Purpose: Body mass index (BMI) is widely used in childhood obesity surveillance despite limitations in capturing central adiposity, which has been hypothesized to relate to reduced participation in movement. This study compared associations between z-score waist circumference (zWC), z-score waist-to-height ratio (zWHR), and BMI and device-measured physical activity in predominantly African American, low-income schoolchildren. Methods: This cross-sectional study included 264 schoolchildren aged 5–12 years (146 girls, 118 boys; mean age 8.5 ± 1.8 years; ~86% African American; ~93% eligible for free/reduced-price lunch). Anthropometrics and free-living PA (Actigraph GT9X) were measured. Regression models evaluated associations between each anthropometric z-score and PA intensities, adjusting for age, sex, wear time, and school. Results: Measures of central adiposity showed inverse associations with physical activity that were of similar or slightly greater magnitude than those for BMI, although differences between models were modest. All three adiposity measures (zWC, zWHR, zBMI) were significantly and negatively associated with total moderate–vigorous physical activity (MVPA), only in girls. A one-unit increase in zWC was associated with a decrease of 3.334 min/day in MVPA. The largest negative associations were observed for zWC and zWHR with vigorous activity. Conclusions: In this population of schoolchildren, waist-based measures showed inverse associations with physical activity of similar or slightly greater magnitude than BMI, particularly among girls. Although modest differences in model fit prohibit claiming superiority over BMI, these findings support utilizing waist-based measures as practical, low-cost complements to traditional BMI in school-based surveillance and activity targeting.

BACKGROUND:This study aimed to examine the cumulative effect of income on hepatocellular carcinoma (HCC) risk in individuals with type 2 diabetes (T2D). METHODS:A nationwide cohort of 1,516,897 adults with T2D and no history of cancer (2015-2016 baseline) from the Korean National Health Insurance Service was analyzed. Annual income was categorized into quartiles based on health insurance premiums, designating the highest quartile and lowest quartile as high- and low-income groups, respectively. Cumulative income status was assessed over 5 years, including the 4 years preceding and the baseline year. Incident HCC was identified via International Classification of Diseases, Tenth Revision (ICD-10) code. RESULTS:The hazard ratio (HR) for 5-year consistent high-income status was 0.68 [95% confidence interval (CI), 0.65-0.72] compared with those never classified as the high-income group, whereas the HR for 5-year consistent low-income status was 1.34 (95% CI, 1.26-1.43) compared with those never classified as the low-income group. The HCC risk showed a significant duration-dependent trend in relation to cumulative exposure to low or high income, respectively (Ptrend < 0.0001). The association was stronger in those without chronic liver disease or major cancer risk factors and remained robust after adjusting for diabetes-related factors. CONCLUSIONS:Prolonged low- or high-income status was independently associated with HCC risk among individuals with T2D, with a clear duration-dependent pattern. IMPACT:These findings emphasize how income stability independently affects the incidence risk of HCC in individuals with T2D.

Introduction:Universal free meal (UFM) policies provide school breakfast and lunch at no cost to all students, increasing participation, improving dietary quality, and reducing household food insecurity. Whether these policies affect children's health care spending is unknown. Methods:Using linked Arkansas education and Medicaid claims data (2013-2020) and a stacked difference-in-differences design across 4 UFM adoption cohorts, we examined changes in Medicaid spending among 131 851 continuously enrolled Medicaid children before and after school-level UFM adoption. Results:The aggregate effect across the 2 post-adoption years was not statistically significant (spending ratio 0.973; 95% CI 0.932-1.016). However, spending declined significantly in the second post-adoption year (spending ratio 0.937; 95% CI 0.889-0.987), a 6.3% reduction. Reductions were concentrated in inpatient and pharmacy spending for mental, behavioral, and neurodevelopmental disorders, alongside increased outpatient spending in these categories. Conclusions:UFM adoption was associated with a delayed but significant reduction in Medicaid spending, driven largely by shifts in mental and behavioral health care utilization. These findings suggest school nutrition policy may influence health care spending among publicly insured children.

Supplementary Table S1 presents the baseline characteristics of study participants stratified by the cumulative number of years in low- or high-income groups over a 5-year period.

Supplementary Table S4 provides the results of a 5-year landmark analysis assessing the hazard ratios for hepatocellular carcinoma according to cumulative income consistency and baseline income status.

Since 2014, the number of schools offering universal free meals to all enrolled children without requiring annual meal applications has increased meaningfully. Using USDA's Purchase to Plate Crosswalk, a difference-in-differences framework, and a nationwide consumer panel, the effect of universal-free-meal exposure on the diet quality of food-at-home purchases is assessed in terms of the Healthy Eating Index (HEI). Consistent with earlier findings, households exposed to universal free meals reduce grocery spending by over 6%. There is no deleterious overall effect of universal-free-meal exposure on the diet quality of food-at-home purchases as measured by the HEI.

Supplementary Table S3 displays the association between income parameters (cumulative years in income groups and baseline status) and the risk of hepatocellular carcinoma, adjusted for additional potential mediators in Models 4 and 5.

Objectives: This study characterized variation in rates of new medical diagnoses of ADHD among kindergartners and identified factors associated with diagnosis rates.Methods: This study analyzed 87,383 kindergartners who were not diagnosed with ADHD prior to kindergarten who attended at least one of 490 elementary schools in Arkansas. The study examined five kindergarten cohorts from the 2015/16 to 2019/20 academic years, assessing school-level variation in ADHD diagnosis rates. Schools were categorized by quintiles of their ADHD diagnosis rates. A mixed-effects logistic regression model was used to examine individual-level factors associated with new ADHD diagnosis.Results: Diagnosis rates varied 570% across school quintiles. Schools with higher rates of ADHD diagnoses served a higher percentage of African American children, children from lower-income families, and children living in neighborhoods with lower Child Opportunity Index (COI) scores. Results of an individual-level logistic regression analysis indicated children in census tracts with very high or high social and economic COI scores had lower odds of having new ADHD diagnoses compared to those from very low COI neighborhoods. Children who were young-for-grade had higher odds of an ADHD diagnosis. Children who were in schools providing universal free school meals had lower odds of an ADHD diagnosis, despite these schools serving more children from families with lower incomes, a finding that warrants further exploration.Conclusions: New ADHD diagnoses in kindergarten varies substantially across schools.

Abstract Introduction: Cancer survivors are at elevated risk of developing diabetes and often experience treatment-related changes in body composition and insulin sensitivity. However, few studies have evaluated whether general and central obesity, independently and jointly, are associated with diabetes risk in long-term cancer survivors. We examined whether obesity phenotype (general, central, or combined) is associated with incident diabetes among women cancer survivors. Methods: We included 1,924 women (aged 35 to 74 years) from the Sister Study (enrolled 2003-2009) who reported a history of cancer other than breast or non-melanoma skin cancer and had no diabetes at baseline. We excluded participants diagnosed <1 year before enrollment (median time since diagnosis: 11.6 years). Participants were followed through September 2021. General obesity was defined as examiner-measured body mass index (BMI)≥30 kg/m2, and central obesity as waist-hip ratio (WHR)≥0.85. Participants were categorized as: no obesity (BMI<30, WHR<0.85), central-only (WHR≥ 0.85, BMI<30), general-only (BMI ≥30, WHR<0.85), and combined obesity (BMI≥30 and WHR ≥0.85). Incident diabetes was identified by self-reported new physician diagnosis during follow-up. Multivariable Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for incident diabetes across obesity phenotypes. Results: At baseline 16.5% of participants had central-only obesity, 14.0% had general-only obesity, and 13.3% had combined obesity. Over a median follow-up of 12.9 years, 157 women (8.2%) developed incident diabetes. After adjusting for potential confounders, central obesity alone was associated with more than 2-fold higher diabetes incidence (HR 2.14, 95% CI 1.25-3.68), and general obesity alone showed a similar >2-fold association (HR 2.33, 95% CI 1.38-3.92), each compared with no obesity. The combined obesity phenotype was associated with the highest incidence, showing a more than 6-fold risk (HR 6.48, 95% CI 4.13-10.19) with a significant multiplicative interaction between general and central obesity (p for interaction <0.0001). Alternative central obesity parameters (waist circumference ≥88 cm and waist-height ratio ≥0.50) showed similar associations. Associations were generally consistent across categories of time since cancer diagnosis (<5 years, 5-<15 years, and ≥15 years). These associations also were seen among women with prevalent hypertension, dyslipidemia, or cardiovascular disease. Conclusion: Our findings suggest that central and general obesity, especially in combination, are strongly positively associated with diabetes incidence in cancer survivors. Incorporating WHR-based obesity assessment into survivorship care may help identify women cancer survivors who would benefit from targeted diabetes prevention and monitoring. Citation Format: Mahfuja Luna, Hazel B. Nichols, Katie M. O'Brien, Michael G. Fradley, Mario Schootman, Michael R. Thomsen, Benjamin C. Amick III, Clarice R. Weinberg, Dale P. Sandler, Yong-Moon (Mark) Park. Waist-hip ratio (WHR) defined obesity phenotype and risk of diabetes in cancer survivor women from Sister Study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2026; Part 1 (Regular Abstracts); 2026 Apr 17-22; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2026;86(7 Suppl):Abstract nr 884.

We examine whether providing free school meals to all students causes changes in out-of-school suspensions for schools adopting those policies in the United States. Using updated data and modern difference-in-differences methods that account for staggered adoption, we show suspensions fall by approximately 10% in elementary schools and 6% in middle and high schools, with larger effects in schools that previously served fewer students eligible for free and reduced-price meals in preadoption periods. These findings contrast with earlier null results, primarily due to better methods that account for staggered program adoption as opposed to the updated dataset.

ABSTRACT Introduction Adolescent obesity is a strong predictor of adult obesity and increases the risk of costly comorbidities. Estimating the long‐term individual medical expenditures associated with adolescent weight status is critical for evaluating the cost‐effectiveness of prevention and treatment strategies. Objective Measure the association between adolescent weight status and health care expenditures in early adulthood. adulthood. Methods This longitudinal cohort study linked students' 10th grade body weight to health care expenditures (total medical, outpatient, inpatient, emergency department, and pharmacy) during the 30th year of life. A two‐part model was used to assess differences in costs within the extensive (having “any” spending) or intensive (amount of spending among those with spending) margins. Marginal effects were used to estimate the difference in health care expenditures at age 30 between individuals with higher weight status in the 10th grade (overweight, obesity, or severe obesity) compared with those with a healthy weight. Results Individuals with obesity in the 10th grade had greater total annual expenditures at age 30 ($542, 95% CI $139–$945) compared to individuals with a healthy weight. Individuals with severe obesity had higher expenditures across all outcomes. Total medical expenditures were $874 more than individuals with a healthy weight, while inpatient expenditures were $159 more, outpatient expenditures were $387 more, and pharmacy expenditures were $222 more. Differences in inpatient expenditures were primarily at the intensive margin, while emergency department expenditures differed mainly at the extensive margin. Outpatient expenditures varied at both margins. Conclusions Higher weight status in adolescence is associated with higher health expenditures in young adulthood, with the highest spending among 10th graders with severe obesity.

Supplementary Table S2 shows the baseline demographic and clinical characteristics of individuals with type 2 diabetes, categorized by their baseline income status including Medical Aid beneficiaries and income quartiles.

Background: This study aimed to compare recess physical activity, social behaviors, and social/school perceptions among children with obesity and severe obesity and those without obesity. Methods: Recess observations were done using the System of Observing Children's Activity and Relationships during Play. School climate surveys and anthropometric measurements were also completed. A total of 414 observations from 160 (52% female) children were collected at four schools in Little Rock, AR, during three semesters from 2023 to 2024. Children were in kindergarten through 5th grade. Linear mixed-effects models were used to estimate adjusted associations. Results: Thirteen percent of observations reflected children with severe obesity, 21% were from children with obesity, and 66% were from children with a BMI below the 95th percentile on the age- and gender-specific reference growth charts. Overall, children were engaged in moderate-vigorous physical activity 64% of the time and played alone 22% of the time. Positive play was observed 50% of the time. Children with severe obesity played alone 8% (p < 0.05) more than the reference group without obesity. There was no evidence of an inverse association between obesity and physical activity. Surveys from upper elementary children showed no differences in self-reports of being happy, having friends, or enjoying recess by weight status. Conclusions: While we observed more alone play at recess among children with severe obesity, we did not observe less physical activity or more negative play experiences among children with obesity or severe obesity. Recess appears to be beneficial regardless of weight status, both socially and for physical activity.

Objective:The Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides access to nutritional resources to low-income children starting at birth through enrollment in kindergarten or turning five years old. The objective of this study was to quantify the effect of aging out of WIC prior to kindergarten on a child's weight status in kindergarten. Methods:This study used WIC certification data merged with a state-wide body mass index (BMI) dataset among kindergarteners measured between 2019 and 2023 in Arkansas and included children who remained enrolled in WIC until at least 30 days before their fifth birthday (N = 14,045). We used a multivariable linear regression to estimate the association between a child's WIC gap (i.e., the time in days between when a child aged out of WIC at age five and the child's kindergarten start date) and the child's BMI/BMI95 in kindergarten. Results:Among kindergarteners, the mean BMI/BMI95 was 0.915 and the average WIC gap was 0.56 years. The fully adjusted multivariable regression found no association between the duration of aging out of WIC and BMI/BMI95 in kindergarten (β = -0.002, 95 %CI = -0.012, 0.008). The association between the duration of aging out of WIC and BMI/BMI95 in kindergarten remained insignificant even after the population was subset to kindergartners with a free (β = -0.003, 95 %CI = -0.013, 0.007) or paid (β = -0.001, 95 %CI = -0.017, 0.015) meal status. Conclusions:Aging out WIC is not associated with a kindergartener's weight status. Additional analyses are needed to better understand the potential implications of extending WIC until a child's sixth birthday.

Objective:Physical activity opportunities, such as recess, in educational settings are vital yet only a handful of states have policies in place to ensure daily minimum recess allotment. We aim to investigate associations between physical activity during recess and other time periods to better understand the extent to which recess physical activity is related to physical activity throughout the week. Methods:Children K-5th grade were from four schools in Little Rock, Arkansas. Children wore accelerometers on their waist to assess physical activity across the week. Chi-square and t-tests or Wilcoxon rank-sum tests and multi-level mixed effects generalized linear regression were used for non-normally distributed variables and accounting for repeated observations. Data collection took place from Spring 2023 through Spring 2024 and included three semesters. Results:Children (n = 135, 51.9 % girls) had a median of 37.0 min of MVPA on both weekdays and weekend days. Children spent 16.7 % of recess in MVPA equaling 26.8 % of their total school MVPA, and 15.5 % of weekday MVPA. Children meeting physical activity guidelines, especially boys, had higher levels of MVPA across all time periods. Conclusions:Recess plays a crucial role in overall physical activity, with recess MVPA showing a positive correlation with physical activity across all time periods. Further research is needed examining the effects of changes in recess policies and interventions to increase recess MVPA, which may lead to increases in children's overall physical activity.

Background:Physical activity levels are declining among middle and high school students, and schools could provide an ideal space for engaging adolescents in physical activity. The study aimed to assess physical activity levels among male and female middle to high school students and the impact of perceived school climate. Methods:This longitudinal study utilized the Georgia Student Health Survey (GSHS) from 2016 to 2020, with change in the proportion of physically active students as an outcome and school climate measures as predictors. Factor analysis yielded a composite index for each school climate measure. Descriptive analysis measured the trend and male vs. female differences in physical activity. A multivariable linear regression model was developed to assess the impact of school climate on physical activity and male-female differences. Results:The decline in physical activity with increasing grade levels was notably more pronounced in females than males. Improvement in the perception of school climate measures was consistently linked to an increased proportion of physically active students as they progressed to higher grades (for example, change in perception of school connectedness: β = 5.39; p < 0.001). Conclusion:The study findings underscore the importance of fostering positive school climates to mitigate the decline in physical activity levels, especially among adolescent females.

Overweight and obesity is a complex, multifactorial disease that increases the risk of several cancers. The purpose of this study is to calculate the population-attributable fraction (PAF%) of obesity-associated cancer rates among adults from 2010-2019 in Arkansas by sex, race, and ethnicity. Obesity-associated cancer data for this period were obtained from the Arkansas Central Cancer Registry. The PAF% was calculated using obesity prevalence and global relative risks. Obesity prevalence data were gathered from the Arkansas Behavioral Risk Factor Surveillance System. Global relative risks for each obesity-associated cancer were gathered from large-scale epidemiological studies, meta-analyses, and systematic reviews in which body mass index (BMI) was ≥ 30 kg/m2. Obesity-attributable cancer age-adjusted incidence rates (AAIRs) were calculated by multiplying the obesity-associated cancer's AAIR by the estimated PAF%. Breast, esophageal adenocarcinoma, gallbladder, kidney, and liver obesity-associated cancers each had a PAF% greater than 25% by sex, race, and ethnicity. Arkansas non-Hispanic (NH) Black women were disproportionately impacted by obesity-attributable cancers, with a disparity driven primarily by the higher incidence of breast and other female-specific cancers. Findings suggest that targeted screening among those with BMI ≥ 30 kg/m2 could decrease the burden of obesity-associated and attributable cancers in Arkansas, particularly for breast and colorectal cancers.

Abstract Introduction: Type 2 diabetes (T2D) is associated with over 2 times increased risk of hepatocellular carcinoma (HCC). Low-income status is associated with a higher risk of developing HCC, more advanced stage, and mortality. Evidence is limited on whether income dynamics are associated with the risk of developing HCC in individuals with T2D who are susceptible to income changes. We examined whether income levels and income changes are associated with HCC risk. Methods: Using representative data from the Korean National Health Insurance Service (NHIS), 2,227,893 adults with T2D (aged ≥ 20 years) without a cancer history were included between 2015-2016. Income levels were measured based on health insurance premiums and categorized into 4 levels (quartiles [Q], 1 [low income], to 4 [high income]). These quartiles excluded the very low-income individuals who qualified as Medical Aids beneficiaries (MAB), which comprised a 5th income category. To identify income change, income levels were collected annually from the baseline year backward 4 years. The incident HCC, defined based on ICD-10 codes and special reimbursement codes, was identified until December 2020. Hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated to assess the association between income parameters and HCC after adjusting for sociodemographic factors, comorbidities, and diabetes duration and treatment. Income parameters included 1) the baseline income status, 2) the cumulative number of years being in each income level, and 3) changes in income level between the two time points (4 years ago vs. baseline). Results: During follow-up (median, 3.9 years), 9,887 HCC cases developed. Individuals who had experienced at least one episode of MAB during the five years showed a significantly higher HCC risk than those who had never qualified as MAB (HRs ranging from 1.52 to 2.01). In contrast, individuals who had experienced high-income status (Q4) during the five years had a lower HCC risk than those who had never experienced (HRs ranging from 0.79 to 0.92; HRn=5 years vs. n=0 years 0.79, 95% CI 0.75-0.83; P for trend <0.05). Individuals in the low-income status (MAB-Q1) at the first assessment (4 years ago) but experienced increased income had a reduced risk of HCC, which linearly declined with increasing income rise. Also, those who experienced a substantial increase in income up to the top quartile (Q4) had the lowest HCC risk (HR 0.73, 95% CI 0.60-0.88; P for trend<0.05) than those who maintained the low-income status. Conclusions: Experiencing any very low- or high-income state was independently associated with increased or decreased HCC risk. Improved income levels among those in the low-income status had an inverse linear association with reduced HCC risk. Our findings underline the need for increased public policy awareness of the impact of income dynamics on HCC risk in adults with T2D. Citation Format: Jongha Baek, Benjamin C. Amick III, Clare C. Brown, Mario Schootman, Marie-Rachelle Narcisse, Seung-Hyun Ko, Pearl A. McElfish, Michael R. Thomsen, Seong-Su Lee, Kyungdo Han, Yong-Moon Mark Park. Income dynamics and the risk of hepatocellular carcinoma in individuals with type 2 diabetes: A nationwide population-based cohort study [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4865.

Objective: Recess contributes meaningfully to physical activity (PA), but recess time has declined. The study's purpose was to report PA by age, gender, and playground feature to inform potential playground configurations more conducive to PA during recess. Methods: Using the System for Observing Play and Leisure Activity in the Youth, kindergarten through 5th grade recesses were observed on at least four days at four schools in Little Rock, Arkansas, United States during May 2023. Target playground features were ball courts, grass, pavement, play structures, and swings. To provide inferential analysis, a comparison of conditional means across playground features, age, and gender was conducted using linear regression with robust standard errors clustered by school. Results: 3,356 playground scans (intercoder correlation = 0.93) were collected and aggregated by school, day, gender, age (grade), and target feature for a sample size of 292 observations. The gender gap was widest among 4-5th graders, 79 % (95 % CI: 72, 86) for males and 64 % (95 % CI: 58, 70) for females. Among females, PA was highest on swings [82 % (95 % CI: 77, 86)] and lowest on paved areas [56 % (95 % CI: 43, 69)]. Among males, it was highest on both swings [81 % (95 % CI: 75, 86)] and ball courts [83 % (95 % CI: 77, 89)] and lowest on grassy areas [64 % (95 % CI: 60, 67)]. Conclusion: Swings, courts, and play structures were associated with a higher proportion of children being engaged in PA. Research is needed to identify whether physical improvements to facilitate access to these features increase PA.

Purpose:To evaluate the impact of the 2022 infant formula shortage on self-reported anxiety and depression. Background:The US national infant formula shortage of 2022 originated from supply chain disruptions triggered by the COVID-19 pandemic, and the shortage was further compounded by a recall of tainted formula products. Methods:We used survey-weighted data from the Household Pulse Survey (HPS) to measure self-reported anxiety and depression among individuals with formula-fed infants less than 1 year of age. We evaluated the association between 2 formula disruption variables (being impacted by the infant formula shortage or having difficulty obtaining formula in the last 7 days) with 2 mental health outcomes (anxiety and depression) using multivariable logistic regressions. Results:We found increased odds of self-reported anxiety (aOR: 3.13; P < .001) and depression (aOR: 3.05; P = .005) for respondents affected by the infant formula shortage. There were no adjusted associations between having difficulty obtaining formula in the last 7 days and anxiety and depression. Conclusions:Individuals affected by the infant formula shortage had increased odds of both anxiety and depression. Continued efforts to improve food security for low-income infants is critical for ensuring equitable nutritional and health outcomes across infant populations. Implications for practice and research:Continued efforts to reduce food insecurity for low-income infants are critically needed, as infant nutrition impacts caregiver mental health and infant health. Efforts to improve lactation support and breastfeeding initiation are needed in addition to improvements in access to formula.