key: cord-0805152-7476kt94
authors: Pérez‐Escamilla, Rafael; Vilar‐Compte, Mireya; Rhodes, Elizabeth; Sarmiento, Olga L.; Corvalan, Camila; Sturke, Rachel; Vorkoper, Susan
title: Implementation of childhood obesity prevention and control policies in the United States and Latin America: Lessons for cross‐border research and practice
date: 2021-05-05
journal: Obes Rev
DOI: 10.1111/obr.13247
sha: c2b12546e264edd0149a03011cf0d1a51e5551b1
doc_id: 805152
cord_uid: 7476kt94

Progress has been made in the development and widespread implementation of effective interventions to address childhood obesity, yet important challenges remain. To understand how the United States and Latin American countries achieved success in implementing obesity policies and programs (PAPs) and identify improvement opportunities using implementation science principles. We identified three comparative case studies: (1) front‐of‐food package labeling (Mexico and Chile); (2) Open Streets/play streets (Colombia and the United States); and (3) the Baby‐Friendly Hospital Initiative (Brazil and the United States). Information from multiple sources (e.g., scientific and gray literature and key informant interviews) was synthesized to describe barriers, facilitators, and progress of PAPs across RE‐AIM framework dimensions. Evidence‐based advocacy along with political will and evidence of scalability and impact were key for successful launch and implementation of all PAPs. Diverse adaptations of PAP design and implementation had to be done across contexts. Stronger process and impact monitoring and evaluation systems that track equity indicators are needed to maximize the population benefits of these PAPs. Implementation science offers an important contribution toward addressing knowledge gaps, enhancing obesity policy dialogue, and producing transferable lessons across the Americas and, therefore, should be used for research and evaluation during PAP development and throughout the implementation and maintenance phases.

interventions have not been fully realized because of enduring barriers to adoption and adaptation that have restricted scale-up and sustainability. The field of implementation science holds promise for addressing these barriers.

The National Institutes of Health (NIH) defines implementation science as the study of methods to promote integration of research findings and evidence into healthcare policy and practice. 3 Implementation science makes use of diverse study designs including observational studies, efficacy trials, and large-scale implementation and effectiveness trials of complex health interventions while emphasizing the use of epidemiologic methods, economic evaluation, and qualitative methods to understand "how" and "why" implementation efforts The case studies were designed to present information regarding the goal and intended outcome, barriers, facilitators, systems and processes involved, key stakeholders, equity considerations, and the dynamic process of PAP implementation. Given that the type of information available differed across PAPs and settings, we used a variety of approaches for accessing, documenting, and synthesizing the information. They included (1) a literature review to identify reports and peer-reviewed articles describing implementation aspects of the policy/program; (2) key informant interviews as needed to confirm and/or gather new information; and (3) qualitative thematic analyses.

The case examples presented in this paper were analyzed using the RE-AIM framework (Tables S1-S4), a commonly utilized framework in implementation science. Specifically, RE-AIM conceptualizes the public health impact of an intervention as a product of the interaction between five factors: reach, effectiveness, adoption, implementation, and maintenance. 6 This framework suggests that the public health impact of an evidence-based intervention will be achieved if an effective intervention reaches a broad and representative segment of the population by being adopted by key stakeholders, implemented with fidelity, and maintained over time. Initially used primarily as an evaluation tool for health behavior research, RE-AIM has expanded to cover diverse public health domains and multiple research and evaluation stages, including planning and study design, as well as retrospective assessment and evaluation of PAPs. 7, 8 As a result, all case studies mapped the findings onto one or more dimensions of the RE-AIM framework depending on the stage of implementation of each PAP.

The author leads for each case study (see acknowledgments section) conducted the initial comparative analysis for their respective case study. All authors participated in reaching final consensus on the key lessons learned from these analyses.

A key goal of front-of-pack warning labeling (FOPL) is to improve the transparency and easiness of understanding by consumers of the nutritional value of a food product. FOPL is considered key to helping consumers readily identify calorie-rich ultra-processed foods and beverages with added sugars and almost no nutritional value in addition to foods high in saturated and trans fats and sodium. Hence, FOPL is expected to empower consumers to reduce their consumption of these obesogenic foods and beverages and to help prevent dietrelated noncommunicable diseases (NCDs). This case study compares the adoption and implementation of front-of-pack warning labels on food and beverage products in Chile and Mexico.

In June 2016, Chile implemented the Food Labeling and Advertising Law to benefit the health of the entire population, particularly children. As previously reported, the law was successfully developed and approved as a result of a multiyear multisectoral dialogue with key actors. 9 This process greatly benefited from strong evidence-based advocacy led by academic champions in partnership with a charismatic and influential legislator. 9 This national policy called for a package of actions for promoting healthier diets and preventing obesity, including the placement of black octagonal labels similar to a STOP sign on the front of packages to warn consumers of packaged foods that have high concentrations of critical nutrients that increase the risk for dietrelated NCDs (i.e., sugars, saturated fats, and sodium 9,10 ; Figure 1 ).

Specifically, all prepackaged foods with ingredients such as added sugars, saturated fats, or sodium were subject to the use of labels if they exceeded the law's limits; notably, these products account for 60% of the energy intake of Chileans. 11 The Chilean law also included regulations on the foods that could be offered in schools and a prohibition to market unhealthy foods to children under 14 years old. Limits of energy and nutrient content were defined by the regulation mandating that food products incorporate one black octagon for each of the limits exceeded (e.g., a product exceeding energy and sugars limits would need to have two FOPLs). The policy was implemented in three phases, with the limits became progressively stricter over time. Full implementation was achieved in June 2019.

Governmental and academic reports have described the process of developing front-of-food pack labeling (FOPL) legislation, the degree of implementation, and its impact evaluation after the first phase of implementation. 4, [12] [13] [14] [15] Of note is that the FOPL policy was implemented together with comprehensive marketing restrictions to children under 14 years old and the prohibition to sell or provide regulated foods and beverages at early child care and education centers and schools 9 (Table S1 ).

Our RE-AIM mapping analyses were based on reviewing ongoing research conducted by the Institute of Nutrition and Food Technology of the University of Chile and the University of North Carolina designed to evaluate the impact of the Chilean Food Labeling and Advertising on economic impacts, food environment, and consumer and food industry behavior. We also examined official government documents and conducted six key informant interviews with governmental officials, most of whom were from the Chilean Ministry of Health.

The first year after the labels were implemented, the industry showed strong compliance with 95% of packaged foods and beverages requiring labels actually including them. From the consumers side, about 60% of the consumers self-reported using the FOPL when interviewed about food shoping decisions 16, 17 ; these results were independent of educational level. Also, our analyses have shown that F I G U R E 1 Front-of-Food Pack warning labeling and marketing legislation timeline in Chile (2007-2019). Abbreviations: FOP, Front-of-Food Package; MKT, marketing consumers' food perceptions and knowledge improved; purchases of unhealthy beverage and food purchases decreased; and industry driven product reformulation decreased sugars and sodium in some food products such as sweetened beverages and cheeses, respectively. [17] [18] [19] One concern with the regulation relates to the substitution of sugar by nonnutritive sweeteners as there are also health concerns associated with the consumption of these products. [20] [21] [22] Another concern was related to job losses as a result of a reduction in sales of the food products targeted by the law. However, research shows that there has been no change in job losses or wages when comparing food industries with product lines that include regulated foods compared with food industries that do not sell such food products. 23 All food companies implemented the policy simultaneously, with the exception of small food companies, which were given 3 extra years for implementation. The regulation was also implemented throughout all food assistance programs immediately. However, among programs with external providers with contracts that were renewable every 3 years, implementation of the regulation was delayed until the next cycle of renewal. An interesting finding is that at the retail level, the food distributers had the ultimate responsibility to ensure that all their products complied with the FOPL. Hence, supermarkets or food stores pressured food companies to comply with the law in order for them to sell their products.

The FOPL continues to be implemented according to plan, (Table S1 ). In the current case, we used available information retrospectively to map the implementation of the FOPL legislation from Chile into the RE-AIM framework. Moreover, because of the retrospective nature of the analysis, we identified gaps in information limiting what could be mapped into RE-AIM. In these instances, key informant interviews were helpful in filling in gaps.

Mexico began implementing the new FOPL policy October 1, 2020, to address the highly obesogenic environment of the country and the aggressive food marketing targeted at children. In October 2019, the Mexican Congress approved the inclusion of a FOPL in the General Health Law, leading to a reform in the regulation NOM-051. Figure 2 summarizes the timeline of key events related to the adoption of FOPL between 2019 and 2020. (Table S5) . We extracted data from 21 articles and 15 gray literature documents using the RE-AIM framework. Twitter analysis was performed using data mining for social networks and machine learning algorithms on Python. 24 The goal was to assess attention to the FOPL legislation, and to understand who the key actors were, which advocacy strategies were used, and document public sentiments evoked by the pro- Fifth, emulating strategies used during the adoption of the sugarsweetened beverage tax in Mexico, 38 social media also served as an active motivator for civil society mobilization. 39 Sixth, the Twitter analysis showed that compared with other policies to combat obesity, the FOPL had a high level of public support. 35 The Twitter analysis highlighted that 40% of the tweets evoked positive emotions around the FOPL such as "good work" or "safes lives," whereas close to 60% were linked to negative emotions toward industry actions like "misleading," "poisoning," or "lies."

The adoption phase faced significant barriers linked to the food industry's response through well-known strategies to prevent the FOPL legislation from being enacted. They worked through common lobbying tactics such as alliances with governmental officials and legislators to influence policy design. 26 As the proposal advanced, the food industry tried to slow down the process by providing many comments during public consultations ( Figure 2 ). They also used indirect mechanisms to increase confusion among the public, such as newspaper editorials, and organizing events with international "experts" to counteract the robust international and local scientific evidence backing the FOPL legislation. In addition, they introduced a legal challenge through the Federal Court. These attempts to derail the FOPL policy were overcome largely because the political context favored evidence-based public health interventions to address the obesity epidemic. 39 The FOPL legislation process began in the initial months of a new political administration. The FOPL system was adopted (i.e., NOM-051) and published in April 2020.

The use of the RE-AIM framework in studying the FOPL policy in Mexico was helpful but limited as only the adoption step could be addressed. In the future, as the FOLP is implemented, it will be relevant to document the other steps of RE-AIM as it was done in the Chilean case presented above.

The Chilean and Mexican FOPL policies were mapped onto the RE-AIM framework. In the case of Chile, RE-AIM was used to assess the policy's reach, effectiveness, adoption, implementation, and maintenance, whereas in Mexico it was used to understand the extent to which the policy had been adopted. Even though the policies are similar in substance, the processes for approving these policies differed including the role played by civil society organizations, which has been much stronger in Mexico, perhaps as a result of less political will at the start of the process compared with Chile. The evidence from the twitter analysis in Mexico clearly illustrates this finding. On the other hand, this case study underscores how powerful the combination of evidence, civil society organizations' engagement, public opinion, and political will is at advancing adoption of anti-obesity policies such as FOPL despite strong opposition from powerful food industries. 4, 40 Given that Chile is in a more advanced stage of policy implementation, Mexico has an opportunity to learn from Chile as it plans a sys- 46 For the case study in Colombia, described below, we conducted an interview with Bibiana Sarmiento, the coordinator of Bogotá's Ciclovía. Information from these sources was mapped to the RE-AIM framework.

In the United States, the Sunday Streets San Francisco program, an Open Streets initiative that started in 2008, showed increased physical activity levels for residents in low-income areas. 47 48 Each of the San Francisco Play Street program segments is developed by an organizing team of community members and nonprofit representatives who plan and host at least three healthfocused block parties on a designated street, which is usually flat and straight and already has low car traffic. 49 Play streets community organizers must provide equipment or programming support for at least three physical activity programs, including an activity that is accessible to people with limited mobility and a community building activity.

The initial San Francisco Play Streets program aimed to increase youth physical activity time on weekends and targeted four neighborhoods that were low income, had higher rates than the city average of chronic diseases including childhood obesity, and encompassed underserved areas in terms of recreational resources. 46 The neighborhood demographics showed that Latino populations represented between 17.5% and 45% of the groups who participated. 46 A program process evaluation identified the programs' strengths, weaknesses, reach, and sustainability or maintenance using questionnaires and a validated tool called System for Observing Play and Recreation in Communities to observe participant activities. An outcome evaluation sought to understand participants' use and attitudes toward the Play Streets events by comparing both the use of the space before (baseline) and during (treatment) the event and through a comparison group with a nontreatment neighborhood that matched the Play Streets sites based on demographic measures, health disparities, and availability of recreation amenities. 46 In terms of reach, they found that the community members that participated in the program were younger and more racially and ethnically diverse, particularly for Latinos, than the comparison neighborhoods. The program attracted families with young children and older adults, though evaluators observed that the adults were more sedentary than the children. They also found that the play streets did not bring out the initially targeted teens and pre-teens, 46 which Dr. Zieff believes may be due in part to the name "play streets." In terms of effectiveness, they found that vigorous physical activity increased threefold (11.5%-35%) and that 93% of participants agreed that play streets "strengthen our community" at the end of the program period. The program, using Google Earth Pro, reported adding 47%-100% more open space for physical activity in the neighborhood. In fact, Dr. Zieff reported that in one neighborhood with high drug activity, as the children came outside to participate in the program, those adults moved out of the area, giving the children a place to play and providing a safe space that was previously deemed unsafe or inappropriate for play.

Adoption and maintenance of the program have been possible through financial support from the San Francisco Municipal Transportation Agency; however, neighborhoods have to apply to be part of the program, making community buy-in and leadership a cornerstone of the program. In addition, as part of the implementation plan, there are guidelines for times, frequency, and types of activity that help to promote fidelity across the programs while also allowing neighborhoods to adapt the program to their community's individual needs and interests. Though Dr. Zieff reported that schools and community centers were originally unable to participate, restrictions have been lessened, and the program now encourages partnerships with these other organizations. In addition, it does not appear that the initial focus on underserved neighborhoods is still a requirement, as the 2019 Program Guidelines do not include this. 49 

In Latin America, the largest Ciclovía with specific programs for children was inaugurated in 1974 in Bogotá, Colombia. 45 The development and sustainability of the program has been influenced by multisectoral policies. Ciclovía has been identified by political leaders within the local and national government as an initiative that aligns with policies aimed at overcoming inequalities and providing health and quality of life for citizens. Importantly, successive policymakers with common views have contributed to the expansion and sustainability of the programs. 50 The Ciclovía of Bogotá is a multisectoral program coordinated by Ciclovía to incentivize biking for transport. 52 

The RE-AIM framework enabled a structured approach to evaluating the implementation and comparing the experiences of play streets in San Francisco and Ciclovía in Bogotá (Table S3) .

Although Bogotá and San Francisco have created successful programs that promote physical activity, the implementation pathways and features have been quite different. On the one hand, their reach in terms of size, frequency, and documented long-term impacts is different due to the influence of when they started and the social, political, economic, and healthcare systems contexts in which they operate. On the other hand, both Play Streets in San Francisco and Ciclovía in Bogotá had similar aspects in regard to adoption, implementation, and maintenance, demonstrating the need for multisectoral support along with community buy-in, including local leadership, and establishing guidelines for ongoing and future projects. Each program was implemented in underserved communities, thereby reaching vulnerable populations that may not otherwise have had access to active play spaces. Although neither program was expensive, each has financial support through citywide public funding that will contribute to sustainability or maintenance of the program, but data on these dimensions of the RE-AIM framework were not available. Indeed, moving forward, the effectiveness of the programs in terms of sustainable communitybased physical activity increases needs to be evaluated. A crosssectional study of the Ciclovía of Bogotá showed that children 

The Baby Friendly Hospital Initiative (BFHI) is an important approach for addressing the global epidemic of childhood obesity, given evidence that breastfeeding is likely to protect against overweight and obesity in childhood. 53 Launched in 1991 by the WHO and the United Nations Children's Fund (UNICEF), BFHI is centered on adherence to the Ten Steps to Successful Breastfeeding (Ten Steps), a set of actions that have been shown to improve breastfeeding outcomes 54 (Table S6) . To achieve Baby-Friendly status, a facility must adhere to the Ten Steps as well as the WHO International Code of Marketing of Breastmilk Substitutes, which prohibits distribution and promotion of formula. 54 We searched PubMed and Embase databases using search terms related to BFHI (Baby Friendly or BFHI, Ten Steps or 10 steps) and breastfeeding (breastfed, breastfeed, breastfeeding) and, after an initial screening, identified 148 articles on the BFHI in the United States and Brazil to inform this case study through a two-phase screening process. We then reviewed the full text of these articles to identify articles that focused on the history of BFHI in these countries and/or one or more of the dimensions of the RE-AIM framework. In addition, we reviewed gray literature and content on government and nongovernmental agency websites. Findings were mapped to the RE-AIM framework (Table S4 ).

In the United States, the BFHI is managed by Baby-Friendly USA, an organization that provides implementation guidance for facilities seeking designation and serves as an independent accrediting body. 55 Since 1996 when the BFHI launched in the United States, the number of Baby-Friendly facilities has grown exponentially. 55 The rapid expansion of Baby-Friendly hospitals across the country was likely fueled by strong evidence and political support for BFHI.

The American Academy of Pediatrics endorsed the Ten Steps in 2009. 56 In 2011, the US Surgeon General's Call to Action to Support

Breastfeeding called for accelerated implementation of the BFHI. 57 Adherence to the Ten Steps was promoted by several broader health policy statements or recommendations that identify the nation's health priorities and drive the national agenda for health promotion and disease prevention, such as the National Prevention Strategy and Healthy People 2020 goals and objectives. 56 The Ten Steps were also included as an evidence-based strategy for slowing the rising prevalence of childhood obesity as part of a former Centers for Disease Control and Prevention (CDC) Director's Winnable Battles program (2010-2015). 58 Political support for BFHI was matched by large public investment and targeted training and technical assistance that may have accelerated adoption and reach of the Ten Steps (Table S4 ). It is noteworthy that the CDC also provided funding and technical assistance to support state health departments nationwide in improving hospital policies and practices that increase breastfeeding rates. 56, 57 States have used a diversity of strategies to encourage statewide adoption of the Ten Steps (Table S4) . 59 In California, for instance, the 2013 Senate Bill 402 required that all birthing facilities in the state implement the Ten

Steps. 60 CDC then sends each participating facility an individualized benchmark report that compares the facility's maternity care policies and practices to recommended standards, enabling the facility to identify opportunities for improvement. 57 CDC also disseminates mPINC state reports, which have garnered media attention. 57 In addition, the CDC telephone National Immunization Survey collects data to monitor breastfeeding rates at state and national levels. 61 The results are used to track progress toward the Healthy People 2020 goals on breastfeeding, as well as to identify opportunities for improved maternity care practices. 61 Together, these surveillance activities have likely encouraged adoption, implementation, and maintenance of the Ten

Steps. 56, 57 Measurement of the effectiveness of the Ten Steps has been possible because of the availability of data on breastfeeding and maternity care practices (Table S4 ). Adherence to the Ten Steps improves breastfeeding outcomes, 54, 62 and there is a dose-response relationship between the number of BFHI steps mothers experience and the likelihood of breastfeeding initiation 63 and duration. 64, 65 Moreover, BFHI may reduce socioeconomic and racial disparities in breastfeeding outcomes by providing systemic breastfeeding-friendly services across populations regardless of their sociodemographic characteristics. 63, 66 In spite of this, notable barriers for BFHI success remain including high caesarean section rates 67 and widespread provision of in-hospital infant formula. 68 To sustain momentum of the BFHI in the United States, future efforts should address barriers to adoption of the Ten Steps, such as the high cost of Baby-Friendly designation. 55 Two barriers to maintain Baby-Friendly status are lack of economic incentives for hospitals and the lack of a critical mass of healthcare staff properly trained on breastfeeding and human lactation. Adoption and maintenance of the Ten Steps are also hampered by organizations that question the effectiveness and safety of the BFHI approach. 55 Implementing the Ten

Steps with high fidelity is also challenging because most healthcare systems have not established systems for monitoring maternity care policies and practices. Additionally, there has been a lack of clarity and recommended standards on how to implement Step 10 (foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic), which has often resulted in weak implementation, despite evidence that this step is key for sustaining breastfeeding benefits of BFHI. 54, 62 Furthermore, there is no system for overall coordination and monitoring of BFHI activities at the national, state, and local levels, such as an empowered "National Breastfeeding Committee." Early implementation of the BFHI in Brazil was propelled by public policies that promoted women and children's health. 69, 71 Through the BFHI, the Brazilian government changed practices and routines of maternity units linked to the Unified Health System. 72 In addition, Brazil is a special case in that hospital accreditation not only requires fulfilling the Ten Steps but also other requirements including adoption of the Brazilian version of the WHO International Code of Marketing of Breastmilk Substitutes, as well as birth and delivery best practices. 69, 73 Several implementation strategies contributed to the successful implementation of BFHI. For example, an important strategy for promoting the adoption of BFHI in Brazil was the delivery of a train-thetrainer model and countrywide workshops that facilitated continuous training of health professionals. 74 In 2010, the MOH introduced a computerized monitoring tool for the BFHI accreditation process. This web-based system allows hospitals and evaluators to register the pre-assessment, external evaluation, monitoring, and annual external assessments. Hospitals can access their own data and results, and assessors and states can access information about the hospitals. It also enables the MOH to track progress. 75 In addition, to monitor implementation, the MOH originally hired external evaluators every 3 years to carry out a reaccreditation process; though starting in 2010, BFHI-accredited hospitals began monitoring themselves annually. This self-monitoring process, which is performed by internal health professionals and staff, 73 was established to allow more frequent feedback to hospitals and prevent accredited hospitals from losing their Baby-Friendly status.

Furthermore, successful implementation of BFHI can be attributed, in part, to the strong multisectoral coordination among civil society, celebrities, politicians, health policymakers, the media, international organizations, and researchers. 75 This coordination allowed for adoption and translation of policies into programs by fostering synergies instead of redundancies across sectors and actors (including civil society) and by facilitating decentralization of decision making and consistency of implementation of BFHI across municipalities. 75, 76 As in the United States, the effectiveness of the Ten Steps has been associated with improved short-and longer term breastfeeding outcomes, 77 benefiting both infants and mothers. For example, one study found a 29% decreased risk for mastitis among mothers who gave birth in BFHI hospitals. 78 Successful BFHI implementation has also been associated with increased skin-to-skin contact and roomingin. 69, 79 As a result, exclusive breastfeeding is two times more likely to happen in the first 15 days postpartum in children born in BFHIcertified or accredited hospitals (i.e., accredited refers to those complying with BFHI standards but not yet certified) than among children born in non-BFHI hospitals. 80 Another positive aspect of BFHI has been its extended influence to Baby-Friendly primary healthcare clinics in Brazil. 81, 82 There were also positive spillover effects; evidence indicates that the Ten Steps have extended to hospitals that have not been certified. 83 Opportunities to strengthen the implementation of BFHI in Brazil remain. A current challenge is that the Ten Steps have not been consistently implemented across facilities. 84 For example, there is evidence that BFHI Steps 4 through 10 have not been evenly implemented across hospitals, even after staff received the same training (Step 2), resulting in different exclusive breastfeeding outcomes across settings. 85 Studies examining compliance of the Ten

Steps in Baby-Friendly hospitals in Brazil have documented unsuccessful implementation of Steps 2 (training), 9 (no artificial teats or pacifiers), and 10 (breastfeeding support groups after discharge from the hospital). 86 Furthermore, progress in breastfeeding rates resulting from the BFHI implementation in Brazil can be hampered if there is a decrease in births in BFHI hospitals, as reported in the northeastern region of Brazil. 87 

The RE-AIM framework enabled a structured and systematic approach to evaluating the implementation of the BFHI in the United States and Brazil while allowing comparison of the experiences of each country. Although the United States and Brazil have achieved successful implementation of the Ten Steps of the BFHI following international guidance, the implementation pathways have differed substantially, which is expected given the differences in social, political, economic, and healthcare systems contexts. For example, whereas Brazil has a national healthcare system, the United States does not. Likewise, regulations of infant formula companies' marketing practices have been adopted in Brazil but not in the United States, and therefore, it is not possible for the US government to penalize infant formula companies who market their products disregarding the WHO Code. On the other hand, the experiences of the BFHI in the United States and Brazil illustrate shared drivers for the adoption and reach of the Ten Steps across different country contexts, namely, a combination of strong political support at the national level, public investment, and training and technical assistance. The adoption and implementation of the Ten Steps across many facilities in these two countries, however, required different approaches, given their differing healthcare systems. The Brazil MOH scaled up the BFHI across one national health system, whereas the fragmented health system in the United States required active involvement of numerous hospital systems and government and nongovernmental agencies from the federal to the county or town level.

Finally, both countries established systems for monitoring maternity care practices and policies related to breastfeeding and ensured results were available to facilities, though Brazil employed a selfmonitoring process and the US CDC spearheaded monitoring efforts.

Although the RE-AIM framework does not include an explicit focus on health equity, we were able to capture information about equity in the implementation of the BFHI. For example, we found that equity considerations were at the forefront in the United States, as demonstrated by CDC-led surveillance of breastfeeding rates by states and sociodemographics and efforts directed toward improving maternity care practices to reduce racial/ethnic, income, and geographic disparities in breastfeeding. Our evaluation of the implementation of BFHI in Brazil using the RE-AIM framework yielded information showing that the country applied an equity lens as BFHI was framed into a set of broader national policies aimed at reducing disparities in maternal and infant mortality.

Policies and programs to address childhood obesity are being rolled out at scale in various country contexts, and a consolidated method for evaluating the implementation of these initiatives is needed to enable cross-initiative comparisons and catalyze learning across borders. The analysis in this paper shows that implementation science holds promise for providing insights on drivers and barriers to successful implementation and that the use of specific implementation science frameworks like RE-AIM enables a systematic approach to identifying commonalities and differences in implementation of PAPs to address childhood obesity.

Across the case studies, multisector buy-in and monitoring were instrumental for the successful launch, adoption, and maintenance of PAPs. National governments can use our findings to implement obesity policy changes more efficiently. For example, the FOPL case from Mexico illustrates the great importance of creating demand for such policies, a task that requires heavy evidence-driven civil society mobilization in the absence of political will. 40 The FOPL case from Chile illustrates how rapidly widespread reach can happen followed by rapid documentation of effectiveness (e.g., overwhelming compliance by food industry and reduction in sales of unhealthy foods and beverages) when sound policies are implemented with guidance from monitoring and evaluation systems. These systems also allowed for the rapid detection of an increase in consumption of products containing nonnutritive sweeteners. Mexico, which has just passed the law, was able to take this finding from Chile into account in the development of its FOPL. Mexico could also benefit from other regulations deployed and strongly enforced in Chile to protect minors against the marketing of unhealthy foods and beverages. 88 Similarly, Chile and other countries could learn from the experiences of two Mexican states, Oaxaca and Tabasco, that passed legislation to ban the sales to minors of these products in stores and within school premises. 89 Our findings also illustrate how much context matters when implementing PAPs. For example, despite being based on 10 standardized "steps," BFHI has followed quite different pathways of adoption and implementation across countries. Whereas Brazil has a national healthcare system, the United States does not, making it much more difficult to have national coordination mechanisms to enhance reach, quality of implementation, and overall effectiveness of the Ten Steps in the United States. Likewise, important differences with respect to adoption and implementation were impacted by substantially different approaches to design and stakeholder engagement in the "Open Streets" programs in the United States and Colombia.

The analysis in this paper illustrated major gaps in knowledge regarding RE-AIM dimensions specifically in terms of effectiveness.

Indeed, using RE-AIM to systematically evaluate childhood obesity PAPs highlighted the fact that some key outcome data are not routinely monitored and thus unavailable. This information gap highlights the need for engaging the health sector in longitudinal monitoring and evaluation of childhood obesity PAPs. For example, other than financing, aspects of implementation quality and maintenance were only partially addressed across settings, and therefore, data on those dimensions were limited. In Brazil, documentation of maintenance of the BFHI was sparse. Accordingly, application of the RE-AIM helped point to aspects of implementation that require future investigation.

In addition, our analysis using the RE-AIM framework generated some important insights on equity in the implementation of PAPs to address childhood obesity. In the future, the RE-AIM framework could be enhanced by incorporating an explicit and well-operationalized focus on equity. This would prevent inequities from being overlooked, enable thoughtful attention to equity across the RE-AIM dimensions, and yield more robust assessments of equity in implementation of evidence-based interventions, social justice, and people-centered approaches in design, implementation, and evaluation.

Overall, our analysis highlights that each of the RE-AIM dimensions is instrumental and interdependent, and thus, PAPs to address childhood obesity should work to collect data on all dimensions to help achieve the greatest impact. 7 As illustrated by the three case studies, it is necessary to document all aspects of policy development and subsequent implementation and maintenance phases to identify what works and what does not and take timely corrective actions as needed. This in turn is crucial for cross-pollination or knowledge sharing across countries and regions as clearly illustrated by the FOPL comparative case study. In this way, using an implementation science approach can make important contributions toward addressing these knowledge gaps, enhancing obesity policy dialogue, and producing transferable lessons across the Americas based on North-South-South capacity building collaborations.

In conclusion, we strongly recommend that countries use the tools implementation science offers 90 for research and evaluation during PAP development and on an ongoing basis throughout the implementation and maintenance phases. Although in our study RE-AIM was very useful for doing post hoc policy analysis, future analysis is needed to understand the value of different implementation science systems oriented frameworks that can inform obesity policy decision making, context fit, equitable impact, and cost-effectiveness on a large scale. 90 Looking ahead, this research is also needed to understand how best to adapt anti-obesity PAPs as a result of public health emergencies such as COVID-19 that are affected by and can lead to obesity through disrupted food and physical activity systems. 91 

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Supporting Information section at the end of this article. How to cite this article

Implementation of childhood obesity prevention and control policies in the United States and Latin America: Lessons for cross-border research and practice