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.

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.

Health care providers' attitudes and counseling behaviors related to obesity.

Background: Obesity affects over 42% of the U.S. adult population, yet it remains undertreated. Many healthcare providers are biased in their perceptions and attitudes regarding obesity management and lack knowledge about how to treat it. Methods: The authors analyzed the results of the 2021 DocStyles survey to examine primary care providers' treatment and perceptions of obesity. The sample consisted of primary care physicians and nurse practitioners/physician assistants. Questions assessed healthcare providers' attitudes and counseling behaviors related to obesity, including referrals, use of medical therapy, barriers to care, and perceived risk factors for obesity. Results: 1168 primary care providers who treat obesity participated in the survey. About half of the providers reported referring patients for obesity treatment. Almost two-thirds of providers had prescribed anti-obesity medications in the last 12 months. Those who did not prescribe anti-obesity medications reported a lack of familiarity with the medications or concerns about safety. Over three-quarters of providers indicated at least one barrier to treating obesity. Over half of the providers reported that poverty and food insecurity contributed significantly to the high prevalence of obesity in communities of color. Conclusion: Increased familiarity with anti-obesity medications may improve treatment. Reasons for patients' low priority accorded to obesity care remain the focus of future research.

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.

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.

Coverage for obesity prevention and treatment: analysis of state employee health plans and use of benefits.

OBJECTIVE: Using data from 2017, the authors have previously examined the coverage of obesity-related services in state employee health plans since 2009 and found improvements in coverage for obesity-related treatments. This study repeated the collection of similar data for 2021 and explored whether coverage had continued to increase or decline. METHODS: Data on obesity benefits for state employees were obtained from publicly available documents from relevant state websites. Source documents were reviewed for language that would indicate the availability of coverage for nutritional counseling, pharmacotherapy, and bariatric surgery. Use data were collected when available, but availability was limited. RESULTS: Coverage for some treatments of obesity continued to trend upward, as was the case between 2009 and 2017, but coverage for pharmacotherapy declined from 2017 to 2021. Use data were received from only eight states; analysis of these data indicated underuse of obesity benefits by plan enrollees compared with each state's rate of obesity. CONCLUSIONS: Despite promising new therapies, states in 2021 were less likely to provide coverage for antiobesity medications. Additionally, limited use data suggested that few eligible individuals may be receiving these services. In conclusion, state employee health plans are currently inadequate given the prevalence, severity, and costs of obesity.

Food Insecurity and Childhood Obesity: A Systematic Review.

BACKGROUND AND OBJECTIVES: Addressing food insecurity while promoting healthy body weights among children is a major public health challenge. Our objective is to examine longitudinal associations between food insecurity and obesity in US children aged 1 to 19 years. METHODS: Sources for this research include PubMed, CINAHL, and Scopus databases (January 2000 to February 2022). We included English language studies that examined food insecurity as a predictor of obesity or increased weight gain. We excluded studies outside the United States and those that only considered the unadjusted relationship between food security and obesity. Characteristics extracted included study design, demographics, methods of food security assessment, and anthropometric outcomes. RESULTS: Literature searches identified 2272 articles; 13 met our inclusion criteria. Five studies investigated the relationship between food insecurity and obesity directly, whereas 12 examined its relationship with body mass index or body mass index z-score. Three studies assessed multiple outcomes. Overall, evidence of associations between food insecurity and obesity was mixed. There is evidence for possible associations between food insecurity and obesity or greater weight gain in early childhood, for girls, and for children experiencing food insecurity at multiple time points. Heterogeneity in study methods limited comparison across studies. CONCLUSIONS: Evidence is stronger for associations between food insecurity and obesity among specific subgroups than for children overall. Deeper understanding of the nuances of this relationship is critically needed to effectively intervene against childhood obesity.

Advocacy to support climate and health policies: recommended actions for the Society of Behavioral Medicine.

Climate change poses serious threats to public health and is exacerbating health inequities. Policy changes are essential to mitigate climate change impacts on human and planetary health. The purpose was to describe recommendations by the Policy and Advocacy Subgroup of the Society of Behavioral Medicine (SBM) Climate Change, Behavior Change and Health Presidential Working Group (PWG). The Policy and Advocacy subgroup was comprised of experts in public health, climate policy, and health behavior change, who worked together to identify priorities and develop recommendations. We worked under the premise that building political will for climate policy action is the most urgent goal, and we recommended promotion of citizen advocacy for this purpose. Because citizen advocacy is a set of behaviors, SBM members can use behavioral science to identify and scale up interventions, working collaboratively with communities targeted for marginalization. Recommendations for SBM included establishing an organizational home for climate and health work, providing training and resources, engaging in climate advocacy as an organization, and networking with other organizations. Recommendations for a proposed SBM Climate and Health Committee, Council, or Special Interest Group included developing trainings and resources, seeking opportunities for networking and collaborations, and identifying a research agenda. Individual behavior changes are insufficient to address climate change; policy actions are needed. SBM and similar organizations can support their members to work in developing, evaluating, and scaling up advocacy interventions for action on climate policy to magnify the power of the health and medical sectors to protect planetary and human health.

Increasing advocacy for climate protection policies is a top priority. Recommendations are made for research and advocacy engagement by the Society of Behavioral Medicine and its members.

Stop the Pop: A Mixed-Methods Study Examining Children's Physical and Emotional Responses during Three Days of Sugary Drink Cessation.

Despite public health efforts to reduce sugary drink consumption, children's intake continues to exceed recommendations. While numerous barriers to lowering sugary drink consumption have been identified, aversive feelings during sugary drink cessation may further challenge sustained reduction in children's sugary drink consumption. Herein, we describe "Stop the Pop", an intervention to examine children's physical and emotional responses during three days of sugary drink cessation. Children (n = 150) ages 8-14, who reported habitual consumption of ≥12 ounces of sugary drinks daily, were instructed to avoid sweetened beverages for three days. At baseline and on each day of cessation, children completed a daily feelings questionnaire, and a subset of children (n = 30) also completed a qualitative interview following cessation. During sugary drink cessation, children reported physical and emotional improvements, including being less tired, angry, and annoyed; having less trouble sleeping; and less frequently arguing with others, getting in trouble, and getting mad. However, unfavorable responses, such as mood disturbances and having less energy, were reported by some participants. Our results suggest that children who habitually consume sugary drinks may experience physical and emotional improvements during short-term sugary drink cessation, although longer-term examination is needed and inter-individual variability in responses to cessation warrants further study.

How Can We Act to Mitigate the Global Syndemic of Obesity, Undernutrition, and Climate Change?

PURPOSE OF REVIEW: The goal of this manuscript is to identify dietary and active transport strategies that reduce greenhouse gases and obesity, and thereby mitigate the effects of climate change on crop yields and micronutrient content. RECENT FINDINGS: This report builds on our earlier publication that described the Global Syndemic of Obesity, Undernutrition, and Climate Change. We focus here on the contributions that the USA makes to the Global Syndemic and the policy solutions necessary to reduce the effects of the transport and food and agriculture systems on greenhouse gas emissions and environmental degradation. A recent study suggests that people are interested and ready to address local solutions to climate change. Changing the individual behaviors that sustain the US transport and food and agriculture systems is the first step to the broader engagement necessary to build the political will that to achieve institutional, municipal, state, and federal policy.

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.

Feasibility and acceptability of a randomized controlled trial to investigate withdrawal symptoms in response to caffeinated sugary drink cessation among children.

BACKGROUND: Sugary drinks (SDs) are key contributors to excess added sugar intake and the predominant source of caffeine among children. Chronic caffeine intake causes dependence, and evidence for sugar dependence is emerging. Development of withdrawal symptoms may pose an obstacle to SD cessation among children. We examined the feasibility and acceptability of a three-arm randomized controlled trial (RCT) designed to investigate withdrawal symptoms resulting from replacement of children's usual caffeinated SD intake with either caffeine-free alternatives or caffeine-free and sugar-free alternatives, compared with continued consumption of caffeinated SDs. METHODS: Twenty-nine children 8-12 years old, who consumed ≥12 ounces caffeinated SDs daily, enrolled. The two-week RCT required three in-person meetings and daily completion of electronic questionnaires to assess withdrawal symptoms and intervention adherence. Children were randomized to replace their usual caffeinated SD consumption with 1) caffeine-free alternatives, 2) caffeine-free and sugar-free alternatives, or 3) caffeinated SDs (control), provided by the study team. Feasibility and acceptability were assessed quantitatively and qualitatively. RESULTS: Twenty-eight participants (97%) completed the study. Adherence was high, with 73% reporting compliance with beverage assignments, and 76% completing all questionnaires. In qualitative interviews at follow-up, children described feelings of importance and commitment, and parents did not find the procedures to be overly burdensome. While challenges to adherence were reported (e.g., child wanting other SDs, time commitment), participants described innovative strategies (e.g., designating a place for study drinks in the refrigerator) to maintain adherence. CONCLUSION: Results indicated high levels of RCT feasibility and acceptability. The reported barriers and strategies for adherence will inform modifications required to design a larger and longer-term trial investigating withdrawal symptoms after SD cessation in children.

Weight Can't Wait: A Guide to Discussing Obesity and Organizing Treatment in the Primary Care Setting.

OBJECTIVE: The objective of this study was to develop a simple and practical guide for discussing and managing obesity in primary care settings. METHODS: This study convened representatives from 12 primary care and obesity specialty organizations for a series of roundtable meetings to discuss the key components of obesity treatment in primary care. Attendees identified the need for a guide for primary care providers that outlined the key steps for discussing obesity with patients and managing their care while recognizing the significant time constraints on such provider/patient encounters. RESULTS: Prevailing themes from the roundtable sessions suggested that the key components of addressing obesity in primary care settings are obtaining patient permission, addressing weight bias, providing a diagnosis, and emphasizing shared decision-making. A modified "6A" framework with the steps "Ask," "Assess," "Advise," "Agree," "Assist," and "Arrange" was deemed appropriate to organize the process of weight management in primary care. An algorithm was developed to provide a script for the patient/provider encounter. CONCLUSIONS: The expert panel developed a short, accessible, practical, and informative guide for obesity management by primary care clinicians. Efforts are under way to disseminate the guide to primary care providers through the 11 participating organizations that have endorsed it.