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

INTRODUCTION

Amid the successes of local sugar-sweetened beverage (SSB) taxes, interest in state-wide policies has grown. This study evaluated the cost effectiveness of a hypothetical 2-cent-per-ounce excise tax in California and its implications for population health and health equity.

METHODS

Using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model, tax impacts on health, health equity, and cost effectiveness over 10 years in California were projected, both overall and stratified by race/ethnicity and income. Expanding on previous models, differences in the effect of intake of SSBs on weight by BMI category were incorporated. Costing was performed in 2020, and analyses were conducted in 2021-2022.

RESULTS

The tax is projected to save $4.55 billion in healthcare costs, prevent 266,000 obesity cases in 2032, and gain 114,000 quality-adjusted life years. Cost-effectiveness metrics, including cost/quality-adjusted life year gained, were cost saving. Spending on SSBs was projected to decrease by $33 per adult and $26 per child overall in the first year. Reductions in obesity prevalence for Black and Hispanic Californians were 1.8 times larger than for White Californians, and reductions for adults with lowest incomes (<130% Federal Poverty Level) were 1.4 times the reduction among those with highest incomes (>350% Federal Poverty Level). The tax is projected to save $112 in obesity-related healthcare costs per $1 invested.

CONCLUSIONS

A state-wide SSB tax in California would be cost saving, lead to reductions in obesity and improvement in SSB-related health equity, and lead to overall improvements in population health. The policy would generate more than $1.6 billion in state tax revenue annually that can also be used to improve health equity.

Cost Effectiveness of Calorie Labeling at Large Fast-Food Chains Across the U.S

INTRODUCTION

Calorie labeling of standard menu items has been implemented at large restaurant chains across the U.S. since 2018. The objective of this study was to evaluate the cost effectiveness of calorie labeling at large U.S. fast-food chains.

METHODS

This study evaluated the national implementation of calorie labeling at large fast-food chains from a modified societal perspective and projected its cost effectiveness over a 10-year period (2018-2027) using the Childhood Obesity Intervention Cost-Effectiveness Study microsimulation model. Using evidence from over 67 million fast-food restaurant transactions between 2015 and 2019, the impact of calorie labeling on calorie consumption and obesity incidence was projected. Benefits were estimated across all racial, ethnic, and income groups. Analyses were performed in 2022.

RESULTS

Calorie labeling is estimated to be cost saving; prevent 550,000 cases of obesity in 2027 alone (95% uncertainty interval=518,000; 586,000), including 41,500 (95% uncertainty interval=33,700; 50,800) cases of childhood obesity; and save $22.60 in healthcare costs for every $1 spent by society in implementation costs. Calorie labeling is also projected to prevent cases of obesity across all racial and ethnic groups (range between 126 and 185 cases per 100,000 people) and all income groups (range between 152 and 186 cases per 100,000 people).

CONCLUSIONS

Calorie labeling at large fast-food chains is estimated to be a cost-saving intervention to improve long-term population health. Calorie labeling is a low-cost intervention that is already implemented across the U.S. in large chain restaurants.

Cost-effectiveness of Improved WIC Food Package for Preventing Childhood Obesity

BACKGROUND AND OBJECTIVES

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) prevents food insecurity and supports nutrition for more than 3 million low-income young children. Our objectives were to determine the cost-effectiveness of changes to WIC's nutrition standards in 2009 for preventing obesity and to estimate impacts on socioeconomic and racial/ethnic inequities.

METHODS

We conducted a cost-effectiveness analysis to estimate impacts from 2010 through 2019 of the 2009 WIC food package change on obesity risk for children aged 2 to 4 years participating in WIC. Microsimulation models estimated the cases of obesity prevented in 2019 and costs per quality-adjusted-life year gained.

RESULTS

An estimated 14.0 million 2- to 4-year old US children (95% uncertainty interval (UI), 13.7-14.2 million) were reached by the updated WIC nutrition standards from 2010 through 2019. In 2019, an estimated 62 700 (95% UI, 53 900-71 100) cases of childhood obesity were prevented, entirely among children from households with low incomes, leading to improved health equity. The update was estimated to cost $10 600 per quality-adjusted-life year gained (95% UI, $9760-$11 700). If WIC had reached all eligible children, more than twice as many cases of childhood obesity would have been prevented.

CONCLUSIONS

Updates to WIC's nutrition standards for young children in 2009 were estimated to be highly cost-effective for preventing childhood obesity and contributed to reducing socioeconomic and racial/ethnic inequities in obesity prevalence. Improving nutrition policies for young children can be a sound public health investment; future research should explore how to improve access to them.

Use of Evidence-Based Interventions to Promote Healthy Weight, Nutrition, and Physical Activity in Community Health Improvement Plans from Large Local Health Departments

We sought to identify evidence-based healthy weight, nutrition, and physical activity strategies related to obesity prevention in large local health department (LHD) Community Health Improvement Plans (CHIPs). We analyzed the content of the most recent, publicly available plans from 72 accredited LHDs serving a population of at least 500 000 people. We matched CHIP strategies to the County Health Rankings and Roadmaps' What Works for Health (WWFH) database of interventions. We identified 739 strategies across 55 plans, 62.5% of which matched a "WWFH intervention" rated for effectiveness on diet and exercise outcomes. Among the 20 most commonly identified WWFH interventions in CHIPs, 10 had the highest evidence for effectiveness while 4 were rated as likely to decrease health disparities according to WWFH. Future prioritization of strategies by health agencies could focus on strategies with the strongest evidence for promoting healthy weight, nutrition, and physical activity outcomes and reducing health disparities.

The societal costs and health impacts on obesity of BMI report cards in US schools

OBJECTIVE

This study aimed to estimate the 10-year cost-effectiveness of school-based BMI report cards, a commonly implemented program for childhood obesity prevention in the US where student BMI is reported to parents/guardians by letter with nutrition and physical activity resources, for students in grades 3 to 7.

METHODS

A microsimulation model, using data inputs from evidence reviews on health impacts and costs, estimated: how many students would be reached if the 15 states currently measuring student BMI (but not reporting to parents/guardians) implemented BMI report cards from 2023 to 2032; how many cases of childhood obesity would be prevented; expected changes in childhood obesity prevalence; and costs to society.

RESULTS

BMI report cards were projected to reach 8.3 million children with overweight or obesity (95% uncertainty interval [UI]: 7.7-8.9 million) but were not projected to prevent any cases of childhood obesity or significantly decrease childhood obesity prevalence. Ten-year costs totaled $210 million (95% UI: $30.5-$408 million) or $3.33 per child per year with overweight or obesity (95% UI: $3.11-$3.68).

CONCLUSIONS

School-based BMI report cards are not cost-effective childhood obesity interventions. Deimplementation should be considered to free up resources for implementing effective programs.

Lead Concentrations in US School Drinking Water: Testing Programs, Prevalence, and Policy Opportunities, 2016‒2018

Objectives. To detail baseline drinking water sample lead concentrations and features of US state-level programs and policies to test school drinking water for lead in 7 states' operating programs between 2016 and 2018. Methods. We coded program and policy documents using structured content analysis protocols and analyzed state-provided data on lead concentration in drinking water samples collected in public schools during initial testing phases. Results. We analyzed data from 5688 public schools, representing 35% of eligible schools in 7 states. The number of samples per school varied. The proportion of schools identifying any sample lead concentration exceeding 5 parts per billion varied (13%-81%). Four states exceeded 20%. Other program features varied among states. Instances of lead above the state action level were identified in all states. Conclusions. In 2018, many US public school students attended schools in states without drinking water lead-testing programs. Testing all drinking water sources may be recommended. Public Health Implications. Initiating uniform school drinking water lead testing programs and surveillance over time could be used to reduce risk of lead exposure in drinking water. (Am J Public Health. 2022;112(S7):S679-S689. https://doi.org/10.2105/AJPH.2022.306961).

Limiting Television to Reduce Childhood Obesity: Cost-Effectiveness of Five Population Strategies

Objective: To quantify the potential population-wide costs, number of individuals reached, and impact on obesity of five effective interventions to reduce children's television viewing if implemented nationally. Study Design: Utilizing evidence from systematic reviews, the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES) microsimulation model estimated the cost, population reach, and impact on childhood obesity from 2020 to 2030 of five hypothetical policy strategies to reduce the negative impact of children's TV exposure: (1) eliminating the tax deductibility of food and beverage advertising; (2) targeting TV reduction during home visiting programs; (3) motivational interviewing to reduce home television time at Women, Infants, and Children (WIC) clinic visits; (4) adoption of a television-reduction curriculum in child care; and (5) limiting noneducational television in licensed child care settings. Results: Eliminating the tax deductibility of food advertising could reach the most children [106 million, 95% uncertainty interval (UI): 105-107 million], prevent the most cases of obesity (78,700, 95% UI: 30,200-130,000), and save more in health care costs than it costs to implement. Strategies targeting young children in child care and WIC also cost little to implement (between $0.19 and $32.73 per child reached), and, although reaching fewer children because of the restricted age range, were estimated to prevent between 25,500 (95% UI: 4600-59,300) and 35,400 (95% UI: 13,200-62,100) cases of obesity. Home visiting to reduce television viewing had high costs and a low reach. Conclusions: Interventions to reduce television exposure across a range of settings, if implemented widely, could help prevent childhood obesity in the population at relatively low cost.

A Theoretical Model of Transition to Practice for Athletic Trainers

CONTEXT

The transition to practice of newly credentialed athletic trainers (ATs) has become an area of focus in the athletic training literature. However, no theoretical model has been developed to describe the phenomenon and drive investigation.

OBJECTIVE

To better understand the lived experience of the transition to practice and develop a theoretical model of transition to practice for ATs.

DESIGN

Qualitative study.

SETTING

Telephone interviews.

PATIENTS OR OTHER PARTICIPANTS

Fourteen professional master's athletic training students (7 men, 7 women, age = 25.6 ± 3.7 years, from 9 higher education institutions) in the first year of clinical practice as newly credentialed ATs.

DATA COLLECTION AND ANALYSIS

Participants completed semistructured phone interviews at 3 timepoints over 12 to 15 months. The first interview was conducted just before graduation, the second 4 to 6 months later, and the third at 10 to 12 months. The interviews were transcribed and analyzed using a grounded theory approach.

RESULTS

We developed a theoretical model to explain the causal conditions that triggered transition, how the causal conditions were experienced, the coping strategies used to persist through the first year of practice, and the consequences of those strategies.

CONCLUSIONS

The model provides a framework for new athletic training clinicians, educators, and employers to better understand the transition process in order to help new clinicians respond by accepting or adapting to their environment or their behaviors.

Impact Of The Healthy, Hunger-Free Kids Act On Obesity Trends

The Healthy, Hunger-Free Kids Act of 2010 strengthened nutrition standards for meals and beverages provided through the National School Lunch, Breakfast, and Smart Snacks Programs, affecting fifty million children daily at 99,000 schools. The legislation's impact on childhood obesity is unknown. We tested whether the legislation was associated with reductions in child obesity risk over time using an interrupted time series design for 2003-18 among 173,013 youth in the National Survey of Children's Health. We found no significant association between the legislation and childhood obesity trends overall. For children in poverty, however, the risk of obesity declined substantially each year after the act's implementation, translating to a 47 percent reduction in obesity prevalence in 2018 from what would have been expected without the legislation. These results suggest that the Healthy, Hunger-Free Kids Act's science-based nutritional standards should be maintained to support healthy growth, especially among children living in poverty.

Projected U.S. State-Level Prevalence of Adult Obesity and Severe Obesity

BACKGROUND

Although the national obesity epidemic has been well documented, less is known about obesity at the U.S. state level. Current estimates are based on body measures reported by persons themselves that underestimate the prevalence of obesity, especially severe obesity.

METHODS

We developed methods to correct for self-reporting bias and to estimate state-specific and demographic subgroup-specific trends and projections of the prevalence of categories of body-mass index (BMI). BMI data reported by 6,264,226 adults (18 years of age or older) who participated in the Behavioral Risk Factor Surveillance System Survey (1993-1994 and 1999-2016) were obtained and corrected for quantile-specific self-reporting bias with the use of measured data from 57,131 adults who participated in the National Health and Nutrition Examination Survey. We fitted multinomial regressions for each state and subgroup to estimate the prevalence of four BMI categories from 1990 through 2030: underweight or normal weight (BMI [the weight in kilograms divided by the square of the height in meters], <25), overweight (25 to <30), moderate obesity (30 to <35), and severe obesity (≥35). We evaluated the accuracy of our approach using data from 1990 through 2010 to predict 2016 outcomes.

RESULTS

The findings from our approach suggest with high predictive accuracy that by 2030 nearly 1 in 2 adults will have obesity (48.9%; 95% confidence interval [CI], 47.7 to 50.1), and the prevalence will be higher than 50% in 29 states and not below 35% in any state. Nearly 1 in 4 adults is projected to have severe obesity by 2030 (24.2%; 95% CI, 22.9 to 25.5), and the prevalence will be higher than 25% in 25 states. We predict that, nationally, severe obesity is likely to become the most common BMI category among women (27.6%; 95% CI, 26.1 to 29.2), non-Hispanic black adults (31.7%; 95% CI, 29.9 to 33.4), and low-income adults (31.7%; 95% CI, 30.2 to 33.2).

CONCLUSIONS

Our analysis indicates that the prevalence of adult obesity and severe obesity will continue to increase nationwide, with large disparities across states and demographic subgroups. (Funded by the JPB Foundation.).

Cost-Effectiveness of Water Promotion Strategies in Schools for Preventing Childhood Obesity and Increasing Water Intake

OBJECTIVE

This study aimed to estimate the cost-effectiveness and impact on childhood obesity of installation of chilled water dispensers ("water jets") on school lunch lines and to compare water jets' cost, reach, and impact on water consumption with three additional strategies.

METHODS

The Childhood Obesity Intervention Cost Effectiveness Study(CHOICES) microsimulation model estimated the cost-effectiveness of water jets on US childhood obesity cases prevented in 2025. Also estimated were the cost, number of children reached, and impact on water consumption of the installation of water jets and three other strategies.

RESULTS

Installing water jets on school lunch lines was projected to reach 29.6 million children (95% uncertainty interval [UI]: 29.4 million-29.8 million), cost $4.25 (95% UI: $2.74-$5.69) per child, prevent 179,550 cases of childhood obesity in 2025 (95% UI: 101,970-257,870), and save $0.31 in health care costs per dollar invested (95% UI: $0.15-$0.55). In the secondary analysis, installing cup dispensers next to existing water fountains was the least costly but also had the lowest population reach.

CONCLUSIONS

Installating water jet dispensers on school lunch lines could also save almost half of the dollars needed for implementation via a reduction in obesity-related health care costs. School-based interventions to promote drinking water may be relatively inexpensive strategies for improving child health.

Assessing the effectiveness of training models for national scale-up of an evidence-based nutrition and physical activity intervention: a group randomized trial

BACKGROUND

There is a great need to identify implementation strategies to successfully scale-up public health interventions in order to achieve their intended population impact. The Out-of-school Nutrition and Physical Activity group-randomized trial previously demonstrated improvements in children's vigorous physical activity and the healthfulness of foods and beverages consumed. This implementation study aimed to assess the effects and costs of two training models to scale-up this evidence-based intervention.

METHODS

A 3-arm group-randomized trial was conducted to compare effectiveness of in-person and online training models for scaling up the intervention compared to controls. One-third of sites were randomized to the in-person train-the-trainer model: local YMCA facilitators attended a training session and then conducted three learning collaborative meetings and technical assistance. One-third were assigned to the online model, consisting of self-paced monthly learning modules, videos, quizzes, and facilitated discussion boards. Remaining sites served as controls. Fifty-three afterschool sites from three YMCA Associations in different regions of the country completed baseline and follow-up observations using a validated tool of afterschool nutrition and physical activity practices. We used multivariable regression models, accounting for clustering of observations, to assess intervention effects on an aggregate afterschool practice primary outcome, and conducted secondary analyses of nine intervention goals (e.g. serving water). Cost data were collected to determine the resources to implement each training model.

RESULTS

Changes in the primary outcome indicate that, on average, sites in the in-person arm achieved 0.44 additional goals compared to controls (95%CI 0.02, 0.86, p = 0.04). Increases in the number of additional goals achieved in sites in the online arm were not significantly greater than control sites (+ 0.28, 95% CI -0.18, 0.73, p = 0.24). Goal-specific improvements were observed for increasing water offered in the in-person arm and fruits and vegetables offered in the online arm. The cost per person trained was $678 for the in-person training model and $336 for the on-line training model.

CONCLUSIONS

This pilot trial presents promising findings on implementation strategies for scale-up. It validated the in-person training model as an effective approach. The less expensive online training may be a useful option for geographically disbursed sites where in-person training is challenging.

TRIAL REGISTRATION

Although this study does not report the results of a health care intervention on human subjects, it is a randomized trial and was therefore retrospectively registered in ClinicalTrials.gov on July 4, 2019 in accordance with the BMC guidelines to ensure the complete publication of all results (NCT04009304).

Effects of a before-school program on student physical activity levels

Many children are not sufficiently physically active. This study uses a quasi-experimental design to evaluate whether participation in a before-school physical activity program called Build Our Kids' Success (BOKS) increases physical activity. Participants (n = 426) were students in Fall, 2016 enrolled in BOKS programming and matched non-BOKS control students from the same grades (Kindergarten-6) and schools in Massachusetts and Rhode Island. Analyses conducted in 2017 examined differences between children in BOKS versus controls in total daily steps, minutes of moderate-to-vigorous (MVPA), vigorous (VPA), and total physical activity (TPA) assessed via Fitbit Charge HR™ monitors. Additional analyses compared physical activity on program days and non-program days. Students (mean age = 8.6 y; 47% female, 58% White, Non-Hispanic) wore monitors an average of 21.7 h/day on 3.2 days during the school week. Compared with controls, on BOKS days, BOKS participants accumulated more steps (1147, 95% confidence interval (CI): 583-1712, P < 0.001), MVPA minutes (13.4, 95% CI: 6.6-20.3, P < 0.001), and VPA minutes (4.0, 95% CI: 1.2-6.7, P = 0.005). Across all school days, BOKS participants accumulated more total steps than controls (716, 95% CI: 228-1204, P = 0.004). Compared to days without BOKS programming, on BOKS days, BOKS participants accumulated more steps (1153; 95% CI: 841-1464, P < 0.001) and daily minutes of MVPA (8.8, 95% CI: 5.3-12.2, P < 0.001), VPA (3.0, 95% CI: 1.6-4.5, P < 0.001), and TPA (20.8, 95% CI: 13.6-28.1, P < 0.001). BOKS programming promotes engagement in additional accumulated steps during the school week and physical activity on days that students participate. Clinical Trial Registration: www.ClinicalTrials.gov, NCT03403816, available at: https://clinicaltrials.gov/ct2/show/NCT03403816?term=NCT03403816&rank=1.

Driven to Support: Individual- and County-Level Factors Associated With Public Support for Active Transportation Policies

PURPOSE

To assess predictors of stated support for policies promoting physically active transportation.

DESIGN

Cross-sectional.

SETTING

US counties selected on county-level physical activity and obesity health status.

PARTICIPANTS

Participants completing random-digit dialed telephone survey (n = 906).

MEASURES

Survey measures assessed stated support for 5 policies to promote physically active transportation, access to active transportation facilities, and time spent in a car. County-level estimates included household car dependence and funding for bicycle-pedestrian projects.

ANALYSIS

Multivariable generalized linear mixed models using binary distribution and logit link, accounting for clustering within county.

RESULTS

Respondents supported policies for accommodating bicyclists and pedestrians through street improvements (89%), school active transportation programs (75%), employer-funded active commuting incentives (67%), and allocation of public funding (68%) and tax support (56%) for building and maintaining public transit. Residents spending >2 h/d (vs <0.7 hours) in cars were more likely to support street (odds ratio [OR]: 1.87; confidence interval [CI]: 1.09-3.22) and public transit (OR: 1.85; CI: 1.24-2.77) improvements. Residents in counties investing >$1.6 million in bicycle and pedestrian improvements expressed greater support for funding (OR: 1.71; CI: 1.04-2.83) and tax increases (OR: 1.73; CI: 1.08-2.75) for transit improvements compared to those with lower prior investments (<$276 100).

CONCLUSION

Support for policies to enable active transportation is higher where relevant investments in active transportation infrastructure are large (>$1.6 M), public transit is nearby, and respondents drive >2 h/d.

Gaining Access to Providing Medical Care to Male Sport Teams: The Female Athletic Trainer Perspective

CONTEXT

  Female athletic trainers (ATs) can face barriers to employment within the profession. Although there is evidence for an increasing percentage of women in athletic training, the portion providing medical care to male sport teams within the professional sport and collegiate settings continues to be small.

OBJECTIVE

  To investigate the experiences of female ATs when seeking employment with male sport teams within the Division I setting.

DESIGN

  Qualitative study.

SETTING

  National Collegiate Athletic Association (NCAA) Division I.

PATIENTS OR OTHER PARTICIPANTS

  A total of 15 NCAA Division I female ATs providing medical care to a male sport team participated in our study. Their mean age was 33 ± 9 years, and they had a mean of 11 ± 9 years of overall clinical experience.

DATA COLLECTION AND ANALYSIS

  All participants completed one-on-one phone interviews, which were recorded and transcribed. Analysis of the data followed thematic analysis using a phenomenologic approach. Credibility was established through credibility checks, peer review, and researcher triangulation.

RESULTS

  Factors that played a role in women gaining employment with male sport teams were (1) preexisting professional relationships, (2) prior experience with a male sport, and (3) perseverance. Participants in our study were most attracted to their current positions because of (1) the environment of the collegiate setting and (2) the location of the university.

CONCLUSIONS

  Job access for female ATs in this study was not viewed as a challenge. Familiarity through previous connections with the university and staff and commitment to career goals helped these women obtain the positions they held. The desire to work in male sports was not a primary contributing factor to the decision-making process. Progress continues for women in athletic training, as evidenced by the reported ease of job access with male sport teams.

Clinical effectiveness of the massachusetts childhood obesity research demonstration initiative among low-income children

OBJECTIVE

To examine the extent to which a clinical intervention resulted in reduced BMI z scores among 2- to 12-year-old children compared to routine practice (treatment as usual [TAU]).

METHODS

The Massachusetts Childhood Obesity Research Demonstration (MA-CORD) project is a multifaceted initiative to prevent childhood obesity among low-income children. At the federally qualified community health centers (FQHCs) of two communities (Intervention Site #1 and #2), the following were implemented: (1) pediatric weight management training, (2) electronic decision supports for clinicians, (3) on-site Healthy Weight Clinics, (4) community health worker integration, and (5) healthful clinical environment changes. One FQHC in a demographically matched community served as the TAU site. Using electronic health records, we assessed BMI z scores and used linear mixed models to examine BMI z score change over 2 years in each intervention site compared to a TAU site.

RESULTS

Compared to children in the TAU site (n = 2,286), children in Intervention Site #2 (n = 1,368) had a significant decline in BMI z scores following the start of the intervention (-0.16 units/y; 95% confidence interval: -0.21 to -0.12). No evidence of an effect was found in Intervention Site #1 (n = 111).

CONCLUSIONS

The MA-CORD clinical interventions were associated with modest improvement in BMI z scores in one of two intervention communities compared to a TAU community.

Student obesity prevalence and behavioral outcomes for the massachusetts childhood obesity research demonstration project

OBJECTIVE

To examine changes in prevalence of obesity and target health behaviors (fruit, vegetable, and beverage consumption; physical activity; screen time; sleep duration) among students from communities that participated in the Massachusetts Childhood Obesity Research Demonstration (MA-CORD) project compared to controls.

METHODS

MA-CORD was implemented in two low-income communities. School-level prevalence of obesity among students in first, fourth, and seventh grades was calculated for the intervention communities and nine matched control communities pre and post intervention. Fourth- and seventh-grade students' self-reported health behaviors were measured in intervention communities at baseline and post intervention.

RESULTS

Among seventh-graders (the student group with greatest intervention exposure), a statistically significant decrease in prevalence of obesity from baseline to post intervention in Community 2 (-2.68%, P = 0.049) and a similar but nonsignificant decrease in Community 1 (-2.24%, P = 0.099) was observed. Fourth- and seventh-grade students in both communities were more likely to meet behavioral targets post intervention for sugar-sweetened beverages (both communities: P < 0.0001) and water (Community 1: P < 0.01; Community 2: P = 0.04) and in Community 2 for screen time (P < 0.01).

CONCLUSIONS

This multisector intervention was associated with a modest reduction in obesity prevalence among seventh-graders in one community compared to controls, along with improvements in behavioral targets.

Promising and Established Investigators' Experiences Participating in the National Athletic Trainers' Association Foundation Research Mentor Program

CONTEXT

  Mentorship is a helpful resource for individuals who transition from doctoral student to tenure-track faculty member. The National Athletic Trainers' Association (NATA) Research & Education Foundation offers a Research Mentor Program to provide mentorship to promising investigators, particularly as they work to establish independent lines of research.

OBJECTIVE

  To gain the perspectives of promising and established investigators on their participation in the NATA Foundation Research Mentor Program.

DESIGN

  Qualitative, phenomenological research.

SETTING

  Higher education institutions.

PATIENTS OR OTHER PARTICIPANTS

  Seven promising investigators (5 women, 2 men) and 7 established investigators (2 women, 5 men), all of whom had completed the NATA Foundation Research Mentor Program. Data Collection and Analysis We developed and piloted intervi: ew guides designed to gain participants' perspectives on their experiences participating in the NATA Foundation Research Mentor Program. Semistructured telephone interviews were completed with each individual and transcribed verbatim. Data were analyzed using a phenomenological approach, and saturation was obtained. Trustworthiness was established with the use of member checking, multiple-analyst triangulation, and data-source triangulation.

RESULTS

  Three themes emerged from the interviews: (1) motivation, (2) collaboration, and (3) resources. Participants were motivated to become involved because they saw the value of mentorship, and mentees desired guidance in their research. Participants believed that collaboration on a project contributed to a positive relationship, and they also desired additional program and professional resources to support novice faculty.

CONCLUSIONS

  Promising and established investigators should be encouraged to engage in mentoring relationships to facilitate mentees' research agendas and professional development. The NATA Foundation and athletic training profession may consider providing additional resources for novice faculty, such as training on effective mentoring; grant writing and other research-related tasks; and support for broader faculty responsibilities, such as teaching, service, and work-life balance.

Using cost-effectiveness analysis to prioritize policy and programmatic approaches to physical activity promotion and obesity prevention in childhood

Participation in recommended levels of physical activity promotes a healthy body weight and reduced chronic disease risk. To inform investment in prevention initiatives, we simulate the national implementation, impact on physical activity and childhood obesity and associated cost-effectiveness (versus the status quo) of six recommended strategies that can be applied throughout childhood to increase physical activity in US school, afterschool and childcare settings. In 2016, the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES) systematic review process identified six interventions for study. A microsimulation model estimated intervention outcomes 2015-2025 including changes in mean MET-hours/day, intervention reach and cost per person, cost per MET-hour change, ten-year net costs to society and cases of childhood obesity prevented. First year reach of the interventions ranged from 90,000 youth attending a Healthy Afterschool Program to 31.3 million youth reached by Active School Day policies. Mean MET-hour/day/person increases ranged from 0.05 MET-hour/day/person for Active PE and Healthy Afterschool to 1.29 MET-hour/day/person for the implementation of New Afterschool Programs. Cost per MET-hour change ranged from cost saving to $3.14. Approximately 2500 to 110,000 cases of children with obesity could be prevented depending on the intervention implemented. All of the six interventions are estimated to increase physical activity levels among children and adolescents in the US population and prevent cases of childhood obesity. Results do not include other impacts of increased physical activity, including cognitive and behavioral effects. Decision-makers can use these methods to inform prioritization of physical activity promotion and obesity prevention on policy agendas.

Three Interventions That Reduce Childhood Obesity Are Projected To Save More Than They Cost To Implement

Policy makers seeking to reduce childhood obesity must prioritize investment in treatment and primary prevention. We estimated the cost-effectiveness of seven interventions high on the obesity policy agenda: a sugar-sweetened beverage excise tax; elimination of the tax subsidy for advertising unhealthy food to children; restaurant menu calorie labeling; nutrition standards for school meals; nutrition standards for all other food and beverages sold in schools; improved early care and education; and increased access to adolescent bariatric surgery. We used systematic reviews and a microsimulation model of national implementation of the interventions over the period 2015-25 to estimate their impact on obesity prevalence and their cost-effectiveness for reducing the body mass index of individuals. In our model, three of the seven interventions--excise tax, elimination of the tax deduction, and nutrition standards for food and beverages sold in schools outside of meals--saved more in health care costs than they cost to implement. Each of the three interventions prevented 129,000-576,000 cases of childhood obesity in 2025. Adolescent bariatric surgery had a negligible impact on obesity prevalence. Our results highlight the importance of primary prevention for policy makers aiming to reduce childhood obesity.

Examining the Role Mentorship Plays in the Development of Athletic Training Preceptors

Context: Mentorship has been identified as a contributor to the socialization of athletic training preceptors. Understanding how mentorship occurs and contributes to preceptor development may help athletic training educators facilitate effective mentorship within their athletic training programs.

Objective: Examine preceptors' perceptions of mentoring as part of their socialization into this role.

Design: Qualitative study.

Setting: Commission on Accreditation of Athletic Training Education programs.

Patients or Other Participants: Twelve athletic trainers representing 4 National Athletic Trainers' Association districts, including 5 men and 7 women, average age = 32 ± 10.5 years, and average of 5 ± 5.0 years' experience as a preceptor.

Main Outcome Measure(s): Participants responded to 14 interview questions regarding their perceptions of mentoring. Two researchers analyzed data using an inductive approach to identify themes and supporting categories. Trustworthiness was established by piloting the interview, using multiple analyst triangulation, and peer review.

Results: Four themes emerged from the data: (1) characteristics, (2) processes, (3) mentoring by emulating, and (4) roles of mentoring. Participants identified that communication and commitment are characteristics of effective mentorship. Preceptors learn to mentor by emulating other preceptors, and mentoring relationships develop through both formal and informal processes. Mentoring serves multiple roles for preceptors, including providing a support system and facilitating reciprocal learning for both mentors and protégés.

Conclusions: Participants perceive mentoring as beneficial to their initial and ongoing development as preceptors. Preceptors learn to mentor by emulating current and past mentors, emphasizing the importance of modeling for both preceptors and students. Clinical education coordinators can facilitate the mentoring of preceptors by educating them on the benefits of engaging in it as well as connecting experienced preceptors with newer preceptors.

Promoting Physical Activity With the Out of School Nutrition and Physical Activity (OSNAP) Initiative: A Cluster-Randomized Controlled Trial

IMPORTANCE

Millions of children attend after-school programs in the United States. Increasing physical activity levels of program participants could have a broad effect on children's health.

OBJECTIVE

To test the effectiveness of the Out of School Nutrition and Physical Activity (OSNAP) Initiative in increasing children's physical activity levels in existing after-school programs.

DESIGN, SETTING, AND PARTICIPANTS

Cluster-randomized controlled trial with matched program pairs. Baseline data were collected September 27 through November 12, 2010, with follow-up data collected April 25 through May 27, 2011. The dates of our analysis were March 11, 2014, through August 18, 2015. The setting was 20 after-school programs in Boston, Massachusetts. All children 5 to 12 years old in participating programs were eligible for study inclusion.

INTERVENTIONS

Ten programs participated in a series of three 3-hour learning collaborative workshops, with additional optional opportunities for training and technical assistance.

MAIN OUTCOMES AND MEASURES

Change in number of minutes and bouts of moderate to vigorous physical activity, vigorous physical activity, and sedentary activity and change in total accelerometer counts between baseline and follow-up.

RESULTS

Participants with complete data were 402 racially/ethnically diverse children, with a mean age of 7.7 years. Change in the duration of physical activity opportunities offered to children during program time did not differ between conditions (-1.2 minutes; 95% CI, -14.2 to 12.4 minutes; P = .87). Change in moderate to vigorous physical activity minutes accumulated by children during program time did not differ significantly by intervention status (-1.0; 95% CI, -3.3 to 1.3; P = .40). Total minutes per day of vigorous physical activity (3.2; 95% CI, 1.8-4.7; P < .001), vigorous physical activity minutes in bouts (4.1; 95% CI, 2.7-5.6; P < .001), and total accelerometer counts per day (16,894; 95% CI, 5101-28,686; P = .01) increased significantly during program time among intervention participants compared with control participants.

CONCLUSIONS AND RELEVANCE

Although programs participating in the OSNAP Initiative did not allot significantly more time for physical activity, they successfully made existing time more vigorously active for children receiving the intervention.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01396473.

Cost Effectiveness of Childhood Obesity Interventions: Evidence and Methods for CHOICES

INTRODUCTION

The childhood obesity epidemic continues in the U.S., and fiscal crises are leading policymakers to ask not only whether an intervention works but also whether it offers value for money. However, cost-effectiveness analyses have been limited. This paper discusses methods and outcomes of four childhood obesity interventions: (1) sugar-sweetened beverage excise tax (SSB); (2) eliminating tax subsidy of TV advertising to children (TV AD); (3) early care and education policy change (ECE); and (4) active physical education (Active PE).

METHODS

Cost-effectiveness models of nationwide implementation of interventions were estimated for a simulated cohort representative of the 2015 U.S. population over 10 years (2015-2025). A societal perspective was used; future outcomes were discounted at 3%. Data were analyzed in 2014. Effectiveness, implementation, and equity issues were reviewed.

RESULTS

Population reach varied widely, and cost per BMI change ranged from $1.16 (TV AD) to $401 (Active PE). At 10 years, assuming maintenance of the intervention effect, three interventions would save net costs, with SSB and TV AD saving $55 and $38 for every dollar spent. The SSB intervention would avert disability-adjusted life years, and both SSB and TV AD would increase quality-adjusted life years. Both SSB ($12.5 billion) and TV AD ($80 million) would produce yearly tax revenue.

CONCLUSIONS

The cost effectiveness of these preventive interventions is greater than that seen for published clinical interventions to treat obesity. Cost-effectiveness evaluations of childhood obesity interventions can provide decision makers with information demonstrating best value for the money.

Validity of a practitioner-administered observational tool to measure physical activity, nutrition, and screen time in school-age programs

BACKGROUND

Nutrition and physical activity interventions have been effective in creating environmental changes in afterschool programs. However, accurate assessment can be time-consuming and expensive as initiatives are scaled up for optimal population impact. This study aims to determine the criterion validity of a simple, low-cost, practitioner-administered observational measure of afterschool physical activity, nutrition, and screen time practices and child behaviors.

METHODS

Directors from 35 programs in three cities completed the Out-of-School Nutrition and Physical Activity Observational Practice Assessment Tool (OSNAP-OPAT) on five days. Trained observers recorded snacks served and obtained accelerometer data each day during the same week. Observations of physical activity participation and snack consumption were conducted on two days. Correlations were calculated to validate weekly average estimates from OSNAP-OPAT compared to criterion measures. Weekly criterion averages are based on 175 meals served, snack consumption of 528 children, and physical activity levels of 356 children.

RESULTS

OSNAP-OPAT validly assessed serving water (r = 0.73), fruits and vegetables (r = 0.84), juice >4oz (r = 0.56), and grains (r = 0.60) at snack; sugary drinks (r = 0.70) and foods (r = 0.68) from outside the program; and children's water consumption (r = 0.56) (all p <0.05). Reports of physical activity time offered were correlated with accelerometer estimates (minutes of moderate and vigorous physical activity r = 0.59, p = 0.02; vigorous physical activity r = 0.63, p = 0.01). The reported proportion of children participating in moderate and vigorous physical activity was correlated with observations (r = 0.48, p = 0.03), as were reports of computer (r = 0.85) and TV/movie (r = 0.68) time compared to direct observations (both p < 0.01).

CONCLUSIONS

OSNAP-OPAT can assist researchers and practitioners in validly assessing nutrition and physical activity environments and behaviors in afterschool settings.

TRIAL REGISTRATION

Phase 1 of this measure validation was conducted during a study registered at clinicaltrials.gov NCT01396473.

Impact of the Boston Active School Day Policy to Promote Physical Activity among Children

Purpose.

To test effectiveness of Active School Day policy implementation on physical activity outcomes and estimate school-level implementation costs.

Design.

The design of the study was quasi-experimental (pretest–posttest matched controls).

Setting.

The study took place in six elementary schools with three matched pairs in Boston, Massachusetts, February to June 2011.

Subjects.

Subjects were 455 consenting fourth- and fifth-grade students among 467 eligible.

Intervention.

Active School Day policy implementation provided equipment, curricular materials, and training to physical educators and school wellness champions to promote 150 weekly minutes of quality physical education, recess, and physical activity integrated into classrooms.

Measures.

Accelerometer assessments of accumulated minutes and bouts of moderate, vigorous, and sedentary physical activity on 5 school days before and after implementation were used. Implementation costs were collected by record review and reported resource utilization.

Analysis.

Analysis was conducted using multivariate mixed models estimated with repeated measures of daily physical activity, adjusted for student demographics and other confounding and design/clustering variables.

Results.

Accelerometer data were provided by 201 intervention and 192 comparison students for an average of 4 days per period (84% response). During school time, students in intervention schools demonstrated greater increases in minutes per day of moderate-to-vigorous physical activity (3.9, 95% confidence interval [CI] 1.8–6.0; p < .001) and vigorous physical activity (1.8, 95% CI.7–3.0; p < .001), and greater decreases in minutes per day of sedentary time (–10.6, 95% CI—15.3– −5.8; p < .001) than controls. Ongoing annual implementation costs totaled $4,523/school ($14/student).

Conclusion.

Active School Day implementation increased student moderate-to-vigorous physical activity levels by 24% and decreased sedentary time during school at modest cost.

Program practices and demographic factors associated with federal funding for the Safe Routes to School program in the United States

In 2005, the United States Congress authorized $612 million for use in implementing the US Safe Routes to School program to address physical inactivity, air quality, safety and traffic near schools. Each US state developed administrative practices to implement the program. Based on state-specific annual obligations, on average, states have obligated 44% of available funds. State project obligations were directly associated with programmatic factors, including broader adherence to federal agency administrative guidance objectives and the number of years for which the states obligated new projects and indirectly associated with student enrollment and state child poverty. Research and policy recommendations are discussed.

Effect of school district policy change on consumption of sugar-sweetened beverages among high school students, Boston, Massachusetts, 2004-2006

INTRODUCTION

Consumption of sugar-sweetened beverages has increased among youth in recent decades, accounting for approximately 13% of total calories consumed. The Boston Public Schools passed a policy restricting sale of sugar-sweetened beverages in Boston schools in June 2004. The objective of this study was to determine whether high school students' consumption of sugar-sweetened beverages declined after this new policy was implemented.

METHODS

We conducted a quasi-experimental evaluation by using data on consumption of sugar-sweetened beverages by public high school students who participated in the Boston Youth Survey during February through April 2004 and February through April 2006 (N = 2,033). We compared the observed change with national trends by using data from the 2003-2004 and 2005-2006 National Health and Nutrition Examination Survey (NHANES). Regression methods were adjusted for student demographics.

RESULTS

On average, Boston's public high school students reported daily consumption of 1.71 servings of sugar-sweetened beverages in 2004 and 1.38 servings in 2006. Regression analyses showed significant declines in consumption of soda (-0.16 servings), other sugar-sweetened beverages (-0.14 servings), and total sugar-sweetened beverages (-0.30 servings) between 2004 and 2006 (P < .001 for all). NHANES indicated no significant nationwide change in adolescents' consumption of sugar-sweetened beverages between 2003-2004 and 2005-2006.

DISCUSSION

Data from Boston youth indicated significant reductions in consumption of sugar-sweetened beverages, which coincided with a policy change restricting sale of sugar-sweetened beverages in schools. Nationally, no evidence was found for change in consumption of sugar-sweetened beverages among same-aged youth, indicating that implementing policies that restrict the sale of sugar-sweetened beverages in schools may be a promising strategy to reduce adolescents' intake of unnecessary calories.

Neuro-angiostrongylosis in wild Black and Grey-headed flying foxes (Pteropus spp)

OBJECTIVE

To identify nematodes seen in histological sections of brains of flying foxes (fruit bats) and describe the associated clinical disease and pathology.

PROCEDURES

Gross and histological examination of brains from 86 free-living flying foxes with neurological disease was done as part of an ongoing surveillance program for Australian bat lyssavirus. Worms were recovered, or if seen in histological sections, extracted by maceration of half the brain and identified by microscopic examination. Histological archives were also reviewed.

RESULTS

There was histological evidence of angiostrongylosis in 16 of 86 recently submitted flying foxes with neurological disease and in one archival case from 1992. In 10 flying foxes, worms were definitively identified as Angiostrongylus cantonensis fifth-stage larvae. A worm fragment and third stage larvae were identified as Angiostrongylus sp, presumably A cantonensis, in a further three cases. The clinical picture was dominated by paresis, particularly of the hindlimbs, and depression, with flying foxes surviving up to 22 days in the care of wildlife volunteers. Brains containing fifth-stage larvae showed a moderate to severe eosinophilic and granulomatous meningoencephalitis (n = 14), whereas there was virtually no inflammation of the brains of bats which died when infected with only smaller, third-stage larvae (n = 3). There was no histological evidence of pulmonary involvement.

CONCLUSION

This is the first report of the recovery and identification of A cantonensis from free-living Australian wildlife. While angiostrongylosis is a common cause of paresis in flying foxes, the initial clinical course cannot be differentiated from Australian bat lyssavirus infection, and wildlife carers should be urged not to attempt to rehabilitate flying foxes with neurological disease.

God's beliefs versus mother's: the development of nonhuman agent concepts

Little research exists on how children understand the actions of nonhuman agents. Researchers often assume that children overgeneralize and attribute human properties such as false beliefs to nonhuman agents. In this study, three experiments were conducted to test this assumption. The experiments used 24 children in New York (aged 2,11-6,11 years), 52 children in Michigan (aged 3,5-6,11 years), and a second group of 45 children in Michigan (3,4-8,5 years) from Christian backgrounds. In the first two experiments, children participated in false-belief tests in which they were asked about human and various nonhuman agents including animals and God. Experiment 3 consisted of a modified perspective-taking task, also including nonhuman agents. The results of the study suggest that children do not consistently use human agent concepts but instead can use different agent concepts for some nonhuman agents like God and special animals. Children are not bound to anthropomorphize, but they often do.

Conceptualizing a nonnatural entity: anthropomorphism in God concepts

We investigate the problem of how nonnatural entities are represented by examining university students' concepts of God, both professed theological beliefs and concepts used in comprehension of narratives. In three story processing tasks, subjects often used an anthropomorphic God concept that is inconsistent with stated theological beliefs; and drastically distorted the narratives without any awareness of doing so. By heightening subjects' awareness of their theological beliefs, we were able to manipulate the degree of anthropomorphization. This tendency to anthropomorphize may be generalizable to other agents. God (and possibly other agents) is unintentionally anthropomorphized in some contexts, perhaps as a means of representing poorly understood nonnatural entities.

The Na,K-ATPase Hypothesis for Bipolar Disorder: Implications of Normal Development

ABSTRACT The Na,K pump is the indispensable component of excitable tissue that maintains transmembrane ion-based potentials. Adequate human data regarding the developmental trends in Na,K pump activity in childhood are unavailable, but human nonneuronal and animal studies demonstrate a developmental shift toward declining Na,K pump activity with increasing age. The decline in pump activity is paralleled by an age-related increase in intracellular sodium ions and a concomitant decrease in intracellular potassium ions. These changes appear to decrease the potential difference across neuronal membranes with advancing age, suggesting an increase in neuronal excitability. The Na,K-ATPase hypothesis of bipolar disorder proposes that manic symptoms are related to a modest decrease in Na,K pump activity and a consequent increase in neuronal excitability, whereas bipolar depression is consequent to a greater decrease in pump activity and a resultant decrease in neurotransmitter release. Changes in ion transport and distribution with age may offer an explanation for clinical observations of developmental variations in lithium response, including the apparent agerelated decline in maximal pretoxic lithium level, decline in therapeutic blood level range, and perhaps an increase in the therapeutic efficacy of lithium. The clinical implications of the hypothesis regarding the course of bipolar disorder would include an explanation of the increasing frequency and severity of episodes with advancing age. The hypothesis makes numerous predictions which are testable and suggests new avenues of pharmacological intervention.

Lymphatic bullae arising as a complication of second-intention healing

Cutaneous bullae secondary to lymphatic fluid reflux are rare. We report the case of a patient with lymphatic bullae without lymphedema following second-intention wound healing.

Heterodyne efficiency of quadrant photodetectors

In this paper we compare quadrant heterodyne efficiencies. Differences in efficiencies between circular and square detectors are small while relative spacing between quadrants is more important in its effect on efficiencies. Spot size relative to detector size is also important. The effect of angular misalignment on efficiency is smallest for the Airy-Airy combination.

Bullous lichen planus: diagnosis by indirect immunofluorescence and treatment with dapsone

Bullous lichen planus may be confused with other subepidermal bullous dermatoses, especially if bullae arise on normal-appearing skin. We present two patients who were originally thought, on the basis of clinical and histopathologic criteria, to have bullous pemphigoid. However, results of standard indirect and direct immunofluorescence assays did not support the diagnosis of bullous pemphigoid. Further investigation using the indirect autologous immunofluorescence assay revealed deposits of immunoglobulins in the stratum granulosum. Moreover, the indirect allogeneic immunofluorescence assay (using papular lichen planus lesional substrates from different patients) was positive for the same pattern, confirming the diagnosis of bullous lichen planus. Bullous lichen planus with bullous pemphigoid-like histologic features can be differentiated from bullous pemphigoid on the basis of the indirect autologous and allogeneic immunofluorescence assays for circulating antigranulosum antibodies. Both patients were treated with systemic corticosteroids. One patient went into remission with this therapy alone; the other patient had a favorable response when dapsone was given with systemic corticosteroids. The suggestion that there is a subset of bullous lichen planus with bullous pemphigoid-like histologic features that responds to dapsone needs to be explored.

Familial medullary carcinoma of the thyroid

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