key: cord-0902295-e2mgk3ay authors: Finn, Emily B.; Beck, Amy; Sharifi, Mona title: Equitable approaches to reducing the prevalence of pediatric obesity: school nutrition policies and beyond date: 2021-07-30 journal: Int J Obes (Lond) DOI: 10.1038/s41366-021-00924-0 sha: 31eeb27bf3b9285a0937f9ebe778b2440df6eca9 doc_id: 902295 cord_uid: e2mgk3ay nan policies, systems, and environmental factors rooted in structural racism, which drive disparities in overweight/obesity [6] . Promising evidence-based options to mitigate disparities in childhood overweight/obesity include efforts to reduce sugarsweetened beverage (SSB) intake, promote healthy behaviors through affordable summer programming, and modify the built environment in low-income neighborhoods. Despite policy measures enacted to limit SSB intake across various settings, the majority of 5-17 year-old drink SSB daily, with the highest intake among Latino and Black youth, a pattern which is likely driven by targeted marketing to these groups [7] . Equity-focused policies to replace children's SSB intake with water include: eliminating SSB marketing to children, SSB taxes, SSB warning labels, mandating the availability of water in schools and childcare settings, and revising federally-funded nutrition programs by restricting use of Supplemental Nutrition Assistance Program funds to purchase SSB coupled with incentives for fruit and vegetable purchases and eliminating juice allowances from the Special Supplemental Nutrition Program for Women, Infants, and Children [8] . Offering affordable structured summertime programming that encourages healthy behaviors, including healthier eating, more physical activity, and less screen time, may mitigate the accelerated weight gain observed among children during summer school breaks [9] . To best promote equity, such programming should be located within neighborhoods where children are at greatest risk of developing overweight/obesity. Last, children's built environments, including park accessibility, safety, and presence and quality of sidewalks, may protect against pediatric overweight/ obesity by facilitating no-cost physical activity. However, these benefits are modified by local contextual factors such as safety and the size and quality of recreational spaces [10] . Creative and accessible solutions, such as temporarily closing streets, may effectively increase children's physical activity [11] . Importantly, community-based interventions must be developed with community input and engagement to shape the planning process from the very beginning. Cost is certainly an important consideration in intervention selection, and cost-effectiveness models have suggested the costsaving potential of three primary prevention interventions: an excise tax on SSB, eliminating tax deductions on unhealthy foods marketed to children, and standards for food and drink sold in schools [12] . While an external stakeholder group advised the investigators on topics including equity, Gortmaker et al.'s simulation results are based on the US population as a whole. Models are needed that specifically examine differential costeffectiveness among populations disproportionately affected by overweight/obesity to guide identification of the most impactful, efficient, and equitable policies. If policy changes are to have the desired impact on the obesity epidemic, policymakers should consider the wider lens of equity to ensure that policies will be most effective against the historic and ongoing structural racism driving many of the disparities seen in pediatric overweight/obesity. While school nutrition policies are certainly needed, and may have somewhat narrowed disparities in pediatric overweight/obesity, they alone are insufficient and must be part of a broader policy package developed specifically to eliminate disparities. Prevalence of overweight, obesity, and severe obesity among children and adolescents aged 2-19 years: United States School nutrition laws in the US: do they influence obesity among youth in a racially/ethnically diverse state? COVID-19 and changes in child obesity Association between competitive food and beverage policies in elementary schools and childhood overweight/obesity trends: differences by neighborhood socioeconomic resources A framework for increasing equity impact in obesity prevention COVID-19, obesity, and structural racism: understanding the past and identifying solutions for the future Characterizing sugar-sweetened beverage consumption for US children and adolescents by race/ethnicity Sugar-sweetened beverage reduction policies: progress and promise The state of the summer: a review of child summer weight gain and efforts to prevent it Health-equity issues related to childhood obesity: a scoping review Systematic review of how play streets impact opportunities for active play, physical activity, neighborhoods, and communities Three interventions that reduce childhood obesity are projected to save more than they cost to implement This work was supported in part by the National Heart, Lung, and Blood Institute (R01HL151603 and K12HL138037), the National Institute on Minority Health and Health Disparities (R01MD014853), and the National Institute of Child Health and Human Development (1K23HD080876-01A1) of the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. All three authors (EBF, AB, MS) conceived of the work that led to the submission. EBF led the manuscript drafting, all three authors collaboratively revised the manucsript. All three authors approved the final manuscript and agree to be accountable for all aspects of the work. EBF had final responsibility for the decision to submit for publication. The authors declare no competing interests. Correspondence and requests for materials should be addressed to E.B.F. Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.