From Tobacco to Obesity Prevention Policies: A Framework for Implementing Community-Driven Policy Change.

Efforts to reverse the obesity epidemic require policy, systems, and environmental (PSE) change strategies. Despite the availability of evidence-based and other promising PSE interventions, limited evidence exists on the "how-to" of transitioning them into practice. For the past 13 years, the Los Angeles County Department of Public Health has been building capacity among community residents and other stakeholders to create effective community coalitions and to implement well-designed policy strategy campaigns using an evidence-based approach to policy change, the policy adoption model (PAM). Implementing a phase-based approach to policy change, the PAM was initially used to support the passage of over 140 tobacco control and prevention policies in Los Angeles County. Following these successes, Los Angeles County Department of Public Health applied the PAM to obesity prevention, operationalizing the policy process by training community residents and other stakeholders on the use of the model. The PAM has shown to be helpful in promoting PSE change in tobacco control and obesity prevention, suggesting a local-level model potentially applicable to other fields of public health seeking sustainable, community-driven policy change.

Implementation and Evaluation of Adverse Childhood Experiences Screening in Pediatrics and Obstetrics Settings.

BACKGROUND: Screening for adverse childhood experiences (ACEs) in prenatal and pediatric populations is recommended by the California ACEs Aware initiative and is a promising practice to interrupt ACEs in children and mitigate ACEs-related health complications in children and families. Yet, integrating ACEs screening into clinical practice poses several challenges. OBJECTIVE: The objective of this report was to evaluate the Kaiser Permanente Northern California and Kaiser Permanente Southern California pilots and implementation of ACEs screening into routine prenatal (Kaiser Permanente Northern California) and pediatric (Kaiser Permanente Southern California) care. MATERIALS AND METHODS: These pilots were evaluated and compared to identify common challenges to implementation and offer promising practices for negotiating these challenges. Evaluation methods included feedback from staff, clinicians, and patients, as well as comparisons of methods to overcome various barriers to screening implementation. RESULTS: Implementing ACEs screening, like implementation of any new component of clinical care, takes careful planning, education, creation of content and workflows, and continuous integration of feedback from both patients and staff. CONCLUSION: This evaluation can serve as support for care teams who are considering implementing ACEs screening or who are already screening for ACEs. More research is needed regarding the relationship between ACEs and preventable and treatable health outcomes to improve health for patients and their families.

Pediatric ACEs Screening and Referral: Facilitators, Barriers, and Opportunities for Improvement.

Despite well-documented associations between adverse childhood experiences (ACEs) and lifelong impairments in health and well-being, few studies have examined how to facilitate implementation of ACEs screening and referral programs in pediatric settings. We sought to identify facilitators and barriers related to screening for and addressing ACEs in a large integrated healthcare delivery system in Southern California. Using a developmental evaluation approach, we conducted twenty semi-structured interviews with pediatricians, nurses, social workers, and community referral organization staff. Interviews took place across six pediatric clinic pilot sites in Kaiser Permanente Southern California, where more than 7,000 pediatric patients were screened for ACEs between July 2018 and December 2019. Thematic analysis was conducted to identify themes. Key facilitators for screening and referrals for pediatric ACEs screening included providing clinician education to normalize conversations about ACEs, using screening data to provide more holistic and compassionate care, and collaborating across different types of clinicians. Key barriers included screening tool challenges related to patient confusion and cultural differences, capacity limitations, training issues, and care team silos. When used in the context of a trauma- and resilience-informed workforce, ACEs screening may be a powerful tool to support more collaborative and impactful care decisions that move away from symptom management to address root causes and promote prevention.

Does Exposure to the Choose Water Campaign Increase Parental Intentions to Promote More Water and Less Sugar-Sweetened Beverage Consumption?

PURPOSE: To assess if exposure to the Choose Water public health media campaign increased parents' intentions to promote healthier beverage consumption in their household. DESIGN: A cross-sectional evaluation administered post-campaign. SETTING: A 2017 internet panel survey in Los Angeles County, California. PARTICIPANTS: The survey included 499 parents of young children. INTERVENTION: The Choose Water media campaign included digital media and out-of-home advertisements (eg, transit shelters, interiors of buses) in both English and Spanish. MEASURES: Dichotomous outcome variables were parental intentions to give child(ren) (1) more water and (2) less sugar-sweetened beverage consumption in their households. The independent variable was campaign exposure, categorized as no exposure, exposed but did not discuss visual, and exposed and discussed visual with someone. ANALYSIS: Descriptive, bivariate, and multivariable logistic regressions. RESULTS: Among those who were exposed and discussed a campaign visual, the adjusted odds of intending to promote water consumption were 2.82 times greater than for those who reported no exposure (95% confidence interval [CI]: 1.46-5.46). Similar odds to promote less sugar-sweetened beverage consumption were observed for those who were exposed and discussed a campaign visual (adjusted odds ratio: 3.27, 95% CI: 1.76-6.08). Those with the lowest educational attainment discussed the visual(s) less (10.5%). CONCLUSION: Word of mouth may enhance health messaging by allowing time for intended audiences to process campaign content within their interpersonal network.

Fructose content in popular beverages made with and without high-fructose corn syrup.

OBJECTIVE: Excess fructose consumption is hypothesized to be associated with risk for metabolic disease. Actual fructose consumption levels are difficult to estimate because of the unlabeled quantity of fructose in beverages. The aims of this study were threefold: 1) re-examine the fructose content in previously tested beverages using two additional assay methods capable of detecting other sugars, especially maltose, 2) compare data across all methods to determine the actual free fructose-to-glucose ratio in beverages made either with or without high-fructose corn syrup (HFCS), and 3) expand the analysis to determine fructose content in commonly consumed juice products. METHODS: Sugar-sweetened beverages (SSBs) and fruit juice drinks that were either made with or without HFCS were analyzed in separate, independent laboratories via three different methods to determine sugar profiles. RESULTS: For SSBs, the three independent laboratory methods showed consistent and reproducible results. In SSBs made with HFCS, fructose constituted 60.6% ± 2.7% of sugar content. In juices sweetened with HFCS, fructose accounted for 52.1% ± 5.9% of sugar content, although in some juices made from 100% fruit, fructose concentration reached 65.35 g/L accounting for 67% of sugars. CONCLUSION: Our results provide evidence of higher than expected amounts of free fructose in some beverages. Popular beverages made with HFCS have a fructose-to-glucose ratio of approximately 60:40, and thus contain 50% more fructose than glucose. Some pure fruit juices have twice as much fructose as glucose. These findings suggest that beverages made with HFCS and some juices have a sugar profile very different than sucrose, in which amounts of fructose and glucose are equivalent. Current dietary analyses may underestimate actual fructose consumption.

The obesogenic effect of high fructose exposure during early development.

Obesogens are compounds that disrupt the function and development of adipose tissue or the normal metabolism of lipids, leading to an increased risk of obesity and associated diseases. Evidence for the adverse effects of industrial and agricultural obesogens, such as tributyltin, bisphenol A and other organic pollutants is well-established. Current evidence suggests that high maternal consumption of fat promotes obesity and increased metabolic risk in offspring, but less is known about the effects of other potential nutrient obesogens. Widespread increase in dietary fructose consumption over the past 30 years is associated with chronic metabolic and endocrine disorders and alterations in feeding behaviour that promote obesity. In this Perspectives, we examine the evidence linking high intakes of fructose with altered metabolism and early obesity. We review the evidence suggesting that high fructose exposure during critical periods of development of the fetus, neonate and infant can act as an obesogen by affecting lifelong neuroendocrine function, appetite control, feeding behaviour, adipogenesis, fat distribution and metabolic systems. These changes ultimately favour the long-term development of obesity and associated metabolic risk.