Reaching the Healthy People Goals for Reducing Childhood Obesity: Closing the Energy Gap

doi:10.1016/j.amepre.2012.01.018

American Journal of Preventive Medicine

Volume 42, Issue 5, May 2012, Pages 437-444

https://doi.org/10.1016/j.amepre.2012.01.018 Get rights and content

Background

The federal government has set measurable goals for reducing childhood obesity to 5% by 2010 (Healthy People 2010), and 10% lower than 2005–2008 levels by 2020 (Healthy People 2020). However, population-level estimates of the changes in daily energy balance needed to reach these goals are lacking.

Purpose

To estimate needed per capita reductions in youths' daily “energy gap” (calories consumed over calories expended) to achieve Healthy People goals by 2020.

Methods

Analyses were conducted in 2010 to fit multivariate models using National Health and Nutrition Examination Surveys 1971–2008 (N=46,164) to extrapolate past trends in obesity prevalence, weight, and BMI among youth aged 2–19 years. Differences in average daily energy requirements between the extrapolated 2020 levels and Healthy People scenarios were estimated.

Results

During 1971–2008, mean BMI and weight among U.S. youth increased by 0.55 kg/m² and by 1.54 kg per decade, respectively. Extrapolating from these trends to 2020, the average weight among youth in 2020 would increase by ∼1.8 kg from 2007–2008 levels. Averting this increase will require an average reduction of 41 kcal/day in youth's daily energy gap. An additional reduction of 120 kcal/day and 23 kcal/day would be needed to reach Healthy People 2010 and Healthy People 2020 goals, respectively. Larger reductions are needed among adolescents and racial/ethnic minority youth.

Conclusions

Aggressive efforts are needed to reverse the positive energy imbalance underlying the childhood obesity epidemic. The energy-gap metric provides a useful tool for goal setting, intervention planning, and charting progress.

Introduction

Since the 1970s, the prevalence of obesity in the U.S. doubled among preschool children and adolescents, and more than tripled among children aged 6–11 years.¹ Based on the most recent data, one of every six U.S. children and adolescents aged 2–19 years are obese (defined as having a BMI ≥95th age- and gender-specific percentiles).2, 3 The prevalence of obesity is highest in lower-income populations and African-American and Hispanic populations.⁴

A landmark IOM report in 2006 indicated that childhood obesity prevention efforts remained too few, too small, and too fragmented⁵; it recommended setting benchmark goals to drive action plans and allocate resources.⁶ Changes in obesity prevalence remain the primary metric used to track national progress on reducing childhood obesity. Each decade, the DHHS released and monitored a list of health objectives to guide the nation's health promotion and disease prevention efforts. Along with several targets for better nutrition and more-active lifestyles, Healthy People 2010 set the goal of reducing the percentage of children and adolescents who are obese to 5%—the level observed in the early 1970s—by 2010.⁷

To meet this goal, numerous policy- and community-level initiatives have been launched to change one or both sides of the energy-balance equation for children and adolescents—by reducing calories consumed or increasing calories expended from physical activity. Despite evidence for recent stabilization,2, 4 it is clear that a 5% target was extremely ambitious (even for 2020). The new Healthy People 2020 goal, released in November 2010, set a more modest target of reducing the prevalence of obesity by 10% from 2005–2008 levels among youth aged 2–19 years—to bring overall prevalence down to 14.6% by 2020. Healthy People 2020 goals also specified age-specific childhood obesity targets: 9.6% among children aged 2–5 years, 15.7% among children aged 6–11 years, and 16.1% among adolescents aged 12–19 years.

These concrete Healthy People goals provide benchmarks for charting our progress in reversing the childhood obesity epidemic. However, what has been missing is a metric for linking these obesity prevalence targets to interventions with the potential to restore energy balance at the population level. The objective of this study is to propose a framework for estimating the sizes of daily per capita “energy gap” reductions (kcal/person/day) needed to reach both Healthy People 2010 and Healthy People 2020 prevalence targets by 2020. Estimates are developed by extrapolating annual changes in youth body weight and obesity prevalence observed during the period from 1971 to 2008 overall and among sociodemographic subgroups.

Section snippets

Data

Data on height and weight among U.S. children and adolescents aged 2–19 years were obtained from the following waves of National Health and Nutrition Examination Surveys (NHANES): 1971–1975 (N=7040); 1976–1980 (N=7351); 1988–1994 (N=10,793); and 1999–2008 (N=20,680 including 1999–2000, 2001–2002, 2003–2004, 2005–2006, 2007–2008, 2009–2010).8, 9, 10, 11 Each wave of NHANES is an unequal probability sample with a multistage, clustered, and stratified sampling design, to ensure that each sample

Secular Trends in Obesity and Average Weight

Appendix B (available online at www.ajpmonline.org) summarizes the sample size and prevalence of obesity across time periods covered by NHANES surveys. Controlling for age, gender, and race/ethnicity, there was a small increase in mean height during the past 30 years among U.S. youth (Table 1; +0.3 cm per decade, p-value for trend <0.01). In contrast to the small changes in average height, average body weights increased significantly by 1.54 kg (95% CI=1.34, 1.74 per decade), with larger

Discussion

Monitoring secular trends using long time series of nationally representative population data is an essential component of goal setting and policy planning.¹⁵ Using surveys from 1971 to 2008, the current paper describes the upward trends in obesity prevalence, body weight, BMI, and BMI z-scores among the U.S. pediatric population. Consistent with prior studies,¹⁶ since the early 1970s U.S. youth have increased their average BMI by 0.5 per decade and their average weight by 1.5 kg per decade. If

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Introduction of a conversation starter tool to improve health habits in young children
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Childhood overweight and obesity rates in the United States continue to climb. Providers must identify feasible interventions to improve health habits to prevent and treat obesity in children.
Parents (n = 91) of four-to eight-year-old children were recruited and surveyed regarding their child’s current health habits and perception of their child’s weight status. A conversation starter tool was developed and utilized to improve health habits in children ages four-to-eight over a period of four-to-six weeks.
Health habits in children improved in the comparison and intervention groups. There was a 42% improvement in health habits in the intervention group who chose a specific goal to work on compared to 30% improvement in the comparison group. There was no statistically significant relationship between health habit adherence and the assigned group when assessing the health habits individually.
Overall, 42% of the selected goals were met, according to parent report at the follow-up survey; however, use of the conversation starter tool did not demonstrate statistically significant improvement in health habits. Parental perception of children’s weight status remained unchanged. Health habits in children improved in the comparison and intervention groups. Further studies should enroll a larger sample to assess differences between these two groups.
The conversation starter tool was designed to be implemented into practice without the need for any specific training. The tool can be used on all children to promote improved health habits.
Longer Family Participation in WIC is Associated With Lower Childhood Sugar-Sweetened Beverage Intake
2022, Journal of Nutrition Education and Behavior
To evaluate if children of families with a longer duration of participation in the Special Supplementation Nutrition Program for Women, Infants, and Children (WIC) consume fewer sugar-sweetened beverages (SSB) and more water.
A repeated cross-sectional study.
Conducted among representative samples of WIC-participating families in Los Angeles County, California, in 2014, 2017, and 2020.
Children aged 4–59 months participating in WIC.
Daily servings of total SSBs, daily servings of specific types of SSBs, and daily servings of water.
Multivariable count regression models were used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI) for associations of the duration of family WIC participation with daily servings of total SSBs, water, and specific types of SSBs. Zero-inflated negative binomial regression models were used for total SSBs and specific types of SSBs, and Poisson regression was used for water.
Children of families with 2 years of WIC participation consumed significantly fewer daily servings of total SSBs (IRR, 0.95; 95% CI, 0.93–0.98; P = 0.002), fruit-flavored SSBs (IRR, 0.95; 95% CI, 0.91–0.99; P = 0.02), soda (IRR, 0.86; 95% CI, 0.76–0.98; P = 0.02), and water (IRR, 0.99; 95% CI, 0.98 to < 1.00; P = 0.03) than children of families with 1 year of WIC participation. Protective associations for total SSBs, fruit-flavored SSBs, and soda remained statistically significant and increased in magnitude through 10 years of family WIC participation.
Duration of WIC participation was associated with decreased SSB intake by young children. Given the role that increasing water intake in lieu of SSBs plays in child obesity, improving the effectiveness of WIC nutrition education on parental perceptions and provision of fruit-flavored SSBs and water to their children merits detailed evaluation.
Impact of slow versus rapid digesting carbohydrates on substrate oxidation in pre-pubertal children: A randomized crossover trial
2021, Clinical Nutrition
Consumption of rapid digesting sugars by children are under increased scrutiny because of their contribution to unhealthy weight gain. Previous studies in adults and children have suggested that altering the blend of carbohydrates (CHOs) consumed may cause shifts in substrate utilization. The purpose of this study was to examine the effects of consuming a slow digesting carbohydrate (SDC) and rapid digesting carbohydrate (RDC) on CHO and fat oxidation, glucose, and insulin responses at rest, during exercise, and post-exercise rest in pre-pubescent children.
A randomized, double-blind, crossover design was used. Nineteen pre-pubescent children (n = 10 boys, n = 9 girls, mean ± standard error, age = 9.84 ± 0.37-yrs) participated. Visits to the laboratory began with a 30-min measurement of resting metabolism followed by consumption of either an RDC or SDC drink. Postprandial resting metabolism was recorded for 60-min, immediately followed by 60-min of submaximal cycling exercise while metabolism was recorded, which was immediately followed by another 60-min recording of post-exercise metabolism. Total CHO and fat oxidation, endogenous and exogenous CHO oxidation, blood glucose, and insulin were assessed.
Total CHO oxidation rate (g∙min⁻¹) was greater after the RDC drink at 60 min (p = 0.032). Endogenous CHO oxidation rate (g∙min⁻¹) was greater after the SDC drink at 15 min (p ≤ 0.010). Cumulative endogenous CHO oxidation (g) was greater after the SDC drink at 45 min (p = 0.009). Endogenous CHO oxidation accounted for a greater proportion of substrate oxidation after the first 60-min rest period (p = 0.028), while exogenous CHO oxidation accounted for a greater proportion of substrate oxidation for the RDC at all time points (p ≤ 0.019).
The present study provides novel data suggesting that an SDC promotes greater endogenous substrate utilization in pre-pubertal children, which may have beneficial health impacts on energy intake and carbohydrate regulation/metabolism during growth and development.
NCT03185884, clinicaltrials.gov
Sugar-sweetened beverage (SSB) consumption is associated with lower quality of the non-SSB diet in US adolescents and young adults
2021, American Journal of Clinical Nutrition
Since 2003–4, the United States has seen large declines in sugar-sweetened beverage (SSB) intake overall, especially among non-Hispanic white (NHW) subpopulations. However, obesity prevalence has not shown comparable declines in the 2 highest SSB-consuming groups, adolescents and young adults. Little is understood about the quality of the diet excluding SSBs (non-SSB diet).
The objective of this study was to evaluate differences in non-SSB diet quality in SSB consumers and nonconsumers in adolescents and young adults and in the 3 major race/ethnic subgroups.
This study utilized data from the NHANES, a cross-sectional, nationally representative survey of the US population. Data from 6426 participants aged 12–29 y from the NHANES (2009–2014) was included. Quality of the non-SSB diet was measured using the 2015 Healthy Eating Index (HEI). Multivariate linear regressions controlled for sociodemographic characteristics and included interactions by race/ethnicity [NHWs, non-Hispanic blacks (NHBs), Hispanics]. Individuals were classified as non-, low- (<10% of daily calories), or high-SSB consumers (≥10% of daily calories), according to the US Dietary Guidelines added sugar intake recommendation.
Non-SSB HEI scores differed among SSB consumer groups (53 for adolescent nonconsumers compared with 46 for high consumers, P < 0.001; 57 for young adult nonconsumers compared with 45 for high consumers, P < 0.001), although all scores were low and require improvement. Among NHBs, significant differences in non-SSB HEI were found only between non- and low-SSB consumers. In Hispanics, associations varied by age group, with significant differences found for young adults but no association found for adolescents.
Low non-SSB HEI scores in SSB consumers suggest that reducing SSB consumption alone will not be a sufficient strategy for improving dietary quality in adolescents and young adults. Future policies must also consider improving the non-SSB diet.
BMI trajectories after primary school-based lifestyle intervention: Unravelling an uncertain future. A mixed methods study
2021, Preventive Medicine Reports
This mixed methods study aimed to examine plausible body mass index (BMI) trajectories after exposure to a primary school-based lifestyle intervention to aid in estimating the long-term intervention benefits.
BMI trajectories for children at control schools (mean 7.6 years of age) were modelled until 20 years of age through extrapolating trial evidence (N = 1647). A reference scenario assumed that the observed 2-year effects of the ‘Healthy Primary Schools of the Future’ (HPSF) and ‘Physical Activity Schools’ (PAS) were fully maintained over time. This was modelled by applying the observed 2-year BMI effects until 20 years of age.
Expert opinions on likely trends in effect maintenance after the 2-year intervention period were elicited qualitatively and quantitatively, and were used for developing alternative scenarios.
Expert elicitation revealed three scenarios: (a) a constant exposure-effect and an uncontrolled environment with effect decay scenario, (b) a household multiplier and an uncontrolled environment with effect decay scenario, and (c) a household multiplier and maintainer scenario. The relative effect of HPSF at 20 years of age was −0.21 kg/m² under the reference scenario, and varied from −0.04 kg/m² (a) to −0.06 kg/m² (b), and −0.50 kg/m² (c). For PAS, the relative effect was −0.17 kg/m² under the reference scenario, and varied from −0.04 kg/m² (a, b), to −0.21 kg/m² (c).
The mixed methods approach proved to be useful in modelling plausible BMI trajectories and specifying uncertainty on effect maintenance. Further observations until adulthood could reduce the uncertainty around future benefits. This trial was retrospectively registered at Clinicaltrials.gov (NCT02800616).
Utilizing a Board Game to Measure Family/Parenting Factors and Childhood Obesity Risk
2019, Journal of Nutrition Education and Behavior
Citation Excerpt :
For example, 2prior studies showed that parents used different feeding practices (eg, restriction, pressure to eat) between siblings28,32 and other studies showed that siblings have more similar eating behaviors and dietary intake compared with parents and children.30,33 Given the high prevalence of childhood obesity and the disparities by race/ethnicity and socioeconomic status, it is important to identify ways to improve the measurement of parent and child behaviors with regard to weight and weight-related behaviors.1–6 The improved accuracy of measures will likely allow modifiable factors to be identified in the home environment to target in reducing childhood obesity.
To describe a direct observational approach (ie, interactive family board game) to measure familyfunctioning and parenting behaviors of relevance to child weight and weight-related behaviors and to examine family functioning and parenting factors from multiple family dyads (eg, siblings, parent–child) and their associations with child weight and weight-related behaviors.
Cross-sectional, mixed-methods study.
Two home visits were conducted with families 10days apart with a 7-day observational period between home visits.
Children (n = 150) aged 5–7years and their families from 1 of 6 racial and ethnic or immigrant and refugee groups, including African American, Hispanic, Hmong, Native American, Somali, and white, participated in the Family Matters study between 2014 and 2016.
Child weight status and weight-related behaviors (ie, diet quality, physical activity).
Adjusted logistic and linear regression models with robust SEs were used in analysis.
Higher family functioning scores across the majority of family dyads were significantly associated with lower child weight status (P < .05). In addition, some family functioning scores were associated with child diet and physical activity, but not consistently. Parenting behavior scores were inconsistently associated with child weight and weight-related outcomes.
Results suggest that the interactive family board game task is a direct observational approach that researchers can use with family members to measure family functioning and parenting behaviors related to childhood obesity. Future interventions may want to consider including multiple family members in both measurement and intervention development to target childhood obesity.

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Research articleReaching the Healthy People Goals for Reducing Childhood Obesity: Closing the Energy Gap

Background

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Data

Secular Trends in Obesity and Average Weight

Discussion

Lancet

Lancet

Lancet

Prevalence and trends in overweight among U.S. children and adolescents, 1999–2000

JAMA

Prevalence of high body mass index in U.S. children and adolescents, 2007–2008

JAMA

CDC growth charts: U.S. Hyattsville MD: National Center for Health Statistics

High body mass index for age among U.S. children and adolescents, 2003–2006

JAMA

Committee on Prevention of Obesity in Children and YouthPreventing childhood obesity: health in the balance

Food and Nutrition BoardProgress in preventing childhood obesity: how do we measure up?

Healthy People 2010

A statistical methodology for analyzing data from a complex survey: the first National Health and Nutrition Examination Survey

Vital Health Stat 2

Plan and operation of the Second National Health and Nutrition Examination Survey, 1976-1980

Vital Health Stat 1

Plan and operation of the Third National Health and Nutrition Examination Survey

Vital Health Stat 1

National health and nutrition examination survey: questionnaires, datasets, and related documentation

Research article
Reaching the Healthy People Goals for Reducing Childhood Obesity: Closing the Energy Gap