Weight management and physical activity throughout the cancer care continuum.

Mounting evidence suggests that weight management and physical activity (PA) improve overall health and well being, and reduce the risk of morbidity and mortality among cancer survivors. Although many opportunities exist to include weight management and PA in routine cancer care, several barriers remain. This review summarizes key topics addressed in a recent National Academies of Science, Engineering, and Medicine workshop entitled, "Incorporating Weight Management and Physical Activity Throughout the Cancer Care Continuum." Discussions related to body weight and PA among cancer survivors included: 1) current knowledge and gaps related to health outcomes; 2) effective intervention approaches; 3) addressing the needs of diverse populations of cancer survivors; 4) opportunities and challenges of workforce, care coordination, and technologies for program implementation; 5) models of care; and 6) program coverage. While more discoveries are still needed for the provision of optimal weight-management and PA programs for cancer survivors, obesity and inactivity currently jeopardize their overall health and quality of life. Actionable future directions are presented for research; practice and policy changes required to assure the availability of effective, affordable, and feasible weight management; and PA services for all cancer survivors as a part of their routine cancer care. CA Cancer J Clin 2018;68:64-89. © 2017 American Cancer Society.

Community Resilience: A Dynamic Model for Public Health 3.0.

OBJECTIVE: To establish a model for Public Health 3.0 in order to define and measure community resilience (CR) as a method to measure equity, address structural racism, and improve population health. DESIGN: To develop the CR model, we conducted a literature review in medicine, psychology, early childhood development, neurobiology, and disaster preparedness and response and applied system dynamics modeling to analyze the complex interactions between public systems, policies, and community. MAIN OUTCOME MEASURES: The CR model focuses on community and population health outcomes associated with the policies and practices of the housing, public education, law enforcement, and criminal justice sectors as CR measures. The model demonstrates how behaviors of these systems interact and produce outcome measures such as employment, homelessness, educational attainment, incarceration, and mental and physical health. RESULTS: The policies and practices within housing, public schools, law enforcement, and criminal justice can suppress resilience for families and communities because they are shaped by structural racism and influence the character and nature of resources that promote optimal community health and well-being. CONCLUSIONS: Community resilience is relational and place-based and varies depending on the demographic makeup of residents, historical patterns of place-based racism and discrimination, jurisdictional policy, and investment priorities-all influenced by structural racism. IMPLICATIONS FOR POLICY AND PRACTICE: Using system dynamics modeling and the CR approach, chief health strategists can convene partners from multiple sectors to systematically identify, measure, and address inequities produced by structural racism that result in and contribute to adverse childhood and community experiences.

Beyond taste and easy access: Physical, cognitive, interpersonal, and emotional reasons for sugary drink consumption among children and adolescents.

Consumption of sugary drinks is associated with the development of obesity and cardiometabolic diseases among children and adolescents. In addition to high added sugar content, many sugary drinks also contain caffeine. However, whether the combination of sugar and caffeine uniquely influences children's sugary drink intake is presently unknown. This study aimed to evaluate contextual factors surrounding children's sugary drink consumption and investigate reasons for sugary drink intake among children and adolescents, with a specific focus on caffeinated sodas and sweet tea. We also evaluated how sugary drink consumption makes children feel and how they anticipated that they would respond if sugary drinks were restricted. Focus group discussions (n = 9, 2-8 participants per group) were conducted with 37 predominantly AfricanAmerican children and adolescents, ages 8-14 years, who consumed ≥1 caffeine-containing sugary drink(s) daily, based on parental report. Focus groups were audio-recorded and transcribed verbatim. Transcripts were independently coded by two coders, after which emergent themes were identified. Reported reasons for sugary drink consumption encompassed five themes: 1) perceived need (e.g., satisfy cravings, quench thirst); 2) physical and cognitive benefits (e.g., provide energy, improve attention); 3) emotional and interpersonal benefits (e.g., relieve anger, facilitate socializing); 4) sensory properties (e.g., taste, carbonation); and, 5) external cues (e.g., family/peer modeling, availability). Negative consequences resulting from excess intake were also reported, including gastrointestinal symptoms, headaches, fatigue, hyperactivity, and chronic disease. Perceived physical, cognitive, emotional, and interpersonal benefits encourage sugary drink consumption and exacerbate well-described challenges of sugary drink reduction, including their palatability, accessibility, and affordability. Findings also suggest that incorporation of strategies to enhance physical, cognitive, and emotional health may hold promise in reducing sugary drink consumption among children and adolescents.

Food Consumption Patterns of Infants and Toddlers: Findings from the Feeding Infants and Toddlers Study (FITS) 2016.

Background: The prevalence of obesity and type 2 diabetes continues to increase. These conditions disproportionately affect minorities and are associated with poor nutrition early in life. Current food-consumption patterns can inform pending dietary guidelines for infants and toddlers. Objective: The aim of this study was to describe infant feeding, complementary feeding, and food and beverage consumption patterns of 0- to 23.9-mo-olds in the general population. Methods: The Feeding Infants and Toddlers Study 2016 is a cross-sectional survey of caregivers of children aged <4 y. Dietary data were collected from a national random sample by using a 24-h dietary recall (n = 3235). The percentage of children consuming foods from >400 food groups was calculated. Differences in the percentage consuming between Hispanic, non-Hispanic white, and non-Hispanic black children aged 0-23.9 mo were evaluated with the use of ORs and 95% CIs. Results: Eighty-three percent of 0- to 23.9-mo-olds (n = 2635) were ever breastfed, 34% of 0- to 3.9-mo-olds (n = 305) and 15% of 4- to 5.9-mo-olds (n = 295) were exclusively breastfed, and 24% of 12- to 14.9-mo-olds (n = 412) consumed breast milk on the day of the recall. Complementary foods were more likely to be introduced before 4 mo in formula-fed infants (27%) than in infants who did not consume formula (5%). Half of 4- to 5.9-mo-olds consumed iron-fortified infant cereal, but few consumed iron-rich meats. Among toddlers (12-23.9 mo; n = 1133), >20% consumed no servings of fruit or vegetables on the day of the recall, approximately half consumed 100% fruit juice, and one-quarter to one-third consumed a sugar-sweetened beverage (SSB). Conclusions: Breastfeeding initiation and duration have improved, but exclusivity remains low. Low consumption of iron-rich foods, fruit, and vegetables and lack of variety in vegetable consumption are problems. Efforts to reduce the consumption of SSBs and 100% fruit juice are warranted in early childhood.

Management of obesity: improvement of health-care training and systems for prevention and care.

Although the caloric deficits achieved by increased awareness, policy, and environmental approaches have begun to achieve reductions in the prevalence of obesity in some countries, these approaches are insufficient to achieve weight loss in patients with severe obesity. Because the prevalence of obesity poses an enormous clinical burden, innovative treatment and care-delivery strategies are needed. Nonetheless, health professionals are poorly prepared to address obesity. In addition to biases and unfounded assumptions about patients with obesity, absence of training in behaviour-change strategies and scarce experience working within interprofessional teams impairs care of patients with obesity. Modalities available for the treatment of adult obesity include clinical counselling focused on diet, physical activity, and behaviour change, pharmacotherapy, and bariatric surgery. Few options, few published reports of treatment, and no large randomised trials are available for paediatric patients. Improved care for patients with obesity will need alignment of the intensity of therapy with the severity of disease and integration of therapy with environmental changes that reinforce clinical strategies. New treatment strategies, such as the use of technology and innovative means of health-care delivery that rely on health professionals other than physicians, represent promising options, particularly for patients with overweight and patients with mild to moderate obesity. The co-occurrence of undernutrition and obesity in low-income and middle-income countries poses unique challenges that might not be amenable to the same strategies as those that can be used in high-income countries.

The response of the US Centers for Disease Control and Prevention to the obesity epidemic.

The recognition of the obesity epidemic as a national problem began in 1999 with the Centers for Disease Control and Prevention's (CDC's) publication of a series of annual state-based maps that demonstrated the rapid changes in the prevalence of obesity. Increasing rates of obesity had been noted in earlier CDC studies, but the maps provided evidence of a rapid, nationwide increase. The urgent need to respond to the epidemic led to the identification of state targets and the first generation of interventions for obesity prevention and control. The CDC's role was to provide setting- and intervention-specific guidance on implementing these strategies, and to assess changes in targeted policies and behaviors. The CDC's efforts were augmented by Congressional funding for community initiatives to improve nutrition and increase physical activity. Complementary investments by Kaiser Permanente, the Robert Wood Johnson Foundation, and the Institute of Medicine improved the evidence base and provided policy recommendations that reinforced the need for a multisectoral approach. Legislative, regulatory, and voluntary initiatives enacted by President Obama's administration translated many of the strategies into effective practice. Whether current efforts to address obesity can be sustained will depend on whether they can be translated into greater grass-roots engagement consistent with a social movement.

Murine Notch1 is required for lymphatic vascular morphogenesis during development.

BACKGROUND: The transmembrane receptor Notch1 is a critical regulator of arterial differentiation and blood vessel sprouting. Recent evidence shows that functional blockade of Notch1 and its ligand, Dll4, leads to postnatal lymphatic defects in mice. However, the precise role of the Notch signaling pathway in lymphatic vessel development has yet to be defined. Here we show the developmental role of Notch1 in lymphatic vascular morphogenesis by analyzing lymphatic endothelial cell (LEC)-specific conditional Notch1 knockout mice crossed with an inducible Prox1CreER(T2) driver. RESULTS: LEC-specific Notch1 mutant embryos exhibited enlarged lymphatic vessels. The phenotype of lymphatic overgrowth accords with increased LEC sprouting from the lymph sacs and increased filopodia formation. Furthermore, cell death was significantly reduced in Notch1-mutant LECs, whereas proliferation was increased. RNA-seq analysis revealed that expression of cytokine/chemokine signaling molecules was upregulated in Notch1-mutant LECs isolated from E15.5 dorsal skin, whereas VEGFR3, VEGFR2, VEGFC, and Gja4 (Connexin 37) were downregulated. CONCLUSIONS: The lymphatic phenotype of LEC-specific conditional Notch1 mouse mutants indicates that Notch activity in LECs controls lymphatic sprouting and growth during development. These results provide evidence that similar to postnatal and pathological lymphatic vessel formation, the Notch signaling pathway plays a role in inhibiting developmental lymphangiogenesis.

Healthy kids out of school: using mixed methods to develop principles for promoting healthy eating and physical activity in out-of-school settings in the United States.

INTRODUCTION: Widespread practices supporting availability of healthful foods, beverages, and physical activity in out-of-school-time (OST) settings would further obesity prevention efforts. The objective of this article was to describe principles to guide policy development in support of healthy eating and physical activity practices in out-of-school settings to promote obesity prevention. METHODS: The Institute of Medicine's L.E.A.D. framework (Locate Evidence, Evaluate it, Assemble it, and Inform Decisions) was used to identify practices relevant to children's healthful eating in most OST settings: 1) locate and evaluate information from a national survey of children's perceptions of healthful-food access; published research, reports, policies and guidelines; and roundtables with OST organizations' administrators; 2) assemble information to prioritize actionable practices; and 3) inform programmatic direction. RESULTS: Three evidence-informed guiding principles for short-duration OST resulted: 1) drink right: choose water instead of sugar-sweetened beverages; 2) move more: boost movement and physical activity in all programs; and 3) snack smart: fuel up on fruits and vegetables. CONCLUSION: Healthy Kids Out of School was launched to support the dissemination and implementation of these guiding principles in short-duration OST settings, complementing efforts in other OST settings to shift norms around eating and physical activity.

Screening Accuracy of BMI for Adiposity Among 8- to 19-Year-Olds.

BACKGROUND AND OBJECTIVES: Although the limitations of BMI have long been recognized, there are recent concerns that it is not a good screening tool for adiposity. We therefore examined the cross-sectional relation of BMI to adiposity among 6923 8- to 19-year-olds in the National Health and Nutrition Survey from 2011 through 2018. METHODS: Participants were scanned with dual-energy x-ray absorptiometry. Adiposity was expressed as fat mass index (FMI, fat mass kg ÷ m2) and percentage of body fat (%fat). Lean mass was expressed as lean mass index (LMI, lean mass ÷ m2). Regression models and 2 × 2 tables were used to assess the relation of BMI to FMI, %fat, and LMI. RESULTS: Age and BMI accounted (R2) for 90% to 94% of the variability of FMI and LMI in each sex. Associations with %fat were weaker (R2s ∼0.70). We also examined the screening abilities of a BMI ≥ Centers for Disease Control and Prevention 95th percentile for high levels of adiposity and LMI. Cut points were chosen so that prevalences of high values of these variables would be similar to that for high BMI. Of participants with a high BMI, 88% had a high FMI, and 76% had a high %fat. Participants with a high BMI were 29 times more likely to have a high FMI than those with lower BMIs; comparable relative risks were 12 for high %fat and 14 for high LMI. CONCLUSIONS: Despite its limitations, a high BMI is a very good screening tool for identifying children and adolescents with elevated adiposity.

The abilities of body mass index and skinfold thicknesses to identify children with low or elevated levels of dual-energy X-ray absorptiometry-determined body fatness.

OBJECTIVE: To examine the accuracies of body mass index (BMI) and skinfold thicknesses in classifying the body fatness of 7365 8- to 19-year-old subjects in a national sample. STUDY DESIGN: We used percent body fat determined by dual-energy x-ray absorptiometry (PBFDXA) between 1999 and 2004. Categories of PBFDXA and the skinfold sum (triceps plus subscapular) were constructed so that that numbers of children in each category were similar to the number in each of 5 BMI categories based on the Centers for Disease Control and Prevention growth charts. RESULTS: Approximately 75% of the children and adolescents who had a BMI-for-age ≥ 95th percentile (considered obese) had elevated body fatness, but PBFDXA levels were more variable at lower BMIs. For example, only 41% of the boys who had a BMI < 25th percentile, had a similarly low PBFDXA. The use of the skinfold sum, rather than BMI, slightly improved the identification of elevated levels of body fatness among boys (P = .03), but not among girls (P > .10). A low sum of the triceps and subscapular skinfold thicknesses was a better indicator of low PBFDXA than was a low BMI, but differences were smaller among children with greater levels of body fatness. Among girls who had a PBFDXA above the median, for example, BMI and the skinfold sum were correlated similarly (r = 0.77-0.79) with body fatness. CONCLUSIONS: Both BMI and skinfold thicknesses are fairly accurate in identifying children who have excess body fatness. In contrast, if the goal is to identify children who have low body fatness, skinfold thicknesses would be preferred.

Is the body adiposity index (hip circumference/height(1.5)) more strongly related to skinfold thicknesses and risk factor levels than is BMI? The Bogalusa Heart Study.

Because of its strong association (r 0.85) with percentage of body fat determined by dual-energy X-ray absorptiometry, hip circumference divided by height(1.5) (the body adiposity index) has recently been proposed as an index of body fatness among adults. We examined whether this proposed index was more strongly associated with skinfold thicknesses and levels of CVD risk factors (lipids, fasting insulin and glucose, and blood pressure) than was BMI among 2369 18- to 49-year-olds in the Bogalusa Heart Study. All analyses indicated that the body adiposity index was less strongly associated with skinfold thicknesses and CVD risk factors than was either waist circumference or BMI. Correlations with the skinfold sum, for example, were r 0.81 (BMI) v. r 0.75 (body adiposity index) among men, and r 0.87 (BMI) v. r 0.80 among women; P< 0.001 for both differences. An overall index of seven CVD risk factors was also more strongly associated with BMI (r 0.58) and waist circumference (r 0.61) than with the body adiposity index (r 0.49). The weaker associations with the body adiposity index were observed in analyses stratified by sex, race, age and year of examination. Multivariable analyses indicated that if either BMI or waist circumference were known, the body adiposity index provided no additional information on skinfold thicknesses or risk factor levels. These findings indicate that the body adiposity index is likely to be an inferior index of adiposity than is either BMI or waist circumference.

The COVID-19 lockdown increased obesity disparities; will the increases in type 2 diabetes continue?

OBJECTIVE: The aim of this study was to compare the prevalence of the increases in pediatric obesity during the COVID-19 lockdown with the annual increases in obesity in the National Health and Nutrition Examination Survey (NHANES). METHODS: This study compared two reports of increases in the prevalence of obesity in youth during the COVID-19 lockdown with the annual rate of increase in obesity in NHANES. RESULTS: When expressed as multiples, the changes in prevalence among elementary school children observed in two population-based surveys were 28 to 63 times greater than the annual changes in the prevalence of obesity observed in NHANES. Increases in Black and Hispanic youth were greater than those in White youth. The net impact of the COVID-19 lockdown increased the disparities in obesity among this age group. CONCLUSIONS: The rapid increases in obesity are likely to persist and may be associated with an increase in the prevalence of severe obesity as these children age. Furthermore, the increased susceptibility to diabetes in Hispanic and Black children, as well as the reported increase in diabetes among 0- to 18-year-old individuals during the COVID-19 pandemic, may lead to an increased incidence of type 2 diabetes in minority youth with obesity.

Quality Measurement Gaps and Future Directions in the Assessment of Obesity.

PURPOSE OF REVIEW: The disease of obesity continues to increase in prevalence and severity yet obesity care, treatment, and coverage are scarce. Progress has been made in the development and implementation of quality measures in clinical practice and organizational performance. However, major gaps and limitations exist in the context of measuring guideline-based clinical care for obesity. RECENT FINDINGS: Obesity quality measures have entered various stages of testing and development, but only a select few are included in reporting and payment programs. One process measure for adults, "Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan" is used in Medicare. One process measure for pediatrics, "Weight Assessment and Counseling for Nutrition and Physical Activity in Children and Adolescence" is used in Medicare, health insurance plans, and Medicaid. No outcome or digital quality measure exists for the disease of obesity. One quality measure development project is underway that is testing the performance of four measures, including outcome measures for obesity. The general absence of quality measures for obesity means that there are no objective measures to address the quality of obesity care or its outcome. More meaningful efforts are needed to seriously integrate obesity with quality performance measurement and value in healthcare payment programs.

Mitigation of the U.S. agrifood sector's contribution to human and planetary health: a case study.

The relationship of the United States (U.S.) agrifood sector to climate change is bidirectional; cattle production for beef consumption generates methane and nitrous oxide, both of which are potent greenhouse gases (GHGs). These gases contribute to global warming which in turn increase the frequency and strength of adverse catastrophic events, which compromise the food supply. Increased GHGs also affect crop yields and the micronutrient content of crops, which adversely affect the prevalence of food and nutrition insecurity, particularly in low- and middle-income countries. Because the U.S. is a major contributor to global warming, we have a special responsibility to reduce our contribution to the generation of GHGs. The dilemma is that beef is a highly nutritious and desirable food, with excess consumption in the U.S. and under consumption in other parts of the world, but a desirable source of nutrients in low- and middle-income countries (LMICs). Reductions in fossil fuels have been a major focus of concern, and the agrifood system has been largely ignored. Policy changes to reduce beef consumption have been resisted at the highest levels of government. Furthermore, shifts to more plant-based diets have been contentious. Successful reductions in beef consumption will require individual, institutional, municipal, and state initiatives. Building the political will for change will require a compelling communication campaign that emphasizes the unsustainable contribution of beef consumption to climate change and land and water use.