Society of Behavioral Medicine (SBM) position statement: Enact taxes on sugar sweetened beverages to prevent chronic disease.

The Society of Behavioral Medicine (SBM) encourages stakeholders to implement a sugar sweetened beverage excise tax. Sugar sweetened beverages are the largest source of added sugars in the USA and have detrimental effects on population health by increasing risks for chronic diseases. Based on existing research evidence, SBM supports an excise tax equivalent to at least 20% to meaningfully affect consumption patterns. As evidenced by research studies in Mexico and the USA, sugar sweetened beverage taxes can have positive impacts on population health and can raise significant tax revenue. To avoid potential unintended consequences that may arise from taxes to improve diet-related behaviors, it is important to monitor industry and consumer behavior in response to the tax.

Fruit Juice and Change in BMI: A Meta-analysis.

CONTEXT: Whether 100% fruit juice consumption causes weight gain in children remains controversial. OBJECTIVE: To determine the association between 100% fruit juice consumption and change in BMI or BMI z score in children. DATA SOURCES: PubMed, Embase, CINAHL, and Cochrane databases. STUDY SELECTION: Longitudinal studies examining the association of 100% fruit juice and change in BMI measures were included. DATA EXTRACTION: Two independent reviewers extracted data using a predesigned data collection form. RESULTS: Of the 4657 articles screened, 8 prospective cohort studies (n = 34 470 individual children) met the inclusion criteria. Controlling for total energy intake, 1 daily 6- to 8-oz serving increment of 100% fruit juice was associated with a 0.003 (95% CI: 0.001 to 0.004) unit increase in BMI z score over 1 year in children of all ages (0% increase in BMI percentile). In children ages 1 to 6 years, 1 serving increment was associated with a 0.087 (95% confidence interval: 0.008 to 0.167) unit increase in BMI z score (4% increase in BMI percentile). 100% fruit juice consumption was not associated with BMI z score increase in children ages 7 to 18 years. LIMITATIONS: All observational studies; studies differed in exposure assessment and covariate adjustment. CONCLUSIONS: Consumption of 100% fruit juice is associated with a small amount of weight gain in children ages 1 to 6 years that is not clinically significant, and is not associated with weight gain in children ages 7 to 18 years. More studies are needed in children ages 1 to 6 years.

Cross-sector analysis of socioeconomic, racial/ethnic, and urban/rural disparities in food policy enactment in the United States.

We examined racial/ethnic, socioeconomic, and urban/rural disparities in food policy enactment across different sectors, as well as retail food access, throughout the United States. Policy and retail food store data were obtained from 443 communities as part of the Bridging the Gap Community Obesity Measures Project. Our results indicated that median household income was inversely associated with healthier retail food zoning policies in Hispanic communities, where competitive food policies for schools were also healthier and mean fruit/vegetable access in stores was higher. In contrast, income was positively associated with healthier retail food zoning in rural communities, where competitive food policies were weaker. Black communities had low scores across all policy domains. Overall, Hispanic communities had the strongest food policies across sectors. Barriers to policy adoption in both rural and Black communities must be explored further.

The spatial distribution of gender differences in obesity prevalence differs from overall obesity prevalence among US adults.

PURPOSE: Although obesity disparities between racial and socioeconomic groups have been well characterized, those based on gender and geography have not been as thoroughly documented. This study describes obesity prevalence by state, gender, and race and/or ethnicity to (1) characterize obesity gender inequality, (2) determine if the geographic distribution of inequality is spatially clustered, and (3) contrast the spatial clustering patterns of obesity gender inequality with overall obesity prevalence. METHODS: Data from the Centers for Disease Control and Prevention's 2013 Behavioral Risk Factor Surveillance System were used to calculate state-specific obesity prevalence and gender inequality measures. Global and local Moran's indices were calculated to determine spatial autocorrelation. RESULTS: Age-adjusted, state-specific obesity prevalence difference and ratio measures show spatial autocorrelation (z-score = 4.89, P-value < .001). Local Moran's indices indicate the spatial distributions of obesity prevalence and obesity gender inequalities are not the same. High and low values of obesity prevalence and gender inequalities cluster in different areas of the United States. CONCLUSIONS: Clustering of gender inequality suggests that spatial processes operating at the state level, such as occupational or physical activity policies or social norms, are involved in the etiology of the inequality and necessitate further attention to the determinates of obesity gender inequality.

Deconstructing race and gender differences in adolescent obesity: Oaxaca-blinder decomposition.

OBJECTIVE: To analyze sources of racial and gender disparities in adolescent obesity prevalence in the United States using Oaxaca-Blinder decomposition. METHODS: Data were obtained from the National Youth Physical Activity and Nutrition Study, a 2010 nationally representative study of 9th-12th grade students. Obesity status was determined from objective height and weight data; weight-related behaviors and school, home, and environmental data were collected via questionnaire. Oaxaca-Blinder decomposition was used to independently analyze racial and gender obesity prevalence differences (PD), i.e., comparing Black girls to White girls, and Black girls to Black boys. RESULTS: Overall, measured characteristics accounted for 46.8% of the racial PD but only 11.9% of the gender PD. Racial PD was associated with Black girls having less fruit/vegetable access at home, obtaining lunch at school more often, and playing fewer sports than White girls. Gender PD was associated with differential associations between physical activity (PA) measures-including total activities in the past year and days of moderate to vigorous physical activity (MVPA) in the past week-and obesity. CONCLUSIONS: School lunch and home food environmental variables accounted for racial disparities, but not gender disparities, in obesity prevalence. Gender differences in mechanisms between PA and obesity should be explored further.

Socioeconomic Differences in the Association Between Competitive Food Laws and the School Food Environment.

BACKGROUND: Schools of low socioeconomic status (SES) tend to sell fewer healthy competitive foods/beverages. This study examined whether state competitive food laws may reduce such disparities. METHODS: School administrators for fifth- and eighth grade reported foods and beverages sold in school. Index measures of the food/beverage environments were constructed from these data. Schools were classified into SES tertiles based on median household income of students' postal zip code. Regression models were used to estimate SES differences in (1) Healthy School Food Environment Index (HSFEI) score, Healthy School Beverage Environment Index (HSBEI) score, and specific food/beverage sales, and (2) associations between state competitive food/beverage laws and HSFEI score, HSBEI score, and specific food/beverage sales. RESULTS: Strong competitive food laws were positively associated with HSFEI in eighth grade, regardless of SES. Strong competitive beverage laws were positively associated with HSBEI particularly in low-SES schools in eighth grade. These associations were attributable to schools selling fewer unhealthy items, not providing healthy alternatives. High-SES schools sold more healthy items than low-SES schools regardless of state laws. CONCLUSIONS: Strong competitive food laws may reduce access to unhealthy foods/beverages in middle schools, but additional initiatives are needed to provide students with healthy options, particularly in low-SES areas.

The association between state bans on soda only and adolescent substitution with other sugar-sweetened beverages: a cross-sectional study.

BACKGROUND: Across the United States, many states have actively banned the sale of soda in high schools, and evidence suggests that students' in-school access to soda has declined as a result. However, schools may be substituting soda with other sugar-sweetened beverages (SSBs), and national trends indicate that adolescents are consuming more sports drinks and energy drinks. This study examined whether students consumed more non-soda SSBs in states that banned the sale of soda in school. METHODS: Student data on consumption of various SSBs and in-school access to vending machines that sold SSBs were obtained from the National Youth Physical Activity and Nutrition Study (NYPANS), conducted in 2010. Student data were linked to state laws regarding the sale of soda in school in 2010. Students were cross-classified based on their access to vending machines and whether their state banned soda in school, creating 4 comparison groups. Zero-inflated negative binomial models were used to compare these 4 groups with respect to students' self-reported consumption of diet soda, sports drinks, energy drinks, coffee/tea, or other SSBs. Students who had access to vending machines in a state that did not ban soda were the reference group. Models were adjusted for race/ethnicity, sex, grade, home food access, state median income, and U.S. Census region. RESULTS: Students consumed more servings of sports drinks, energy drinks, coffee/tea, and other SSBs if they resided in a state that banned soda in school but attended a school with vending machines that sold other SSBs. Similar results were observed where schools did not have vending machines but the state allowed soda to be sold in school. Intake was generally not elevated where both states and schools limited SSB availability ­ i.e., states banned soda and schools did not have SSB vending machines. CONCLUSION: State laws that ban soda but allow other SSBs may lead students to substitute other non-soda SSBs. Additional longitudinal research is needed to confirm this. Elevated SSB intake was not observed when both states and schools took steps to remove SSBs from school.

How state taxes and policies targeting soda consumption modify the association between school vending machines and student dietary behaviors: a cross-sectional analysis.

BACKGROUND: Sodas are widely sold in vending machines and other school venues in the United States, particularly in high school. Research suggests that policy changes have reduced soda access, but the impact of reduced access on consumption is unclear. This study was designed to identify student, environmental, or policy characteristics that modify the associations between school vending machines and student dietary behaviors. METHODS: Data on school vending machine access and student diet were obtained as part of the National Youth Physical Activity and Nutrition Study (NYPANS) and linked to state-level data on soda taxes, restaurant taxes, and state laws governing the sale of soda in schools. Regression models were used to: 1) estimate associations between vending machine access and soda consumption, fast food consumption, and lunch source, and 2) determine if associations were modified by state soda taxes, restaurant taxes, laws banning in-school soda sales, or student characteristics (race/ethnicity, sex, home food access, weight loss behaviors.). RESULTS: Contrary to the hypothesis, students tended to consume 0.53 fewer servings of soda/week (95% CI: -1.17, 0.11) and consume fast food on 0.24 fewer days/week (95% CI: -0.44, -0.05) if they had in-school access to vending machines. They were also less likely to consume soda daily (23.9% vs. 27.9%, average difference  =  -4.02, 95% CI: -7.28, -0.76). However, these inverse associations were observed primarily among states with lower soda and restaurant tax rates (relative to general food tax rates) and states that did not ban in-school soda sales. Associations did not vary by any student characteristics except for weight loss behaviors. CONCLUSION: Isolated changes to the school food environment may have unintended consequences unless policymakers incorporate other initiatives designed to discourage overall soda consumption.

Participation in vigorous sports, not moderate sports, is positively associated with cardiorespiratory fitness among adolescent girls.

BACKGROUND: There is controversy regarding whether moderately-intense sports can improve physical fitness, which declines throughout adolescence among girls. The objective was to estimate the association between moderate and vigorous sports participation and cardiorespiratory fitness in a racially diverse sample of adolescent girls. METHODS: Cardiorespiratory fitness was measured using a modified physical work capacity test in 1029 eighth-grade girls participating in the Trial of Activity for Adolescent Girls. Girls reported sports in which they participated in the last year on an organized activity questionnaire. Using general linear mixed models, the study regressed absolute and relative fitness on the number of vigorous and moderate sports in which girls participated, race/ethnicity, age, treatment group, fat mass, fat-free mass, and an interaction between race and fat-free mass. RESULTS: The number of vigorous sports in which girls participated was positively associated with absolute fitness (ß = 10.20, P = .04) and relative fitness (ß = 0.17, P = .04). Associations were reduced, but not eliminated, after controlling for MET-weighted MVPA. Participation in moderate sports was not associated with either fitness measure. CONCLUSIONS: Vigorous sports participation is positively associated with cardiorespiratory fitness. Future longitudinal research should analyze whether promoting vigorous sports at an early age can prevent age-related declines in cardiorespiratory fitness among adolescent girls.

Association between state physical education (PE) requirements and PE participation, physical activity, and body mass index change.

OBJECTIVE: To determine if state physical education (PE) laws are associated with student physical education attendance and physical activity (PA), and whether physical education and competitive food laws, in conjunction, are associated with lower BMI change. METHOD: State laws regarding physical education time requirements and competitive foods in 2003 and 2006 were classified as strong, weak, or none, based on codified law ratings obtained from the Classification of Laws Associated with School Students. Laws were linked to student data on PE attendance and physical activity (8th grade, Spring 2007) and BMI change (5th-8th grade, 2004-2007), obtained from the Early Childhood Longitudinal Study (n=5510 students in 40 states). RESULTS: Girls reported 0.31 more days of activity (95% CI: 0.02, 0.61) and were more likely to attend physical education ≥ 3 days/week (74.1% versus 52.1%, difference=22.0, 95% CI: 2.1, 42.0) if they resided in states with strong physical education laws compared to no physical education laws. Weak physical education laws had modest associations with PE and activity, and there was no evidence that weak laws reduce BMI gain regardless of competitive food laws. CONCLUSION: Strong physical education laws with specific time requirements may increase physical education attendance and activity in girls. There is insufficient evidence that physical education laws reduce student weight gain.

Association between district and state policies and US public elementary school competitive food and beverage environments.

IMPORTANCE: Given the importance of developing healthy eating patterns during early childhood, policies to improve the elementary school food and beverage environments are critical. OBJECTIVE: To examine the association between district and state policy and/or law requirements regarding competitive food and beverages and public elementary school availability of foods and beverages high in fats, sugars, and/or sodium. DESIGN AND SETTING: Multivariate, pooled, cross-sectional analysis of data gathered annually during elementary school years 2008-2009 through 2010-2011 in the United States. PARTICIPANTS: Survey respondents at 1814 elementary schools (1485 unique) in 957 districts in 45 states (food analysis) and 1830 elementary schools (1497 unique) in 962 districts and 45 states (beverage analysis). EXPOSURES Competitive food and beverage policy restrictions at the state and/or district levels. MAIN OUTCOME AND MEASURE: Competitive food and beverage availability. RESULTS Sweets were 11.2 percentage points less likely to be available (32.3% vs 43.5%) when both the district and state limited sugar content, respectively. Regular-fat baked goods were less available when the state law, alone and in combination with district policy, limited fat content. Regular-fat ice cream was less available when any policy (district, state law, or both) limited competitive food fat content. Sugar-sweetened beverages were 9.5 percentage points less likely to be available when prohibited by district policy (3.6% vs 13.1%). Higher-fat milks (2% or whole milk) were less available when prohibited by district policy or state law, with either jurisdiction's policy or law associated with an approximately 15 percentage point reduction in availability. CONCLUSIONS: Both district and state policies and/or laws have the potential to reduce in-school availability of high-sugar, high-fat foods and beverages. Given the need to reduce empty calories in children's diets, governmental policies at all levels may be an effective tool.

Association between state laws governing school meal nutrition content and student weight status: implications for new USDA school meal standards.

IMPORTANCE: This study assessed whether stronger school meal nutrition standards may improve student weight status. Results have immediate implications because of the ongoing implementation of new nutrition standards for the National School Lunch Program. OBJECTIVE To determine if state laws with stricter school meal nutrition standards are inversely associated with adolescent weight status, while controlling for unmeasured state-level confounders. DESIGN: Quasi-experiment. SETTING: Public schools. PARTICIPANTS: Four thousand eight hundred seventy eighth-grade students in 40 states. Students were categorized by type of school lunch they usually obtained (free/reduced price, regular price, or none). INTERVENTIONS State laws governing school meal nutrition standards. States with standards that exceeded US Department of Agriculture (USDA) school meal standards were compared with states that did not exceed USDA standards. The parameter of interest was the interaction between state laws and student lunch participant status, ie, whether disparities in weight status between school lunch participants and nonparticipants were smaller in states with stricter standards. MAIN OUTCOME MEASURES: Body mass index percentile and obesity status. RESULTS: In states that exceeded USDA standards, the difference in obesity prevalence between students who obtained free/reduced-price lunches and students who did not obtain school lunches was 12.3 percentage points smaller (95% CI, -21.5 to -3.0) compared with states that did not exceed USDA standards. Likewise, differences in mean body mass index percentile between those student populations were 11 units smaller in states that exceeded USDA standards (95% CI, -17.7 to -4.3). There was little evidence that students compensated for school meal laws by purchasing more sweets, salty snacks, or sugar-sweetened beverages from other school venues (eg, vending machines) or other sources (eg, fast food). CONCLUSIONS AND RELEVANCE: Stringent school meal standards that reflect the latest nutrition science may improve weight status among school lunch participants, particularly those eligible for free/reduced-price lunches.

State laws governing school meals and disparities in fruit/vegetable intake.

BACKGROUND: Home access to fruits/vegetables (FV) is a consistent predictor of adolescent FV intake, but many adolescents face barriers to home access. PURPOSE: To determine if state laws that require FV in school meals are positively associated with FV intake, particularly among students with limited home access to FV. METHODS: Student data on home food access and FV intake were obtained from the National Youth Physical Activity and Nutrition Study (n=9574) and linked to state laws regarding FV requirements for school meals. All data were collected in 2010. Ordinary least-squares models were utilized in 2012 to estimate differences in intake between states with different FV laws, overall and by whether students had access to various foods at home (FV, unhealthy snacks). Models were weighted to account for the sample design and controlled for race, gender, age, fast-food intake, and school lunches consumed per week. RESULTS: The association between FV requirement laws and FV intake was strongest among students without regular home access to FV. Particularly among students who had home access to only unhealthy snacks and who regularly consumed school meals, mean FV intake was 0.45 and 0.61 cups/day higher, respectively (95% CIs=0.07, 0.84 and 0.21, 1.00), in states with FV requirements. Students with access to healthier foods at home tended to consume more FV, but such disparities in intake were smaller in states with FV laws. CONCLUSIONS: Laws that require FV in school meals may improve FV intake, particularly among students with limited access to healthy foods at home.

Weight status among adolescents in States that govern competitive food nutrition content.

OBJECTIVES: To determine if state laws regulating nutrition content of foods and beverages sold outside of federal school meal programs ("competitive foods") are associated with lower adolescent weight gain. METHODS: The Westlaw legal database identified state competitive food laws that were scored by using the Classification of Laws Associated with School Students criteria. States were classified as having strong, weak, or no competitive food laws in 2003 and 2006 based on law strength and comprehensiveness. Objective height and weight data were obtained from 6300 students in 40 states in fifth and eighth grade (2004 and 2007, respectively) within the Early Childhood Longitudinal Study-Kindergarten Class. General linear models estimated the association between baseline state laws (2003) and within-student changes in BMI, overweight status, and obesity status. Fixed-effect models estimated the association between law changes during follow-up (2003-2006) and within-student changes in BMI and weight status. RESULTS: Students exposed to strong laws at baseline gained, on average, 0.25 fewer BMI units (95% confidence interval: -0.54, 0.03) and were less likely to remain overweight or obese over time than students in states with no laws. Students also gained fewer BMI units if exposed to consistently strong laws throughout follow-up (ß = -0.44, 95% confidence interval: -0.71, -0.18). Conversely, students exposed to weaker laws in 2006 than 2003 had similar BMI gain as those not exposed in either year. CONCLUSIONS: Laws that regulate competitive food nutrition content may reduce adolescent BMI change if they are comprehensive, contain strong language, and are enacted across grade levels.

Differences in nutrient intake associated with state laws regarding fat, sugar, and caloric content of competitive foods.

OBJECTIVE: To determine whether nutrient intake is healthier among high school students in California, which regulates the nutrition content of competitive foods sold in high schools, than among students in states with no such standards. DESIGN: Cross-sectional study. SETTING: California and 14 states without high school competitive food nutrition standards in the 2009-2010 school year. PARTICIPANTS: A total of 680 high school students sampled in February through May 2010 as part of the National Youth Physical Activity and Nutrition Study. INTERVENTIONS: State laws governing fat, sugar, and caloric content of competitive foods sold in vending machines, school stores, and cafeterias (à la carte). MAIN OUTCOME MEASURES: Several measures of nutrient intake assessed by 24-hour recall, overall and stratified by location of consumption (school, home, other). RESULTS: On average, California students reported consuming less fat, sugar, and total calories at school than students in states with no competitive food nutrition standards. California students also reported less at-school intake of vitamins and minerals. All at-school differences in nutrient intake were null after adjusting for total caloric intake; California students consumed a lower proportion of their daily calories in school (21.5%) than students in other states (28.4%). Mean overall intake was lower in California for most measures that were analyzed, particularly added sugars. CONCLUSIONS: California high school students consumed lower quantities of fat, sugar, and calories in school than students in states with no competitive food nutrition standards, but the nutrition composition of California students' in-school diet was similar. Policy initiatives should promote competitive foods that are consistent with the Dietary Guidelines for Americans.

Association and diffusion of nutrition and physical activity policies on the state and district level.

BACKGROUND: School district wellness policies designed to reduce obesity and promote student health and well-being often lack specific requirements or any mandate that schools comply with the policy. Researchers, educators, and policymakers have called for states to take an active role in shaping district policies. The objective of this study was to determine if states with strong school-based nutrition and physical activity (PA)-related policies have stronger district wellness policies, and explore the direction of policy diffusion between states and districts. METHODS: State policies and nationally representative samples of district policies for the 2006-2007 and 2008-2009 school years were obtained across 5 domains-competitive foods, school meals, nutrition education, physical education (PE), and PA-and were classified as "strong" or "weak," based on policy language, in each grade level (elementary, middle, high). Linear models estimated the cross-sectional and longitudinal associations between state and district policies. RESULTS: In 2006-2007 and 2008-2009, district elementary school competitive food policies were stronger in states with strong policies. For policies governing competitive foods in high schools and school meals at all grade levels, mean district policy strength increased from 2006-2007 to 2008-2009 in states with strong 2006-2007 policies. States that strengthened their PE policies from 2006-2007 to 2008-2009 saw an increase in mean district PE policy strength. Across all domains, states that had weak 2006-2007 policies and made no changes saw little increase in district policy strength. CONCLUSION: District competitive food, school meal, and PE policies are stronger in states that have developed strong policies in these domains.

The impact of state safe routes to school-related laws on active travel to school policies and practices in U.S. elementary schools.

This study examined the relationship between state laws requiring minimum bussing distances, hazardous route exemptions, sidewalks, crossing guards, speed zones, and traffic control measures around schools and active travel to school (ATS) policies/practices in nationally representative samples of U.S. public elementary schools between 2007-2009. The state laws and school data were compiled through primary legal research and annual mail-back surveys of principals, respectively. Multivariate logistic and zero-inflated poisson regression indicated that all state law categories (except for sidewalks) relate to ATS. These laws should be considered in addition to formal safe routes to school programs as possible influences on ATS.

State disparities in time trends of adolescent body mass index percentile and weight-related behaviors in the United States.

Evidence is conflicting as to whether youth obesity prevalence has reached a plateau in the United States overall. Trends vary by state, and experts recommend exploring whether trends in weight-related behaviors are associated with changes in weight status trends. Thus, our objective was to estimate between-state variation in time trends of adolescent body mass index (BMI) percentile and weight-related behaviors from 2001 to 2007. A time series design combined cross-sectional Youth Risk Behavior Survey data from 272,044 adolescents in 29 states from 2001 to 2007. Self-reported height, weight, sports participation, physical education, television viewing, and daily consumption of 100% fruit juice, milk, and fruits and vegetables were collected. Linear mixed models estimated state variance in time trends of behaviors and BMI percentile. Across states, BMI percentile trends were consistent despite differences in behavioral trends. Boys experienced a modest linear increase in BMI percentile (ß = 0.18, 95% CI: 0.07, 0.30); girls experienced a non-linear increase, as the rate of increase declined over time from 1.02 units in 2001-2002 (95% CI: 0.68, 1.36) to 0.23 units in 2006-2007 (95% CI: -0.09, 0.56). States in which BMI percentile decreased experienced a greater decrease in TV viewing than states where BMI percentile increased. Otherwise, states with disparate BMI percentile trends did not differ with respect to behaviors. Future research should explore the role of other behaviors (e.g., soda consumption), measurement units (e.g., portion size), and societal trends (e.g., urban sprawl) on state and national adiposity trends.

Banning all sugar-sweetened beverages in middle schools: reduction of in-school access and purchasing but not overall consumption.

OBJECTIVE: To determine whether state policies that regulate beverages in schools are associated with reduced in-school access and purchase of sugar-sweetened beverages (SSBs) and reduced consumption of SSBs (in and out of school) among adolescents. DESIGN: Cross-sectional. SETTING: Public schools in 40 states. PARTICIPANTS: Students sampled in fifth and eighth grades (spring 2004 and 2007, respectively). MAIN EXPOSURES: State policies that ban all SSBs and state policies that ban only soda for 2006-2007. MAIN OUTCOME MEASURES: In-school SSB access, in-school SSB purchasing behavior, and overall SSB consumption (in and out of school) in eighth grade. RESULTS: The proportions of eighth-grade students who reported in-school SSB access and purchasing were similar in states that banned only soda (66.6% and 28.9%, respectively) compared with states with no beverage policy (66.6% and 26.0%, respectively). In states that banned all SSBs, fewer students reported in-school SSB access (prevalence difference, -14.9; 95% CI, -23.6 to -6.1) or purchasing (-7.3; -11.0 to -3.5), adjusted for race/ethnicity, poverty status, locale, state obesity prevalence, and state clustering. Results were similar among students who reported access or purchasing SSBs in fifth grade compared with those who did not. Overall SSB consumption was not associated with state policy; in each policy category, approximately 85% of students reported consuming SSBs at least once in the past 7 days. Supplementary analyses indicated that overall consumption had only a modest association with in-school SSB access. CONCLUSION: State policies that ban all SSBs in middle schools appear to reduce in-school access and purchasing of SSBs but do not reduce overall consumption.

Geographic disparities in state and district policies targeting youth obesity.

BACKGROUND: States and school districts nationwide have enacted policies targeting youth obesity, but many policies lack specific requirements or enforcement language. Geographic disparities in youth obesity could worsen if policies are weaker in areas with higher obesity prevalence. PURPOSE: To determine if state or district policy strength varies with youth obesity prevalence across Census divisions. METHODS: Policies in five domains related to nutrition and physical activity in schools were obtained from all states and nationally representative samples of 578 and 592 public school districts in the 2006-2007 and 2008-2009 school years, respectively. Policy language strength was rated on a 0-100 scale on both the state and district level. Regression models were used to determine if mean 2006-2007 strength scores, and changes in mean scores from 2006-2007 to 2008-2009, were associated with youth obesity prevalence across Census divisions. Analyses were conducted in 2010. RESULTS: State and district policies governing foods sold outside of school meal programs ("competitive foods") were stronger in 2006-2007 in the two divisions with the highest youth obesity prevalence (East South Central, West South Central). Furthermore, mean competitive food policy strength increased the most from 2006-2007 to 2008-2009 in these divisions. The West South Central had the weakest district physical education policies in 2006-2007, however, and was the only division in which average strength of district school meal policies decreased. CONCLUSIONS: State and districts in Census divisions with the highest youth obesity prevalence are taking steps to restrict competitive foods in schools, but many have not targeted other policy domains as aggressively.