Unraveling common threads in obesity risk among racial/ethnic minority and migrant populations.

BACKGROUND: Epidemic obesity poses a major threat to global health. This phenomenon reflects the inability of the average person to cope, biologically and behaviorally, with environmental contexts that promote caloric overconsumption and inadequate caloric expenditure. There is still much to be learned about how to improve these contexts nationally and within-countries for sociodemographic groups with above-average obesity risks. METHODS: Higher obesity risks relative to respective white majority populations were identified among diverse indigenous, other native-born, or migrant 'racial' or ethnic minority (hereafter, ethnic minority) populations in the United States, Canada, Australia, New Zealand, and the Netherlands, using publicly available national survey data or other sources. Cross-national comparisons were of interest for identifying common risk pathways associated with social and economic inequities. Potential explanations were explored through a narrative review of peer-reviewed literature, informed by the World Health Organization's Conceptual Framework for Action on The Social Determinants of Health. MAIN FINDINGS: Identifying viable solutions to the high risk of obesity in ethnic minority populations in these high-income countries requires examination of national-level social, economic, and health system contexts, food systems, and built environments for physical activity, as well as patterns of social stratification and cultural biases related to ethnicity, migration, and other determinants of social disadvantage. These factors can be linked to mediators of exposure or vulnerability to obesity-related risks, such as poverty, being an 'outsider', stress and trauma resulting from historical and current oppression, exposure to bias and discrimination, related biological or behavioral consequences, and inadequate health and social care. CONCLUSIONS: Focusing on ethnic minority populations in high-income countries is critical for public health efforts to address epidemic obesity. Mitigating intersecting risk pathways arising from stratification and bias based on ethnicity and migrant status should be prominent in these efforts.

Supplement overview: what the Healthy Communities Study is telling us about childhood obesity prevention in U.S. communities.

The Healthy Communities Study (HCS), conducted between 2010 and 2016, tells a real-world story of how childhood obesity prevention efforts have unfolded in 130 U.S. communities. The study documented nearly 10,000 current and past community policies and programs (CPPs) and assessed dietary and physical activity behaviors, weight, height, and waist circumference of more than 5,000, 4- to 15-year-old children. The articles in this HCS supplement describe the variables created to characterize the CPPs, CPP relationships with children's behavioral and weight status, other analyses of interest, and recruitment challenges. Findings suggest that many of the strategies being implemented work as intended to improve children's behaviors and weight status. However, of concern, findings also indicate lesser reach to children in demographic groups at highest risk of obesity. Overall, the HCS insights can guide the next phase of efforts to strengthen existing CPPs and motivate other, novel approaches to combating childhood obesity.

Motivating systems-oriented research on environmental and policy changes for obesity prevention.

BACKGROUND: Research on the types of interventions needed for population-level prevention of childhood obesity in complex societal systems can benefit from greater use of systems-science concepts and tools. OBJECTIVES: We report outcomes of a funding programme promoting incorporation of systems-science approaches into studies of imminent policy or environmental changes potentially impacting childhood obesity. METHODS: Seven funding cycles over 3 years yielded 172 initial submissions from 29 US states and 25 other countries were analyzed. RESULTS: Submissions focused primarily on aspects of school or child-care settings, parks and recreational settings, or access to healthy food; about half reflected attention to systems perspectives. CONCLUSIONS: Analysis of initial submissions as well as the 15 funded projects showed some success in motivating use of systems concepts and tools but suggested the need for a more focused effort to educate and prepare the childhood obesity prevention research community for this potentially crucial type of research.

School beverage environment and children's energy expenditure associated with physical education class: an agent-based model simulation.

BACKGROUND: Physical activity contributes to children's energy expenditure and prevents excess weight gain, but fluid replacement with sugar-sweetened beverages (SSBs) may diminish this benefit. OBJECTIVE: The aim of this study was to explore the net energy expenditure (EE) after physical education (PE) class given the competition between water and SSB consumption for rehydration and explore environmental factors that may influence the net EE, e.g. PE duration, affordability of SSB and students' SSB preference. METHODS: We built an agent-based model that simulates the behaviour of 13-year-old children in a PE class with nearby water fountains and SSB vending machines available. RESULTS: A longer PE class contributed to greater prevalence of dehydration and required more time for rehydration. The energy cost of a PE class with activity intensity equivalent to 45 min of jogging is about 300 kcal on average, i.e. 10-15% of average 13-year-old children's total daily EE. Adding an SSB vending machine could offset PE energy expenditure by as much as 90 kcal per child, which was associated with PE duration, students' pocket money and SSB preference. CONCLUSIONS: Sugar-sweetened beverage vending machines in school may offset some of the EE in PE classes. This could be avoided if water is the only readily available source for children's fluid replacement after class.

Prevention of excess weight gain in paediatric primary care: beverages only or multiple lifestyle factors. The Smart Step Study, a cluster-randomized clinical trial.

BACKGROUND: Insufficient evidence exists to support obesity prevention in paediatric primary care. OBJECTIVES: To test a theory-based behaviour modification intervention delivered by trained paediatric primary care providers for obesity prevention. METHODS: Efficacy trial with cluster randomization (practice level) and a 12-session 12-month sweetened beverages decrease intervention or a comprehensive dietary and physical activity intervention, compared with a control intervention among children ages 8-12 years. RESULTS: A low recruitment rate was observed. The increase in body mass index z-score (BMIz) for the 139 subjects (11 practices) randomized to any of the two obesity interventions (combined group) was less than that of the 33 subjects (five practices) randomized to the control intervention (-0.089, 95% confidence interval [CI]: -0.170 to -0.008, P = 0.03) with a -1.44 kg weight difference (95% CI: -2.98 to +0.10 kg, P = 0.095). The incidences of obesity and excess weight gain were lower in the obesity interventions, but the number of subjects was small. Post hoc analyses comparing the beverage only to the control intervention also showed an intervention benefit on BMIz (-0.083, 95% CI: -0.165 to -0.001, P = 0.048). CONCLUSIONS: For participating families, an obesity prevention intervention delivered by paediatric primary care clinicians, who are compensated, trained and continuously supported by behavioural specialists, can impact children's BMIz.

Introduction to the special issue on achieving healthy weight in black American communities.

The prevalence of obesity is high in the United States, and highest among racial and ethnic minority groups. This special issue of Obesity Reviews is based upon evidence reviews prepared for and presented at a national invited workshop convened by the African American Collaborative Obesity Research Network (AACORN) in August of 2012. A set of potential topics was developed, a priori, and AACORN network members and colleagues with relevant expertise were invited to lead evidence reviews. The result is 10 articles focused on providing a comprehensive picture of what is known and unknown about interventions to prevent and treat obesity or improve weight-related behaviours in African American adults and children. Evidence reviews included in this special issue focus on children and adolescents (n=2); adults from various perspectives (n=5); eHealth interventions (n=1); interventions within faith organizations (n=1); and environmental and policy change interventions (n=1). Overall, the reviews show a small evidence base for research on African Americans and call for additional prioritization of funding to include studies that can inform action and bring progress in obesity prevention and treatment in African Americans on par with the scope and seriousness of the problem.

Examining the evidence for policy and environmental strategies to prevent childhood obesity in black communities: new directions and next steps.

Exposure to physical and policy environments that limit availability, affordability and appeal of healthy eating and active living options is higher for U.S. blacks than whites. This may contribute to high risk of obesity in black communities and limit effectiveness of preventive interventions. Here, we assess applicability to black Americans of findings from a prior evidence review system designed to accelerate the discovery and application of policy and environmental strategies for childhood obesity prevention and assess external validity. The database included 600 peer-reviewed articles reporting data from 396 sets of studies (study groupings) published from January 2000 through May 2009 and pertained to 24 types of policy and environmental strategies. Only 33 study groupings (~8%) included ≥ 50% black Americans or reported subgroup analyses. Of 10 evaluation studies for interventions rated as effective for all populations in the primary review, 8 suggested effectiveness of child-focused interventions in school or child care settings for obesity- or physical activity-related outcomes in black Americans. Overall findings highlight the need for rigorous evaluations of interventions that reach black children in community or institutional settings, and conceptual frameworks and research designs geared to identifying ethnic or ethnicity-income group differences in intervention effects.

What works for obesity prevention and treatment in black Americans? Research directions.

Obesity prevalence in black/African American children and adults of both sexes is high overall and compared with US whites. What we know, and do not know, about how to enhance the effectiveness of obesity prevention and treatment interventions in African Americans is the focus of the 10 articles in this special issue of Obesity Reviews. The evidence base is limited in quantity and quality and insufficient to provide clear guidance. With respect to children, there is relatively consistent, but not definitive support for prioritizing the systematic implementation and evaluation of child-focused interventions in pre-school and school settings and outside of school time. For adults or all ages, developing and refining e-health approaches and faith-based or other culturally and contextually relevant approaches, including translation of the Diabetes Prevention Program intervention to community settings is indicated. Major evidence gaps were identified with respect to interventions with black men and boys, ways to increase participation and retention of black adults in lifestyle behaviour change programmes, and studies of the impact of environmental and policy changes on eating and physical activity in black communities. Bold steps related to research funding priorities, research infrastructure and methodological guidelines are recommended to improve the quantity and quality of research in this domain.

Monitoring policy and actions on food environments: rationale and outline of the INFORMAS policy engagement and communication strategies.

The International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support (INFORMAS) proposes to collect performance indicators on food policies, actions and environments related to obesity and non-communicable diseases. This paper reviews existing communications strategies used for performance indicators and proposes the approach to be taken for INFORMAS. Twenty-seven scoring and rating tools were identified in various fields of public health including alcohol, tobacco, physical activity, infant feeding and food environments. These were compared based on the types of indicators used and how they were quantified, scoring methods, presentation and the communication and reporting strategies used. There are several implications of these analyses for INFORMAS: the ratings/benchmarking approach is very commonly used, presumably because it is an effective way to communicate progress and stimulate action, although this has not been formally evaluated; the tools used must be trustworthy, pragmatic and policy-relevant; multiple channels of communication will be needed; communications need to be tailored and targeted to decision-makers; data and methods should be freely accessible. The proposed communications strategy for INFORMAS has been built around these lessons to ensure that INFORMAS's outputs have the greatest chance of being used to improve food environments.

INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support): overview and key principles.

Non-communicable diseases (NCDs) dominate disease burdens globally and poor nutrition increasingly contributes to this global burden. Comprehensive monitoring of food environments, and evaluation of the impact of public and private sector policies on food environments is needed to strengthen accountability systems to reduce NCDs. The International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) is a global network of public-interest organizations and researchers that aims to monitor, benchmark and support public and private sector actions to create healthy food environments and reduce obesity, NCDs and their related inequalities. The INFORMAS framework includes two 'process' modules, that monitor the policies and actions of the public and private sectors, seven 'impact' modules that monitor the key characteristics of food environments and three 'outcome' modules that monitor dietary quality, risk factors and NCD morbidity and mortality. Monitoring frameworks and indicators have been developed for 10 modules to provide consistency, but allowing for stepwise approaches ('minimal', 'expanded', 'optimal') to data collection and analysis. INFORMAS data will enable benchmarking of food environments between countries, and monitoring of progress over time within countries. Through monitoring and benchmarking, INFORMAS will strengthen the accountability systems needed to help reduce the burden of obesity, NCDs and their related inequalities.

Monitoring and benchmarking government policies and actions to improve the healthiness of food environments: a proposed Government Healthy Food Environment Policy Index.

Government action is essential to increase the healthiness of food environments and reduce obesity, diet-related non-communicable diseases (NCDs), and their related inequalities. This paper proposes a monitoring framework to assess government policies and actions for creating healthy food environments. Recommendations from relevant authoritative organizations and expert advisory groups for reducing obesity and NCDs were examined, and pertinent components were incorporated into a comprehensive framework for monitoring government policies and actions. A Government Healthy Food Environment Policy Index (Food-EPI) was developed, which comprises a 'policy' component with seven domains on specific aspects of food environments, and an 'infrastructure support' component with seven domains to strengthen systems to prevent obesity and NCDs. These were revised through a week-long consultation process with international experts. Examples of good practice statements are proposed within each domain, and these will evolve into benchmarks established by governments at the forefront of creating and implementing food policies for good health. A rating process is proposed to assess a government's level of policy implementation towards good practice. The Food-EPI will be pre-tested and piloted in countries of varying size and income levels. The benchmarking of government policy implementation has the potential to catalyse greater action to reduce obesity and NCDs.

A proposed approach to monitor private-sector policies and practices related to food environments, obesity and non-communicable disease prevention.

Private-sector organizations play a critical role in shaping the food environments of individuals and populations. However, there is currently very limited independent monitoring of private-sector actions related to food environments. This paper reviews previous efforts to monitor the private sector in this area, and outlines a proposed approach to monitor private-sector policies and practices related to food environments, and their influence on obesity and non-communicable disease (NCD) prevention. A step-wise approach to data collection is recommended, in which the first ('minimal') step is the collation of publicly available food and nutrition-related policies of selected private-sector organizations. The second ('expanded') step assesses the nutritional composition of each organization's products, their promotions to children, their labelling practices, and the accessibility, availability and affordability of their products. The third ('optimal') step includes data on other commercial activities that may influence food environments, such as political lobbying and corporate philanthropy. The proposed approach will be further developed and piloted in countries of varying size and income levels. There is potential for this approach to enable national and international benchmarking of private-sector policies and practices, and to inform efforts to hold the private sector to account for their role in obesity and NCD prevention.

Monitoring the levels of important nutrients in the food supply.

A food supply that delivers energy-dense products with high levels of salt, saturated fats and trans fats, in large portion sizes, is a major cause of non-communicable diseases (NCDs). The highly processed foods produced by large food corporations are primary drivers of increases in consumption of these adverse nutrients. The objective of this paper is to present an approach to monitoring food composition that can both document the extent of the problem and underpin novel actions to address it. The monitoring approach seeks to systematically collect information on high-level contextual factors influencing food composition and assess the energy density, salt, saturated fat, trans fats and portion sizes of highly processed foods for sale in retail outlets (with a focus on supermarkets and quick-service restaurants). Regular surveys of food composition are proposed across geographies and over time using a pragmatic, standardized methodology. Surveys have already been undertaken in several high- and middle-income countries, and the trends have been valuable in informing policy approaches. The purpose of collecting data is not to exhaustively document the composition of all foods in the food supply in each country, but rather to provide information to support governments, industry and communities to develop and enact strategies to curb food-related NCDs.

Monitoring food and non-alcoholic beverage promotions to children.

Food and non-alcoholic beverage marketing is recognized as an important factor influencing food choices related to non-communicable diseases. The monitoring of populations' exposure to food and non-alcoholic beverage promotions, and the content of these promotions, is necessary to generate evidence to understand the extent of the problem, and to determine appropriate and effective policy responses. A review of studies measuring the nature and extent of exposure to food promotions was conducted to identify approaches to monitoring food promotions via dominant media platforms. A step-wise approach, comprising 'minimal', 'expanded' and 'optimal' monitoring activities, was designed. This approach can be used to assess the frequency and level of exposure of population groups (especially children) to food promotions, the persuasive power of techniques used in promotional communications (power of promotions) and the nutritional composition of promoted food products. Detailed procedures for data sampling, data collection and data analysis for a range of media types are presented, as well as quantifiable measurement indicators for assessing exposure to and power of food and non-alcoholic beverage promotions. The proposed framework supports the development of a consistent system for monitoring food and non-alcoholic beverage promotions for comparison between countries and over time.

Monitoring the health-related labelling of foods and non-alcoholic beverages in retail settings.

Food labelling on food packaging has the potential to have both positive and negative effects on diets. Monitoring different aspects of food labelling would help to identify priority policy options to help people make healthier food choices. A taxonomy of the elements of health-related food labelling is proposed. A systematic review of studies that assessed the nature and extent of health-related food labelling has been conducted to identify approaches to monitoring food labelling. A step-wise approach has been developed for independently assessing the nature and extent of health-related food labelling in different countries and over time. Procedures for sampling the food supply, and collecting and analysing data are proposed, as well as quantifiable measurement indicators and benchmarks for health-related food labelling.

Monitoring the price and affordability of foods and diets globally.

Food prices and food affordability are important determinants of food choices, obesity and non-communicable diseases. As governments around the world consider policies to promote the consumption of healthier foods, data on the relative price and affordability of foods, with a particular focus on the difference between 'less healthy' and 'healthy' foods and diets, are urgently needed. This paper briefly reviews past and current approaches to monitoring food prices, and identifies key issues affecting the development of practical tools and methods for food price data collection, analysis and reporting. A step-wise monitoring framework, including measurement indicators, is proposed. 'Minimal' data collection will assess the differential price of 'healthy' and 'less healthy' foods; 'expanded' monitoring will assess the differential price of 'healthy' and 'less healthy' diets; and the 'optimal' approach will also monitor food affordability, by taking into account household income. The monitoring of the price and affordability of 'healthy' and 'less healthy' foods and diets globally will provide robust data and benchmarks to inform economic and fiscal policy responses. Given the range of methodological, cultural and logistical challenges in this area, it is imperative that all aspects of the proposed monitoring framework are tested rigorously before implementation.

Monitoring foods and beverages provided and sold in public sector settings.

This paper outlines a step-wise framework for monitoring foods and beverages provided or sold in publicly funded institutions. The focus is on foods in schools, but the framework can also be applied to foods provided or sold in other publicly funded institutions. Data collection and evaluation within this monitoring framework will consist of two components. In component I, information on existing food or nutrition policies and/or programmes within settings would be compiled. Currently, nutrition standards and voluntary guidelines associated with such policies/programmes vary widely globally. This paper, which provides a comprehensive review of such standards and guidelines, will facilitate institutional learnings for those jurisdictions that have not yet established them or are undergoing review of existing ones. In component II, the quality of foods provided or sold in public sector settings is evaluated relative to existing national or sub-national nutrition standards or voluntary guidelines. Where there are no (or only poor) standards or guidelines available, the nutritional quality of foods can be evaluated relative to standards of a similar jurisdiction or other appropriate standards. Measurement indicators are proposed (within 'minimal', 'expanded' and 'optimal' approaches) that can be used to monitor progress over time in meeting policy objectives, and facilitate comparisons between countries.

Monitoring the impacts of trade agreements on food environments.

The liberalization of international trade and foreign direct investment through multilateral, regional and bilateral agreements has had profound implications for the structure and nature of food systems, and therefore, for the availability, nutritional quality, accessibility, price and promotion of foods in different locations. Public health attention has only relatively recently turned to the links between trade and investment agreements, diets and health, and there is currently no systematic monitoring of this area. This paper reviews the available evidence on the links between trade agreements, food environments and diets from an obesity and non-communicable disease (NCD) perspective. Based on the key issues identified through the review, the paper outlines an approach for monitoring the potential impact of trade agreements on food environments and obesity/NCD risks. The proposed monitoring approach encompasses a set of guiding principles, recommended procedures for data collection and analysis, and quantifiable 'minimal', 'expanded' and 'optimal' measurement indicators to be tailored to national priorities, capacity and resources. Formal risk assessment processes of existing and evolving trade and investment agreements, which focus on their impacts on food environments will help inform the development of healthy trade policy, strengthen domestic nutrition and health policy space and ultimately protect population nutrition.