A Sugar-Sweetened Beverage Excise Tax in California: Projected Benefits for Population Obesity and Health Equity.

INTRODUCTION: Amid the successes of local sugar-sweetened beverage (SSB) taxes, interest in state-wide policies has grown. This study evaluated the cost effectiveness of a hypothetical 2-cent-per-ounce excise tax in California and its implications for population health and health equity. METHODS: Using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model, tax impacts on health, health equity, and cost effectiveness over 10 years in California were projected, both overall and stratified by race/ethnicity and income. Expanding on previous models, differences in the effect of intake of SSBs on weight by BMI category were incorporated. Costing was performed in 2020, and analyses were conducted in 2021-2022. RESULTS: The tax is projected to save $4.55 billion in healthcare costs, prevent 266,000 obesity cases in 2032, and gain 114,000 quality-adjusted life years. Cost-effectiveness metrics, including cost/quality-adjusted life year gained, were cost saving. Spending on SSBs was projected to decrease by $33 per adult and $26 per child overall in the first year. Reductions in obesity prevalence for Black and Hispanic Californians were 1.8 times larger than for White Californians, and reductions for adults with lowest incomes (<130% Federal Poverty Level) were 1.4 times the reduction among those with highest incomes (>350% Federal Poverty Level). The tax is projected to save $112 in obesity-related healthcare costs per $1 invested. CONCLUSIONS: A state-wide SSB tax in California would be cost saving, lead to reductions in obesity and improvement in SSB-related health equity, and lead to overall improvements in population health. The policy would generate more than $1.6 billion in state tax revenue annually that can also be used to improve health equity.

Associations between Changes in Food Acquisition Behaviors, Dietary Intake, and Bodyweight during the COVID-19 Pandemic among Low-Income Parents in California.

COVID-19 disrupted food access, potentially increasing nutritional risk and health inequities. This study aimed to describe and assess associations between changes in food/meal acquisition behaviors and relative changes in dietary intake and bodyweight from before to during the pandemic. Low-income parents (n = 1090) reported these changes by online survey in April-August 2021. Associations were assessed by multinomial logistic regression. Compared to those with no change, those who decreased supermarket shopping had greater odds of decreased fruit and vegetable (FV; OR[95%CI] = 2.4[1.4-4.1]) and increased salty snack intakes (OR[95%CI] = 1.7[1.0-2.8]). Those who decreased farmer's market shopping had greater odds of decreased FV intake (OR[95%CI] = 1.8[1.0-3.1]), increased bodyweight (OR[95%CI] = 1.7[1.1-2.6]), and increased SSB (OR[95%CI] = 1.9[1.1-3.2]) and sweets intakes (OR[95%CI] = 1.8[1.1-2.9]). Those who increased online food ordering had greater odds of increased sweets (OR[95%CI] = 1.7[1.1-2.8]), salty snacks (OR[95%CI] = 1.9[1.2-3.2]), and fast food (OR[95%CI] = 2.0[1.2-3.5]) intakes and bodyweight (OR[95%CI] = 1.8[1.1-2.9]). Those who increased healthy meal preparation had greater odds of increased FV intake (OR[95%CI] = 4.0[2.5-6.5]), decreased SSB (OR[95%CI] = 3.7[2.3-6.0]), sweets (OR[95%CI] = 2.7[1.6-4.4]), salty snacks (OR[95%CI] = 3.0[1.8-5]) and fast food intakes (OR[95%CI] = 2.8[1.7-4.6]) and bodyweight (OR[95%CI] = 2.2[1.2-4.0]). Interventions to address the potentially negative impacts of online food/meal shopping and support healthy home cooking may be needed to improve nutrition-related outcomes and reduce health disparities in the aftermath of the current pandemic and during future emergencies requiring similar restrictions.

Parent perceptions of changes in eating behavior during COVID-19 of school-aged children from Supplemental Assistance Program Education (SNAP-Ed) eligible households in California.

This cross-sectional study examined the associations between parent-reported, perceptions of changes in school-aged children's (ages 5-18) school meal participation, household cooking, fast food consumption, dietary intake, and weight during the COVID-19 pandemic. Respondents with low-income and school-aged children (n = 1040) were enrolled using quota sampling to approximate the distribution of low-income households and race/ethnicity among California residents who completed an on-line questionnaire developed by the authors. Adjusted multinomial models examined associations between parent-reported changes in school meal participation and time spent cooking, with parent-reported changes in child diet and body weight during COVID-19 (from before March 2020 to January-March 2021). During the pandemic, decreased school meal participation was associated with decreased child's fast food intake (OR[95 %CI] = 1.47[1.04-2.07]); conversely, increased school meal participation was associated with increased child's fast food intake (OR[95 %CI] = 1.71[1.09-2.68]). Decreased cooking at home was associated with decreased fruit and vegetable intake (OR[95 %CI] = 2.71[1.62-4.53]), increased sugar-sweetened beverage intake (OR[95 %CI] = 3.83[2.16-6.81]), and increased fast food intake (OR[95 %CI] = 4.09[2.45-6.84]); while increased cooking at home was associated with increased fruit and vegetable (OR[95 %CI] = 2.26[1.59-3.20]), sugar-sweetened beverage (OR[95 %CI] = 1.88[1.20-2.94]), sweets (OR[95 %CI] = 1.46[1.02-2.10]), and salty snack food intake (OR[95 %CI] = 1.87[1.29-2.71]). These parent-reported perceived changes in meal sources during the pandemic for children from low-income California households, and the mixed results in their associations with changes in parent-reported child dietary intake, suggest the need for strengthening policies and programs to support both access to, and healthfulness of, meals from school and home during prolonged school closures.

California's Supplemental Nutrition Assistance Program-Education (SNAP-Ed) Be Better social marketing campaign: mothers' fruit and vegetable consumption and facilitation of children's healthy behaviours.

OBJECTIVE: Evaluation of California Department of Public Health's three-year social marketing campaign (Be Better) to encourage healthy eating and water consumption among Supplemental Nutrition Assistance Program-Education (SNAP-Ed) California mothers. Andreasen's social marketing framework was used to outline the development and evaluation of the campaign. DESIGN: Quantitative, pre-post cross-sectional study with three cohorts nested within survey years. Generalised estimating equation modeling was used to obtain population estimates of campaign reach and changes in mothers' fruit and vegetable (FV) consumption and facilitative actions towards their children's health behaviours. SETTING: CalFresh Healthy Living (California's SNAP-Ed). PARTICIPANTS: Three separate cohorts of SNAP mothers were surveyed (pre, post) between 2016 and 2018 inclusive. A total of 2229 mothers (ages 18-59) self-identified as White, Latina, African American or Asian/Pacific Islander participated. RESULTS: Approximately 82 percent of surveyed mothers were aware of the campaign as assessed by measures of recall and recognition. Ad awareness was positively associated with mothers' FV consumption (R2 = 0·45), with the proportion of FV on plates and with behaviours that facilitate children's FV consumption and limit unhealthy snacks and sugary drinks (ßs ranged from 0·1 to 0·7). CONCLUSIONS: The campaign successfully reached 82 percent of surveyed mothers. Positive associations between California's Be Better campaign and targeted health behaviours were observed, although the associations varied by year and media channel (i.e. television, radio, billboards and digital). Most associations between ad awareness and outcomes were noted in years two and three of the campaign, suggesting that more than 1 year of campaign exposure was necessary for associations to emerge.

A Harvest of the Month Curriculum Increases Fruit and Vegetable Intake among 4th-6th Grade Students.

BACKGROUND: Most children do not eat enough fruits and vegetables (FV). Schools are a critical setting for supporting children to consume FV. To fill a gap in available materials, a classroom curriculum was developed and evaluated to determine impacts on student FV-related knowledge, attitudes, and behaviors. METHODS: A pre-/post-intervention survey was administered to 4th-6th grade students in 3 intervention and one comparison schools. Post-intervention student focus groups, parent/guardian surveys, and teacher surveys provided complementary information. RESULTS: Intervention students had a significantly greater increase in total FV intake, fruit intake, and 100% juice consumption, and preference for several types of FV relative to comparison group students. Students, teachers, and parents reported overall high levels of satisfaction with the curriculum. CONCLUSIONS: The Harvest of the Month curriculum is effective at increasing fruit intake among a low-income, diverse student population in grades 4-6, is acceptable to students, teachers, and parents, and is feasible to implement. Findings suggest this impact is the result of changes in preferences, skills, and motivation but not self-efficacy or perceived social norms. Some tailoring of the curriculum may be needed to increase its appropriateness for 6th-grade students, increase the impact on vegetable intake, and limit intake of juice.

SNAP-Ed physical activity interventions in low-income schools are associated with greater cardiovascular fitness among 5th and 7th grade students in California.

INTRODUCTION: California's Department of Public Health (CDPH) distributes Supplemental Nutrition Assistance Program-Education (SNAP-Ed) funding, known as CalFresh Healthy Living (CFHL) in California, to local health departments to implement school-based physical activity/nutrition interventions. We determined the association between intervention presence/dose and student cardiorespiratory fitness and BMI. METHODS: This cross-sectional, observational study included 5th and 7th grade students with 2016-17 FitnessGram® results who attended SNAP-Ed eligible California schools. Intervention group students attended schools with CDPH-CFHL interventions during October 2015-September 2016 (n = 904 schools; 97,504 students, 49% female); comparison group students attended schools without CDPH-CFHL interventions (n = 3,506 schools; 372,298 students, 49% female). Adjusted multilevel models determined the association between school-level intervention presence/dose and students' cardiorespiratory fitness (estimated VO2max) and BMI z-score, and tested for effect modification by student grade and sex. RESULTS: Students attending intervention schools demonstrated greater VO2max (males: 0.18 mL/kg per min, 95% CI: 0.03, 0.34; females = 0.26 mL/kg per min, 95% CI: 0.13, 0.39) and lower BMI z-scores (males: -0.03, 95% CI: -0.05, -0.02; females = -0.02, 95% CI: -0.04, -0.01) than students in comparison schools. Students in schools with the highest intervention levels demonstrated higher VO2max (0.37 (95% CI: 0.06, 0.16) and 0.22 (95% CI: 0.02, 0.42), respectively), than comparison students, with the strongest associations seen for females and 7th graders. CONCLUSION: On average, students in schools with CDPH-CFHL physical activity interventions demonstrated better cardiorespiratory fitness and slightly lower BMI z-scores than students in comparable schools without such programing. Investment in these interventions may positively impact students' cardiorespiratory health, though further causal investigation is warranted.

Three-year trends in dietary behaviours among mothers, teenagers and children from SNAP-Ed (Supplemental Nutrition Assistance Program-Education) eligible households across California.

OBJECTIVE: To examine trends from 2015 to 2017 in dietary behaviours and diet quality among low-income mothers, teenagers and children. DESIGN: Cross-sectional telephone surveys using a validated 24 h dietary assessment. SETTING: Randomly sampled households with incomes ≤185 % of the US federal poverty level across California. PARTICIPANTS: Survey participants were 13 247 mothers (≥18 years), 3293 teenagers (12-17 years) and 6043 children (5-11 years). Respondents were mostly Latino. RESULTS: Over the 3-year study period, consumption of fruits and vegetables with and without 100 % fruit juice increased (P ≤ 0·05) by at least 0·3 cups/d for mothers, teenagers and children. Intake of water also increased (P ≤ 0·001) by more than 1 cup/d for mothers and children and 2 cups/d for teenagers. Sugar-sweetened beverage (SSB) consumption was unchanged over the 3 years. Overall diet quality, as assessed by the Healthy Eating Index-2015, improved (P ≤ 0·01) for mothers, teenagers and children. Covariates for the fifteen regression models (three age groups by five outcome variables) included race/ethnicity, age, education for mothers, and gender for teenagers and children. CONCLUSIONS: The observed increases in fruit and vegetable intake and improvements in overall diet quality during the 3-year period suggest that low-income Californians may have lowered their risk of preventable diseases. However, more intense or strategic SSB-reduction interventions are required. Regional- or state-level, population-based surveillance of dietary behaviours is useful for public health nutrition policy and programme decision making, and can be used to assess potential trends in future negative health outcomes and related costs associated with poor dietary behaviours within at-risk populations.

The SNAP-Ed Evaluation Framework: demonstrating the impact of a national framework for obesity prevention in low-income populations.

The United States Department of Agriculture's Supplemental Nutrition Assistance Program Education, known as SNAP-Ed, is the country's largest and most diverse community nutrition program. In 2017, nearly 140 SNAP-Ed implementing agencies (SIAs) and hundreds of contractors delivered nutrition education to almost 5 million people in nearly 60,000 low-resource sites. Millions more were impacted with social marketing campaigns and policy, systems, and environmental changes. This article introduces and describes the benefits of the newly developed SNAP-Ed Evaluation Framework (Framework) and companion Interpretive Guide to consistently measure SNAP-Ed outcomes across different settings. The Framework uses the social ecological model as its underlying theory and features 51 indicators across four levels: Individual, Environmental Supports, Sectors of Influence, and Population Results. Topline findings from the first-year Census to track Framework adoption found that most SIAs intended to impact indicators closer to the inner levels of influence: Individual (mean = 59% of SIAs; SD = 22%) and Environmental Settings (mean = 48%; SD = 23%). As yet, few SIAs targeted outcomes for long-term indicators (mean = 26%; SD = 15%), Sectors of Influence (mean = 20%; SD = 12%), or Population Results (mean = 30%; SD = 11%). An in-depth example of how one state is using the Framework is described. The SNAP-Ed Evaluation Framework offers a new suite of evaluation measures toward eliminating disparities that contribute to poor diet, physical inactivity, food insecurity and obesity. Practitioners will need technical assistance to implement the Framework, especially to measure longer-term, multi-sector and population results, and to maximize effectiveness in SNAP-Ed.

Using synchronous distance education to deliver a weight loss intervention: A randomized trial.

OBJECTIVE: To implement a randomized trial to evaluate the effectiveness of a weight loss program delivered using synchronous distance education compared with a wait-list control group with 6-month follow-up. METHODS: Adults with a body mass index (BMI) ≥25 were randomized to the intervention (n = 42) or wait-list control group (n = 38). The intervention group participated in a synchronous, online, 15-week weight loss program; weight loss was the primary outcome. Secondary measures included height, BMI, and confidence in ability to be physically active and eat healthy. Assessments occurred at three and four time points in the intervention and control group, respectively. RESULTS: Participants who completed the program lost significantly more weight (1.8 kg) than those in the wait-list control group (0.25 kg) at week 15 [F(1,61) = 6.19, P = 0.02] and had a greater reduction in BMI (0.71 vs. 0.14 kg/m(2) ), [F(1,61) = 7.45, P = 0.01]. There were no significant differences between the intervention and the wait-list control groups for change in confidence in ability to be physically active or eat healthy. Weight loss was maintained at 6 months. CONCLUSIONS: Use of synchronous distance education is a promising approach for weight loss. The results of this study will help to inform future research that employs Web-based interventions.

Nutrition-related policy and environmental strategies to prevent obesity in rural communities: a systematic review of the literature, 2002-2013.

INTRODUCTION: Residents of rural communities in the United States are at higher risk for obesity than their urban and suburban counterparts. Policy and environmental-change strategies supporting healthier dietary intake can prevent obesity and promote health equity. Evidence in support of these strategies is based largely on urban and suburban studies; little is known about use of these strategies in rural communities. The purpose of this review was to synthesize available evidence on the adaptation, implementation, and effectiveness of policy and environmental obesity-prevention strategies in rural settings. METHODS: The review was guided by a list of Centers for Disease Control and Prevention Recommended Community Strategies and Measurements to Prevent Obesity in the United States, commonly known as the "COCOMO" strategies. We searched PubMed, Cumulative Index of Nursing and Allied Health Literature, Public Affairs Information Service, and Cochrane databases for articles published from 2002 through 2013 that reported findings from research on nutrition-related policy and environmental strategies in rural communities in the United States and Canada. Two researchers independently abstracted data from each article, and resolved discrepancies by consensus. RESULTS: Of the 663 articles retrieved, 33 met inclusion criteria. The interventions most commonly focused on increasing access to more nutritious foods and beverages or decreasing access to less nutritious options. Rural adaptations included accommodating distance to food sources, tailoring to local food cultures, and building community partnerships. CONCLUSIONS: Findings from this literature review provide guidance on adapting and implementing policy and environmental strategies in rural communities.

Adoption of cardiovascular risk reduction guidelines: a cluster-randomized trial.

BACKGROUND AND OBJECTIVES: Cardiovascular disease (CVD) and underlying atherosclerosis begin in childhood and are related to CVD risk factors. This study evaluates tools and strategies to enhance adoption of new CVD risk reduction guidelines for children. METHODS: Thirty-two practices, recruited and supported by 2 primary care research networks, were cluster randomized to a multifaceted controlled intervention. Practices were compared with guideline-based individual and composite measures for BMI, blood pressure (BP), and tobacco. Composite measures were constructed by summing the numerators and denominators of individual measures. Preintervention and postintervention measures were assessed by medical record review of children ages 3 to 11 years. Changes in measures (pre-post and intervention versus control) were compared. RESULTS: The intervention group BP composite improved by 29.5%, increasing from 49.7% to 79.2%, compared with the control group (49.5% to 49.6%; P < .001). Intervention group BP interpretation improved by 61.1% (from 0.2% to 61.3%), compared with the control group (0.4% to 0.6%; P < .001). The assessment of tobacco exposure or use for 5- to 11-year-olds in the intervention group improved by 30.3% (from 3.4% to 49.1%) versus the control group (0.6% to 21.4%) (P = .042). No significant change was seen in the BMI or tobacco composites measures. The overall composite of 9 measures improved by 13.4% (from 48.2% to 69.8%) for the intervention group versus the control group (47.4% to 55.2%) (P = .01). CONCLUSIONS: Significant improvement was demonstrated in the overall composite measure, the composite measure of BP, and tobacco assessment and advice for children aged 5 to 11 years.

Perceptions of community health center impact on private primary care physician practice.

CONTEXT: Community health centers (CHCs) were created in the mid-1960s to expand access to care in impoverished and underserved areas. The number of CHC sites has more than tripled in eastern North Carolina from 28 primary care centers in 2000 to 89 in 2010. OBJECTIVE: This study determined the perceptions of physicians on the impact of CHC expansion on the local practice environment. DESIGN: Descriptive statistics and correlations were used to compare responses regarding perceptions and differences between practice characteristics as well as physician ratios by year. Both CHC and private practice physician addresses were mapped using ArcGIS. SETTING AND PARTICIPANTS: Surveys were sent to 1422 (461 returns/32.5% response rate) primary care physicians residing in 43 predominantly rural eastern North Carolina counties. RESULTS: A large percentage of the respondents (82.7%) affirmed that they felt neutral or did not view CHCs to be competitors, whereas a minority (17%) did view them to be difficult to compete against. Forty-two percent of private practice respondents disagreed that CHCs offer a wider range of services despite significantly more CHC physicians than private practice respondents indicating that their facility provided basic services. CONCLUSION: The CHCs were perceived to offer a wider range of services, employ more staff, and have more practice locations than private practices. However, private practice physicians did not perceive CHCs to have a competitive advantage or to unfairly impact their practices, possibly due to inconsistent population growth in relation to the physician retention during the last 10 years.

Using synchronous distance-education technology to deliver a weight management intervention.

OBJECTIVE: To compare the effectiveness of online delivery of a weight management program using synchronous (real-time), distance-education technology to in-person delivery. METHODS: Synchronous, distance-education technology was used to conduct weekly sessions for participants with a live instructor. Program effectiveness was indicated by changes in weight, body mass index (BMI), waist circumference, and confidence in ability to eat healthy and be physically active. RESULTS: Online class participants (n = 398) had significantly greater reductions in BMI, weight, and waist circumference than in-person class participants (n = 1,313). Physical activity confidence increased more for in-person than online class participants. There was no difference for healthy eating confidence. CONCLUSIONS AND IMPLICATIONS: This project demonstrates the feasibility of using synchronous distance-education technology to deliver a weight management program. Synchronous online delivery could be employed with no loss to improvements in BMI, weight, and waist circumference.

Implementation of the NHLBI integrated guidelines for cardiovascular health and risk reduction in children and adolescents: rationale and study design for young hearts, strong starts, a cluster-randomized trial targeting body mass index, blood pressure, and tobacco.

BACKGROUND: Cardiovascular disease (CVD) and the underlying atherosclerosis begin in childhood, and their presence and intensity are related to known cardiovascular disease risk factors. Attention to risk factor control in childhood has the potential to reduce subsequent risk of CVD. OBJECTIVE: The Young Hearts Strong Starts Study was designed to test strategies facilitating adoption of the National, Heart, Lung and Blood Institute supported Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents. This study compares guideline-based quality measures for body mass index, blood pressure, and tobacco using two strategies: a multifaceted, practice-directed intervention versus standard dissemination. STUDY DESIGN: Two primary care research networks recruited practices and provided support for the intervention and outcome evaluations. Individual practices were randomly assigned to the intervention or control groups using a cluster randomized design based on network affiliation, number of clinicians per practice, urban versus nonurban location, and practice type. The units of observation are individual children because measure adherence is abstracted from individual patient's medical records. The units of randomization are physician practices. This results in a multilevel design in which patients are nested within practices. The intervention practices received toolkits and supported guideline implementation including academic detailing, an ongoing e-learning group. This project is aligned with the American Board of Pediatrics Maintenance of Certification requirements including monthly physician self-abstraction, webinars, and other elements of the trial. SIGNIFICANCE: This trial will provide an opportunity to demonstrate tools and strategies to enhance CV prevention in children by guideline-based interventions.

Stakeholder perceptions of obesity-prevention strategies: a comparison of geographically diverse rural counties.

Understanding barriers and facilitators to strategies directed at obesity-prevention policy change, particularly in rural, southern US counties where obesity is more prevalent, is important so that strategies deemed most winnable can be pursued. As such, community stakeholders and policy makers were interviewed using the Centers for Disease Control and Prevention's Common Community Measures for Obesity Prevention Assessment in 2 rural, geographically diverse regions of North Carolina. Stakeholder interviews revealed many similarities despite population differences and unique geographic challenges to each region. In both Western and Eastern North Carolina, strategies involving increasing opportunities for physical activity were deemed the most winnable, whereas strategies incentivizing businesses to locate in underserved areas and limiting advertisements of unhealthy food and beverages were deemed the least winnable. Differences among Western and Eastern North Carolina regions revolved around zoning, geographic constraints, and topographically influenced local food strategies. These findings add to the literature by systemically identifying similarities and differences among geographically diverse rural communities.

Delivering a behavior-change weight management program to teachers and state employees in North Carolina.

PURPOSE: To ascertain the effectiveness of a behavior-change weight management program offered to teachers and state employees in North Carolina (NC). DESIGN: Fifteen-week weight management program with premeasures and postmeasures. SETTING: State agencies and public K-12 schools in five NC counties. SUBJECTS: A total of 2574 NC state employees enrolled in 141 classes. INTERVENTION: Eat Smart, Move More, Weigh Less (ESMMWL) is a 15-week weight management program delivered by trained instructors. Lessons inform, empower, and motivate participants to live mindfully as they make choices about eating and physical activity. MEASURES: Height, weight, body mass index (BMI), waist circumference, blood pressure, confidence in ability to eat healthy and be physically active, changes in eating, and physical activity behaviors. ANALYSIS: Descriptive statistics, t-tests, χ(2) tests, and analyses of variance. RESULTS: Data are reported for 1341 participants in ESMMWL who completed the program, submitted an evaluation, and had not participated in the program in the past; 89% were female and mean age was 48.8 years. Average BMI and waist circumference decreased significantly. Confidence in eating healthfully and being physically active increased significantly. The percentage of participants with a BMI < 30 kg/m(2) increased from 40% to 45% and those with a normal blood pressure increased from 23% to 32.5%. Participants reported being more mindful of what and how much they ate (92%), being more mindful of how much daily physical activity they got (88%), and eating fewer calories (87.3%). CONCLUSION: This project demonstrated the feasibility of implementing a behavior change-based weight management program at the worksite to achieve positive outcomes related to weight, blood pressure, healthy eating, and physical activity behaviors. Programs such as this have the potential to provide health care cost savings.

Participation in community-originated interventions is associated with positive changes in weight status and health behaviors in youth.

PURPOSE: To assess changes in children's health behaviors and weight status after participation in community-originated interventions. DESIGN: Prospective cohort study following body mass index (BMI) z-score trajectory over time. SETTING: Schools and community settings in 19 locations in North Carolina. SUBJECTS: A total of 1144 children, with an average age of 9.5 years, participating in community-originated physical activity and nutrition interventions, such as active recess and healthy cafeteria offerings, and environment and policy changes designed to prevent and reduce the prevalence of childhood obesity. Retention from baseline to final collection was 54%. Measures . Self-reported physical activity and eating behaviors; measured height and weight were collected at baseline and after interventions (average of 20 months). Z-score was compared with expected growth without intervention. ANALYSIS: Descriptive statistics, χ(2) tests and t-tests, and ANOVA analyses of variance to assess changes in health behaviors and weight status. RESULTS: More than 11% of children improved their weight status, and 86% of children who began at a healthy weight remained there. The average BMI for children who were overweight at enrollment was significantly lower after intervention (1.1 kg/m(2) lower for boys and 0.88 kg/m(2) lower for girls). Overweight and obese children who made improvements in key health behaviors showed greater decreases in BMI z-score than those who did not improve those behaviors (increased fruit [-.2207 vs. -.0793] and vegetable [-.2215 vs. -.0855] intake, and drinking less soda [-.1985 vs. -.0912]). There were no significant increases in physical activity, and changes in physical activity were not related to decreases in BMI z-score in this study. CONCLUSION: Community-originated interventions to raise awareness about food choices and to change policies and environments may improve BMI z-scores.

A community-driven approach to identifying "winnable" policies using the Centers for Disease Control and Prevention's Common Community Measures for Obesity Prevention.

Federally funded, community-based participatory research initiatives encourage the development and implementation of obesity prevention policies. In 2009, the Centers for Disease Control and Prevention (CDC) published the Common Community Measures for Obesity Prevention (COCOMO), which include recommended strategies and measures to guide communities in identifying and evaluating environmental and policy strategies to prevent obesity. Agreeing on "winnable" policy issues can be challenging for community members. We used CDC's COCOMO to structure in-depth interviews and group discussions with local stakeholders (ie, planners, town managers, and a local community advisory council) to stimulate interest in and identify health-promoting policies for local policy and planning agendas. We first asked stakeholders to rank the COCOMO recommendations according to feasibility and likelihood of success given community culture, infrastructure, extent of leadership support, and likely funding support. Rankings were used to identify the most and least "winnable" COCOMO policy strategies. We then used questions from the evidence-based Community Readiness Handbook to aid discussion with stakeholders on the facilitators and barriers to enacting the most and least winnable policy options identified. Finally, we discuss potential adaptations to COCOMO for rural jurisdictions.

Effects of a behavior-based weight management program delivered through a state cooperative extension and local public health department network, North Carolina, 2008-2009.

INTRODUCTION: Eat Smart, Move More, Weigh Less (ESMMWL) is an adult weight management program developed in response to North Carolina Obesity Plan recommendations to make weight management interventions accessible to underserved populations. ESMMWL was designed to be delivered through the North Carolina Cooperative Extension and North Carolina Division of Public Health. Program coursework included content on evidence-based eating and physical activity behaviors and incorporated mindful eating concepts. The objectives of this study were to describe participant changes in weight and behaviors and to document the effectiveness of the program. METHODS: In this prospective pilot study, courses were delivered and data collected from January 2008 through June 2009. Instructors provided feedback about implementation. For participants, height, weight, and waist circumference were measured at baseline and completion. Participants completed a questionnaire about changes in their eating and physical activity behaviors, changes in their confidence to engage in weight management behaviors, and their satisfaction with the course. RESULTS: Seventy-nine instructors delivered 101 ESMMWL courses in 48 North Carolina counties. Most of the 1,162 completers were white women. Approximately 83% reported moving toward or attaining their goal. The average weight loss was 8.4 lb. Approximately 92% reported an increase in confidence to eat healthfully, and 82% reported an increase in confidence to be physically active. Instructors made suggestions for program standardization. CONCLUSION: This study demonstrated the effectiveness, diffusion, and implementation of a theoretically based weight management program through a state extension and local public health department network. Study of the sustainability of changes in eating and physical activity behaviors is needed.

The illusion of safety in "monogamous" undergraduate relationships.

OBJECTIVES: To determine the prevalence of sexual infidelity and disclosure among undergraduates and to identify the characteristics of those engaging in infidelity. METHODS: Analysis of responses from an online survey of 1341 undergraduate. RESULTS: Approximately 27% of males and 20% of females reported having oral, vaginal, or anal sex outside a partner-perceived monogamous relationship. Men over the age of 20, binge drinkers, fraternity members, male NCAA athletes, or the nonreligious were most likely to engage in these behaviors. CONCLUSIONS: Implement educational strategies to encourage undergraduates in committed relationships to reconsider their STI risk and to protect themselves via condom usage.