A tale of many neighborhoods: Latent profile analysis to derive a national neighborhood typology for the US

INTRODUCTION

Neighborhoods are complex and multi-faceted. Analytic strategies used to model neighborhoods should reflect this complexity, with the potential to better understand how neighborhood characteristics together impact health. We used latent profile analysis (LPA) to derive a residential neighborhood typology applicable for census tracts across the US.

METHODS

From tract-level 2015-2019 American Community Survey (ACS) five-year estimates, we selected five indicators that represent four neighborhood domains: demographic composition, commuting, socioeconomic composition, and built environment. We compared model fit statistics for up to eight profiles to identify the optimal number of latent profiles of the selected neighborhood indicators for the entire US. We then examined differences in national tract-level 2019 prevalence estimates of physical and mental health derived from CDC's PLACES dataset between derived profiles using one-way analysis of variance (ANOVA).

RESULTS

The 6-profile LPA model was the optimal categorization of neighborhood profiles based on model fit statistics and interpretability. Neighborhood types were distinguished most by demographic composition, followed by commuting and built environment domains. Neighborhood profiles were associated with meaningful differences in the prevalence of health outcomes. Specifically, tracts characterized as "Less educated non-immigrant racial and ethnic minority active transiters" (n = 3,132, 4%) had the highest poor health prevalence (Mean poor physical health: 18.6 %, SD: 4.30; Mean poor mental health: 19.6 %, SD: 3.85), whereas tracts characterized as "More educated metro/micropolitans" (n = 15, 250, 21%) had the lowest prevalence of poor mental and physical health (Mean poor physical health: 10.6 %, SD: 2.41; Mean poor mental health: 12.4 %, SD: 2.67; p < 0.001).

CONCLUSION

LPA can be used to derive meaningful and standardized profiles of tracts sensitive to the spatial patterning of social and built conditions, with observed differences in mental and physical health by neighborhood type in the US.

Youth Sport Participation by Metropolitan Status: 2018-2019 National Survey of Children's Health (NSCH)

Purpose: This cross-sectional study used data from the 2018-2019 National Survey of Children's Health to examine the association between metropolitan statistical area (MSA) status and sports participation among American youth ages 6-17. Methods: Weighted prevalence statistics were computed for sports participation by MSA status (non-MSA, MSA), overall and by child sex and age. Modified Poisson regression was used to estimate prevalence ratios (PR) for non-MSA versus MSA youth, before and after adjusting for special health-care needs, race/ethnicity, household income, parent education, and family structure. Results: The final sample included 30,029 youth [Mage = 11.6 years (SD = 0.4), 51.4% female, 49.0% White]. About 56% participated in sports in the past year. Sports participation was significantly higher among females versus males [59.1% (95% CI: 57.4%-60.7%) versus 52.1% (95% CI: 50.4%-53.8%), p < .001]. Among ages 6-11, those in non-MSAs (versus MSAs) were less likely to participate in sports [PR 0.92 (95% CI: 0.86-0.99), p = .033], which was non-significant after adjustment. In adjusted models, youth ages 12-17 in non-MSAs (versus in MSAs) were more likely to participate in sports overall [aPR 1.07 (95% CI: 1.00-1.15), p = .042] and among males [aPR 1.12 (95% CI: 1.01-1.23), p = .026]. Conclusion: The relationship between MSA status and sports participation may be largely driven by factors that affect youth's ability to participate in sports. Sports participation was higher among females versus males overall. In the models adjusted for demographics, non-MSA youth ages 12-17 were more likely to participate, particularly males. Efforts promoting youth sports should consider differences in socio-demographic factors between MSA versus non-MSA areas to help increase participation.

Seattle's sweetened beverage tax implementation and changes in interior marketing displays

Policymakers aim sugar-sweetened beverage (SSB) taxes at decreasing SSB consumption; however, little is known about their impact on beverage marketing in the retail environment. We assessed changes in interior marketing displays within large food stores before and after the implementation of Seattle's SSB tax. We used Poisson difference-in-difference (DID) models to estimate whether presence and variety of interior beverage marketing displays in Seattle changed from before to after the tax compared to displays in non-taxed comparison area stores, overall, and by beverage type. We found no significant changes in overall SSB or non-SSB interior marketing displays in Seattle versus the comparison area. There was less of an increase in displays for diet soda (DID 0.79, 90% CI 0.65, 0.97), and more of an increase in displays for diet energy drinks (DID 1.78, 90% CI 1.03, 3.09) in Seattle versus comparison area. There was mixed evidence that stores changed interior marketing displays in response to the SSB tax.

Sugar-sweetened beverage intake and convenience store shopping as mediators of the food insecurity-Tooth decay relationship among low-income children in Washington state

INTRODUCTION

There are oral health disparities in the U.S. and children in food-insecure households have a higher burden of tooth decay. Identifying the mechanisms underlying the food insecurity-tooth decay relationship could inform public health interventions. This study examined how sugar-sweetened beverage (SSB) intake and frequent convenience store shopping mediated the food insecurity-tooth decay relationship for lower-income children.

MATERIALS AND METHODS

Cross-sectional study data included a household survey, beverage questionnaire, and dental examination. The sample included 452 lower-income, racially-diverse, child-caregiver dyads in 2018 from King County in Washington state. The exposure was household food insecurity, the outcome was untreated decayed tooth surfaces, and the proposed mediators were SSB intake and frequent convenience store shopping (≥2 times/week). Causal mediation analyses via the potential outcomes framework was used to estimate natural indirect and direct effects.

RESULTS

Fifty-five percent of participants were in food-insecure households, the mean number of decayed tooth surfaces among children was 0.87 (standard deviation [SD] = 1.99), the mean SSB intake was 17 fluid ounces (fl/oz)/day (SD = 35), and 18% of households frequently shopped at a convenience store. After adjusting for confounders, household food insecurity and log-transformed SSB intake (fluid ounces/day) were positively associated with decayed tooth surfaces, but not at the a α = 0.05 level (mean ratio [MR] 1.60; 95% confidence interval [CI] 0.89, 2.88; p = .12 and MR 1.16; 95% CI 0.93, 1.46; p = .19, respectively). Frequent convenience store shopping was associated with 2.75 times more decayed tooth surfaces (95% CI 1.61, 4.67; p < .001). SSB intake mediated 10% of the food insecurity-tooth decay relationship (p = .35) and frequent convenience store shopping mediated 22% (p = .33).

CONCLUSIONS

Interventions aimed at addressing oral health disparities in children in food-insecure households could potentially focus on reducing intake of SSBs and improving access to healthful foods in lower-income communities.

Availability of Recreation Facilities and Parks In Relation to Adolescent Participation in Organized Sports and Activity Programs

Most adolescents do not meet physical activity guidelines, so understanding facilitators and barriers is important. This study used surveys and geocoded location data to examine associations of availability of parks and recreation facilities with adolescent-reported participation in organized team sports and physical activity classes. The study was conducted with 928 adolescents aged 12-17 years, plus one parent/caretaker, recruited from two regions of the US. Adolescents' participation in teams and classes was positively associated with parents' perceptions of multiple available recreation environments, but not with objectively-measured availability. Having multiple nearby parks and recreation facilities may provide adolescents with more options for participating in preferred organized team sports and activity classes.

Neighborhood walkability, neighborhood social health, and self-selection among U.S. adults

OBJECTIVES

Neighborhood walkability is favorably related to multiple physical health outcomes, but associations with social health are less clear. Present analyses examined how neighborhood walkability was related to neighborhood social health and explored the potential confounding role of neighborhood self-selection.

METHODS

Cross-sectional data were analyzed for 1745 adults, ages 20-66, recruited from two US regions. We created a walkability index around each participant's home (1 km street network buffer) based on residential density, street intersection density, mixed land use, and retail floor area ratio. Neighborhood social health outcomes included reported social interactions with neighbors and sense of community. Two mixed model regressions were conducted for each outcome, with and without adjusting for walkability-related reasons for moving to the neighborhood (self-selection). Covariates included sex, age, socioeconomic status, white/nonwhite race/ethnicity, marital status, and time living in the neighborhood.

RESULTS

Neighborhood walkability was positively related to social interactions with neighbors, both without (b = 0.13, p < .001) and with adjustment for self-selection (b = 0.09, p = .008). Neighborhood walkability was positively associated with sense of community, but only before adjusting for self-selection (b = 0.02, p = .009).

CONCLUSION

Neighborhood walkability may promote specific aspects of neighborhood social health, which together are beneficial for physical and mental health. These findings provide additional impetus for enhancing walkability of US communities.

Navigating Health Equity Through Mobility Justice: Youth of Color Organizing for Transportation Equity in Our Backyards

There is growing awareness that the built environment and transportation affect many aspects of individual and community well-being and health. Built environment and transportation planning and decision-making, however, rarely integrate robust engagement and input from youth, particularly racially/ethnically and economically diverse youth, despite the likelihood that such planning and decisions will affect their futures. Strategies are needed that prepare, engage, and ultimately empower youth in changing systems, processes, and programs that promote equitable mobility access and opportunity for youth now and in these futures. This article describes the development, implementation, actions, and impact of the Youth for Equitable Streets (YES) Fellowship program, through the perspective of the program participants, including the youth (the Fellows), program manager, and program evaluator, focusing on key factors for making this work youth-centered and oriented to successfully influence social change in transportation for mobility justice.

Use of the Nutrition Environment Measures Survey: A Systematic Review

INTRODUCTION

The Nutrition Environment Measurement Survey (NEMS) measures were developed to assess the consumer food environment in stores and restaurants. NEMS tools have been widely used in research and adapted for diverse settings and populations in the 15 years since they were created. This systematic review examines the use and adaptations of these measures and what can be learned from published studies using NEMS tools.

METHODS

A comprehensive search of bibliographic databases was conducted from 2007 to September 2021, supplemented by backward searches and communications with authors, to identify research articles using NEMS tools. Data on purpose, key findings, sample characteristics, NEMS characteristics, and modifications were abstracted. Articles were categorized on the basis of study goals, NEMS tool(s) used, variables measured, and common themes.

RESULTS

A total of 190 articles from 18 countries were identified. Most studies (69.5%, n=123) used a modified version of NEMS tools. There were 23 intervention studies that used measures from NEMS tools or adaptations as outcomes, moderators, or process assessments. A total of 41% (n=78) of the articles evaluated inter-rater reliability, and 17% (n=33) evaluated test-retest reliability.

DISCUSSION

NEMS measures have played an important role in the growth of research on food environments and have helped researchers to explore the relationships among healthy food availability, demographic variables, eating behaviors, health outcomes, and intervention-driven changes in food environments. The food environment is constantly changing, so NEMS measures should continue to evolve. Researchers should document data quality of modifications and use in new settings.

Associations of home and neighborhood environments with children's physical activity in the U.S.-based Neighborhood Impact on Kids (NIK) longitudinal cohort study

INTRODUCTION

Physical activity is important for children's health and well-being. Supportiveness for physical activity of home and neighborhood environments may affect children's PA, but most studies are cross-sectional. We examined environmental predictors of change in children's physical activity over two years.

METHODS

Data were from the longitudinal, observational cohort study, 'Neighborhood Impact on Kids'. Participants were children (initially aged 6-12 years) and their parent/caregiver (n = 727 dyads) living in neighborhoods throughout San Diego County, California and King County (Seattle area), Washington, USA. Children's moderate-to-vigorous physical activity (MVPA) was measured using accelerometers at T1 (Time 1 or baseline, 2007-2009) and T2, the two-year follow-up. At T1, parents survey-reported on physical activity (PA) equipment at home and demographics. Neighborhood environment was measured using spatial data in Geographic Information Systems (intersection density; park availability) and in-person audits (informal play space near home; park-based PA facilities; land use; support for walking/cycling). Generalized additive mixed models estimated total effects, then direct effects, of environmental attributes on MVPA at T1. Two-way moderating effects of child's sex and age were examined at T1. To examine associations of environmental exposures with changes in MVPA, we estimated interaction effects of environmental attributes on the association between time and MVPA.

RESULTS

On average, children accumulated 146 min/day (standard deviation or SD = 53) of MVPA at T1, and 113 (SD = 58) min/day at T2. There were no significant total or direct effects of environmental attributes on MVPA at T1, and no significant two-way interaction effects of child's age and sex for T1 MVPA. Having informal play spaces proximal to home with more amenities was associated with less MVPA decline from T1 to T2. Higher residential density, higher land use mix, and higher number of PA facilities in nearby parks were unexpectedly associated with greater MVPA decline.

CONCLUSION

Higher quality informal play spaces close to home may help offset declines in MVPA during middle childhood, as they may promote unstructured active play with opportunities for parental or neighbor surveillance. Unexpectedly, environmental factors consistent with higher walkability were associated with greater declines in children's MVPA. As physical activity differs across the lifespan, so may environmental factors that facilitate it.

The Availability and Price of Healthy Food in Seattle by Neighborhood Sociodemographic Characteristics

INTRODUCTION

Unequal access to healthy food in the local food retail environment contributes to diet quality disparities. We assessed whether in-store availability and prices of healthy foods differ by neighborhood-level income and racial and ethnic composition in a representative sample of food stores in Seattle, Washington.

METHODS

We developed and validated an in-store survey tool and surveyed 134 stores. We measured availability and prices of 19 items. For each store, we calculated a healthy food availability score (range, 0-25), and mean prices within each category. Using census tract data, we identified the median household income and proportions of Black and Hispanic residents for each store's neighborhood and grouped them by tertiles of these neighborhood characteristics across Seattle census tracts. We used Wald tests to compare mean availability scores and prices between tertiles and applied postestimation weights to reflect store-type distributions within each tertile.

RESULTS

Neighborhoods with lower income and a larger proportion of Black residents had lower healthy food availability scores compared with neighborhoods with higher income (8.06 [95% CI, 7.04-9.07] vs 12.40 [95% CI, 10.63-14.17], P < .001) and fewer Black residents (8.88 [95% CI, 7.79-9.98] vs 12.32 [95% CI, 10.51-14.14], P = .003). Availability did not differ by Hispanic population proportions. Mean prices of grains, eggs, and meat were lower in neighborhoods with larger proportions of Black residents.

CONCLUSION

We found systematic differences in healthy food availability based on neighborhood-level income and racial composition. In-store assessments of the food retail environment can inform local, tailored strategies to improve healthy food access.

Location-specific psychosocial and environmental correlates of physical activity and sedentary time in young adolescents: preliminary evidence for location-specific approaches from a cross-sectional observational study

BACKGROUND

A better understanding of the extent to which psychosocial and environmental correlates of physical activity are specific to locations would inform intervention optimization.

PURPOSE

To investigate cross-sectional associations of location-general and location-specific variables with physical activity and sedentary time in three common locations adolescents spend time.

METHODS

Adolescents (N = 472,Mage = 14.1,SD = 1.5) wore an accelerometer and global positioning systems (GPS) tracker and self-reported on psychosocial (e.g., self-efficacy) and environmental (e.g., equipment) factors relevant to physical activity and sedentary time. We categorized each survey item based on whether it was specific to a location to generate psychosocial and environmental indices that were location-general or specific to either school, non-school, or home location. Physical activity (MVPA) and sedentary time were based on time/location match to home, school, or all "other" locations. Mixed-effects models investigated the relation of each index with location-specific activity.

RESULTS

The location-general and non-school physical activity psychosocial indices were related to greater MVPA at school and "other" locations. The school physical activity environment index was related to greater MVPA and less sedentary time at school. The home activity environment index was related to greater MVPA at home. The non-school sedentary psychosocial index was related to less sedentary time at home. Interactions among indices revealed adolescents with low support on one index benefited (i.e., exhibited more optimal behavior) from high support on another index (e.g., higher scores on the location-general PA psychosocial index moderated lower scores on the home PA environment index). Concurrent high support on two indices did not provide additional benefit.

CONCLUSIONS

No psychosocial or environment indices, including location-general indices, were related to activity in all locations. Most of the location-specific indices were associated with activity in the matching location(s). These findings provide preliminary evidence that psychosocial and environmental correlates of activity are location specific. Future studies should further develop location-specific measures and evaluate these constructs and whether interventions may be optimized by targeting location-specific psychosocial and environmental variables across multiple locations.

Impaired Brain Satiety Responses After Weight Loss in Children With Obesity

CONTEXT

Obesity interventions often result in increased motivation to eat.

OBJECTIVE

We investigated relationships between obesity outcomes and changes in brain activation by visual food cues and hormone levels in response to obesity intervention by family-based behavioral treatment (FBT).

METHODS

Neuroimaging and hormone assessments were conducted before and after 24-week FBT intervention in children with obesity (OB, n = 28), or children of healthy weight without intervention (HW, n = 17), all 9- to 11-year-old boys and girls. We evaluated meal-induced changes in neural activation to high- vs low-calorie food cues across appetite-processing brain regions and gut hormones.

RESULTS

Among children with OB who underwent FBT, greater declines of BMI z-score were associated with lesser reductions after the FBT intervention in meal-induced changes in neural activation to high- vs low-calorie food cues across appetite-processing brain regions (P < 0.05), and the slope of relationship was significantly different compared with children of HW. In children with OB, less reduction in brain responses to a meal from before to after FBT was associated with greater meal-induced reduction in ghrelin and increased meal-induced stimulation in peptide YY and glucagon-like peptide-1 (all P < 0.05).

CONCLUSION

In response to FBT, adaptations of central satiety responses and peripheral satiety-regulating hormones were noted. After weight loss, changes of peripheral hormone secretion support weight loss, but there was a weaker central satiety response. The findings suggest that even when peripheral satiety responses by gut hormones are intact, the central regulation of satiety is disturbed in children with OB who significantly improve their weight status during FBT, which could favor future weight regain.

Design and rationale for the supermarket and web-based intervention targeting nutrition (SuperWIN) for cardiovascular risk reduction trial

PURPOSE

The prevalence of chronic diseases is increasing largely due to suboptimal dietary habits. It is not known whether individualized, supermarket-based, nutrition education delivered by registered dietitians, utilizing the advantages of the in-store and online environments, and electronically collected purchasing data, can increase dietary quality.

METHODS AND RESULTS

The supermarket and web-based intervention targeting nutrition (SuperWIN) for cardiovascular risk reduction trial is a randomized, controlled dietary intervention study. Adults identified from a primary care network with 1 or more risk factors were randomized at their preferred store to: (1) standard of care plus individualized, point- of-purchase nutrition education; (2) standard of care plus individualized, point- of-purchase nutrition education enhanced with online shopping technologies and training; or (3) standard of care alone. Educational sessions within each store's clinic and aisles, emphasized the dietary approaches to stop hypertension (DASH) diet. The primary assessment was an intention-to-treat comparison on the effects of the dietary interventions on mean change in DASH score (90-point range) from baseline to 3 months (post-intervention). Additional outcomes included blood pressure, lipids, weight, purchasing behavior, food literacy, and intervention feedback. Between April 2019 to February 2021, 267 participants were randomized (20 excluded due to coronavirus disease pandemic). Median age was 58 years, 69% were female, 64% had a college degree, 53% worked full-time, 64% were obese, 73% were treated with blood pressure and 42% with cholesterol medications, and most had low-to-moderate diet quality.

CONCLUSION

The SuperWIN trial was designed to provide a rigorous evaluation of the efficacy of 2 novel, comprehensive, supermarket-based dietary intervention programs.

Evaluation of Seattle’s Sweetened Beverage Tax on Tax Support and Perceived Economic and Health Impacts

It is important to understand whether the publics’ attitudes towards sugary beverage taxes (SBT) change after tax implementation to ensure the long-term success of tax policies. Seattle’s SBT went into effect on January 1, 2018. We administered a mixed-mode survey to adults in Seattle and comparison areas, pre- and 2-years post-tax, to evaluate the impact of the SBT on 1) tax support and 2) perceived tax impacts (N = 2,933). Using a difference-in-differences approach, we employed adjusted income-stratified modified Poisson models to test the impacts of the tax on net changes in attitudes in Seattle versus the comparison areas, pre- to post-tax. Among lower-income individuals in Seattle, support for the tax increased by 14% (PR_DD: 1.14; 95% CI: 1.08, 1.21) and there was a 20% net-increase in the perception that the SBT would positively affect the economy (PR_DD: 1.20; 95% CI: 1.05, 1.39), compared to changes in the comparison areas. Among higher-income individuals in Seattle, support for the tax was not different (PR_DD: 0.93; 95% CI: 0.70, 1.22) pre- to post-tax, but there was a net-increase in the perception that the tax would have negative effects on small businesses (PR_DD: 1.44; 95% CI: 1.03, 2.00) and family finances (PR_DD: 1.86; 95% CI: 1.09, 3.19). After living with the tax for 2-years, support for the tax increased among lower-income individuals in Seattle. Tax support was high and unchanged among higher-income individuals, but overall attitudes became more negative. Policy makers should consider investing in ongoing campaigns that explain the benefits of SSB taxes and revenues.

Losing sleep by staying up late leads adolescents to consume more carbohydrates and a higher glycemic load

This study examined how short sleep impacts dietary consumption in adolescents by testing whether experimentally shortening sleep influences the amount, macronutrient content, food types, and timing of food consumed. Ninety-three adolescents completed a within-subjects crossover paradigm comparing five nights of short sleep (6.5-hour sleep opportunity) to five nights of Healthy Sleep (9.5-hour sleep opportunity). Within each condition, adolescents completed three multiple-pass dietary recalls that recorded the types, amount, and timing of food intake. The following outcomes were averaged across days of dietary recall within condition: kilocalories, grams of carbohydrates, fat, protein, and added sugars, glycemic load of foods, and servings of specific types of foods (low-calorie drinks, sweetened drinks, fruits/vegetables, meats/proteins, processed snacks, "fast food" entrees, grains, and sweets/desserts). Timing of consumption of kilocalorie and macronutrient outcomes were also examined across four noncumulative time bins: 06:00-10:59, 11:00-15:59, 16:00-20:59, and 21:00-01:00. Adolescents slept 2 h and 20 min longer in Healthy Sleep than in Short Sleep (p < .0001). While in Short Sleep, adolescents ate more grams of carbohydrates (p = .031) and added sugars (p = .047), foods higher in glycemic load (p = .013), and servings of sweet drinks (p = .023) and ate fewer servings of fruits/vegetables (p = .006) compared to Healthy Sleep. Differences in consumption of kilocalories, fat, and carbohydrates emerged after 9:00 pm (ps = .012, .043, .006, respectively). These experimental findings suggest that adolescents who have insufficient sleep exhibit dietary patterns that may increase the risk for negative weight and cardiometabolic outcomes. Future health promotion efforts should include promoting optimal sleep to increase healthy dietary habits.

Transit Use and Health Care Costs: A Cross-sectional Analysis

INTRODUCTION

Greater transit use is associated with higher levels of physical activity, which is associated with lower health risks and better health outcomes. However, there is scant evidence about whether health care costs differ based on level of transit ridership.

METHODS

A sample (n=947) of members of Kaiser Permanente in the Portland, Oregon area were surveyed in 2015 about their typical use of various modes of travel including transit. Electronic medical record-derived health care costs were obtained among these members for the prior three years. Analysis examined proportional costs between High transit users (3+ days/week), Low transit users (1-2 days/week), and Non-users adjusting for age and sex, and then individually (base models) and together for demographic and health status variables.

RESULTS

In separate base models across individual covariates, High transit users had lower total health care costs (59-69% of Non-user's costs) and medication costs (31-37% of Non-users' costs) than Non-users. Low transit users also had lower total health care (69%-76% of Non-users' costs) and medication costs (43-57% transit of Non-user's costs) than Non-users. High transit users' outpatient costs were also lower (77-82% of Non-users). In fully-adjusted models, total health care and medication costs were lower among High transit users' (67% and 39%) and Low transit users' (75% and 48%) compared to Non-users, but outpatient costs did not differ by transit use.

CONCLUSIONS

Findings have implications for the potential cost benefit of encouraging and supporting more transit use, although controlled longitudinal and experimental evidence is needed to confirm findings and understand mechanisms.

Causal evaluation of the health effects of light rail line: A Natural Experiment

BACKGROUND AND OBJECTIVE

No research to date has causally linked built environment data with health care costs derived from clinically assessed health outcomes within the framework of longitudinal intervention design. This study examined the impact of light rail transit (LRT) line intervention on health care costs after controlling for mode-specific objectively assessed moderateto-vigorous physical activity (MVPA), participant-level neighborhood environmental measures, demographics, attitudinal predispositions, and residential choices.

DATA AND METHODS

Based on a natural experiment related to a new LRT line in Portland - 282 individuals divided into treatment and control groups were prospectively followed during the pre- and post-intervention periods. For each individual, we harness high-resolution data on Electronic Medical Record (EMR) based health care costs, mode-specific MVPA, survey-based travel behavior, attitudinal/perception information, and objectively assessed built environment measures. Simulation-assisted longitudinal grouped random parameter models are developed to gain more accurate insights into the effects of LRT line intervention.

RESULTS

Regarding the "average effect" of the LRT line intervention, no statistically significant reductions in health care costs were observed for the treated individuals over time. However, substantial heterogeneity was observed not only in the magnitude of effects but its direction as well after controlling for the within- and between-individual variations. For a subgroup of treated individuals, the LRT line opening decreased health care costs over time relative to the control group. Further comparative analysis based on the findings of heterogeneity-based models revealed that the effect of LRT intervention for the treated individuals differed by individual characteristics, attitudes/perceptions, and neighborhood level environmental features.

CONCLUSIONS

The study revealed the presence of significant effect modifiers and distinct subgroup structures in the data related to the effects of LRT line intervention on health care costs. Severe implications of ignoring unobserved heterogeneity are highlighted. Limitations and potential avenues for future research are discussed.

General and Food-Specific Impulsivity and Inhibition Related to Weight Management

Background: Understanding child characteristics that relate to weight management treatment outcome could help identify opportunities for intervention innovation or tailoring. The limited evidence available is inconsistent regarding whether and which aspects of children's general or food-specific impulsivity and inhibition relate to treatment outcomes. Methods: Children with (n = 54) and without obesity (n = 22) were compared on various measures of impulsivity and inhibition. Children with obesity (n = 40) then completed family-based treatment for weight management. Analyses examined associations between baseline children's impulsivity and inhibition and child weight status change (BMI z-score) and between treatment-based changes in impulsivity and inhibition and weight status change, with and without adjustment by baseline functional magnetic resonance imaging-measured appetitive drive. Results: Children with obesity scored more poorly on some, but not all, measures of impulsivity and inhibition than children without obesity. Lower baseline general inhibition and greater parent-report of child impulsivity were associated (independently) with greater improvements in child weight status, with modest attenuation after appetite drive adjustment. Children improved task-based general inhibition during treatment. Improvements in general inhibition and snack food discounting were associated with better child weight outcomes, although adjusting for baseline values attenuated these associations. Conclusions: Children with obesity having greater initial impulsivity had better weight outcomes in treatment even after adjusting for initial appetitive drive. In contrast, improvements in task-based inhibition and food-related discounting during treatment were also related to better outcomes. Research is needed on innovative approaches to better address impulsivity and inhibition in children's weight management. Clinical Trial Registration number: NCT02484976.

Impacts of the Seattle Sweetened Beverage Tax on the Perceived Healthfulness of Sweetened Beverages

Sweetened beverage taxes are associated with significant reductions in the purchase of sweetened beverages. However, it is unclear whether these taxes play a role in shifting perceptions about sweetened beverages and their health impacts. We utilized pre- and post-tax survey data collected from residents in Seattle, WA, a city that implemented a sweetened beverage tax in 2018 and from residents in an untaxed comparison area. We used income-stratified difference-in-difference linear probability models to compare net changes in the perceived healthfulness of overall sweetened beverage consumption and of different types of sugary beverages over time and across income groups. We found significant increases in the percentage of Seattle respondents with lower incomes who agreed that sweetened beverage consumption raises the risk of diabetes (DD = 9 percentage points (pp) (95% CI: 5 pp, 13 pp); p = 0.002), heart disease (DD = 7 pp (95% CI: 2 pp, 12 pp); p = 0.017), and serious health problems (DD = 12 pp (95% CI: 5 pp, 19 pp); p = 0.009), above and beyond changes in the comparison area. The most prominent changes in perceived health impacts of sweetened beverages were found among lower-income Seattle respondents, while fewer changes were found among higher-income Seattle respondents. Future work could examine the relationship between exposure to pro-tax messaging and changes in consumer perceptions of sweetened beverages.

From the clinic to the community: Can health system data accurately estimate population obesity prevalence?

OBJECTIVE

Health system data were assessed for how well they can estimate obesity prevalence in census tracts.

METHODS

Clinical visit data were available from two large health systems (Kaiser Permanente Washington and University of Washington Medicine) in King County, Washington, as were census tract-level obesity prevalence estimates from the Behavioral Risk Factor Surveillance System (BRFSS). The health system data were geocoded to identify each patient's tract of residence, and the cross-sectional concordance between census tract-level obesity prevalence estimates computed from the two health systems in 2005 to 2006 and the concordance between University of Washington Medicine and BRFSS from 2012 to 2016 were assessed.

RESULTS

The spatial distribution of obesity was similar between the health systems (Spearman r = 0.63). The University of Washington Medicine estimates of rank order correlated well with BRFSS estimates (Spearman r = 0.85), though prevalence estimates from BRFSS were lower (mean obesity prevalence = 26% for University of Washington Medicine versus 20% for BRFSS, Wilcoxon rank sum test p < 0.001). Across all data sources, obesity was more prevalent in tracts with less educational attainment.

CONCLUSIONS

Health system clinical weight data can reliably replicate census tract-level spatial patterns in the ranking of obesity prevalence. Health system data may be an efficient resource for geographic obesity surveillance.

Walkability measures to predict the likelihood of walking in a place: A classification and regression tree analysis

Walkability is a popular and ubiquitous term at the intersection of urban planning and public health. As the number of potential walkability measures grows in the literature, there is a need to compare their relative importance for specific research objectives. This study demonstrates a classification and regression tree (CART) model to compare five familiar measures of walkability from the literature for their relative ability to predict whether or not walking occurs in a dataset of objectively measured locations. When analyzed together, the measures had moderate-to-high accuracy (87.8% agreement: 65.6% of true walking GPS-measured points classified as walking and 93.4% of non-walking points as non-walking). On its own, the most well-known composite measure, Walk Score, performed only slightly better than measures of the built environment composed of a single variable (transit ridership, employment density, and residential density).Thus there may be contexts where transparent and longitudinally available measures of urban form are worth a marginal tradeoff in prediction accuracy. This comparison of walkability measures using CART highlights the importance for public health and urban design researchers to think carefully about how and why particular walkability measures are used.

Racial and socioeconomic disparities in the efficacy of a family-based treatment programme for paediatric obesity

BACKGROUND

Family-based behavioural weight loss treatment (FBT) is an evidence-based intervention for paediatric overweight/obesity (OV/OB), but little research has examined the relative efficacy of FBT across socioeconomic status (SES), and racial groups.

METHOD

A total of 172 youth (7-11 years; 61.6% female; 70.1% White, 15.7% Black; child percent OV = 64.2 ± 25.2; 14.5% low-income) completed 4 months of FBT and 8 months of additional intervention (either active social facilitation-based weight management or an education control condition). Parents reported family income, social status (Barratt simplified measure of social status) and child race at baseline. Household income was dichotomized into < or >50% of the area median family income. Race was classified into White, Black or other/multi-race. Treatment efficacy was assessed by change in child % OV (BMI % above median BMI for age and sex) and change in child BMI % of 95th percentile (BMI % of the 95th percentile of weight for age and sex). Latent change score models examined differences in weight change between 0 and 4 months, 4 and 12 months and 0 and 12 months by income, social status and race.

RESULTS

Black children had, on average, less weight loss by 4 months compared to White children. Low-income was associated with less weight loss at 4 months when assessed independent of race. No differences by race, social status or income were detected from 4 to 12-months or from 0 to 12 months.

CONCLUSIONS

FBT is effective at producing child weight loss across different SES and racial groups, but more work is needed to understand observed differences in initial efficacy and optimize treatment across all groups.

When physical activity meets the physical environment: precision health insights from the intersection

BACKGROUND

The physical environment can facilitate or hinder physical activity. A challenge in promoting physical activity is ensuring that the physical environment is supportive and that these supports are appropriately tailored to the individual or group in question. Ideally, aspects of the environment that impact physical activity would be enhanced, but environmental changes take time, and identifying ways to provide more precision to physical activity recommendations might be helpful for specific individuals or groups. Therefore, moving beyond a "one size fits all" to a precision-based approach is critical.

MAIN BODY

To this end, we considered 4 critical aspects of the physical environment that influence physical activity (walkability, green space, traffic-related air pollution, and heat) and how these aspects could enhance our ability to precisely guide physical activity. Strategies to increase physical activity could include optimizing design of the built environment or mitigating of some of the environmental impediments to activity through personalized or population-wide interventions.

CONCLUSIONS

Although at present non-personalized approaches may be more widespread than those tailored to one person's physical environment, targeting intrinsic personal elements (e.g., medical conditions, sex, age, socioeconomic status) has interesting potential to enhance the likelihood and ability of individuals to participate in physical activity.

General and Eating Disorder Psychopathology in Relation to Short- and Long-Term Weight Change in Treatment-Seeking Children: A Latent Profile Analysis

BACKGROUND

Concurrent general psychopathology (GP) and eating disorder psychopathology (EDP) are commonly reported among youth with overweight/obesity and may impact weight change.

PURPOSE

We identified patterns of GP and EDP in children with overweight/obesity and examined the impact on weight change following family-based behavioral obesity treatment (FBT) and maintenance interventions.

METHODS

Children (N = 172) participated in 4 month FBT and subsequent 8 month weight maintenance interventions. GP and EDP were assessed prior to FBT (baseline). Child percentage overweight was assessed at baseline, post-FBT (4 months), and post-maintenance (12 months). Latent profile analysis identified patterns of baseline GP and EDP. Linear mixed-effects models examined if profiles predicted 4- and 12-month change in percentage overweight and if there were two-way and three-way interactions among these variables, adjusting for relevant covariates.

RESULTS

Results indicated a three-profile structure: lower GP and EDP (LOWER); subclinically elevated GP and EDP without loss of control (LOC; HIGHER); and subclinically elevated GP and EDP with LOC (HIGHER + LOC). Across profiles, children on average achieved clinically meaningful weight loss (i.e., ≥9 unit change in percentage overweight) from baseline to 4 month FBT and sustained these improvements at 12 month maintenance. There was no evidence that latent profiles were related to percentage overweight change from baseline to FBT (p > .05) or baseline to maintenance (p > .05). There was no evidence for two-way or three-way interactions (p > .05).

CONCLUSION

Concurrent GP and EDP do not portend differential short- or long-term weight change following FBT and maintenance. Future research is warranted on the durability of weight change among youth with GP and EDP.

TRIAL REGISTRATION

NCT00759746.

Testing a tailored weight management program for veterans with PTSD: The MOVE! + UP randomized controlled trial

Post-traumatic stress disorder (PTSD), prevalent among Veterans, increases risk for having a high Body Mass Index. Although the Veterans Health Administration (VHA) offers an evidence-based behavioral weight management program called MOVE!, participants with PTSD lose less weight than those without mental health conditions, despite comparable participation. PTSD symptoms can interfere with one's ability to be physically active and maintain a healthy diet, the key targets in weight management programs. We developed and piloted a behavioral weight management program called MOVE! + UP that targets PTSD-related weight loss barriers. MOVE! + UP includes 16 group sessions with training in evidence-based weight management strategies, coupled with Cognitive Behavior Therapy (CBT) skills to address PTSD-specific barriers. The 16 sessions also include 30-min community walks to address PTSD-related barriers that may impede exercise. Two individual dietician sessions are provided. This hybrid type 1 randomized controlled trial (RCT) will compare MOVE! + UP to standard care-MOVE!-among 164 Veterans with BMI ≥ 25 who are receiving care for PTSD. We will randomize participants to MOVE! + UP or standard care and will compare absolute post-baseline change in weight at 6 (primary outcome) and 12 (secondary outcome) months, and PTSD symptom severity at 6 and 12 months (secondary outcome). Exploratory analyses will compare the treatment conditions on treatment targets measured at 6 months (e.g., physical activity, eating behavior, social support). Finally, we will estimate intervention costs, and identify MOVE! + UP implementation barriers and facilitators. If effective, MOVE! + UP could be an efficient way to simultaneously address physical and mental health for Veterans with PTSD.

Dynamics of sleep, sedentary behavior, and moderate-to-vigorous physical activity on school versus nonschool days

STUDY OBJECTIVES

Studies examining time-use activity behaviors (sleep, sedentary behavior, and physical activity) on school days compared with nonschool days have examined these behaviors independently, ignoring their interrelated nature, limiting our ability to optimize the health benefits of these behaviors. This study examines the associations of school-day (vs. nonschool day) with time-use activity behaviors.

METHODS

Time series data (6,642 days) from Fitbits (Charge-2) were collected (n = 196, 53% female, 5-10 years). We used a variable-centered dynamic structural equation modeling approach to estimate day-to-day associations of time-use activity behaviors on school days for each child. We then used person-centered cluster analyses to group individuals based on these estimates.

RESULTS

Within-participant analysis showed that on school days (vs. nonschool days), children (1) slept less (β = -0.17, 95% CI = -0.21, -0.13), (2) were less sedentary (β = -0.05, 95% CI = -0.09, -0.02), and (3) had comparable moderate-to-vigorous physical activity (MVPA; β = -0.05, 95% CI = -0.11, 0.00). Between-participant analysis showed that, on school days, children with higher sleep carryover experienced greater decreases in sleep (β = 0.44, 95% CI = 0.08, 0.71), children with higher body mass index z-score decreased sedentary behavior more (β = -0.41, 95% CI = -0.64, -0.13), and children with lower MVPA increased MVPA more (β = -0.41, 95% CI -0.64, -0.13). Cluster analysis demonstrated four distinct patterns of connections between time-use activity behaviors and school (High Activity, Sleep Resilient, High Sedentary, and Dysregulated Sleep).

CONCLUSIONS

Using a combination of person-centered and more traditional variable-centered approaches, we identified patterns of interrelated behaviors that differed on school, and nonschool days. Findings can inform targeted intervention strategies tailored to children's specific behavior patterns.

Children with Severe Obesity in Family-Based Obesity Treatment Compared with Other Participants: Conclusions Depend on Metrics

OBJECTIVE

This study compares children with severe obesity and children with mild obesity/overweight participating in family-based obesity treatment (FBT) on change in (1) relative weight and adiposity and (2) psychosocial distress.

METHODS

Children 7 to 11 years old (N = 241) and their parents participated in 12 months of behavioral treatment (FBT + maintenance treatment) and completed anthropometric, adiposity, and psychosocial assessments (psychiatric disorder symptomology, quality of life). Severe obesity was defined as a baseline BMI ≥ 120% of the 95th percentile (N = 105).

RESULTS

At 12 months, 40% of children with baseline severe obesity no longer had severe obesity. Percent overweight and fat mass index measurements showed similar magnitudes of change among children with severe obesity and children with mild obesity/overweight, whereas BMI z score and percent body fat change was lower in the group with severe obesity. Youth with severe obesity were higher on some measures of psychosocial distress at baseline but generally experienced improvements similar to children with mild obesity/overweight.

CONCLUSIONS

FBT with maintenance treatment is beneficial for children with severe obesity and is recommended for use prior to more invasive treatments in severe pediatric obesity. Future studies should assess the necessity of additional treatment, as children with severe obesity still have high relative weights post intervention.

Physical Activity, Sedentary Time, and Diet as Mediators of the Association Between TV Time and BMI in Youth

PURPOSE

This study examined dietary indicators, sedentary time, and physical activity as potential mediators of the association between TV time and BMIz in youth.

DESIGN

Cross-sectional study in 2 independent samples of youth.

SETTING

Data collection occurred by mail and telephone for adolescents and either at home or in medical settings for children.

SAMPLE

928 youth ages 12-16 and 756 youth ages 6-12 and a parent.

MEASURES

TV time, snacking/eating while watching TV, and a 3-day dietary recall were assessed via child/parent report. Physical activity and sedentary time were assessed by accelerometer wear.

ANALYSIS

Direct and indirect associations (through 8 diet and activity variables) of TV time with BMIz were tested in boys and girls in each sample.

RESULTS

TV time had a positive association with BMIz in 6-12 year old boys and girls. Direct associations emerged between TV time and the diet/activity variables, and between diet/activity variables and BMIz. Snacking/eating while watching TV had a significant positive association with BMIz in younger boys and mediated the association between TV time and BMIz (β = .06, p = .019; 25% attenuation).

CONCLUSIONS

Snacking/eating while watching TV may be a possible reason TV time is consistently associated with obesity in youth. Targeting reductions in TV time and associated snacking could improve health impacts.

Perspectives of Caregivers on the Effects of Migration on the Nutrition, Health and Physical Activity of their Young Children: A Qualitative Study with Immigrant and Refugee Families

To explore perspectives on nutrition, health and physical activity among immigrant parents with young children before and after migration. We conducted focus groups in five languages (Arabic, Somali, Dari, Burmese and Nepali), then conducted a phenomenological analysis of the transcripts. Fifty caregivers participated; 42% spent time in a refugee camp. Within the domain Change in Environment, four themes emerged: (1) food access; (2) family experiences with weight and growth; (3) differences in physical activity and perceptions of safety; and (4) health care experience. Within the domain of Parenting Behaviors and Experiences, two themes emerged: (1) Sociocultural differences in early feeding behaviors and (2) concern about feeding behaviors. To support health outcomes for refugee and immigrant families with young children, key focus areas for programming would include access to fresh foods, safe places for physical activity, and feeding practices following a family history of food scarcity.

Associations of social cohesion and quality of life with objective and perceived built environments: a latent profile analysis among seniors

BACKGROUND

Healthy aging requires support from local built and social environments. Using latent profile analysis, this study captured the multidimensionality of the built environment and examined relations between objective and perceived built environment profiles, neighborhood social cohesion and quality of life among seniors.

METHODS

In total, 693 participants aged 66-97 were sampled from two US locales in 2005-2008 as part of the Senior Neighborhood Quality of Life Study (SNQLS). Perceived social cohesion and quality of life were assessed using validated surveys. Six objective (geographic information system (GIS)-based) and seven perceived built environment latent profiles generated in previous SNQLS publications were used for analyses. Mixed-effects models estimated social cohesion and quality of life separately as a function of the built environment profiles.

RESULTS

More walkable and destination-rich perceived built environment profiles were associated with higher social cohesion and quality of life. Objective built environment profiles were not associated with social cohesion and only positively associated with quality of life in only one locale (Baltimore/DC).

CONCLUSIONS

Latent profile analysis offered a comprehensive approach to assessing the built environment. Seniors who perceived their neighborhoods to be highly walkable and recreationally dense experienced higher neighborhood social cohesion and quality of life, which may set the stage for healthier aging.

Impact of a sweetened beverage tax on beverage prices in Seattle, WA

Seattle's Sweetened Beverage Tax is an excise tax of 1.75 cents per ounce on sugar-sweetened beverages and is one of the highest beverage taxes in the U.S. This study examined the impact of Seattle's tax on the prices of beverages. We conducted audits of 407 retail food stores and eating places (quick service restaurants and coffee shops) before and 6 months after the tax was implemented in Seattle and in a comparison area. Ordinary least squares difference-in-differences models with store fixed effects were used to estimate the effect of the tax on prices, stratified by beverage type and store type. In secondary analyses, we assessed the effect of the tax on the price of non-taxed beverages and foods. Results from the adjusted difference-in-differences models indicated the tax was associated with an average increase of 1.58 cents per ounce among Seattle retailers, representing 90 % of the price of the tax. By store type, price increases were highest in smaller grocery stores and drug stores. By beverage type, price increases were highest for energy beverages and soda and lowest for bottled coffee and juice drinks. Prices of some non-taxed beverages also increased while the prices of select healthy foods generally did not. The sweetened beverage tax in Seattle is higher than beverage taxes in most other cities, and nearly the full cost of the tax is being passed through to consumers for many beverage types and stores types.

Dietary Approaches to Stop Hypertension Dietary Intervention Improves Blood Pressure and Vascular Health in Youth With Elevated Blood Pressure

This randomized control trial assessed the post-intervention and 18-month follow-up effects of a 6-month dietary approaches to stop hypertension (DASH)-focused behavioral nutrition intervention, initiated in clinic with subsequent telephone and mail contact, on blood pressure (BP) and endothelial function in adolescents with elevated BP. Adolescents (n=159) 11 to 18 years of age with newly diagnosed elevated BP or stage 1 hypertension treated at a hospital-based clinic were randomized. DASH participants received a take-home manual plus 2 face-to-face counseling sessions at baseline and 3 months with a dietitian regarding the DASH diet, 6 monthly mailings, and 8 weekly and then 7 biweekly telephone calls focused on behavioral strategies to promote DASH adherence. Routine care participants received nutrition counseling with a dietitian consistent with pediatric guidelines established by the National High Blood Pressure Education Program. Outcomes, measured pre- and post-intervention and at 18-months follow-up, included change in BP, change in brachial artery flow-mediated dilation, and change in DASH score based on 3-day diet recalls. Adolescents in DASH versus routine care had a greater improvement in systolic BP (-2.7 mm Hg, P= 0.03, -0.3 z-score, P=0.03), flow-mediated dilation (2.5%, P=0.05), and DASH score (13.3 points, P<0.0001) from baseline to post-treatment and a greater improvement in flow-mediated dilation (3.1%, P=0.03) and DASH score (7.4 points, P=0.01) to 18 months. The DASH intervention proved more effective than routine care in initial systolic BP improvement and longer term improvement in endothelial function and diet quality in adolescents with elevated BP and hypertension. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00585832.

Differences in adolescent activity and dietary behaviors across home, school, and other locations warrant location-specific intervention approaches

BACKGROUND

Investigation of physical activity and dietary behaviors across locations can inform "setting-specific" health behavior interventions and improve understanding of contextual vulnerabilities to poor health. This study examined how physical activity, sedentary time, and dietary behaviors differed across home, school, and other locations in young adolescents.

METHODS

Participants were adolescents aged 12-16 years from the Baltimore-Washington, DC and the Seattle areas from a larger cross-sectional study. Participants (n = 472) wore an accelerometer and Global Positioning Systems (GPS) tracker (Mean days = 5.12, SD = 1.62) to collect location-based physical activity and sedentary data. Participants (n = 789) completed 24-h dietary recalls to assess dietary behaviors and eating locations. Spatial analyses were performed to classify daily physical activity, sedentary time patterns, and dietary behaviors by location, categorized as home, school, and "other" locations.

RESULTS

Adolescents were least physically active at home (2.5 min/hour of wear time) and school (2.9 min/hour of wear time) compared to "other" locations (5.9 min/hour of wear time). Participants spent a slightly greater proportion of wear time in sedentary time when at school (41 min/hour of wear time) than at home (39 min/hour of wear time), and time in bouts lasting ≥30 min (10 min/hour of wear time) and mean sedentary bout duration (5 min) were highest at school. About 61% of daily energy intake occurred at home, 25% at school, and 14% at "other" locations. Proportionately to energy intake, daily added sugar intake (5 g/100 kcal), fruits and vegetables (0.16 servings/100 kcal), high calorie beverages (0.09 beverages/100 kcal), whole grains (0.04 servings/100 kcal), grams of fiber (0.65 g/100 kcal), and calories of fat (33 kcal/100 kcal) and saturated fat (12 kcal/100 kcal) consumed were nutritionally least favorable at "other" locations. Daily sweet and savory snacks consumed was highest at school (0.14 snacks/100 kcal).

CONCLUSIONS

Adolescents' health behaviors differed based on the location/environment they were in. Although dietary behaviors were generally more favorable in the home and school locations, physical activity was generally low and sedentary time was higher in these locations. Health behavior interventions that address the multiple locations in which adolescents spend time and use location-specific behavior change strategies should be explored to optimize health behaviors in each location.

Child neurobiology impacts success in family-based behavioral treatment for children with obesity

Background and Objectives:

Family-based behavioral treatment (FBT) is the recommended treatment for children with common obesity. However, there is a large variability in short- and long-term treatment response and mechanisms for unsuccessful treatment outcomes are not fully understood. In this study, we tested if brain response to visual food cues among children with obesity before treatment predicted weight or behavioral outcomes during a 6-mo. behavioral weight management program and/or long-term relative weight maintenance over a 1-year follow-up period.

Subjects and Methods:

Thirty-seven children with obesity (age 9–11y, 62% male) who entered active FBT (attended 2 or more sessions) and had outcome data. Brain activation was assessed at pre-treatment by functional magnetic resonance imaging across an a priori set of appetite-processing brain regions that included the ventral and dorsal striatum, medial orbitofrontal cortex, amygdala, substantia nigra/ventral tegmental area and insula in response to viewing food images before and after a standardized meal.

Results:

Children with more robust reductions in brain activation to high-calorie food cue images following a meal had greater declines in BMI z-score during FBT (r= 0.42; 95% CI: 0.09, 0.66; P=0.02) and greater improvements in Healthy Eating Index scores (r= −0.41; 95% CI: −0.67, −0.06; P=0.02). In whole-brain analyses, greater activation in the ventromedial prefrontal cortex, specifically by high-calorie food cues, was predictive of better treatment outcomes (whole-brain cluster corrected P=0.02). There were no significant predictors of relative weight maintenance and initial behavioral or hormonal measures did not predict FBT outcomes.

Conclusions:

Children’s brain responses to a meal prior to obesity treatment were related to treatment-based weight outcomes, suggesting that neurophysiologic factors and appetitive drive, more so than initial hormone status or behavioral characteristics, limit intervention success.

Assessing Parent Decisions About Child Participation in a Behavioral Health Intervention Study and Utility of Informed Consent Forms

IMPORTANCE

Obtaining informed consent is an important ethical obligation for clinical research participation that is imperfectly implemented. Research on improving consent processes often focuses on consent forms, but little is known about consent forms' influence on decision-making compared with other types of engagement.

OBJECTIVE

To evaluate whether parents decide whether to enroll their children in research before or after they receive the consent form.

DESIGN, SETTING, AND PARTICIPANTS

An online survey of 88 parents who enrolled or declined to enroll their child in a weight management intervention study between January 2, 2018, and June 24, 2019, was conducted; surveys were completed between February 2, 2018, and July 9, 2019. A 31-item survey asked about impressions of the study throughout the enrollment process, timing of enrollment decisions, and decision-making factors. Responses were summarized descriptively and subgroups were compared using the Fisher exact test or χ2 test.

MAIN OUTCOMES AND MEASURES

Self-reported timing of enrollment decision.

RESULTS

A total of 106 parents were approached and gave permission for their contact information to be shared with the study team; 22 additional parents declined to allow their information to be shared, and 24 lost contact with the partner study before they could be asked for permission. A total of 88 parents (67 enrollees, 21 decliners) completed the survey (83% participation rate); 79 of 88 reporting gender (instead of sex, as biological sex was not relevant to survey) information were women (91%), 66 participants (75%) were non-Hispanic White, and 63 participants (72%) had annual household incomes greater than or equal to $70 000. No significant differences in respondent characteristics between enrollees and decliners were identified. Fifty-nine parents (67%) responded that they decided whether to enroll in the weight management study before receiving the consent form. Only 17 of 69 parents (25%) who remembered receiving the consent form responded that it taught them new information.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that interventions to improve informed consent forms may have limited influence on decision-making because many research decisions occur before review of the consent form. It appears that regulatory review and interventions to improve decision-making should focus more on early engagement (eg, recruitment materials). Future studies should test timing of decisions in other types of research with different populations and clinical settings.

Residential neighborhood features associated with objectively measured walking near home: Revisiting walkability using the Automatic Context Measurement Tool (ACMT)

Many distinct characteristics of the social, natural, and built neighborhood environment have been included in walkability measures, and it is unclear which measures best describe the features of a place that support walking. We developed the Automatic Context Measurement Tool, which measures neighborhood environment characteristics from public data for any point location in the United States. We explored these characteristics in home neighborhood environments in relation to walking identified from integrated GPS, accelerometer, and travel log data from 681 residents of King Country, WA. Of 146 neighborhood characteristics, 92 (63%) were associated with walking bout counts after adjustment for individual characteristics and correction for false discovery. The strongest built environment predictor of walking bout count was housing unit count. Models using data-driven and a priori defined walkability measures exhibited similar fit statistics. Walkability measures consisting of different neighborhood characteristic measurements may capture the same underlying variation in neighborhood conditions.

Family Encouragement of Healthy Eating Predicts Child Dietary Intake and Weight Loss in Family-Based Behavioral Weight-Loss Treatment

Introduction: Social support for healthy eating can influence child eating behaviors; however, little is known about the impact of social support during family-based behavioral weight-loss treatment (FBT). This study aimed to determine the impacts of both baseline and change in family support on change in child diet and weight during FBT. Methods: Children (n = 175; BMI percentile ≥85th; ages 7-11; 61.1% female; 70.9% white) and a participating parent completed 4 months of FBT. Parents were active participants and learned social support-related strategies (i.e., praise and modeling of healthy eating). Child perceived family encouragement and discouragement for healthy eating, child diet quality (via 24-hour recalls), and child weight were assessed pre- and post-FBT. Results: Family encouragement for healthy eating increased during FBT, and this increase was related to increases in child healthy vegetable intake and overall diet quality, as well as decreases in refined grains consumed. Low pre-FBT family encouragement predicted greater increases in healthy vegetable intake, greater weight reduction, and greater increases in family encouragement for healthy eating. Family discouragement for healthy eating did not change during treatment nor did it predict dietary or weight outcomes. Conclusions: FBT successfully improves family encouragement, which is associated with improvements in child diet. Furthermore, even children who began treatment with low family encouragement for healthy eating show great improvements in dietary intake and weight during treatment. Results suggest that changes in child eating behavior during treatment is influenced by active, positive parenting techniques such as praise of healthy eating rather than negative family support.

Development of a Tailored Behavioral Weight Loss Program for Veterans With PTSD (MOVE!+UP): A Mixed-Methods Uncontrolled Iterative Pilot Study

PURPOSE

Veterans with post-traumatic stress disorder (PTSD) lose less weight in the Veterans Affairs (VA) weight management program (MOVE!), so we developed MOVE!+UP.

DESIGN

Single-arm pre-post pilot to iteratively develop MOVE!+UP (2015-2018).

SETTING

Veterans Affairs Medical Center.

PARTICIPANTS

Overweight Veterans with PTSD (5 cohorts of n = 5-11 [N = 44]; n = 39 received ≥1 MOVE+UP session, with cohorts 1-4 [n = 31] = "Development" and cohort 5 [n = 8] = "Final" MOVE!+UP).

INTERVENTION

MOVE!+UP weight management for Veterans with PTSD modified after each cohort. Final MOVE!+UP was coled by a licensed clinical psychologist and Veteran peer counselor in 16 two-hour in-person group sessions and 2 individual dietician visits. Sessions included general weight loss support (eg, behavioral monitoring with facilitator feedback, weekly weighing), cognitive-behavioral skills to address PTSD-specific barriers, and a 30-minute walk to a nearby park.

MEASURES

To inform post-cohort modifications, we assessed weight, PTSD, and treatment targets (eg, physical activity, diet), and conducted qualitative interviews.

ANALYSIS

Baseline to 16-week paired t tests and template analysis.

RESULTS

Development cohorts suggested improvements (eg, additional sessions and weight loss information, professional involvement) and did not lose weight (mean [M] = 1.8 lbs (standard deviation [SD] = 8.2); P = .29. Conversely, the final cohort reported high satisfaction and showed meaningful weight (M = -14 pounds [SD = 3.7] and 71% lost ≥5% baseline weight) and PTSD (M = -17.9 [SD = 12.2]) improvements, P < .05.

CONCLUSIONS

The comprehensive, 16-week, in-person, cofacilitated Final MOVE!+UP was acceptable and may improve the health of people with PTSD. Iterative development likely produced a patient-centered intervention, needing further testing.

Two Approaches to Increase Physical Activity for Preschool Children in Child Care Centers: A Matched-Pair Cluster-Randomized Trial

Early childhood education settings are critical for promoting physical activity (PA) but intervention effects are often small. The aim of this study was to develop, test, and compare two approaches to increasing physical activity among preschoolers at child care centers: one focused on a teacher-led PA curriculum (Active Play!) and the other on increasing outdoor child-initiated free play time (Outdoor Play!). We conducted a matched-pair cluster-randomized study in 10 centers in and around Seattle, WA, USA (n = 97 children, mean age 4.6). Pre- and post-intervention data were collected from observations and accelerometers. At pre-intervention, 19% of Active Play! and 25% of Outdoor Play! children achieved >120 min/day of PA during child care. The total opportunity for PA increased in both interventions (Active Play! = 11 min/day; Outdoor Play! = 14 min/day), with the largest increase in outdoor child-initiated free playtime (Active Play! = 19 min/day; Outdoor Play! = 24 min/day). No changes in sedentary time, light or moderate- to vigorous-intensity PA (MVPA) were observed in either intervention and there was no difference between interventions in the percentage of children attaining more than 120 min/day of PA. A small (<3 min/day) relative increase in teacher-led outdoor activity was observed in the Active Play! intervention. Both intervention strategies led to an increase in active play opportunities, predominantly outdoors, but neither was able to substantially increase the intensity and/or duration of children's PA. Future studies are needed to better understand and inform sustainable approaches to increase PA in early learning settings.

Beyond the bus stop: where transit users walk

OBJECTIVES

Extending the health benefits of public transit requires understanding how transit use affects pedestrian activity, including pedestrian activity not directly temporally or spatially related to transit use. In this study, we identified where transit users walked on transit days compared with non-transit days within and beyond 400m and 800m buffers surrounding their home and work addresses.

METHODS

We used data collected from 2008-2013 in King County, Washington, from 221 non-physically-disabled adult transit users, who were equipped with an accelerometer, global positioning system (GPS), and travel diary. We assigned walking activity to the following buffer locations: less than and at least 400m or 800m from home, work, or home/work (the home and work buffers comprised the latter buffer). We used Poisson generalized estimating equations to estimate differences in minutes per day of total walking and minutes per day of non-transit-related walking on transit days compared with non-transit days in each location.

RESULTS

We found that durations of total walking and non-transit-related walking were greater on transit days than on non-transit days in all locations studied. When considering the home neighborhood in isolation, most of the greater duration of walking occurred beyond the home neighborhood at both 400m and 800m; results were similar when considering the work neighborhood in isolation. When considering the neighborhoods jointly (i.e., by using the home/work buffer), at 400m, most of the greater duration of walking occurred beyond the home/work neighborhood. However, at 800m, most of the greater duration of walking occurred within the home/work neighborhood.

CONCLUSIONS

Transit days were associated with greater durations of total walking and non-transit related walking within and beyond the home and work neighborhoods. Accordingly, research, design, and policy strategies focused on transit use and pedestrian activity should consider locations outside the home and work neighborhoods, in addition to locations within them.

Factors associated with depression and anxiety symptoms among children seeking treatment for obesity: A social-ecological approach

BACKGROUND

Children with overweight/obesity are more likely to exhibit symptoms of depression and anxiety than are their peers without overweight/obesity; however, the rates and correlates of depression and anxiety symptoms among children seeking obesity treatment remain unclear.

OBJECTIVES

Examine the prevalence and associated factors of depression and anxiety symptoms among treatment-seeking children with overweight/obesity.

METHODS

Children 7 to 11 years old (N = 241) and their parents completed assessments before beginning family-based behavioral weight-loss treatment. Disorder-specific self-report questionnaires assessed child depression and anxiety. The social-ecological model served as a framework for examining factors associated with depression and anxiety symptoms.

RESULTS

Among our sample, 39.8% (96/241) met clinical cutoffs for depression and/or anxiety symptomatology. Specifically, of these 96, 48 met criteria for both depression and anxiety, 24 for depression only, and 24 for anxiety only. Child eating disorder pathology, parents' use of psychological control (ie, a parenting style characterized by emotional manipulation), and lower child subjective social status were significantly associated with greater child depression symptomatology. Child eating disorder pathology and parent psychological control were significantly associated with greater child anxiety symptomatology.

CONCLUSION

Nearly 40% of children exhibited psychopathology symptoms, and a variety of correlates were found. Thus, pediatric weight-loss providers may consider screening for and addressing mental health concerns (and associated factors) prior to and during treatment.

Perceptions of the possible health and economic impacts of Seattle's sugary beverage tax

BACKGROUND

Taxes on sugary beverages are an emerging strategy to improve health by reducing consumption and raising revenues to support community wellbeing. However, taxes may have unintended consequences, and perceptions of these consequences may affect attitudes towards this policy.

METHODS

In June 2017, the Seattle City Council passed an ordinance imposing a tax on sugary beverages, effective January 1, 2018. Between October and December 2017, we recruited 851 adults in Seattle to complete a survey (telephone or online) about support for the tax and their perceptions of tax-related health and economic impacts. We first analyzed data for the full sample. We then tested for differences in participants' responses by household income level (< 260% Federal Poverty Level [FPL], ≥ 260% FPL) and across race/ethnicities using chi-square tests. Analyses used population weights and adjusted for multiple comparisons, using the Holm-Bonferroni Sequential Correction (p < 0.01).

RESULTS

A majority of participants supported the sugary beverage tax (59%; 95% Confidence Interval [CI]: 55, 63%) and believed that the tax would improve public health (56%; CI: 52, 60%). Most participants believed that the tax would not negatively affect small businesses (52%; CI: 48, 56%) nor result in job loss (66%; CI: 62, 70%). Most participants also perceived that the tax would not negatively impact their own finances (79%; CI: 75, 82%). However, fewer lower-income (48%; CI: 42, 53%), versus higher-income participants (61%; CI: 55, 66%), perceived that the tax would improve public health, would not result in job loss (lower-income: 58%; CI: 53, 64%; higher-income: 71%; CI: 66, 75%) and would not negatively affect their own finances (lower-income: 68%; CI: 62, 73%; higher-income: 85%; CI: 81, 88%). Compared to non-Hispanic Whites, (82%; CI: 79, 86%), a smaller proportion of non-Hispanic Blacks (63%; 95% CI: 48, 75%), and Hispanics (67%; 95% CI: 51, 79%), perceived that the tax would have negative consequences for their own family finances.

CONCLUSIONS

A majority of respondents supported the sugary beverage tax in Seattle. Lower-income participants were more concerned about potential financial consequences. Further evaluation of the extent to which unintended consequences occur is needed.

Child and parent reports of children's depressive symptoms in relation to children's weight loss response in family-based obesity treatment

BACKGROUND

Studies of the association between children's depressive symptoms and obesity treatment response show mixed results. Different measurement may contribute to the inconsistent findings, as children's depressive symptoms are often based on parent-report about their child rather than child self-report.

OBJECTIVES

We assessed both child- and parent-report of child depressive symptoms as predictors of children's obesity treatment response.

METHODS

Children with overweight/obesity (body mass index [BMI] ≥ 85th percentile; N = 181) and their parents reported on children's depressive symptoms prior to family-based behavioral weight loss treatment.

RESULTS

Child percent overweight reduction from baseline to post-treatment was not predicted by child self-reported depressive symptoms or parent-report of child symptoms (P > 0.80), but was significantly predicted by the interaction between child self-report and parent-report on child (β = 0.14, P = 0.05). In analyses using clinical cutoffs, amongst children with high self-reported symptoms, those whose parents reported low child depressive symptoms had greater reduction in percent overweight (t = 2.67, P = 0.008), whereas amongst children with low self-reported symptoms, parent ratings were not associated with treatment outcome.

CONCLUSIONS

Including both child self-report and parent-report of child depressive symptoms may inform obesity care. Research is needed to examine differences amongst child and parent depressive symptom reports and strategies to address symptoms and optimize pediatric obesity treatment.

Central Nervous System and Peripheral Hormone Responses to a Meal in Children

CONTEXT

Behavioral studies suggest that responses to food consumption are altered in children with obesity (OB).

OBJECTIVE

To test central nervous system and peripheral hormone response by functional MRI and satiety-regulating hormone levels before and after a meal.

DESIGN AND SETTING

Cross-sectional study comparing children with OB and children of healthy weight (HW) recruited from across the Puget Sound region of Washington.

PARTICIPANTS

Children (9 to 11 years old; OB, n = 54; HW, n = 22), matched for age and sex.

INTERVENTION AND OUTCOME MEASURES

Neural activation to images of high- and low-calorie food and objects was evaluated across a set of a priori appetite-processing regions that included the ventral and dorsal striatum, amygdala, substantia nigra/ventral tegmental area, insula, and medial orbitofrontal cortex. Premeal and postmeal hormones (insulin, peptide YY, glucagon-like peptide-1, active ghrelin) were measured.

RESULTS

In response to a meal, average brain activation by high-calorie food cues vs objects in a priori regions was reduced after meals in children of HW (Z = -3.5, P < 0.0001), but not in children with OB (z = 0.28, P = 0.78) despite appropriate meal responses by gut hormones. Although premeal average brain activation by high-calorie food cues was lower in children with OB vs children of HW, postmeal activation was higher in children with OB (Z = -2.1, P = 0.04 and Z = 2.3, P = 0.02, respectively). An attenuated central response to a meal was associated with greater degree of insulin resistance.

CONCLUSIONS

Our data suggest that children with OB exhibit an attenuated central, as opposed to gut hormone, response to a meal, which may predispose them to overconsumption of food or difficulty with weight loss.

Higher residential and employment densities are associated with more objectively measured walking in the home neighborhood

Understanding where people walk and how the built environment influences walking is a priority in active living research. Most previous studies were limited by self-reported data on walking. In the present study, walking bouts were determined by integrating one week of accelerometry, GPS, and a travel log data among 675 adult participants in the baseline sample of the Travel Assessment and Community study. Home neighborhood was defined as being within 0.5 mi of each participants' residence (a 10-minute walk), with home neighborhood walking defined as walking bout lines with at least one GPS point within the home neighborhood. Home neighborhood walkability was constructed with seven built environment variables derived from spatially continuous objective values (SmartMaps). A Zero Inflated Negative Binomial (ZINB) served to estimate associations between home neighborhood environment characteristics and home neighborhood walking frequency. Higher residential density and job density were the two neighborhood walkability measures related to higher likelihood and more time walking in the home neighborhood, highest tertile residential density (22.44 - 62.63 unit/acre) (coefficient=1.434; 95th CI of 1.003, 2.049) and highest tertile job density (12.4 - 272.3 jobs/acre) (coefficient=1.616; 95th CI of 1.102, 2.370). The large proportion of walking that takes place in the home neighborhood highlights the importance of continuing to examine the impact of the home neighborhood environment on walking. Potential interventions to increase walking behavior may benefit from increasing residential and employment density within residential areas.

Home and neighbourhood built environment features in family-based treatment for childhood obesity

BACKGROUND

Family-based behavioural weight loss treatment (FBT) for childhood obesity helps families develop strategies to facilitate healthy choices in their home and other environments (e.g. home neighbourhood). The current study examines how the home food environment, both pre-FBT and post-FBT, and the neighbourhoods in which families live are associated with child weight and weight-related outcomes in FBT.

METHODS

Parent-child dyads (n = 181) completed a 16-session FBT programme and completed home environment, anthropometric and child dietary/activity assessments at pre-FBT and post-FBT. Parents reported on availability of food, electronics and physical activity equipment in the home. The neighbourhood food and recreation environments around each dyad's residence was characterized using existing data within a geographic information system.

RESULTS

Families successfully made healthy home environment modifications during FBT. Regression models showed reducing RED (e.g. high-energy-dense and low-nutrient-dense) foods and electronics in the home during FBT had positive effects on child weight and weight-related outcomes. No neighbourhood food or recreation environment variables were significantly related to outcomes, although having a larger density of public recreation spaces was associated with increases in physical activity at the trend-level.

CONCLUSIONS

Modifying the home environment, specifically reducing RED foods and electronics, may be particularly important for FBT success.

Assessment of Parents' Preferences for Incentives to Promote Engagement in Family-Based Childhood Obesity Treatment

Importance

Family-based treatment (FBT) is recommended for childhood obesity, but even when sought, attrition is high. Extrinsic incentives, which have been effective for improving adult health, could improve FBT engagement.

Objective

To assess parents' preferences for FBT incentives.

Design, Setting, and Participants

Survey study of parents of children aged 6 to 17 years with obesity (body mass index in ≥95th percentile for age and sex). Parents' preferences for FBT incentive program attributes were assessed in a discrete choice experiment conducted using a nationally representative, web-based survey in March 2018. Attributes included (1) the monetary value of the incentive, (2) the payment structure, (3) the goal being incentivized, and (4) the person(s) being incentivized. A fractional factorial design was used to create a set of profiles representing hypothetical FBT incentives. Parents were presented with 10 pairs of profiles and asked which would most motivate them in FBT. Parents were also asked about preferences between a small, guaranteed incentive and a lottery for a large incentive. Analyses used a hierarchical Bayesian model and linear regressions.

Main Outcomes and Measures

Parents' preference for different incentive program attributes and levels.

Results

The nationally representative survey had a 41.4% eligibility rate (n = 339) and a 89.7% completion rate (n = 304). A total of 53.3% of respondents (weighted percentage) were non-Hispanic white, 42.6% had an annual household income less than $50 000, and 28.3% had a bachelor's degree. Parents preferred higher incentives, although they were willing to accept lower-value incentives if both the parent and the child (vs the child alone) were required to meet the goal (mean difference [MD], -$108; 95% CI, -$132 to -$84), if the incentive used a gain-framed vs loss-framed payment structure (MD, -$72; 95% CI, -$85 to -$59), and if physical activity goals were incentivized over weight loss (MD, -$63; 95% CI, -$82 to -$44) or dietary monitoring (MD, -$5; 95% CI, -$1 to $28). Only 20.6% of parents preferred a lottery over a guaranteed payment. Preferences did not vary among demographic or health subgroups.

Conclusions and Relevance

In this study, parent-stated preferences did not align with FBT best practices or behavioral economic theory. A randomized clinical trial could examine whether aligning incentives with preferences or best practices would maximize FBT engagement and behavior change.