Use of Evidence-Based Interventions to Promote Healthy Weight, Nutrition, and Physical Activity in Community Health Improvement Plans from Large Local Health Departments.

We sought to identify evidence-based healthy weight, nutrition, and physical activity strategies related to obesity prevention in large local health department (LHD) Community Health Improvement Plans (CHIPs). We analyzed the content of the most recent, publicly available plans from 72 accredited LHDs serving a population of at least 500 000 people. We matched CHIP strategies to the County Health Rankings and Roadmaps' What Works for Health (WWFH) database of interventions. We identified 739 strategies across 55 plans, 62.5% of which matched a "WWFH intervention" rated for effectiveness on diet and exercise outcomes. Among the 20 most commonly identified WWFH interventions in CHIPs, 10 had the highest evidence for effectiveness while 4 were rated as likely to decrease health disparities according to WWFH. Future prioritization of strategies by health agencies could focus on strategies with the strongest evidence for promoting healthy weight, nutrition, and physical activity outcomes and reducing health disparities.

Projected U.S. State-Level Prevalence of Adult Obesity and Severe Obesity.

BACKGROUND: Although the national obesity epidemic has been well documented, less is known about obesity at the U.S. state level. Current estimates are based on body measures reported by persons themselves that underestimate the prevalence of obesity, especially severe obesity. METHODS: We developed methods to correct for self-reporting bias and to estimate state-specific and demographic subgroup-specific trends and projections of the prevalence of categories of body-mass index (BMI). BMI data reported by 6,264,226 adults (18 years of age or older) who participated in the Behavioral Risk Factor Surveillance System Survey (1993-1994 and 1999-2016) were obtained and corrected for quantile-specific self-reporting bias with the use of measured data from 57,131 adults who participated in the National Health and Nutrition Examination Survey. We fitted multinomial regressions for each state and subgroup to estimate the prevalence of four BMI categories from 1990 through 2030: underweight or normal weight (BMI [the weight in kilograms divided by the square of the height in meters], <25), overweight (25 to <30), moderate obesity (30 to <35), and severe obesity (≥35). We evaluated the accuracy of our approach using data from 1990 through 2010 to predict 2016 outcomes. RESULTS: The findings from our approach suggest with high predictive accuracy that by 2030 nearly 1 in 2 adults will have obesity (48.9%; 95% confidence interval [CI], 47.7 to 50.1), and the prevalence will be higher than 50% in 29 states and not below 35% in any state. Nearly 1 in 4 adults is projected to have severe obesity by 2030 (24.2%; 95% CI, 22.9 to 25.5), and the prevalence will be higher than 25% in 25 states. We predict that, nationally, severe obesity is likely to become the most common BMI category among women (27.6%; 95% CI, 26.1 to 29.2), non-Hispanic black adults (31.7%; 95% CI, 29.9 to 33.4), and low-income adults (31.7%; 95% CI, 30.2 to 33.2). CONCLUSIONS: Our analysis indicates that the prevalence of adult obesity and severe obesity will continue to increase nationwide, with large disparities across states and demographic subgroups. (Funded by the JPB Foundation.).

Lead Concentrations in US School Drinking Water: Testing Programs, Prevalence, and Policy Opportunities, 2016‒2018.

Objectives. To detail baseline drinking water sample lead concentrations and features of US state-level programs and policies to test school drinking water for lead in 7 states' operating programs between 2016 and 2018. Methods. We coded program and policy documents using structured content analysis protocols and analyzed state-provided data on lead concentration in drinking water samples collected in public schools during initial testing phases. Results. We analyzed data from 5688 public schools, representing 35% of eligible schools in 7 states. The number of samples per school varied. The proportion of schools identifying any sample lead concentration exceeding 5 parts per billion varied (13%-81%). Four states exceeded 20%. Other program features varied among states. Instances of lead above the state action level were identified in all states. Conclusions. In 2018, many US public school students attended schools in states without drinking water lead-testing programs. Testing all drinking water sources may be recommended. Public Health Implications. Initiating uniform school drinking water lead testing programs and surveillance over time could be used to reduce risk of lead exposure in drinking water. (Am J Public Health. 2022;112(S7):S679-S689. https://doi.org/10.2105/AJPH.2022.306961).

Assessing the effectiveness of training models for national scale-up of an evidence-based nutrition and physical activity intervention: a group randomized trial.

BACKGROUND: There is a great need to identify implementation strategies to successfully scale-up public health interventions in order to achieve their intended population impact. The Out-of-school Nutrition and Physical Activity group-randomized trial previously demonstrated improvements in children's vigorous physical activity and the healthfulness of foods and beverages consumed. This implementation study aimed to assess the effects and costs of two training models to scale-up this evidence-based intervention. METHODS: A 3-arm group-randomized trial was conducted to compare effectiveness of in-person and online training models for scaling up the intervention compared to controls. One-third of sites were randomized to the in-person train-the-trainer model: local YMCA facilitators attended a training session and then conducted three learning collaborative meetings and technical assistance. One-third were assigned to the online model, consisting of self-paced monthly learning modules, videos, quizzes, and facilitated discussion boards. Remaining sites served as controls. Fifty-three afterschool sites from three YMCA Associations in different regions of the country completed baseline and follow-up observations using a validated tool of afterschool nutrition and physical activity practices. We used multivariable regression models, accounting for clustering of observations, to assess intervention effects on an aggregate afterschool practice primary outcome, and conducted secondary analyses of nine intervention goals (e.g. serving water). Cost data were collected to determine the resources to implement each training model. RESULTS: Changes in the primary outcome indicate that, on average, sites in the in-person arm achieved 0.44 additional goals compared to controls (95%CI 0.02, 0.86, p = 0.04). Increases in the number of additional goals achieved in sites in the online arm were not significantly greater than control sites (+ 0.28, 95% CI -0.18, 0.73, p = 0.24). Goal-specific improvements were observed for increasing water offered in the in-person arm and fruits and vegetables offered in the online arm. The cost per person trained was $678 for the in-person training model and $336 for the on-line training model. CONCLUSIONS: This pilot trial presents promising findings on implementation strategies for scale-up. It validated the in-person training model as an effective approach. The less expensive online training may be a useful option for geographically disbursed sites where in-person training is challenging. TRIAL REGISTRATION: Although this study does not report the results of a health care intervention on human subjects, it is a randomized trial and was therefore retrospectively registered in ClinicalTrials.gov on July 4, 2019 in accordance with the BMC guidelines to ensure the complete publication of all results (NCT04009304).

Using cost-effectiveness analysis to prioritize policy and programmatic approaches to physical activity promotion and obesity prevention in childhood.

Participation in recommended levels of physical activity promotes a healthy body weight and reduced chronic disease risk. To inform investment in prevention initiatives, we simulate the national implementation, impact on physical activity and childhood obesity and associated cost-effectiveness (versus the status quo) of six recommended strategies that can be applied throughout childhood to increase physical activity in US school, afterschool and childcare settings. In 2016, the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES) systematic review process identified six interventions for study. A microsimulation model estimated intervention outcomes 2015-2025 including changes in mean MET-hours/day, intervention reach and cost per person, cost per MET-hour change, ten-year net costs to society and cases of childhood obesity prevented. First year reach of the interventions ranged from 90,000 youth attending a Healthy Afterschool Program to 31.3 million youth reached by Active School Day policies. Mean MET-hour/day/person increases ranged from 0.05 MET-hour/day/person for Active PE and Healthy Afterschool to 1.29 MET-hour/day/person for the implementation of New Afterschool Programs. Cost per MET-hour change ranged from cost saving to $3.14. Approximately 2500 to 110,000 cases of children with obesity could be prevented depending on the intervention implemented. All of the six interventions are estimated to increase physical activity levels among children and adolescents in the US population and prevent cases of childhood obesity. Results do not include other impacts of increased physical activity, including cognitive and behavioral effects. Decision-makers can use these methods to inform prioritization of physical activity promotion and obesity prevention on policy agendas.

Validity of a practitioner-administered observational tool to measure physical activity, nutrition, and screen time in school-age programs.

BACKGROUND: Nutrition and physical activity interventions have been effective in creating environmental changes in afterschool programs. However, accurate assessment can be time-consuming and expensive as initiatives are scaled up for optimal population impact. This study aims to determine the criterion validity of a simple, low-cost, practitioner-administered observational measure of afterschool physical activity, nutrition, and screen time practices and child behaviors. METHODS: Directors from 35 programs in three cities completed the Out-of-School Nutrition and Physical Activity Observational Practice Assessment Tool (OSNAP-OPAT) on five days. Trained observers recorded snacks served and obtained accelerometer data each day during the same week. Observations of physical activity participation and snack consumption were conducted on two days. Correlations were calculated to validate weekly average estimates from OSNAP-OPAT compared to criterion measures. Weekly criterion averages are based on 175 meals served, snack consumption of 528 children, and physical activity levels of 356 children. RESULTS: OSNAP-OPAT validly assessed serving water (r = 0.73), fruits and vegetables (r = 0.84), juice >4oz (r = 0.56), and grains (r = 0.60) at snack; sugary drinks (r = 0.70) and foods (r = 0.68) from outside the program; and children's water consumption (r = 0.56) (all p <0.05). Reports of physical activity time offered were correlated with accelerometer estimates (minutes of moderate and vigorous physical activity r = 0.59, p = 0.02; vigorous physical activity r = 0.63, p = 0.01). The reported proportion of children participating in moderate and vigorous physical activity was correlated with observations (r = 0.48, p = 0.03), as were reports of computer (r = 0.85) and TV/movie (r = 0.68) time compared to direct observations (both p < 0.01). CONCLUSIONS: OSNAP-OPAT can assist researchers and practitioners in validly assessing nutrition and physical activity environments and behaviors in afterschool settings. TRIAL REGISTRATION: Phase 1 of this measure validation was conducted during a study registered at clinicaltrials.gov NCT01396473.

Cost-effectiveness of Improved WIC Food Package for Preventing Childhood Obesity.

BACKGROUND AND OBJECTIVES: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) prevents food insecurity and supports nutrition for more than 3 million low-income young children. Our objectives were to determine the cost-effectiveness of changes to WIC's nutrition standards in 2009 for preventing obesity and to estimate impacts on socioeconomic and racial/ethnic inequities. METHODS: We conducted a cost-effectiveness analysis to estimate impacts from 2010 through 2019 of the 2009 WIC food package change on obesity risk for children aged 2 to 4 years participating in WIC. Microsimulation models estimated the cases of obesity prevented in 2019 and costs per quality-adjusted-life year gained. RESULTS: An estimated 14.0 million 2- to 4-year old US children (95% uncertainty interval (UI), 13.7-14.2 million) were reached by the updated WIC nutrition standards from 2010 through 2019. In 2019, an estimated 62 700 (95% UI, 53 900-71 100) cases of childhood obesity were prevented, entirely among children from households with low incomes, leading to improved health equity. The update was estimated to cost $10 600 per quality-adjusted-life year gained (95% UI, $9760-$11 700). If WIC had reached all eligible children, more than twice as many cases of childhood obesity would have been prevented. CONCLUSIONS: Updates to WIC's nutrition standards for young children in 2009 were estimated to be highly cost-effective for preventing childhood obesity and contributed to reducing socioeconomic and racial/ethnic inequities in obesity prevalence. Improving nutrition policies for young children can be a sound public health investment; future research should explore how to improve access to them.

Cost-effectiveness of a primary care-based Healthy Weight Clinic compared with usual care.

OBJECTIVE: The objective of this study was to project the cost-effectiveness of implementing the Healthy Weight Clinic (HWC), a primary care-based intervention for 6- to 12-year-old children with overweight or obesity, at federally qualified health centers (FQHCs) nationally. METHODS: We estimated intervention costs from a health care sector and societal perspective and used BMI change estimates from the HWC trial. Our microsimulation of national HWC implementation among all FQHCs from 2023 to 2032 estimated cost per child and per quality-adjusted life year (QALY) gained and projected impact on obesity prevalence by race and ethnicity. Probabilistic sensitivity analyses assessed uncertainty around estimates. RESULTS: National implementation is projected to reach 888,000 children over 10 years, with a mean intervention cost of $456 (95% uncertainty interval [UI]: $409-$506) per child to the health care sector and $211 (95% UI: $175-$251) to families (e.g., time participating). Assuming effect maintenance, national implementation could result in 2070 (95% UI: 859-3220) QALYs gained and save $14.6 million (95% UI: $5.6-$23.5 million) in health care costs over 10 years, yielding a net cost of $278,000 (95% CI: $177,000-$679,000) per QALY gained. We project greater reductions in obesity prevalence among Hispanic/Latino and Black versus White populations. CONCLUSIONS: The HWC is relatively low-cost per child and projected to reduce obesity disparities if implemented nationally in FQHCs.

Cost Effectiveness of Calorie Labeling at Large Fast-Food Chains Across the U.S.

INTRODUCTION: Calorie labeling of standard menu items has been implemented at large restaurant chains across the U.S. since 2018. The objective of this study was to evaluate the cost effectiveness of calorie labeling at large U.S. fast-food chains. METHODS: This study evaluated the national implementation of calorie labeling at large fast-food chains from a modified societal perspective and projected its cost effectiveness over a 10-year period (2018-2027) using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model. Using evidence from over 67 million fast-food restaurant transactions between 2015 and 2019, the impact of calorie labeling on calorie consumption and obesity incidence was projected. Benefits were estimated across all racial, ethnic, and income groups. Analyses were performed in 2022. RESULTS: Calorie labeling is estimated to be cost saving; prevent 550,000 cases of obesity in 2027 alone (95% uncertainty interval=518,000; 586,000), including 41,500 (95% uncertainty interval=33,700; 50,800) cases of childhood obesity; and save $22.60 in healthcare costs for every $1 spent by society in implementation costs. Calorie labeling is also projected to prevent cases of obesity across all racial and ethnic groups (range between 126 and 185 cases per 100,000 people) and all income groups (range between 152 and 186 cases per 100,000 people). CONCLUSIONS: Calorie labeling at large fast-food chains is estimated to be a cost-saving intervention to improve long-term population health. Calorie labeling is a low-cost intervention that is already implemented across the U.S. in large chain restaurants.

A Sugar-Sweetened Beverage Excise Tax in California: Projected Benefits for Population Obesity and Health Equity.

INTRODUCTION: Amid the successes of local sugar-sweetened beverage (SSB) taxes, interest in state-wide policies has grown. This study evaluated the cost effectiveness of a hypothetical 2-cent-per-ounce excise tax in California and its implications for population health and health equity. METHODS: Using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model, tax impacts on health, health equity, and cost effectiveness over 10 years in California were projected, both overall and stratified by race/ethnicity and income. Expanding on previous models, differences in the effect of intake of SSBs on weight by BMI category were incorporated. Costing was performed in 2020, and analyses were conducted in 2021-2022. RESULTS: The tax is projected to save $4.55 billion in healthcare costs, prevent 266,000 obesity cases in 2032, and gain 114,000 quality-adjusted life years. Cost-effectiveness metrics, including cost/quality-adjusted life year gained, were cost saving. Spending on SSBs was projected to decrease by $33 per adult and $26 per child overall in the first year. Reductions in obesity prevalence for Black and Hispanic Californians were 1.8 times larger than for White Californians, and reductions for adults with lowest incomes (<130% Federal Poverty Level) were 1.4 times the reduction among those with highest incomes (>350% Federal Poverty Level). The tax is projected to save $112 in obesity-related healthcare costs per $1 invested. CONCLUSIONS: A state-wide SSB tax in California would be cost saving, lead to reductions in obesity and improvement in SSB-related health equity, and lead to overall improvements in population health. The policy would generate more than $1.6 billion in state tax revenue annually that can also be used to improve health equity.

Roles and strategies of state organizations related to school-based physical education and physical activity policies.

School-based physical education (PE) and physical activity (PA) policies can improve PA levels of students and promote health. Studies of policy implementation, communication, monitoring, enforcement, and evaluation are lacking. To describe how states implement, communicate, monitor, enforce, and evaluate key school-based PE and PA policies, researchers interviewed 24 key informants from state-level organizations in 9 states, including representatives from state departments of health and education, state boards of education, and advocacy/professional organizations. These states educate 27% of the US student population. Key informants described their organizations' roles in addressing 14 school-based PE and PA state laws and regulations identified by the Bridging the Gap research program and the National Cancer Institute's Classification of Laws Associated with School Students (C.L.A.S.S.) system. On average, states had 4 of 14 school-based PE and PA laws and regulations, and more than one-half of respondents reported different policies in practice besides the "on the books" laws. Respondents more often reported roles implementing and communicating policies compared with monitoring, enforcing, and evaluating them. Implementation and communication strategies used included training, technical assistance, and written communication of policy to local education agency administrators and teachers. State-level organizations have varying roles in addressing school-based PE and PA policies. Opportunities exist to focus state-level efforts on compliance with existing laws and regulations and evaluation of their impact.

The societal costs and health impacts on obesity of BMI report cards in US schools.

OBJECTIVE: This study aimed to estimate the 10-year cost-effectiveness of school-based BMI report cards, a commonly implemented program for childhood obesity prevention in the US where student BMI is reported to parents/guardians by letter with nutrition and physical activity resources, for students in grades 3 to 7. METHODS: A microsimulation model, using data inputs from evidence reviews on health impacts and costs, estimated: how many students would be reached if the 15 states currently measuring student BMI (but not reporting to parents/guardians) implemented BMI report cards from 2023 to 2032; how many cases of childhood obesity would be prevented; expected changes in childhood obesity prevalence; and costs to society. RESULTS: BMI report cards were projected to reach 8.3 million children with overweight or obesity (95% uncertainty interval [UI]: 7.7-8.9 million) but were not projected to prevent any cases of childhood obesity or significantly decrease childhood obesity prevalence. Ten-year costs totaled $210 million (95% UI: $30.5-$408 million) or $3.33 per child per year with overweight or obesity (95% UI: $3.11-$3.68). CONCLUSIONS: School-based BMI report cards are not cost-effective childhood obesity interventions. Deimplementation should be considered to free up resources for implementing effective programs.

Evaluation of efforts to reduce sodium and ensure access to healthier beverages in four healthcare settings in Massachusetts, US 2016-2018.

Considerable science links diets lower in sodium and sugar-sweetened beverage consumption with better health outcomes. This study describes the evaluation process and outcomes of intervention strategies to reduce sodium in foods and sugar in beverages as part of a collaborative partnership between state public health, academic, community, and healthcare partners in Massachusetts, US. This quasi-experimental, pre-post study used nutrient data linked to observations of foods and beverages available in cafeterias and vending machines in four community healthcare settings to inform intervention strategies and evaluate changes. At post-assessment, beverages with no or very low sugar were significantly more prevalent in vending machines (OR = 1.93, p < 0.001) and cafeterias (OR = 1.83, p = 0.01) and low-sodium packaged foods were significantly more prevalent in cafeterias (OR = 2.45, p < 0.001), but not vending machines. These types of partnerships and tailored feedback and technical assistance strategies may support healthier food and beverage options within healthcare settings that serve patients, their families, and employees each day.

Playground renovations and quality at public parks in Boston,Massachusetts, 1996-2007.

INTRODUCTION: Recreational and transportation infrastructure can promote physical activity among children and adolescents. The Play Across Boston community-based research project sought to estimate and compare playground renovation rates across Boston areas before and after a playground quality assessment, to describe changes in playground quality among a subset of parks, and to document features of local transportation infrastructure around parks. METHODS: We used an observational pretest-posttest design to estimate playground renovation rates among 103 city-operated parks. Renovation rates were calculated on the basis of annual city Parks Department capital budgets from fiscal years 1996 through 2007. We used the same design to describe changes between a 2000 to 2001 baseline assessment of playground quality and a 2007 follow-up measured via observation of a subsample of 18 low-scoring parks in disadvantaged areas. We used χ(2 ) analysis to compare percentages of playgrounds renovated across city areas before and after baseline assessment, logistic regression analysis to calculate odds ratios comparing renovation rates after baseline by city area, and paired t tests to compare playground quality at baseline and follow-up. RESULTS: Overall playground renovation rates before (29%) and after (34%) baseline assessment were similar. Parks scoring low on playground quality at baseline were renovated after baseline at a higher rate than high-scoring playgrounds. After accounting for baseline playground quality, parks in disadvantaged areas were renovated at a rate similar to those in other areas. Playground quality scores improved between baseline (mean, 38.3; 95% confidence interval, 35.3-41.3) and 2007 in a subsample of previously low-scoring parks in disadvantaged areas. CONCLUSION: The findings of the 2007 follow-up assessment indicate an equitable rate of playground renovation across city areas according to need.

Effect of school district policy change on consumption of sugar-sweetened beverages among high school students, Boston, Massachusetts, 2004-2006.

INTRODUCTION: Consumption of sugar-sweetened beverages has increased among youth in recent decades, accounting for approximately 13% of total calories consumed. The Boston Public Schools passed a policy restricting sale of sugar-sweetened beverages in Boston schools in June 2004. The objective of this study was to determine whether high school students' consumption of sugar-sweetened beverages declined after this new policy was implemented. METHODS: We conducted a quasi-experimental evaluation by using data on consumption of sugar-sweetened beverages by public high school students who participated in the Boston Youth Survey during February through April 2004 and February through April 2006 (N = 2,033). We compared the observed change with national trends by using data from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Survey (NHANES). Regression methods were adjusted for student demographics. RESULTS: On average, Boston's public high school students reported daily consumption of 1.71 servings of sugar-sweetened beverages in 2004 and 1.38 servings in 2006. Regression analyses showed significant declines in consumption of soda (-0.16 servings), other sugar-sweetened beverages (-0.14 servings), and total sugar-sweetened beverages (-0.30 servings) between 2004 and 2006 (P < .001 for all). NHANES indicated no significant nationwide change in adolescents' consumption of sugar-sweetened beverages between 2003-2004 and 2005-2006. DISCUSSION: Data from Boston youth indicated significant reductions in consumption of sugar-sweetened beverages, which coincided with a policy change restricting sale of sugar-sweetened beverages in schools. Nationally, no evidence was found for change in consumption of sugar-sweetened beverages among same-aged youth, indicating that implementing policies that restrict the sale of sugar-sweetened beverages in schools may be a promising strategy to reduce adolescents' intake of unnecessary calories.

A Theoretical Model of Transition to Practice for Athletic Trainers.

CONTEXT: The transition to practice of newly credentialed athletic trainers (ATs) has become an area of focus in the athletic training literature. However, no theoretical model has been developed to describe the phenomenon and drive investigation. OBJECTIVE: To better understand the lived experience of the transition to practice and develop a theoretical model of transition to practice for ATs. DESIGN: Qualitative study. SETTING: Telephone interviews. PATIENTS OR OTHER PARTICIPANTS: Fourteen professional master's athletic training students (7 men, 7 women, age = 25.6 ± 3.7 years, from 9 higher education institutions) in the first year of clinical practice as newly credentialed ATs. DATA COLLECTION AND ANALYSIS: Participants completed semistructured phone interviews at 3 timepoints over 12 to 15 months. The first interview was conducted just before graduation, the second 4 to 6 months later, and the third at 10 to 12 months. The interviews were transcribed and analyzed using a grounded theory approach. RESULTS: We developed a theoretical model to explain the causal conditions that triggered transition, how the causal conditions were experienced, the coping strategies used to persist through the first year of practice, and the consequences of those strategies. CONCLUSIONS: The model provides a framework for new athletic training clinicians, educators, and employers to better understand the transition process in order to help new clinicians respond by accepting or adapting to their environment or their behaviors.

Limiting Television to Reduce Childhood Obesity: Cost-Effectiveness of Five Population Strategies.

Objective: To quantify the potential population-wide costs, number of individuals reached, and impact on obesity of five effective interventions to reduce children's television viewing if implemented nationally. Study Design: Utilizing evidence from systematic reviews, the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES) microsimulation model estimated the cost, population reach, and impact on childhood obesity from 2020 to 2030 of five hypothetical policy strategies to reduce the negative impact of children's TV exposure: (1) eliminating the tax deductibility of food and beverage advertising; (2) targeting TV reduction during home visiting programs; (3) motivational interviewing to reduce home television time at Women, Infants, and Children (WIC) clinic visits; (4) adoption of a television-reduction curriculum in child care; and (5) limiting noneducational television in licensed child care settings. Results: Eliminating the tax deductibility of food advertising could reach the most children [106 million, 95% uncertainty interval (UI): 105-107 million], prevent the most cases of obesity (78,700, 95% UI: 30,200-130,000), and save more in health care costs than it costs to implement. Strategies targeting young children in child care and WIC also cost little to implement (between $0.19 and $32.73 per child reached), and, although reaching fewer children because of the restricted age range, were estimated to prevent between 25,500 (95% UI: 4600-59,300) and 35,400 (95% UI: 13,200-62,100) cases of obesity. Home visiting to reduce television viewing had high costs and a low reach. Conclusions: Interventions to reduce television exposure across a range of settings, if implemented widely, could help prevent childhood obesity in the population at relatively low cost.

Impact Of The Healthy, Hunger-Free Kids Act On Obesity Trends.

The Healthy, Hunger-Free Kids Act of 2010 strengthened nutrition standards for meals and beverages provided through the National School Lunch, Breakfast, and Smart Snacks Programs, affecting fifty million children daily at 99,000 schools. The legislation's impact on childhood obesity is unknown. We tested whether the legislation was associated with reductions in child obesity risk over time using an interrupted time series design for 2003-18 among 173,013 youth in the National Survey of Children's Health. We found no significant association between the legislation and childhood obesity trends overall. For children in poverty, however, the risk of obesity declined substantially each year after the act's implementation, translating to a 47 percent reduction in obesity prevalence in 2018 from what would have been expected without the legislation. These results suggest that the Healthy, Hunger-Free Kids Act's science-based nutritional standards should be maintained to support healthy growth, especially among children living in poverty.

Effects of a before-school program on student physical activity levels.

Many children are not sufficiently physically active. This study uses a quasi-experimental design to evaluate whether participation in a before-school physical activity program called Build Our Kids' Success (BOKS) increases physical activity. Participants (n = 426) were students in Fall, 2016 enrolled in BOKS programming and matched non-BOKS control students from the same grades (Kindergarten-6) and schools in Massachusetts and Rhode Island. Analyses conducted in 2017 examined differences between children in BOKS versus controls in total daily steps, minutes of moderate-to-vigorous (MVPA), vigorous (VPA), and total physical activity (TPA) assessed via Fitbit Charge HR™ monitors. Additional analyses compared physical activity on program days and non-program days. Students (mean age = 8.6 y; 47% female, 58% White, Non-Hispanic) wore monitors an average of 21.7 h/day on 3.2 days during the school week. Compared with controls, on BOKS days, BOKS participants accumulated more steps (1147, 95% confidence interval (CI): 583-1712, P < 0.001), MVPA minutes (13.4, 95% CI: 6.6-20.3, P < 0.001), and VPA minutes (4.0, 95% CI: 1.2-6.7, P = 0.005). Across all school days, BOKS participants accumulated more total steps than controls (716, 95% CI: 228-1204, P = 0.004). Compared to days without BOKS programming, on BOKS days, BOKS participants accumulated more steps (1153; 95% CI: 841-1464, P < 0.001) and daily minutes of MVPA (8.8, 95% CI: 5.3-12.2, P < 0.001), VPA (3.0, 95% CI: 1.6-4.5, P < 0.001), and TPA (20.8, 95% CI: 13.6-28.1, P < 0.001). BOKS programming promotes engagement in additional accumulated steps during the school week and physical activity on days that students participate. Clinical Trial Registration: www.ClinicalTrials.gov, NCT03403816, available at: https://clinicaltrials.gov/ct2/show/NCT03403816?term=NCT03403816&rank=1.

Cost-Effectiveness of Water Promotion Strategies in Schools for Preventing Childhood Obesity and Increasing Water Intake.

OBJECTIVE: This study aimed to estimate the cost-effectiveness and impact on childhood obesity of installation of chilled water dispensers ("water jets") on school lunch lines and to compare water jets' cost, reach, and impact on water consumption with three additional strategies. METHODS: The Childhood Obesity Intervention Cost Effectiveness Study(CHOICES) microsimulation model estimated the cost-effectiveness of water jets on US childhood obesity cases prevented in 2025. Also estimated were the cost, number of children reached, and impact on water consumption of the installation of water jets and three other strategies. RESULTS: Installing water jets on school lunch lines was projected to reach 29.6 million children (95% uncertainty interval [UI]: 29.4 million-29.8 million), cost $4.25 (95% UI: $2.74-$5.69) per child, prevent 179,550 cases of childhood obesity in 2025 (95% UI: 101,970-257,870), and save $0.31 in health care costs per dollar invested (95% UI: $0.15-$0.55). In the secondary analysis, installing cup dispensers next to existing water fountains was the least costly but also had the lowest population reach. CONCLUSIONS: Installating water jet dispensers on school lunch lines could also save almost half of the dollars needed for implementation via a reduction in obesity-related health care costs. School-based interventions to promote drinking water may be relatively inexpensive strategies for improving child health.