The impact of a community social marketing campaign on children's meal orders and consumption: main outcomes from a group randomised controlled trial.

OBJECTIVE: Restaurants may be important settings for interventions to reduce children's energy intake. The objective of this study was to test the impact of a parent-focused social marketing campaign to promote healthy children's meals on calories ordered and consumed by children at quick-service restaurants (QSR). DESIGN: Using a repeated cross-sectional study design, two urban communities were randomised to intervention (IN) v. control (C) condition. A community-wide social marketing campaign was implemented in the IN community to empower Black and Latinx mothers who frequent QSR (priority population) to select healthier options for their child. SETTING: Data were collected in 2016 at QSR located within the communities pre- and post-IN and analysed in 2017. PARTICIPANTS: Parents (n 1686; n 819 and n 867 for I and C conditions, respectively) were recruited after placing their QSR order; a survey, receipt and their child's leftovers were collected. RESULTS: Calories ordered did not differ significantly between the IN and C conditions (changeadj = -146·4 kJ (-35·0 kcal); 95 % CI -428·0 kJ (-102·3 kcal), 134·6 kJ (32·2 kcal)). In a sub-analysis of only the priority audience, children in the IN community ordered significantly fewer calories compared to C children in unadjusted models (changeunadj = -510·4 kJ (-122·0 kcal); 95 % CI -1013·4 kJ (-242·2 kcal), -7·5 kJ (-1·8 kcal)), but the trend did not persist after adjusting for covariates (changeadj = -437·2 kJ (-104·5 kcal); 95 % CI -925·5 kJ (-221·2 kcal), 50·6 kJ (12·1 kcal)). Calories consumed followed similar trends. CONCLUSION: The campaign did not significantly reduce children's QSR calories ordered or consumed. However, a quantitatively important mean reduction in calories was suggested among the priority audience, indicating potential for community-wide promotion of healthful children's meals.

Protocol for the Rhode Island CORD 3.0 Study: Adapting, Testing, and Packaging the JOIN for ME Family-Based Childhood Obesity Program in Low-Income Communities.

Background: Overweight and obesity in children is a public health crisis in the United States. Although evidence-based interventions have been developed, such programs are difficult to access. Dissemination of evidence-based pediatric weight management interventions (PWMIs) to families from diverse low-income communities is the primary objective of the CDC Childhood Obesity Research Demonstration (CORD) projects. Methods: The goal of the Rhode Island CORD 3.0 project is to adapt the evidence-based PWMI, JOIN for ME, for delivery among diverse families from low-income backgrounds and to test it in a hybrid effectiveness-implementation trial design in which the aims are to examine implementation and patient-centered outcomes. Children between the ages of 6 and 12 years with BMI ≥85th percentile and a caregiver will be recruited through two settings, a federally qualified health center, which serves as a patient-centered medical home, or low-income housing. Dyads will receive a remotely delivered group-based intervention that is 10 months in duration and includes 16 weekly sessions, followed by 4 biweekly and 4 monthly meetings. Assessments of child and caregiver weight status and child health-related quality of life will be conducted at baseline, and at 4 and 10 months after the start of intervention. Implementation outcomes assessing intervention acceptability, adoption, feasibility, fidelity, and penetration/reach will be collected to inform subsequent dissemination. Conclusions: If the adapted version of the JOIN for ME intervention can be successfully implemented and is shown to be effective, this project will provide a model for a scalable PWMI for families from low-income backgrounds. ClinicalTrials.gov no. NCT04647760.

Helping parents provide vegetable snacks: Investigating price and taste as barriers.

Snacks contribute nearly one-quarter of children's daily energy intake in the USA. Snack time therefore represents an opportunity for parents to provide foods with key nutrients. Instead, the most common snack foods are major contributors to children's consumption of added sugars and sodium. Parents face major barriers to providing healthier snacks, including perceptions of high cost and lack of child acceptance. We obtained both economic and qualitative data to inform and optimize interventions for parents to promote vegetable snacks for children. We conducted a survey with parents (n = 368) to estimate how much of a discount would influence vegetable snack purchases by estimating willingness-to-pay using the contingent valuation method, using baby-cut carrots as a sample product. We conducted three focus groups (n = 19) and 1 group interview (n = 2) with children to help understand how to increase the appeal of vegetable snacks. Most (70%) parents accepted the reference price for the vegetable snack. Among those who did not, contingent valuation analysis revealed that a mean discount of approximately 30% would shift consumers to purchasing the snack. Focus group results revealed that the appeal of vegetable snacks to children was influenced by how they were prepared and presented, and the child's familiarity with the vegetables and ability to choose among them. This study lays the groundwork for effective interventions to promote the provision of vegetable snacks by parents.

Processed and Packed: How Refined Are the Foods That Children Bring to School for Snack and Lunch?

BACKGROUND: Increasing consumption of highly processed foods has been associated with adverse health outcomes among children. In the US, children consume up to half of their daily energy intake at school. OBJECTIVES: We sought to characterize foods that children bring from home to school according to processing level and to evaluate the effectiveness of a school-based intervention, Great Taste Less Waste (GTLW), in reducing the proportion of energy brought from highly processed foods from home compared with control. DESIGN: Secondary data analysis of a 7-month school-based, cluster-randomized trial. PARTICIPANTS/SETTING: Third- and fourth-grade students (n = 502, mean age: 9.0 ± 0.62 years) at 10 public elementary schools in Eastern Massachusetts (school year 2012-2013). INTERVENTION: GTLW included a 22-lesson classroom curriculum, homework activities, monthly parent newsletters, a food shopping and packing guide for parents, food demonstrations, school-wide announcements, and a poster contest. MAIN OUTCOME MEASURES: The energy content of foods brought to school was estimated from digital photographs, and foods were assigned to 1 of 3 processing levels (less processed or unprocessed, moderately processed, or highly processed) based on an established classification system. STATISTICAL ANALYSES PERFORMED: The percentage of energy brought from foods categorized into each processing level was calculated and compared pre- and postintervention using hierarchical linear models. RESULTS: Most of the food brought from home to school was highly processed (70% of food energy brought). Foods categorized as snack foods and desserts contributed the greatest percentage of total energy to the highly processed category at baseline and follow-up (72% and 69%, respectively). Energy from foods brought for snack tended to be more highly processed than those brought for lunch. No significant differences were observed from pre- to postintervention in the GTLW group compared with control for the percentage of energy brought from highly processed foods in adjusted models (ß: -1.1, standard error: 2.2, P = .6) or any other processing level. CONCLUSIONS: Highly processed foods were prevalent in home-packed lunches and snacks, and these patterns persisted after a targeted intervention. Further research is needed to identify strategies to improve the healthfulness of foods brought from home to school.

Addressing Challenges with the Categorization of Foods Processed at Home: A Pilot Methodology to Inform Consumer-Facing Guidance.

The objective of this study was to inform consumer-facing dietary guidance by (1) adapting the current University of North Carolina at Chapel Hill (UNC) food processing framework to include a home processing (HP) component and (2) pilot testing the adapted version using a nationally representative sample of foods consumed in the U.S. The UNC framework was adapted to include guidelines for categorizing home-prepared (HP) foods. The original UNC and adapted HP frameworks were used to code dietary recalls from a random sample of National Health and Nutrition Examination Survey (2015-2016 cycle) participants (n = 100; ages 2-80 years). Percent changes between the UNC and HP adapted frameworks for each processing category were calculated using Microsoft Excel, version 16.23. Participants were 56% female, 35% non-Hispanic white (mean age = 31.3 ± 23.8). There were 1,376 foods with 651 unique foods reported. Using the HP compared to the UNC framework, unprocessed/minimally processed foods declined by 11.7% (UNC: 31.0% vs. HP: 27.4%); basic processed foods increased by 116.8% (UNC: 8.2% vs. HP: 17.8%); moderately processed foods increased by 16.3% (UNC: 14.2% vs. HP: 16.6%); and highly processed foods decreased by 17.8% (UNC: 46.5% vs. HP: 38.2%). Home-prepared foods should be considered as distinct from industrially produced foods when coding dietary data by processing category. This has implications for consumer-facing dietary guidance that incorporates processing level as an indicator of diet quality.

Processed food consumption is associated with diet quality, but not weight status, in a sample of low-income and ethnically diverse elementary school children.

Excess consumption of highly processed foods may be associated with lower diet quality and obesity prevalence, but few studies have examined these relationships in children from low-income households. Therefore, the objective of this study was to evaluate the relationship between food consumption by processing category, diet quality as measured by the Healthy Eating Index-2015 (HEI-2015) and body mass index (BMI) in a sample of low-income children. Data from a study assessing the impact of Summer Food Service participation on diet quality and weight status (N = 131) was used to conduct a cross-sectional analysis of children aged six to twelve years from low-income communities in the Northeastern U.S. Total HEI-2015 score and percentage of calories consumed by processing level were computed per day from three 24-h diet recalls. Multivariable linear regression was used to assess the relationship between percentage of calories from foods by processing category (unprocessed and minimally, basic, moderately and highly processed), HEI-2015 and BMI-z score. The final sample was 58% male and 33.8% obese. On average, children consumed 39.8 ± 17.2% of calories from highly processed foods. A 10% increase in calories consumed from highly processed foods was associated with a 2.0 point decrease in total HEI-2015 score [95% CI (-2.7, -1.2)], and a 10% increase in calories from minimally processed foods was associated with a 3.0 increase in HEI-2015 score [95% CI (2.1, 3.8)]. Relationships between processing level and BMI-z score were not significant. Among this sample of low-income children, greater intake of highly processed foods was associated with lower dietary quality, but not weight status. Future research should explore prospective associations between food consumption by processing category and weight status in children.

Beat osteoporosis - nourish and exercise skeletons (BONES): a group randomized controlled trial in children.

BACKGROUND: Lifelong healthy habits developed during childhood may prevent chronic diseases in adulthood. Interventions to promote these habits must begin early. The BONES (Beat Osteoporosis - Nourish and Exercise Skeletons) project assessed whether early elementary school children participating in a multifaceted health behavior change, after-school based intervention would improve bone quality and muscular strength and engage in more bone-strengthening behaviors. METHODS: The 2-year BONES (B) intervention included bone-strengthening physical activity (85 min/week), educational materials (2 days/week), and daily calcium-rich snacks (380 mg calcium/day) delivered by after-school program leaders. BONES plus Parent (B + P) included an additional parent education component. From 1999 to 2004, n = 83 after-school programs (N = 1434 children aged 6-9 years) in Massachusetts and Rhode Island participated in a group randomized trial with two intervention arms (B only, n = 25 programs; B + P, n = 33) and a control arm (C, n = 25). Outcome measures (primary: bone quality (stiffness index of the calcaneus) and muscular strength (grip strength and vertical jump); secondary: bone-strengthening behaviors (calcium-rich food knowledge, preference, and intake; and physical activity level (metabolic equivalent time (MET) score, and weight-bearing factor (WBF) score)) were recorded at baseline, and after years one and two. Analyses followed an intent-to-treat protocol, and focused on individual subjects' trajectories along the three time points adjusting for baseline age and race via a mixed-effects regression framework. Analyses were performed with and without sex stratification. RESULTS: Children in B + P increased bone stiffness compared to C (p = 0.05); No significant changes were observed in muscle strength, food knowledge, or vertical jump. Children in B + P showed significant improvement in their MET and WBF scores compared to C (p < 0.01) with a stronger effect in boys in both B and B + P (all p < 0.01). CONCLUSION: After-school programs, coupled with parental engagement, serving early elementary school children are a potentially feasible platform to deliver bone-strengthening behaviors to prevent osteoporosis in adulthood, with some encouraging bone and physical activity outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT00065247. Retrospectively registered. First posted July 22, 2003.

Chemicals, cans and factories: how grade school children think about processed foods.

OBJECTIVE: To determine how children interpret terms related to food processing; whether their categorisation of foods according to processing level is consistent with those used in research; and whether they associate the degree of processing with healthfulness. DESIGN: Qualitative data were collected from ten focus groups. Focus groups were audio-recorded, transcribed verbatim, and thematic analysis was conducted. SETTING: Four elementary and afterschool programmes in a large, urban school district in the USA that served predominantly low-income, racial/ethnic minority students. PARTICIPANTS: Children, 9-12 years old, in the fourth-sixth grades (n 53). RESULTS: The sample was 40 % male, 47 % Hispanic with a mean age of 10·4 ± 1·1 years. Children's understanding of unprocessed foods was well aligned with research classifications, while concordance of highly processed foods with research categorisations varied. Five primary themes regarding the way children categorised foods according to their processing level emerged: type and amount of added ingredients; preparation method; packaging and storage; change in physical state or sensory experience; and growing method. Most children associated processing level with healthfulness, describing unprocessed foods as healthier. The most common reason provided for the unhealthfulness of processed foods was added ingredients, including 'chemicals' and 'sugar'. CONCLUSIONS: The current study demonstrated that children have a working knowledge of processing that could be leveraged to encourage healthier eating patterns; however, their understanding is not always consistent with the classification systems used in research. The vocabulary used by researchers and consumers to talk about processing must be reconciled to translate findings into actionable messages.

Perceptions of Processed Foods Among Low-Income and Immigrant Parents.

Background. Parent-aimed guidance on the topic of processed foods may help limit highly processed foods in children's diets, but little is known about parent understanding and perceptions of these products. Aims. To determine how parent perceptions of processing align with processing classification systems used in research, and to identify opportunities for future research in communicating information about processed foods. Method. Six focus groups with lower income, racial/ethnic minority and immigrant parents of fourth to sixth graders (n = 37) were conducted. Parents were asked to discuss their views on terminology related to food processing, classification of foods according to their processing level, the healthfulness of select foods, and criteria for choosing snacks for their children. Focus groups were guided by a thematic approach. NVivo 12 (QSR International) was used to facilitate analyses. Results. Thirty mothers and seven fathers participated. Two thirds (62%) were foreign-born; 38% identified as Hispanic. The term "processing" lacked consistent meaning among parents, with variation by immigrant status. Participants associated highly processed foods with convenience, packaging, and added ingredients; "less-processed" versions of foods (e.g., fresh; homemade) were perceived as healthier. Children's preferences were the main criteria for choosing snacks. Foreign-born parents were more likely to associate processed foods with positive characteristics (e.g., properly cooked). Conclusion. The concept of food processing is an area of misconception among parents, providing an opportunity for education that may be extended to larger audiences. A universally accepted definition of food classification by processing level is necessary to effectively communicate the link between processing and healthfulness.

A qualitative exploration of potential determinants of accelerated summer weight gain among school-age children: perspectives from parents.

BACKGROUND: There is growing evidence that school children in the United States gain weight more rapidly during the summer than the school year, but few studies have explored the causes of this phenomenon. The goal of this study was to qualitatively explore potential determinants of accelerated summer weight gain by interviewing parents of school-age children. METHODS: Key informant interviews were conducted with parents of third and fourth grade students enrolled in a school-based physical activity intervention in three peri-urban communities in Eastern Massachusetts. A structured interview guide was developed to assess school year and summertime differences in child diet, physical activity, daily routine, and family rules. Interviews were recorded and transcribed verbatim. Transcripts were coded and major themes were identified using thematic analysis. RESULTS: Summer activities varied substantially by family. Many parents characterized summer as a time with less structure and more relaxed rules, particularly around bedtime and screen use. Parents perceived their child to be more physically active in the summer and reported few barriers to summertime physical activity. Parents reported increases in both positive (increased consumption of fruits and vegetables) and negative (increased consumption of "sweets" and "junk foods") dietary behaviors. They highlighted several stressors unique to summer, such as the high cost of camps and the need to coordinate childcare and manage children's time. CONCLUSIONS: Parents perceived their children to be more physically active in the summer and consume more fruits and vegetables than during the school year. However, they also perceived children to consume more energy-dense, nutrient poor foods, engage in more screen time, and have later bedtimes during the summer. These behaviors are important targets for summertime obesity prevention interventions. Large-scale quantitative studies are needed to determine whether these parent perceptions reflect meaningful risk factors for accelerated summer weight gain.

Robustness of Food Processing Classification Systems.

Discrepancies exist among food processing classification systems and in the relationship between processed food intake and dietary quality of children. This study compared inter-rater reliability, food processing category, and the relationship between processing category and nutrient concentration among three systems (Nova, International Food Information Council (IFIC), and University of North Carolina at Chapel Hill (UNC)). Processing categories for the top 100 most commonly consumed foods children consume (NHANES 2013-2014) were independently coded and compared using Spearman's rank correlation coefficient. Relative ability of nutrient concentration to predict processing category was investigated using linear discriminant analysis and multinomial logistic regression and compared between systems using Cohen's kappa coefficient. UNC had the highest inter-rater reliability (ρ = 0.97), followed by IFIC (ρ = 0.78) and Nova (ρ = 0.76). UNC and Nova had the highest agreement (80%). Lower potassium was predictive of IFIC's classification of foods as moderately compared to minimally processed (p = 0.01); lower vitamin D was predictive of UNC's classification of foods as highly compared to minimally processed (p = 0.04). Sodium and added sugars were predictive of all systems' classification of highly compared to minimally processed foods (p < 0.05). Current classification systems may not sufficiently identify foods with high nutrient quality commonly consumed by children in the U.S.

Accelerated Summer Weight Gain in a Low-Income, Ethnically Diverse Sample of Elementary School Children in Massachusetts.

Background: Several studies have found that children in the United States gain weight at a faster rate in the summer than in the school year, but little is known about the prevalence of this problem, its effect on high-risk subgroups, or its determinants. This study compares school year and summer weight change in a low-income, ethnically diverse sample of school-age children in Massachusetts and explores differences by race/ethnicity, weight status, and exposure to school year physical activity (PA) programming. Diet and PA are examined as potential mediators of summer weight gain. Methods: Children participating in a school-based PA program evaluation (in which weight change was not a primary outcome) had their height and weight measured three times between October 2015 and September 2016 to capture a school year and summer interval. Diet and PA patterns were assessed mid-school year and mid-summer in a subsample of children. Mixed linear models were used to estimate the effect of season (school year vs. summer) on change in BMI and to examine the influence of race/ethnicity, weight status, and program (walk/run, classroom activity breaks, or control) on any observed effects. Structural equation models were used to explore diet and PA as mediators of seasonal weight change in a subsample of participants. Results: Of 769 participants, 53% were non-Caucasian, 40% were overweight or obese, and 58% were eligible for free or reduced-price school meals. BMI increased in both the school year and summer but increased more rapidly in the summer (0.046 kg/m2 more per month, p = 0.007). Of the three tested interactions, statistical significance was only observed between season and program (χ2 = 14.90, p < 0.001); on average, children exposed to a school year walk/run program did not gain weight more rapidly during the summer, whereas children in the control group and a classroom activity breaks program did. Poorer diet and PA patterns were observed in the summer, but neither diet nor PA was statistically significant mediators of BMI change. Conclusions: Children in this high-risk sample gained weight at a faster rate during the summer than during the school year, with no discernable demographic differences. However, this phenomenon was not observed in the subgroup exposed to a school year walk/run program. More research is needed to clarify the determinants of summer weight gain and understand how school year programming and its effects can be transferred to the summer months.

The State of the Summer: a Review of Child Summer Weight Gain and Efforts to Prevent It.

PURPOSE OF REVIEW: Accumulating evidence shows that children in the USA gain weight more rapidly during the summer, when school is not in session. This narrative review spanning 2007 to 2017 summarizes efforts to characterize the problem, identify key determinants, and intervene to prevent excess summer weight gain. RECENT FINDINGS: Summer weight gain remains a concern for elementary-age youth. Few studies have examined its determinants, but unfavorable summertime shifts in diet, physical activity, sedentary time, screen media use, and sleep have been reported. Increased structure is thought to protect against summer weight gain. Interventions to support physical activity and nutrition during the summer show promise, though large-scale impact on weight outcomes remains to be seen. Supporting health behaviors during the summer remains a priority for obesity prevention researchers, practitioners, and policymakers. Strategies to expand access to structured programs and reach beyond such programs to improve behaviors at home are of particular importance.

Factors Influencing Fluid Milk Waste in a Breakfast in the Classroom School Breakfast Program.

OBJECTIVE: To determine predictors of fluid milk waste in a Breakfast in the Classroom School Breakfast Program. DESIGN: Cross-sectional with 3 repeated measures/classroom. SETTING: Elementary schools in a medium-sized, low-income, urban school district. PARTICIPANTS: Twenty third- through fourth-grade classrooms across 6 schools. MAIN OUTCOMES: Dependent variables include percentage of total and served milk wasted. Independent variables included observed daily menu offerings, program factors, and teacher and student behavior. ANALYSIS: Descriptive statistics were used to characterize variables across classrooms and schools. Multilevel mixed-effects models were used to test associations between predictors and outcomes of interest. P ≤ .05 was considered statistically significant. RESULTS: Total milk waste increased 12% when juice was offered and 3% for each additional carton of unserved milk. Teacher encouragement to take and/or consume breakfast was associated with a 5% and 9% increase in total and served milk waste, respectively. When students were engaged in other activities in addition to eating breakfast, total milk waste decreased 10%. CONCLUSIONS AND IMPLICATIONS: Beverage offerings were predictive of greater total milk waste. Teacher and student behavior also appeared to influence milk consumption. Findings suggest that specific changes to School Breakfast Program implementation policies and practices could have an important role in waste mitigation.

Branding a School-Based Campaign Combining Healthy Eating and Eco-friendliness.

OBJECTIVE: To develop a branding strategy for a campaign to improve the quality of foods children bring from home to school, using a combined healthy eating and eco-friendly approach and for a control campaign focusing solely on nutrition. METHODS: Formative research was conducted with third- and fourth-grade students in lower- and middle-income schools in Greater Boston and their parents. Phase I included concept development focus groups. Phase II included concept testing focus groups. A thematic analysis approach was used to identify key themes. RESULTS: In phase I, the combined nutrition and eco-friendly messages resonated; child preference emerged as a key factor affecting food from home. In phase II, key themes included fun with food and an element of mystery. Themes were translated into a concept featuring food face characters. CONCLUSIONS AND IMPLICATIONS: Iterative formative research provided information necessary to create a brand that appealed to a specified target audience.

Nutritional, Economic, and Environmental Costs of Milk Waste in a Classroom School Breakfast Program.

OBJECTIVES: To measure fluid milk waste in a US School Breakfast in the Classroom Program and estimate its nutritional, economic, and environmental effects. METHODS: Fluid milk waste was directly measured on 60 elementary school classroom days in a medium-sized, urban district. The US Department of Agriculture nutrition database, district cost data, and carbon dioxide equivalent (CO2e) emissions and water footprint estimates for fluid milk were used to calculate the associated nutritional, economic, and environmental costs. RESULTS: Of the total milk offered to School Breakfast Program participants, 45% was wasted. A considerably smaller portion of served milk was wasted (26%). The amount of milk wasted translated into 27% of vitamin D and 41% of calcium required of School Breakfast Program meals. The economic and environmental costs amounted to an estimated $274 782 (16% of the district's total annual School Breakfast Program food expenditures), 644 893 kilograms of CO2e, and 192 260 155 liters of water over the school year in the district. CONCLUSIONS: These substantial effects of milk waste undermine the School Breakfast Program's capacity to ensure short- and long-term food security and federal food waste reduction targets. Interventions that reduce waste are urgently needed.

Lessons learned from two decades of research in nutrition education and obesity prevention: Considerations for alcohol education.

OBJECTIVE: Effective health interventions involve an understanding of the specific needs and wants of the population to be served. Lessons from more than two decades of obesity prevention can be applied to understanding how to design and implement other behaviorally-focused health interventions, including those for alcohol education. METHODS: Three obesity prevention campaigns were reviewed and evaluated for elements critical to their success in achieving desired outcomes. RESULTS: Evaluation of the three cases studies revealed six key elements common to successful interventions. These include: specifying the desired outcome at the outset, understanding the target population, identifying a framework for the intervention, creating a campaign "identity", enlisting champions, and evaluating both outcomes and process. CONCLUSION: Successful health interventions should be behaviorally-focused and include multiple components to address the various factors that influence behavior. A clear understanding of how and why desired outcomes were achieved can inform dissemination to a wider audience and improve sustainability. PRACTICE IMPLICATIONS: Lessons learned from obesity prevention provide guidance for development of alcohol education. It must be acknowledged that there is still much to be learned to maximize success in prevention efforts. It is likely that analysis of future efforts in alcohol education can contribute to that understanding.

The critical role of communications in a multilevel obesity-prevention intervention: Lessons learned for alcohol educators.

OBJECTIVE: Multilevel interventions to prevent underage drinking are more effective than individual-level strategies, and messaging campaigns are key to such approaches. Recognizing the benefits of translating best practices across public health domains, this paper details the communications campaign from Shape Up Somerville (SUS), an exemplar for multilevel community-based approaches to address pediatric obesity, highlighting lessons learned for alcohol educators. METHODS: All elements of SUS, including the communications strategy, were developed collaboratively with local partners. Communication initiatives included community-engaged brand development to unify diverse intervention components; school-based communications to promote new opportunities for healthy eating and physical activity; and media partnerships to promote healthy behaviors community-wide. RESULTS: The overall SUS intervention was effective in reducing prevalence of overweight/obesity among first- to third-graders in Somerville relative to control communities. Process evaluation showed that communications successfully reached diverse community segments and raised awareness of and receptivity to changes. CONCLUSIONS AND PRACTICE IMPLICATIONS: Communications campaigns are essential components of multilevel interventions addressing public health challenges including obesity and underage drinking. Such communications should be developed collaboratively with the target audience and stakeholders, designed to engage community members at multiple levels through multiple channels within a systems framework, and sustained through local partnerships.