Cost and policy implications from the increasing prevalence of obesity and diabetes mellitus

Background: The increasing prevalence of obesity and type 2 diabetes mellitus (DM), among children and adults, has posed important policy and budgetary considerations to government, health insurance companies, employers, physicians, and health care delivery systems.Objective: This article examines issues that are common to obesity and DM, including cost, clinical research, and treatment barriers, and proposes health policies to address these issues.Method: A manual review was performed of authoritative literature from peer-reviewed medical publications and recently published medical textbooks.Results: Obesity has been disproportionately prevalent among women and minorities, accompanied by an increased risk for DM. Women have experienced an increased risk for the metabolic syndrome, DM, and cardiovascular disease after onset of menopause. Obesity has been related to an increased risk for breast cancer among women, and may be a barrier that prevents women from being screened for colon and breast cancers. Maternal obesity has been a risk factor for gestational DM.Conclusions: Obesity and DM represent crises for the health care system and the health of the public, incurring costs and disease burden for adults and children, with increasing costs and prevalence expected unless more coordinated efforts to address the causes of these conditions at the national level are implemented. An investment in infrastructure to promote increased physical activity and reward weight management may be budget neutral in the long term by reducing the costs of morbidity and mortality. About two thirds of the costs from DM complications could be averted with appropriate primary care.     

The Pathway from Diabetes and Obesity to Cancer,on the Route to Targeted Therapy

ObjectiveTo review the epidemiologic studies that describe the relationships among diabetes, obesity, and cancer; animal studies that have helped to decipher the mechanisms of cancer development; and some of the therapeutic targets undergoing investigation.MethodsAn electronic search was performed of Medline, Scopus, Google Scholar, and ClinicalTrials.gov to identify English-language articles and studies published from 1995 through 2010 relating to obesity, insulin, insulinlike growth factors, diabetes mellitus, and cancer.ResultsEpidemiologic studies have reported that diabetes and obesity are linked to an increased risk of certain cancers in association with higher levels of insulin, C-peptide, and insulinlike growth factor 1. Animal models have demonstrated that increased insulin, insulinlike growth factor 1, and insulinlike growth factor 2 signaling can enhance tumor growth, while inhibiting this signaling can reduce tumorigenesis. Therapies that target insulin and insulinlike growth factor 1 signaling pathways have been developed and are currently in clinical trials to treat cancer.ConclusionsInsulin, insulinlike growth factor 1, and insulinlike growth factor 2 signaling through the insulin receptor and the insulinlike growth factor 1 receptor can induce tumorigenesis, accounting to some extent for the link between diabetes, obesity, and cancer. Knowledge of these pathways has enhanced our understanding of tumor development and allowed for the discovery of novel cancer treatments. (Endocr Pract. 2010;16:864-873)     

Accepting immigrants as fellow citizens: citizenship representations in relation to migration policy preferences

Citizenship representations within national populations have mainly been deduced from state policies on migration. Yet, at the individual level, no studies have investigated whether citizenship representations are reliably associated with preferences for specific migration policies (i.e. the underlying assumption for deducing citizenship representations from state policies). Because several studies have shown that state policies may not reflect understandings of citizenship within national populations, it may be more relevant to study citizenship representations at the individual level, in relation to personal preferences regarding migration policies. This study examined how ethnic, cultural and civic citizenship representations relate to migration policy preferences at the individual level among majority group high-school students (N = 1,734) in seven EU countries. Findings add to the understanding of citizenship representations and may have implications for the implementation of migration policies.     

Pathophysiologic Mechanisms Linking Adipose Tissue and Cardiometabolic Risk

ObjectiveTo describe the contribution of adipocytes and adipose tissue to increased cardiometabolic risk as well as the mechanisms by which adipose tissue and obesity contribute to dysglycemia, dyslipidemia, hypertension, and a prothrombotic, inflammatory state favoring atherogenesis.MethodsA review was undertaken of the relevant available reports, compiled by means of a search(PubMed) of the English-language literature published between 1994 and 2010.ResultsCoronary risk factors cause susceptibility to development of atherosclerosis. Traditional coronary risk factors are obesity, smoking, hypertension, diabetes, elevated serum cholesterol levels, male sex, advancing age, and a family history of early coronary events. The currently preferred term of cardiometabolic risk encompasses both the traditional coronary risk factors and the additional contributing factors of insulin resistance, atherogenic dyslipidemia, physical inactivity, unhealthful eating, inflammation, and hypercoagulation. The accumulation of adipose tissue (adiposity) and dysfunctional adipose tissue (adiposopathy) contribute to most, if not all, of the cardiometabolic risk factors. Adipose tissue promotes atherosclerosis through several different pathologic mechanisms, which are reviewed in this report. The treatment of obesity should focus on reducing fat mass and minimizing adipocyte dysfunction.ConclusionAdipose tissue contributes to the development of insulin resistance, hyperglycemia, atherogenic dyslipidemia, and arterial hypertension and favors a prothrombotic and proinflammatory state. Adipose tissue dysfunction increases cardiometabolic risk through a variety of mechanisms. (Endocr Pract. 2010;16:692-698)     

Ginseng and obesity: observations and understanding in cultured cells,animals and humans

Ginseng, a traditional medical herb, has been reported having beneficial effects in fatigue, heart diseases, diabetes, immune function and erectile dysfunction. In recent years, increasing investigations have been conducted on ginseng in preventing and treating of obesity, one of the major worldwide escalating public health concerns. However, the effect and the relevant mechanisms behind how ginseng works as an antiobesity treatment are still controversial. In this review, we briefly discussed the chemical structures, metabolism and pharmacokinetics of ginseng and its major bioactive components ginsenosides. The major focus is on the antiobesity effects and the physiological, cellular and molecular mechanisms of ginseng and its ginsenosides in cultured cells, animal models and humans. We particularly compared the ginsenosides profiles, the antiobesity effects and the mechanisms between Asian ginseng (Panax ginseng) and American ginseng (Panax quinquefolius), the two major ginseng species having opposite medical effects in traditional Chinese medicine. Our unpublished data on the ginseng antiobesity in cultured cells and mice were also included. We further addressed the current problems and future directions of the ginseng antiobesity research.     

California and federal school nutrition policies and obesity among children of Pacific Islander,American Indian/Alaska Native,and Filipino origins: Interrupted time series analysis

BackgroundObesity prevalence remains high among children of Pacific Islander (PI) origin, Filipino (FI), and American Indian/Alaska Native (AIAN) origins in the United States. While school nutrition policies may help prevent and reduce childhood obesity, their influences specifically among PI, FI, and AIAN children remain understudied. We evaluated the association of the California (CA) state school nutrition policies for competitive food and beverages and the federal policy for school meals (Healthy, Hunger-Free Kids Act of 2010 (HHFKA 2010)) with overweight/obesity among PI, FI, and AIAN students.Methods and findingsWe used an interrupted time series (ITS) design with FitnessGram data from 2002 to 2016 for PI (78,841), FI (328,667), AIAN (97,129), and White (3,309,982) students in fifth and seventh grades who attended CA public schools. Multilevel logistic regression models estimated the associations of the CA school nutrition policies (in effect beginning in academic year 2004 to 2005) and HHFKA 2010 (from academic year 2012 to 2013) with overweight/obesity prevalence (above the 85 percentile of the age- and sex-specific body mass index (BMI) distribution). The models were constructed separately for each grade and sex combination and adjusted for school district-, school-, and student-level characteristics such as percentage of students eligible for free and reduced price meals, neighborhood income and education levels, and age. Across the study period, the crude prevalence of overweight/obesity was higher among PI (39.5% to 52.5%), FI (32.9% to 36.7%), and AIAN (37.7% to 45.6%) children, compared to White (26.8% to 30.2%) students. The results generally showed favorable association of the CA nutrition policies with overweight/obesity prevalence trends, although the magnitudes of associations and strengths of evidence varied among racial/ethnic subgroups. Before the CA policies went into effect (2002 to 2004), overweight/obesity prevalence increased for White, PI, and AIAN students in both grades and sex groups as well as FI girls in seventh grade. After the CA policies took place (2005 to 2012), the overweight/obesity rates decreased for almost all subgroups who experienced increasing trends before the policies, with the largest decrease seen among PI girls in fifth grade (before: log odds ratio = 0.149 (95% CI 0.108 to 0.189; p < 0.001); after: 0.010 (−0.005 to 0.025; 0.178)). When both the CA nutrition policies and HHFKA 2010 were in effect (2013 to 2016), declines in the overweight/obesity prevalence were seen among White girls and FI boys in fifth grade. Despite the evidence of the favorable association of the school nutrition policies with overweight/obesity prevalence trends, disparities between PI and AIAN students and their White peers remained large after the policies took place. As these policies went into effect for all public schools in CA, without a clear comparison group, we cannot conclude that the changes in prevalence trends were solely attributable to these policies.ConclusionsThe current study found evidence of favorable associations of the state and federal school nutrition policies with overweight/obesity prevalence trends. However, the prevalence of overweight/obesity continued to be high among PI and AIAN students and FI boys. There remain wide racial/ethnic disparities between these racial/ethnic minority subgroups and their White peers. Additional strategies are needed to reduce childhood obesity and related disparities among these understudied racial/ethnic populations.

Dr. Mika Matsuzaki and co-authors found evidence of favorable associations between state and federal school nutrition policies with overweight/obesity prevalence trends among children of Pacific Islander origin, Filipino, and American Indian/Alaska Native origins in the United States.     

Decreased Inpatient Mortality in Obese Patients With Abdominal Nets

ObjectiveNeuroendocrine tumors (NETs) of the abdomen are rare tumors with an incidence of 3.56 per 100,000 in the general population. Obesity is a growing public health problem with varying effects on the severities of other diseases. We investigated the association between obesity and inpatient morbidity/mortality in patients with abdominal NETs utilizing the Nationwide Inpatient Sample (NIS).MethodsWe analyzed data from the NIS database to investigate the association between obesity and abdominal NETs using patient information from 22,096 patient discharges from January 1, 2009 to December 31, 2010.ResultsWe demonstrate that obesity is strongly associated with decreased rates of inpatient mortality in patients with NET (odds ratio [OR] = 0.6, multivariate P = .02) and that malnutrition is associated with a nearly 5-fold higher risk of inpatient mortality (multivariate P < .0005). We did not find a statistical interaction between obesity and malnutrition; however, patients who were both malnourished and obese had a lower mortality risk than purely malnourished patients.ConclusionsOur data suggests that nutritional status may be an important factor in inpatient mortality in patients with NETs, with obesity being protective. (Endocr Pract. 2014;20:1309-1314)     

Hair growth stimulator property of thienyl substituted pyrazole carboxamide derivatives as a cb1 receptor antagonist with in vivo antiobesity effect

A few thienyl substituted pyrazole derivatives were synthesized to aid in the characterization of the cannabinoid receptor antagonist and also to serve as potentially useful antiobesity agent. Structural requirements for selective CB1 receptor antagonistic activity of 5-thienyl pyrazole derivatives included the structural similarity with potent, specific antagonist rimonabant 1. Compound 3 has been identified as a hair growth stimulator and an antiobesity agent in animal models.     

Evidence-Based Medicine,Clinical Practice Guidelines,and Common Sense in the Management of Osteoporosis

ObjectiveTo evaluate the benefits and limitations of randomized controlled trials (RCTs), clinical practice guidelines (CPGs), and clinical judgment in the management of osteoporosis.MethodsA review was conducted of the English-language literature on the origins and applications of RCTs, CPGs, evidence-based medicine, and clinical judgment in the management of osteoporosis.ResultsEvidence-based medicine is use of the currently available best evidence in making clinical decisions for individual patients. CPGs are recommendations for making clinical decisions based on research evidence, sometimes with consideration of expert opinion, health care policy, and costs of care. The highest levels of medical evidence are usually thought to be RCTs and meta-analyses of high-quality RCTs. Although it is desirable and appropriate for clinicians to consider research evidence from RCTs and recommendations presented in CPGs in making clinical decisions, other factors—such as patient preference, comorbidities, affordability, and availability of care—are important for the actual implementation of evidence-based medicine.ConclusionDecisions about who to treat, which drug to use, how best to monitor, and how long to treat require clinical skills in addition to knowledge of medical research. The necessity of integrating common sense and clinical judgment is highlighted by the fact that many patients treated for osteoporosis in clinical practice would not qualify for participation in the pivotal clinical trials that demonstrated efficacy and safety of the drugs used to treat them. (Endocr Pract. 2009;15:573-579)     

Attitudes,Perceptions, and Practices Among Endocrinologists Managing Obesity

ObjectiveObesity has been globally recognized as a critically important disease by professional medical organizations, in addition to the World Health Organization and American Medical Association, but health care systems, medical teams, and the public have been slow to embrace this concept.MethodsThe American Association of Clinical Endocrinology staff drafted a survey, and 2 endocrinologists independently reviewed the survey’s questions and modified the survey instrument. The survey included questions related to practice and patient demographics, awareness about obesity, treatment of obesity, barriers to improving obesity outcomes, digital health, cognitive behavioral therapy, lifestyle medicine, antiobesity medications, weight stigma, and social determinants of health. The survey was emailed to 493 endocrinologists, with 305 (62%) completing the study.ResultsOf the responders, 98% agreed that obesity is a disease, whereas 2% neither agreed nor disagreed. Of the respondents, 53% were familiar with the term “adiposity-based chronic disease” and 13% were certified by the American Board of Obesity Medicine. Of the respondents, 57% used published obesity guidelines as a resource for treating patients with obesity. Most endocrinologists recommended dietary and lifestyle changes, but fewer prescribed an antiobesity medication or recommended bariatric surgery. American Board of Obesity Medicine-certified endocrinologists were more likely to use a multidisciplinary approach.ConclusionSelf-reported knowledge and practices in the management of obesity highlight the importance of a multimodal approach to obesity and foster collaboration among health care professionals. It is necessary to raise awareness about obesity among clinicians, identify knowledge gaps, and create educational tools to address those gaps.     

Polycystic Ovary Syndrome,Depression, and Affective Disorders

ObjectiveTo assess the prevalence of depression and psychologic disorders and their effect on the quality of life in women with polycystic ovary syndrome.MethodsWe performed a PubMed search of major relevant articles published during the period from 1985 to 2009 dealing with polycystic ovary syndrome, associated psychologic morbidity, and the relationship to clinical and biochemical changes affecting the quality of life.ResultsIn patients with polycystic ovary syndrome, the presence of depression and allied disorders was frequently noted to diminish mental well-being, affect, and self-worth. The symptoms often associated with this syndrome, such as hirsutism, obesity, irregular menses, and subfertility, were a major source of psychologic morbidity. Obesity was the most prevalent cause of mental distress, whereas other features such as hirsutism and infertility were less well defined as major factors. Although the findings in some studies have been inconclusive, the presence of clinically significant eating disorders and a 7-fold increase in the suicide rate have been reported in women with polycystic ovary syndrome.ConclusionWomen with polycystic ovary syndrome have a high risk for depression and affective disorders that impair their quality of life. The presence of obesity, eating disorders, hirsutism, poor self-image, and a significant suicide rate makes evaluation of their emotional state an integral part of their assessment and treatment. For adequate treatment of the woman with polycystic ovary syndrome, a biopsychosocial model should be used, with all aspects of the patient’s mental status considered before implementation of optimal intervention. (Endocr Pract. 2009;15:475-482)     

American Association of Clinical Endocrinologists and American College of Endocrinology Consensus Conference on Obesity: Building an Evidence Base for Comprehensive Action

Objective/MethodsThe American Association of Clinical Endocrinologists/American College of Endocrinology “Consensus conference on obesity: building an evidence base for comprehensive action” convened March 23-25, 2014, in Washington, D.C. The premise of the conference was that by bringing together stakeholders in U.S. obesity care, representing the biomedical and public health models, new information would emerge to formulate actionable recommendations.ResultsKey conference findings include 5 affirmed and 8 emergent concepts. These concepts include the need for a medically meaningful and actionable diagnosis of obesity, research that evaluates and refines a complications- centric clinical approach to obesity, the need for a better understanding of reimbursement mechanisms and the value associated with obesity prevention and management, increased nutrition and obesity education, and enhanced public awareness and health literacy.ConclusionNext steps include deriving a more robust medical definition of obesity, translation of the affirmed and emergent concepts into actionable recommendations in the interests of patients with obesity, and developing logistics for effective implementation. (Endocr Pract. 2014; 20:956-976)     

Measuring Visceral and Hepatic Fat in Clinical Practice and Clinical Research

ObjectiveTo review how visceral and hepatic fat are measured in clinical practice and clinical research.MethodsWe examine different methods employed to assess visceral and hepatic fat in the literature.ResultsFat in the human body is located in 2 main compartments: subcutaneous and visceral, which also includes liver fat. Visceral and liver fats are associated with the metabolic complications of obesity like hypertension, diabetes, and atherosclerosis. Therefore, there is a need to detect those fats early in life before the development of cardiometabolic syndrome (CMS). Many modalities have been proposed to measure visceral and liver fat. Indirect measurements can be done through waist circumference (WC), dual-energy X-ray absorptiometry (DEXA), ultrasound, and bioelectric impedance, whereas direct methods include computed tomography (CT) and magnetic resonance imaging (MRI). An ideal measurement method should be noninvasive, reliable, suitable for all body sizes, widely available, cost and time effective, show low variability, and have no or limited radiation exposure.ConclusionMeasuring visceral and liver fat is not a straightforward procedure in clinical practice or research; several variables may affect measure accuracy and validity. (Endocr Pract. 2013;19:587-595)     

Insulin Resistance and Thrombogenesis: Recent Insights and Therapeutic Implications

ObjectiveTo review the relationship between insulin resistance and thrombogenesis, especially in the context of obesity, diabetes, and cardiovascular disease, and to discuss therapeutic implications.MethodsThe pertinent peer-reviewed literature was examined for evidence in support of the aforementioned relationship, and the reported efficacy of various therapeutic interventions was assessed.ResultsRobust evidence indicates that insulin resistance and enhanced thrombogenesis are closely related pathophysiologic mechanisms, especially in the presence of obesity. Thus, targeting insulin resistance and thrombogenesis may be of value in the prevention and management of type 2 diabetes and associated cardiovascular morbidity and mortality. Many proven preventive and therapeutic strategies, such as weight loss, exercise, and various pharmaceutical agents, affect both thrombogenesis and insulin resistance.ConclusionBoth insulin resistance and thrombogenesis contribute to the morbidity and mortality associated with obesity, diabetes, and cardiovascular disease. Effective measures for prevention and management of diabetes and cardiovascular disease also tend to improve insulin sensitivity and to ameliorate abnormalities in coagulation, fibrinolysis, and platelet function. (Endocr Pract. 2007;13:679-686)     

Advances in Lipid Testing and Management in Patients with Diabetes Mellitus

ObjectiveTo review the pathophysiologic basis for the classic phenotype associated with diabetic dyslipidemia, discuss recent advances in lipid and lipoprotein testing for risk assessment and lipid therapy monitoring, and summarize a systematic approach to the clinical management of diabetic dyslipidemia.MethodsWe review the pertinent literature, including treatment guidelines and results of major clinical trials, and discuss the effectiveness of various pharmacologic interventions for management of lipid levels in patients with diabetes.ResultsThe incidence and prevalence of type 2 diabetes mellitus continue to escalate globally at alarming rates. Diabetes predisposes to multiple microvascular and macrovascular complications, including cardiovascular disease, the number 1 cause of mortality in the United States. The third report of the National Cholesterol Education Program Adult Treatment Panel in 2001 identified diabetes as a coronary heart disease (CHD) risk equivalent, in light of the evidence that CHD risk in persons with diabetes is similar to that of nondiabetic persons with established CHD. Diabetic dyslipidemia is characterized by a constellation of lipid derangements—hypertriglyceridemia, a low concentration of high-density lipoprotein cholesterol (HDL-C), and a high concentration of small, dense low-density lipoprotein (LDL) particles—that accelerate the progression of atherosclerotic disease and the development of atherothrombotic events.ConclusionStatin trials have demonstrated significant reductions in morbidity and mortality from cardiovascular diseases, including in patients with diabetes. Nevertheless, many patients who achieve their LDL cholesterol (LDL-C) goal still have residual CHD risk. Diabetic dyslipidemia contributes to this residual risk because of the increased concentration of atherogenic apolipoprotein B-containing lipoproteins that can persist despite normalized LDL-C levels and low HDL-C levels. Recent clinical trials emphasize the importance of intensive lipid lowering to achieve recommended goals for LDL-C, non-HDL-C, and apolipoprotein B. (Endocr Pract. 2009;15:641-652)     

Access to Orphan Drugs: A Comprehensive Review of Legislations,Regulations and Policies in 35 Countries

ObjectiveTo review existing regulations and policies utilised by countries to enable patient access to orphan drugs.MethodsA review of the literature (1998 to 2014) was performed to identify relevant, peer-reviewed articles. Using content analysis, we synthesised regulations and policies for access to orphan drugs by type and by country.ResultsFifty seven articles and 35 countries were included in this review. Six broad categories of regulation and policy instruments were identified: national orphan drug policies, orphan drug designation, marketing authorization, incentives, marketing exclusivity, and pricing and reimbursement. The availability of orphan drugs depends on individual country’s legislation and regulations including national orphan drug policies, orphan drug designation, marketing authorization, marketing exclusivity and incentives such as tax credits to ensure research, development and marketing. The majority of countries (27/35) had in place orphan drug legislation. Access to orphan drugs depends on individual country’s pricing and reimbursement policies, which varied widely between countries. High prices and insufficient evidence often limit orphan drugs from meeting the traditional health technology assessment criteria, especially cost-effectiveness, which may influence access.ConclusionsOverall many countries have implemented a combination of legislations, regulations and policies for orphan drugs in the last two decades. While these may enable the availability and access to orphan drugs, there are critical differences between countries in terms of range and types of legislations, regulations and policies implemented. Importantly, China and India, two of the largest countries by population size, both lack national legislation for orphan medicines and rare diseases, which could have substantial negative impacts on their patient populations with rare diseases.     

The social negotiation of nature conservation policy: conserving pinewoods in the Scottish Highlands

This paper examines the social and cultural processes through which conservation policy is derived. Focusing on the management of pinewoods in Abernethy Forest, Scotland, it explores the cultural politics involved in developing appropriate management practice. Calling upon participant observation, semi-structured interviews with site managers and the analysis of texts, it traces the gradual moves from a policy of minimum intervention towards more complex management regimes. The paper explores the social construction of the forest’s naturalness that underpinned the early policy of minimum intervention and then the ways that the forest was reconstructed as the managers debated the merits of minimum intervention and the degree to which they should intervene. The paper illustrates how managers have considered different forms of intervention and how they have tried to balance their concern with the naturalness of the forest with a need to intervene on behalf of particularly important species. It highlights the importance of conservationists’ culturally derived understandings of nature and suggests that an awareness of these cultures of nature is vital if conservationists are to develop robust policies.

The Glucocorticoid Receptor and its Expression in the Anterior Pituitary and the Adrenal Cortex: A Source of Variation in Hypothalamic-Pituitary-Adrenal Axis Function; Implications for Pituitary and Adrenal Tumors

ObjectiveTo review the expression of the glucocorticoid receptor (GR) in anterior pituitary and adrenocortical cells and tumors derived from these tissues as well as factors that may influence its expression.MethodsWe present an overview of the relevant literature, with a focus on data generated from our studies.ResultsThe expression of the GR is an essential element of the negative feedback that closes the loop formed by corticotropin-releasing hormone, adrenocorticotropic hormone, and cortisol in the context of the hypothalamicpituitary-adrenal (HPA) axis. Although the GR expression in anterior pituitary cells—and in particular the corticotrophs—was first demonstrated several years ago, it was not known until relatively recently where, by what cells, and in what form the GR is expressed in the adrenal cortex.The variability in the expression of the GR in pituitary and adrenocortical cells may underlie the substantial differences in HPA axis function across individuals, especially when testing for tumors associated with hypercortisolemia. This expression is influenced by a multitude of tissue-specific factors, which may explain why it is so difficult to interpret (or reproduce) studies that are based on GR functional polymorphisms on different cohorts of patients or even different sets of laboratory animals.ConclusionThis review highlights the variability in expression and function of the GR in pituitary and adrenocortical cells as one of the reasons for the appreciable differences in HPA axis function across individuals. Particular attention was paid to interactions that may affect the interpretation of diagnostic testing of the HPA axis in patients with pituitary adenomas (Cushing disease) or adrenocortical tumors (Cushing syndrome). (Endocr Pract. 2011;17:941-948)     

Healthier Fundraising in U. S. Elementary Schools: Associations between Policies at the State,District, and School Levels

Objectives

We examined whether state laws and district policies pertaining to nutritional restrictions on school fundraisers were associated with school policies as reported by administrators in a nationally-representative sample of United States public elementary schools.

Methods

We gathered data on school-level fundraising policies via a mail-back survey during the 2009–10 and 2010–11 school years. Surveys were received from 1,278 public elementary schools (response rate = 60.9%). Data were also gathered on corresponding school district policies and state laws. After removing cases with missing data, the sample size for analysis was 1,215 schools.

Results

After controlling for school characteristics, school policies were consistently associated with state laws and district policies, both those pertaining to fundraising generally, as well as specific restrictions on the sale of candy and soda in fundraisers (all Odds Ratios >2.0 and Ps<.05). However, even where district policies and state laws required fundraising restrictions, school policies were not uniformly present; school policies were also in place at only 55.8% of these schools, but were more common at schools in the West (77.1%) and at majority-Latino schools (71.4%), indicating uneven school-level implementation of district policy and state law.

Conclusions

District policies and state laws were associated with a higher prevalence of elementary school-level fundraising policies, but many schools that were subject to district policies and state laws did not have school-level restrictions in place, suggesting the need for further attention to factors hindering policy implementation in schools.     

Changes in the Regional Prevalence of Child Obesity in 4th, 8th,and 11th Grade Students in Texas From 2000–2002 to 2004–2005

Although national and state estimates of child obesity are available, data at these levels are insufficient to monitor effects of local obesity prevention initiatives. The purpose of this study was to examine regional changes in the prevalence of obesity due to statewide policies and programs among children in grades 4, 8, and 11 in Texas Health Services Regions (HSRs) between 2000–2002 and 2004–2005, and nine selected counties in 2004–2005. A cross‐sectional, probability‐based sample of 23,190 Texas students in grades 4, 8, and 11 were weighed and measured to obtain BMI. Obesity was >95th percentile for BMI by age/sex using Centers for Disease Control and Prevention growth charts. Child obesity prevalence significantly decreased between 2000–2002 and 2004–2005 for 4th grade students in the El Paso HSR (?7.0%, P = 0.005). A leveling off in the prevalence of obesity was noted for all other regions for grades 4, 8, and 11. County‐level data supported the statistically significant decreases noted in the El Paso region. The reduction of child obesity levels observed in the El Paso area is one of the few examples of effective programs and policies based on a population‐wide survey: in this region, a local foundation funded extensive regional implementation of community programs for obesity prevention, including an evidence‐based elementary school‐based health promotion program, adult nutrition and physical activity programs, and a radio and television advertising campaign. Results emphasize the need for sustained school, community, and policy efforts, and that these efforts can result in decreases in child obesity at the population level.