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and summarizes priorities and next steps for enhancing measurement tools and advancing the incorporation of high-quality measurement for surveillance, epidemiology, and intervention research aimed at accelerating progress in addressing the childhood obesity epidemic. It is intended to stimulate and inform new research on diverse aspects of childhood obesity among researchers and those who plan research initiatives.
As a public–private partnership of 4 leading research funders—the Centers for Disease Control and Prevention, National Institutes of Health, Robert Wood Johnson Foundation, and U.S. Department of Agriculture—NCCOR has a mission to accelerate progress in reducing childhood obesity among all children with particular attention to high-risk populations and communities. A key priority for NCCOR is to promote the use of high quality, standardized measures and methods across childhood obesity surveillance, epidemiology, and intervention research. Use of such measures improves comparison of results across different studies and further advances progress against childhood obesity. New measures will be needed as understanding of key influences on childhood obesity including individual, family, policy, and environmental factors continues to evolve.
NCCOR organized 3 workshops in 2019 and 2020. The goal of these workshops was to identify priorities and next steps for enhancing measurement tools and advancing the incorporation of high-quality measurement for surveillance, epidemiology, and intervention research. The first workshop, “Advancing Measurement of Individual-Level Behaviors Related to Childhood Obesity,” focused on measuring diet, physical activity, sedentary behavior, and sleep. The second workshop, “Advancing Measurement for High-Risk Populations and Communities Related to Childhood Obesity,” focused on identifying priorities for measurement of diet and physical activity in children, families, and their communities at high risk of obesity. This workshop also included an assessment of existing methods for developing and adapting individual and environmental measures of diet and physical activity among high-risk populations or settings.
The third workshop, “Advancing Measurement of Environmental and Policy Influences on Childhood Obesity,” focused on identifying priorities to capture policy and environmental influences on childhood obesity, with an emphasis on social determinants of health (SDOH) including housing and transportation.
These workshops were unique in 2 ways. First, the workshops addressed diet, physical activity, sedentary behavior, sleep, and SDOH in concert. Despite their interacting influences on childhood obesity, many past efforts have addressed them separately.
Second, the workshops attempted to address overarching gaps in measurement for surveillance, epidemiology, and intervention research, whereas most other work has focused on measurement needs for a single area.
Interagency Committee on Human Nutrition Research National Nutrition Research Roadmap 2016‒2021: Advancing Nutrition Research to Improve and Sustain Health.
Interagency Committee on Human Nutrition Research,
Washington, DC2016
To achieve these goals, NCCOR engaged experts on diet, physical activity, sedentary behavior, sleep, and SDOH in the areas of research, practice, program evaluation, and surveillance in each workshop. The workshops alternated presentations by experts in the field with breakout groups that discussed priorities and developed lists of specific actions to address gaps. A dot-voting process, with each participant voting for 3 gaps, was used to identify top priorities among those specific gaps.
These challenges (Figure 1) included improving processes for engaging multiple stakeholders and sectors to identify key measurement considerations; combining measurement of multiple factors within the same research or data system and across several levels to enhance understanding of complex interactions; and supporting innovations in measurement methods, analysis, and systems science. Additionally, current techniques for measuring diet, physical activity, and sedentary time are limited by trade-offs between validity and feasibility—the most valid measures can be expensive/technically demanding to properly collect and analyze (e.g., accelerometry), have high respondent burden, and can be challenging for younger children to complete without assistance (e.g., multiple 24-hour diet or physical activity recalls).
Figure 1Common challenges for advancing measurement in childhood obesity.
Each workshop also highlighted specific opportunities. For example, Workshop 1 noted the need to enhance measurement methods for children aged <6 years, to identify key constructs for each developmental age, and to improve the validity and feasibility of measurement of the 24-hour behavior pattern.
Workshop 2 called for efforts to adapt existing measures for high-risk populations and develop new measures as needed. It emphasized the challenge of balancing the need for tailored measures against the need to have common measures facilitating identification of what works across diverse communities and populations. The workshop also emphasized that measures and implementation need to reflect cultural competence relevant to social and racial injustice and the immigrant experience and be developed by engaging high-risk communities as partners in research. Community-based participatory research, ethnography, citizen participation, and other approaches provide tools to foster such engagement.
Workshop 3 focused on engaging diverse sectors, adapting measurement tools and indicators used in sectors other than health, and understanding the role of policy forces. Examples of actions specific to this workshop include calls to: (1) create new platforms for cross-sectoral and cross-disciplinary collaboration on measure development and data collection and (2) identify measurement approaches from other sectors that are needed to understand the multilevel determinants of childhood obesity. Other actions focused on the need to identify and characterize policies that exert the greatest influence on dietary and physical activity behaviors and to enhance systems science and other approaches to better understand how people interact with obesity-related environments.
OPPORTUNITIES FOR SPECIFIC ACTIONS
The workshops identified 6 major categories of potential actions (Figure 2) and 73 specific (Table 1) actions to improve measurement of factors influencing childhood obesity that addressed both domain specific (e.g., diet or physical activity) and cross-cutting needs. Researchers and public and private organizations are beginning to address these priorities.
Interagency Committee on Human Nutrition Research National Nutrition Research Roadmap 2016‒2021: Advancing Nutrition Research to Improve and Sustain Health.
Interagency Committee on Human Nutrition Research,
Washington, DC2016
These opportunities represent actions described during the workshop that were voted on and of particular importance during the day-long discussions. SDOH, social determinants of health; PA, physical activity; SB, sedentary behavior; EHR, electronic health record; ECE, early childhood education; RWJF, Robert Wood Johnson Foundation; NCCOR, National Collaborative on Childhood Obesity Research; SNAP-Ed, SNAP Education; HUD, U.S. Department of Housing and Urban Development; CDC, Centers for Disease Control and Prevention; NOPREN, Nutrition and Obesity Policy Research and Evaluation; PAPREN, Physical Activity Policy Research and Evaluation Network; NHANES, National Health and Nutrition Examination Survey; WIC, Women, Infants and Children Nutrition Program.
SDOH
Diet
PA/SB
Sleep
Develop new measures
Develop measurement methods for capturing exposures for diet and physical activity for children under age 6 years considering key constructs for key developmental stages.
X
X
Define diet-related terms and core indicators/domains that are feasible to measure (including positive health).
X
Define elements of diet quality.
X
Determine how to measure the 24-hour cycle.
X
X
X
Develop recommendations for constructs for each developmental age to include in sleep questionnaires.
X
Develop methods to better understand physical activity patterns.
X
Measure parental competency in relationship to sleep and other behaviors relevant to obesity.
X
X
X
Measure parents’ early organization of child's sleep and association with later sleep trajectories; connect these indicators with early feeding practices.
X
Consider issues of chronotypes and other constructs relevant to obesity and metabolic disorders.
X
X
Develop and adapt multi-level PA measures for understudied populations at high risk of childhood obesity through an intersectional, historical trauma, critical race theory lens.
X
Review and identify which social and environment measures (e.g., social capital) may be relevant to PA.
X
Understand how to measure peer/social environments drawing from expertise in child psychology field. Are specific issues unique to diet and PA?
•
Develop comprehensive measures of the neighborhood child peer/social active play environment. Develop methods to address gaps in knowledge about children's social environment relevant to physical activity.
•
For nutrition, expand EHR measures of perception of how clinicians’ recommendations influenced changes in nutrition behavior.
X
X
X
Develop better psychometrically sound measures, particularly those involving perceptions. This might include measures of implementation and systems change; measures of the social environment that are specific to influences on youth activity (peers, screens); measures of community engagement (community voice) in built environment process and decision making; and measures on perceptions of unhealthy food availability, food marketing, and online food environments.
X
X
X
X
Develop measures for surveillance of children's food environments beyond school and ECE. Consider alternate data sources that help characterize the food environment, e.g., zoning policies, crime data.
X
Address gaps in active transport measurement and incorporate measures into surveillance systems
•
Enhance surveillance data on active transport, particularly at the community level data
•
Expand data on active transport to school to include measures of policies, behavior, and other factors
•
Develop metrics to quantify distance from schools and how this may influence children's use of active transportation
•
Identify types of active transport beyond those used for school or work
•
Develop a child walkability index
X
Create measures that have input from sectors and decision makers and are action-oriented; position measures so that people can use them.
X
X
X
Develop new measures in implementation science to determine what works in ECE settings.
X
X
Review what is known
Connect developmental milestones with feeding practices.
X
Conduct a landscape scan of what is known about improving sensitivity of current sleep measures to enable capturing change within interventions for sleep.
X
Integrate principles of nutrition, child development, and structure into identifying constructs relevant to responsive feeding and measuring it. Consider how to extrapolate this principle of responsive parenting to the behaviors of physical activity and sleep.
X
X
X
Examine the feasibility of using health and childhood obesity measures in non-health studies and surveys with an initial focus on housing, transportation, and planning.
X
X
X
Build measurement tools, guidance, and data resources
Build measurement tools
Create a roadmap for measure selection and adaptation
•
Develop minimum standards for process of validating adapted measures
X
X
X
Identify what SDOH metrics are most relevant to childhood obesity and provide links to existing resources of such measures
•
Add resources from sources (e.g., RWJF's Measuring What Works project)
X
X
X
Update/revamp the NCCOR Measures Registry
•
Add measures for B-24
•
Curate Measures Registry around indicators (SNAP-Ed Eval Framework)
•
Make the Measures Registry more tool focused
•
Add sleep measures and specific measurement protocols.
•
Consider if SDOH measures are added as a new domain or linkage provided to existing SDOH measurement registries (i.e., PhenX)
•
Modify the Measures Registry to better reflect populations for which measures have been developed and tested and to provide more information on validity and reliability/ Identify measures related to high-risk populations
X
X
X
X
Create an annotated accelerometry data repository.
X
Develop toolkits and roadmaps for optimal PA measures selection.
X
Develop guidance on measures
Create a repository of best practices and feedback systems.
X
X
X
Develop guidance on incorporating SDOH measures into: (1) surveillance and (2) large cohort studies of communities.
X
X
X
Help practitioners optimize the relevant set of measures for EHR, evaluation, or research.
X
X
X
Develop better ways to engage with and communicate with research end users. Develop tools with end users to increase the utility of data.
X
X
X
Create planning tool for communities to improve built environment (i.e., a new “active communities” tool). For example, it would include constructs to improve a person's route to desired destinations. The tool should build on existing work and should be written to address a specific purpose (e.g., surveillance, local data, equity).
X
X
X
Enhance data resources
Foster greater dissemination of data such as through data repositories and warehouses.
X
X
X
X
Improve the granularity of data collection and sources
•
Policy implementation; linking policy to behavior, and other linkages (locally all the way up to nationally)
•
Local data and local systems modeling are needed: predictors of behavior may vary by locality and systems’ change, need to understand all the levers for issues such as food purchase.
•
For child-level PA, need to get beyond merely whether children are meeting PA guidelines to learn where and how are kids physically active; understand prevalence of programs and resources that exist to support kids’ PA; overlay different levels of data conveniently (i.e., child and community)
•
Determine priorities for collecting local-level physical activity data, such as through non-traditional proto analyses (e.g., electronic health record, big data analyses) and develop methods for small area estimates
X
X
X
Design policies and program evaluation and monitoring systems taking into account the socio-ecological model and Complex Adaptive Systems frameworks. Such systems are needed for all of the behaviors relevant to childhood obesity.
X
X
X
X
Create “proof of principle” surveillance systems. Deliberately select communities in which to conduct deep-dive data collection. This approach starts small vs building a national surveillance system that might be limited in number of measures.
X
X
X
Enhance capacity, dissemination, and collaboration
Capacity/Dissemination
Encourage capacity building through webinars. Suggested topics include:
•
Addressing frameworks for PA measurement, to help users make decisions about which key PA measures to include
•
Measuring systems change with input from diverse disciplines and topic domains
X
X
X
Enhance impact of dissemination efforts by using approaches, such as community engaged research, adapting tools, ethical issues, critical race theory.
X
X
X
Promote uptake and appropriate adoption of structural measures.
X
X
X
X
Engage experts from other areas that are more advanced in such measurement.
X
X
X
Compile theoretical frameworks and approaches to support and inform community engagement. This may require framing the projects around issues the communities care about, e.g., climate change, multi-disciplinary solutions to local problems. Pay particular attention to populations that have received little attention (e.g., immigrants).
X
X
X
Build capacity for citizen science in PA in high-risk communities.
Improve dissemination; publish in diverse forms; publish null results on what doesn't work.
X
X
X
Highlight examples/case studies, such as historical index/ structural.
X
X
X
Create a roadmap to link the growing body of existing work on SDOH to childhood obesity (e.g., Health and Transportation Index).
X
X
X
Determine how to obtain streamlined access to the food retail data-sharing agreements (e.g., time-intensive intercept surveys have been used to understand impact of the kids’ meal default beverage policy—retailers have sales data that directly answer the question).
X
Establish communications with technology companies, such as Google or Verizon, to explore ways of using technology to gather and analyze data. This could include talking with companies that already use Google street-level and other data for tracking PA or other health data.
X
X
Collaboration
Establish avenues for information sharing and connecting across sectors such as through digital channels, annual meetings, shared membership on panels and other approaches
•
Support a virtual learning collaboration to convene those working in housing, transportation, and urban planning (e.g., CDC NOPREN and PAPREN groups monthly meetings via virtual platforms).
X
X
X
Explore ways for various disciplines, such as housing and transportation, to become versed in each other's methods and vocabularies, perhaps through an online hub for information sharing
•
The Transportation Research Board (TRB) will elevate the health and transportation topic to committee status, which may enhance influencing health priorities within transportation. Consider how to strengthen existing connections with the TRB and its understanding of how its work influences children's health.
X
X
X
Continue work from the December 2019 HUD-CDC-NIH meeting to discuss additional specific metrics and opportunities for collaboration.
X
X
X
Encourage team science, trans-disciplinary teams, and support incorporating team science into academic training.
X
X
X
Develop research methods, approaches, and enhanced linkage
Methods/Approaches
Encourage efforts to combine measures and methods in the same study (triangulation).
X
X
X
Encourage research on reliability and validity of capturing sleep and activity parameters via one device; such an approach could streamline measurement of multiple variables associated with obesity risk.
X
X
Make use of multiple measurement systems to obtain a representative picture of child sleep
•
Diaries and actigraphy can be used across ages
•
Develop standards for reporting algorithms used
X
Develop methods and approaches to address declining survey response rates, such as using hybrid approaches for surveillance. May need to combine and triangulate data.
X
X
X
Encourage improved and diverse sample sizes (innovative methods could allow smaller sample sizes).
X
X
X
Develop approaches to capture structural/historical factors that may influence PA.
X
Develop ways to improve understanding of parent-child interactions in context of facilitating PA (likely varies by age).
X
Develop approaches to encourage better and more extensive use of NHANES dietary data. Some approaches include:
•
Calibrate NHANES data against other dietary data sets
•
Correlate the detailed dietary data collected in NHANES with WHO's 8 core Infant and Young Child Feeding indicators
•
Add WIC infant feeding study questions (i.e., how children are being fed, feeding practices, and developmental milestones) to other dietary instruments, including those within NHANES
X
Enhance data linkages
Assess and identify the most important data linkages for weight related data in the areas of physical activity/sedentary behavior, nutrition, sleep, SDOH.
X
X
X
X
Develop methods to link local, state, and national data.
X
X
X
Develop systems modeling and other approaches for measuring “how” people interact with food and physical activity environments to understand factors influencing interactions, such as social supports, cultural influences, built environment/design, and consumer behaviors.
X
X
Expand data collection, research, and publication
Expand data collection
Collect data to learn more about where and how child-level physical activity occurs.
X
Collect data on perceived discrimination (developed and tested in Black Americans) as a measure of SDOH; assess its validity for use in other populations experiencing discrimination.
X
Collect data on acculturation and pathways to acculturation as they may lead to different lifestyle behaviors among immigrants and influence how immigrants respond to interventions.
X
Ensure policy data are collected with meaningful geographic context
•
Policies are enacted at a jurisdictional level; thus, need data specific to jurisdictional areas (not catchment areas) for data linkage
•
Challenge of trying to link municipalities to Census areas, it's hard to determine how they relate to each other
•
Consider creating a toolbox of examples and best practices organized by type of community (small towns vs large); tools may vary in their effectiveness by community characteristics.
X
X
Modernize ECE and afterschool (particularly, school-based) surveillance systems.
X
X
Encourage research and publication
Encourage research of how responsive parenting influences children's obesity related behaviors (diet, PA, SB, and sleep).
X
X
X
Publish and find additional ways to use data that have been collected but remain unpublished; such data may help with longitudinal research.
X
X
X
Identify and address biases of using found/repurposed data. Determine who are not represented in such data and address endogeneity issues.
X
X
X
Explore how social, family, and environmental contexts influence sleep and how those contexts evolve with age.
X
Encourage and support efforts to engage in “deep dive” examination of interactions in the behavioral and social and physical environment.
X
X
X
Encourage examination of key transitions across the life span that offer opportunities to change PA and diet habits
X
X
a These opportunities represent actions described during the workshop that were voted on and of particular importance during the day-long discussions.SDOH, social determinants of health; PA, physical activity; SB, sedentary behavior; EHR, electronic health record; ECE, early childhood education; RWJF, Robert Wood Johnson Foundation; NCCOR, National Collaborative on Childhood Obesity Research; SNAP-Ed, SNAP Education; HUD, U.S. Department of Housing and Urban Development; CDC, Centers for Disease Control and Prevention; NOPREN, Nutrition and Obesity Policy Research and Evaluation; PAPREN, Physical Activity Policy Research and Evaluation Network; NHANES, National Health and Nutrition Examination Survey; WIC, Women, Infants and Children Nutrition Program.
The need for new measures was a common theme across workshops. Cross-domain actions for this category include enhancing measurement of children's peer/social environments and considering how behavior varies across a 24-hour day. Examples of actions addressing a single domain include defining elements of diet quality, measuring patterns of physical activity and sedentary behavior, and considering chronotypes in sleep measurement.
2 Review What Is Known and Maximize Cross-sectoral Collaboration
Issues that required landscape reviews as a preliminary step to determining key needs were assigned to this category. One area emphasized across the domains was cross-sector reviews. Examples include examining the feasibility of using health and childhood obesity measures in non-health studies, and conversely, identifying metrics from housing and transportation sectors that are well developed and could be useful for community health. Examples of specific actions addressing a single domain include conducting a landscape scan of literature and other resources about improving sensitivity of current sleep measures to enable capturing change or connecting developmental milestones with feeding practices.
3 Build Measurement Tools, Guidance, and Data Resources
This category primarily includes cross-domain actions. Examples include creating a roadmap for cross-domain measure selection and adaptation, updating the NCCOR Measures Registry
for emerging topics, enhancing engagement with end users, and improving the spatial and temporal granularity of data collection and sources, particularly in areas relevant to policy enactment and implementation.
4 Enhance Capacity, Dissemination, and Collaboration
This category also primarily includes cross-domain action. Examples include encouraging capacity building to measure systems change, compiling theoretical frameworks and implementing approaches to support and inform community engagement, and fostering multisector/agency partnerships and information sharing.
5 Develop Research Methods, Approaches, and Enhanced Linkage
Cross-domain actions for this category include developing approaches to address declining survey response rates, assessing and identifying the most important data linkages for weight-related data across behaviors and contextual factors, and developing systems modeling and other approaches for measuring “how” people interact with food and physical activity environments. Examples of actions related to a single domain include developing ways to improve understanding of parent–child interactions that facilitate physical activity and using multiple measurement systems to measure sleep.
6 Expand Data Collection, Research, and Publication
Cross-domain actions in this category include modernizing early child education and afterschool surveillance systems and publishing and finding additional uses for existing data that are underused.
Actions specific to a single domain include collecting data on perceived discrimination, acculturation, and pathways to acculturation, or identifying practices and policies in child care and school settings that exert the greatest influences on children's physical activity.
EMERGING AREAS FOR RESEARCH, DATA, AND RESOURCE NEEDS
The workshops addressed emerging topics related to childhood obesity including sleep, SDOH, parent–child interactions influencing behavioral adoption, and contextual and environmental factors such as the extent of implementation of policies. Other emerging topics include the potential for using new technologies (e.g., the use of wearable devices to collect data on physical activity) to improve measurement and enhancing the data linkages for analyses to explore how children's and families’ interactions with their environments and communities influence their health. Conversations about these areas highlighted the importance of enhancing cross-sectoral collaboration in surveillance, epidemiology, and interventions.
Examples include creating online hubs for best practices, theoretical frameworks, and tools or protocols for measurement; expanding databases that document available measurement tools; and enhancing avenues such as convenings, funding, consensus building, and other approaches that facilitate the use of high-quality measures in research and surveillance.
The focus on SDOH led to calls for improving health monitoring systems and highlighting of several data systems and compendia that could contribute to better understanding social determinants of childhood obesity. For example, in the third workshop, experts from the housing and transportation sectors pointed out that existing metrics and linkages between databases from these sectors and the health sector warrant greater use.
Furthermore, a new compendium of data systems relevant to health disparities, including systems related to housing and transportation, could contribute to childhood obesity research.
Workshop discussions have already prompted the NCCOR member organizations to consider additional initiatives and activities relevant to addressing childhood obesity. For example, agencies are supporting a wide range of national and international virtual learning collaborations in the areas of diet and physical activity to explore policy interventions and programs that are successful at achieving beneficial outcomes; the key actions identified from this workshop series are being considered within such collaboratives.
Since its inception, NCCOR has worked to advance measurement and enhance training and capacity for measurement.
In conjunction with the workshop series, NCCOR has updated its popular resources, the Measures Registry and the Catalogue of Surveillance Systems, including the addition of measures for the Birth-24 population and relevant SDOH data sets.
The National Collaborative on Childhood Obesity Research Catalogue of Surveillance Systems and Measures Registry: new tools to spur innovation and increase productivity in childhood obesity research.
NCCOR also developed guidance to address challenges in measures adaptation for high-risk populations. The resource, available on NCCOR's website (nccor.org/decision-tree), includes a decision tree on whether to apply or adapt an existing measure or develop a new measure and case examples for different scenarios.
Measurement is a fundamental component of research, surveillance, and evaluation, and measurement needs for childhood obesity evolve with new understandings of key influences. Many of the specific recommendations for actions from these workshops reflect similar calls across other national and international organizations, including the WHO's calls for tools to monitor the quality of early feeding practices, youth physical activity, and childhood obesity
; a number of National Academies of Science, Engineering, and Medicine reports over the last decade that highlight gaps in monitoring progress in childhood obesity in the U.S.
National Academies of Sciences, Engineering, and Medicine
Driving Action and Progress on Obesity Prevention and Treatment: Proceedings of a Workshop. The National Academies Press,
Washington, DC2017https://doi.org/10.17226/24734
The 2 unique aspects of the actions identified from this workshop and detailed in the 3 white papers are (1) the level of integration spanning research, practice, evaluation, and surveillance and (2) the focus on addressing topics across the socioecological model from individual-level diet, physical activity, and sleep to environments, policy, and SDOH. Next steps should include further reflection, development of ideas, attention to research needs relevant to childhood obesity, and efforts by NCCOR, its member agencies, and diverse stakeholders to advance the quality of measurement for surveillance, epidemiology, and intervention research.
ACKNOWLEDGMENTS
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of NIH, the Centers for Disease Control and Prevention, the U.S. Department of Agriculture, or the Robert Wood Johnson Foundation.
The workshop series described in this article was funded through a strategic alliance with The JPB Foundation (Grant 949). The National Collaborative on Childhood Obesity Research (NCCOR) forms strategic alliances with organizations that support efforts to reduce childhood obesity in the U.S. These strategic alliances enhance NCCOR's capacity to develop innovative tools and solutions that move the field of childhood obesity research forward.
All authors contributed to the conception and design of this paper. Dr. Ballard prepared the first draft. All authors reviewed, edited, and approved successive and final versions of the paper.
The accomplishments of NCCOR are made possible by the many members of NCCOR. A list of the membership can be found on the NCCOR website (www.nccor.org).
No financial disclosures were reported by the authors of this paper.
REFERENCES
The National Collaborative on Childhood Obesity Research. www.nccor.org. Accessed June 24, 2020.
The National Collaborative on Childhood Obesity Research Catalogue of Surveillance Systems and Measures Registry: new tools to spur innovation and increase productivity in childhood obesity research.
National Academies of Sciences, Engineering, and Medicine
Driving Action and Progress on Obesity Prevention and Treatment: Proceedings of a Workshop. The National Academies Press,
Washington, DC2017https://doi.org/10.17226/24734
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