborative workshops, with additional optional opportunities for training and technical assistance. MAIN OUTCOMES AND MEASURES Change in number of minutes and bouts of moderate to vigorous physical activity, vigorous physical activity, and sedentary activity and change in total accelerometer counts between baseline and follow-up. RESULTS Participants with complete data were 402 racially/ethnically diverse children, with a mean age of 7.7 years. Change in the duration of physical activity opportunities offered to children during program time did not differ between conditions (-1.2 minutes; 95% CI, -14.2 to 12.4 minutes; P = .87). Change in moderate to vigorous physical activity minutes accumulated by children during program time did not differ significantly by intervention status (-1.0; 95% CI, -3.3 to 1.3; P = .40). Total minutes per day of vigorous physical activity (3.2; 95% CI, 1.8-4.7; P < .001), vigorous physical activity minutes in bouts (4.1; 95% CI, 2.7-5.6; P < .001), and total accelerometer counts per day (16,894; 95% CI, 5101-28,686; P = .01) increased significantly during program time among intervention participants compared with control participants. CONCLUSIONS AND RELEVANCE Although programs participating in the OSNAP Initiative did not allot significantly more time for physical activity, they successfully made existing time more vigorously active for children receiving the intervention. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01396473.

Comparing Current Practice to Recommendations for the Child and Adult Care Food Program

BACKGROUND The federal Child and Adult Care Food Program (CACFP) assists child care centers serving low-income preschoolers and regulates the quality and quantity of food served. The aim of this study was to assess the nutritional quality of lunches served at 38 child care centers and examine how current practices compare to proposed meal pattern recommendations. METHODS Preschool-aged children (n = 204) were observed eating lunch in 38 CACFP-participating preschools. All foods served and consumed were measured and compared to the 2011 Institute of Medicine (IOM) recommendations to improve CACFP and the 2015 Proposed Rule issued by the USDA. RESULTS All centers provided access to all required lunch components, but not all components were served (i.e., placed on the childs plate). Vegetables were significantly less likely to be served than meat or grains. Compared with CACFP recommended portion sizes, servings of meat and grain were high, whereas milk was low. Compared with IOM recommendations, average calorie consumption was appropriate, but saturated fat, protein, and sodium intake were high and dietary fiber was low. Meals that offered children both a fruit and a vegetable led to significantly higher produce consumption than meals that offered only one fruit or one vegetable. CONCLUSIONS Child care centers generally comply with current CACFP regulations, but do not provide lunches consistent with the 2011 IOM recommendations for saturated fat, protein, fiber, and sodium. Decreased use of beef and cheese and increased provision of whole grains, fruits, and vegetables are recommended.

The academic penalty for gaining weight: a longitudinal, change-in-change analysis of BMI and perceived academic ability in middle school students.

Background/Objectives:Worse educational outcomes for obese children regardless of academic ability may begin early in the life course. This study tested whether an increase in children’s relative weight predicted lower teacher- and child-perceived academic ability even after adjusting for standardized test scores.Subjects/Methods:Three thousand three hundred and sixty-two children participating in the Early Childhood Longitudinal Study–Kindergarten Cohort were studied longitudinally from fifth to eighth grade. Heights, weights, standardized test scores in maths and reading, and teacher and self-ratings of ability in maths and reading were measured at each wave. Longitudinal, within-child linear regression models estimated the impact of a change in body mass index (BMI) z-score on change in normalized teacher and student ratings of ability in reading and maths, adjusting for test score.Results:A change in BMI z-score from fifth to eighth grade was not independently associated with a change in standardized test scores. However, adjusting for standardized test scores, an increasing BMI z-score was associated with significant reductions in teacher’s perceptions of girls’ ability in reading (−0.12, 95% confidence interval (CI): −0.23, −0.03, P=0.03) and boys’ ability in math (−0.30, 95% CI: −0.43, −0.17, P<0.001). Among children who were overweight at fifth grade and increased in BMI z-score, there were even larger reductions in teacher ratings for boys’ reading ability (−0.37, 95% CI: −0.71, −0.03, P=0.03) and in girls’ self-ratings of maths ability (−0.47, 95% CI: −0.83, −0.11, P=0.01).Conclusions:From fifth to eighth grade, increase in BMI z-score was significantly associated with worsening teacher perceptions of academic ability for both boys and girls, regardless of objectively measured ability (standardized test scores). Future research should examine potential interventions to reduce bias and promote positive school climate.

Grab a Cup, Fill It Up! An Intervention to Promote the Convenience of Drinking Water and Increase Student Water Consumption During School Lunch

OBJECTIVES We evaluated a low-cost strategy for schools to improve the convenience and appeal of drinking water. METHODS We conducted a group-randomized, controlled trial in 10 Boston, Massachusetts, schools in April through June 2013 to test a cafeteria-based intervention. Signage promoting water and disposable cups were installed near water sources. Mixed linear regression models adjusting for clustering evaluated the intervention impact on average student water consumption over 359 lunch periods. RESULTS The percentage of students in intervention schools observed drinking water during lunch nearly doubled from baseline to follow-up compared with controls (+ 9.4%; P < .001). The intervention was associated with a 0.58-ounce increase in water intake across all students (P < .001). Without cups, children were observed drinking 2.4 (SE = 0.08) ounces of water from fountains; with cups, 5.2 (SE = 0.2) ounces. The percentage of intervention students observed with sugar-sweetened beverages declined (-3.3%; P < .005). CONCLUSIONS The current default of providing water through drinking fountains in cafeterias results in low water consumption. This study shows that an inexpensive intervention to improve drinking waters convenience by providing cups can increase student water consumption.