Feasibility of a Physical Activity Index in Clinical Practice: Perspectives of Providers and Cancer Patients.

Physical activity is a common clinical recommendation for cancer survivors, yet the use of clinical tools to counsel patients is understudied. We developed an integrated Physical Activity Index to assist with this task. The purpose of this project was to conduct interviews to assess the feasibility and clinical utility of the Physical Activity Index from both provider and patient perspectives. Our findings indicate that a Physical Activity Index may be a useful tool to facilitate productive patient-provider communication about physical activity goals.

Consumers pay attention to ingredients on the front of a label: an eye tracking study.

Sunscreen is an important part of skin cancer prevention. The Food and Drug Administration (FDA) proposed numerous changes to sunscreen labeling including adding active ingredients to the front of a label. The purpose of the study was to identify and describe differences in attention between current label formatting and the proposed label formatting. Forty-seven participants were interviewed. Participants were presented with mock sunscreen labels that resembled current labeling or labeling based on the proposed FDA rule. While reading the labels, eye movements were recorded. Participants spent 12.3 s longer looking at the front of the proposed rule-compliant label than they did on the front of the current label. They spent the longest time reading the directions (13-14 seconds) compared with other areas. Placing active ingredients on the front of a label in relatively large font makes it more likely consumers will look at the information.

Sunscreen offers important protection against sunburn and skin cancer. In many instances, it is not as effective as it could be. Possible reasons include not applying it frequently enough or failing to understand instructions on the label. The FDA has proposed making changes to sunscreen labeling to increase its effectiveness. This includes adding active ingredients on the front of a label. Previous research has shown that adding active ingredients to the front of a label does not help consumers remember the ingredients. It is possible that consumers are not paying attention to/reading the ingredients when placed on the front label. Using eye tracking hardware, we tracked where 47 participants were looking as they read labels that either had active ingredients or did not have them. We found that the participants looked longer at the front label when the ingredients were on the front. This shows that consumers do pay attention to important information (e.g., active ingredients) on the front of a label. Given these results, and based on previous research that shows consumers have trouble remembering active ingredients, we recommend using the front label space for other types of important information, such as instructions for use.

Sun protection behavior: health impact, prevalence, correlates and interventions.

Sun protection behavior can reduce skin cancer risk. This paper provides an overview of skin cancer risk and the complex behavioral options for sun protection, along with a narrative review of research on determinants of, and interventions to promote, sun protection. Gaps and opportunities for future research are also outlined. Evidence supports the effectiveness of sunscreen use, ultraviolet (UV) protection clothing, and shade seeking. However, these behaviors are complex and are often performed in ways that are inadequate for sun protection. Most research examining and targeting determinants of sun protection behavior has focused on sunscreen use, to the exclusion of other strategies, and has largely ignored the complexity of even sunscreen use. Most research and interventions are theory- driven, drawing on social cognitive constructs, but also considering self and social identity and emotion. Multilevel perspectives considering context, environment, policies, and other structural contexts have also been applied to sun protection behavior, but there is a need to combine psychological constructs with factors at other levels to optimize predictive models and intervention effectiveness. Effective sun protection effectively involves complex behaviors and perceived and actual tradeoffs that should be considered, in combination with multilevel determinants, in research predicting and promoting sun safety.

Associations Between College/University Physical Activity Requirements and Student Physical Activity.

Background: Most U.S. college students do not meet physical activity guidelines. Physical activity requirements (PAR) are a proposed solution for increasing undergraduate physical activity. Purpose: To determine whether college/university PAR are associated with undergraduates' self-reported physical activity. Methods: Undergraduate students (N = 383,632) attending colleges and universities taking part in the American College Health Association-National College Health Assessment II survey (2015-2019) self-reported physical activity and demographics. Using websites and course catalogs, researchers coded schools to indicate binary PAR status. Bayesian Hierarchical Logistic Regression was used to determine the percentage of students meeting physical activity guidelines; interactions between PAR status and student characteristics (sex, BMI) were examined. Results: PAR status was positively associated with percent of students meeting physical activity guidelines (PAR: 43.3%, without: 40.5%; difference score 95% Highest Density Interval [HDI; 1.0, 4.5]). A greater percentage of students attending schools with PAR, versus without, met physical activity guidelines across all categories of sex and weight. However, the positive relationship between PAR status and physical activity was stronger among male students (PAR: 46.7%, without: 43.2%; 95% HDI [1.6, 5.4]) compared to female students (PAR: 39.9%, without: 37.9%; 95% HCI [0.2, 3.8]), and among students with underweight (PAR: 39.2%, without: 35.5%; 95% HDI [1.2, 6.3]) or obesity (PAR: 37.1%, without: 33.7%; 95% HDI [1.4, 5.3]) compared to normal weight (PAR: 49.3%, without: 47.4%; 95% HDI [0.1, 3.7]) or overweight (PAR: 47.5%, without: 45.5%; 95% HDI [0.1, 4.0]). Conclusions: PAR are associated with meeting physical activity guidelines, particularly among college/university students with underweight or obesity.

Visual Aids for Sunscreen Application: A mixed methods study.

BACKGROUND: Consumers routinely underapply sunscreen, and this may be because they misinterpret application quantity directions on sunscreen labels. U.S. labels use ambiguous terms such as "apply generously" to communicate application quantity. Visual aids may be helpful to consumers to determine proper application quantity. PURPOSE: To examine sunscreen application practices and sunscreen quantity visual aid preferences. METHODS: Sets of five GIFs and five static images were created corresponding to five quantities of sunscreen. Participants extracted their typical-use sunscreen quantity from a pre-measured tube and answered questions about their estimation process and use of labeled instructions. Participants then identified their typical-use sunscreen quantity in response to three stimuli: teaspoons, images, and GIFs and reported their preferred format. RESULTS: No participants reported using the label directions for application quantity to inform their sunscreen use. The GIF-based visual aid for sunscreen application quantity (44%) was preferred over image-based (40%) or teaspoon-based (16%) versions (p = .0249). Addition of a GIF demonstration to clarify application quantity was reported as highly helpful. CONCLUSION: Consumers have difficulty determining the appropriate quantity of sunscreen to use and labeling does not influence their application quantity. A QR code incorporating an image or GIF demonstration of proper sunscreen quantity could be useful to sunscreen consumers.

Making decisions about health information on social media: a mouse-tracking study.

Health misinformation is a problem on social media, and more understanding is needed about how users cognitively process it. In this study, participants' accuracy in determining whether 60 health claims were true (e.g., "Vaccines prevent disease outbreaks") or false (e.g., "Vaccines cause disease outbreaks") was assessed. The 60 claims were related to three domains of health risk behavior (i.e., smoking, alcohol and vaccines). Claims were presented as Tweets or as simple text statements. We employed mouse tracking to measure reaction times, whether processing happens in discrete stages, and response uncertainty. We also examined whether health literacy was a moderating variable. The results indicate that information in statements and tweets is evaluated incrementally most of the time, but with overrides happening on some trials. Adequate health literacy scorers were equally certain when responding to tweets and statements, but they were more accurate when responding to tweets. Inadequate scorers were more confident on statements than on tweets but equally accurate on both. These results have important implications for understanding the underlying cognition needed to combat health misinformation online.

Prevalence of Physical Activity Requirements Among US Colleges/Universities Participating in the American College Health Association-National College Health Assessment II.

Physical activity requirements (PAR; ie, courses required for graduation) have been proposed as a policy solution for increasing undergraduate physical activity. This study aimed to report prevalence of PAR among US colleges/universities participating in the American College Health Association-National College Health Assessment (ACHA-NCHA) and to understand whether these requirements were associated with campus characteristics. Data from the American College Health Association-National College Health Assessment II serial cross-sectional survey (2015-2019) were merged with researcher coded variables (2019): binary PAR status, nature of PAR (activity-based, conceptual, or combination), and number of courses required to fulfill the PAR. Logistic regression determined whether campus characteristics were associated with PAR in 2019. Nonparametric tests examined differences in nature and number of PAR courses. Of 379 schools, 59 (15.6%) had PAR, with 36 (61.0%) having activity-based PAR and 23 (39.0%) having a combination. Compared to public and four-year schools, private (OR=3.47 [1.77, 6.80]) and two-year schools (OR=6.55 [2.21, 19.45]) had significantly increased odds of having PAR. Private schools required significantly more PAR courses compared to public schools (2.42 vs. 1.73, P=.005). PAR were less prevalent in this sample than reported historically, indicating need for campus leadership attention to this issue. Research is needed to understand what barriers exist to implementing and maintaining PAR on college/university campuses, particularly among public and four-year schools. Understanding health promotion practices among ACHA member schools, which have made leadership commitments to promote student health, can provide greater knowledge of PAR barriers and best practices in schools across the United States and globally.

Cross-Sectional Association of State Recess Laws With District-Level Policy and School Recess Provision in the United States.

BACKGROUND: State recess laws are recommended to encourage adequate and equitable access to recess and its benefits, but the downstream effects of state recess laws are unknown. We examined the association of state recess laws with district-level policy and school recess provision. METHODS: This is cross-sectional analysis of the School Health Policies and Practices Survey, a US nationally representative sample of school districts (2016) and schools (2014). State-level recess laws were coded as none, recommend, or require recess. Logistic and linear regression were used to examine the association between state law with district policies and school recess provision, respectively. Data from 2000 are presented to highlight changes in recess policy and provision over time. RESULTS: The odds of a district policy requiring recess were 2.22 and 2.34 times greater when state recess law recommended or required recess, respectively, compared to states with no recess policy. There were no significant differences in school-level recess provision by state recess law but point estimates from 2000 indicated states without a law had the largest declines in recess provision over time. CONCLUSIONS: State recess laws are positively associated with district-level policy. Effects at the school level are unclear and continued surveillance is needed.

Associations Between State Laws Governing Recess Policy with Children's Physical Activity and Health.

BACKGROUND: State-level laws governing recess policies vary widely across the United States. We characterize the presence of such laws and assess their associations with child-level outcomes. METHODS: The presence of a state recess law was determined using the Classification of Laws Associated with School Students (CLASS) database. Parents of 6- to 11-year-old children reported physical activity, overall health, school absences, school-related problems, and ability to make/keep friends as part of the National Survey of Children's Health (NSCH). Logistic regression was used to compare outcomes in states with and without recess laws cross-sectionally in 2018 and between 2003 and 2011/2012 using a difference-in-differences analysis. RESULTS: In 2018, 20 states had a law recommending or requiring recess. Cross-sectionally, the odds of being physically active every day (odds ratio, 95% confidence interval: 2.8, 1.2-6.5) and having no difficulty making or keeping friends (2.9, 1.2-7.2) were significantly higher for children residing in states with versus without a recess law. There were no significant associations in the difference-in-differences model. CONCLUSIONS: Significant cross-sectional associations in 2018 were not confirmed by a difference-in-differences analysis of two waves of the NSCH. Short follow-up time and the apparent weakness of existing state laws warrant further assessment of state-level recess law.

Rethinking physical activity assessment in cancer survivors: a multi-component approach using NHANES data.

PURPOSE: To confirm that a multi-component physical activity index (PAI), with physical activity (PA)-related behaviors and performance measures, enhances PA assessment for adults with cancer history ("survivors") vs. for the general population for key health variables. METHODS: Data from 2011 to 2014 NHANES were analyzed (n = 9620 adults, including 866 survivors). We generated PAI scores by calculating subscales for activity-related behaviors (i.e., moderate-to-vigorous PA and TV viewing hours/sedentary time) (n/8) and performance (i.e., cardiorespiratory fitness and muscle strength) (n/8), then combined for an overall PAI score (n/16 points). Dependent variables (self-reported health, multimorbidity, and functional limitations) were dichotomized and tested with logistic regression to estimate associations with PAI variables. RESULTS: Survivors obtaining 22.5 + MET hours/week of PA were >5× more likely to report excellent health than non-exercisers (OR = 5.5, 95% CI 3.27-9.28). We observed a general decrease in likelihood of multimorbidity and functional limitations with increasing PA. Models with the combined score showed that higher PAI scores had larger positive associations with all three for all adults. Survivors with higher PAI scores were >30% more likely to report excellent self-rated health (OR = 1.3, 95% CI 1.2-1.4) and 20% less likely to report multimorbidity and functional limitations compared to survivors with lower PAI scores, considering covariates. CONCLUSIONS: Greater PA-related behavior and performance was beneficial for adults irrespective of cancer history. However, using a combined score elucidates unique needs and benefits for survivors vs. for general population. IMPLICATIONS FOR CANCER SURVIVORS: Using a multi-component approach to PA assessment could help in developing validated tools to plan exercise programs and interventions for survivors.

Survivorship for Individuals Living With Advanced and Metastatic Cancers: National Cancer Institute Meeting Report.

An important and often overlooked subpopulation of cancer survivors is individuals who are diagnosed with or progress to advanced or metastatic cancer. Living longer with advanced or metastatic cancer often comes with a cost of burdensome physical and psychosocial symptoms and complex care needs; however, research is limited on this population. Thus, in May 2021, the National Cancer Institute convened subject matter experts, researchers, clinicians, survivors, and advocates for a 2-day virtual meeting. The purpose of this report is to provide a summary of the evidence gaps identified by subject matter experts and attendees and key opportunities identified by the National Cancer Institute in 5 research areas: epidemiology and surveillance, symptom management, psychosocial research, health-care delivery, and health behaviors. Identified gaps and opportunities include the need to develop new strategies to estimate the number of individuals living with advanced and metastatic cancers; understand and address emerging symptom trajectories; improve prognostic understanding and communication between providers, patients, and caregivers; develop and test models of comprehensive survivorship care tailored to these populations; and assess patient and provider preferences for health behavior discussions throughout the survivorship trajectory. To best address the needs of individuals living with advanced and metastatic cancer and to deliver comprehensive evidence-based quality care, research is urgently needed to fill evidence gaps, and it is essential to incorporate the survivor perspective. Developing such an evidence base is critical to inform policy and practice.

Emotion suppression, coping strategies, dietary patterns, and BMI.

OBJECTIVE: Emotion suppression (ES) is associated with unhealthy coping strategies, such as emotional eating. Physical activity (PA) is a healthy coping strategy that may attenuate the association between emotion suppression and emotional eating (EE). This study evaluated whether: 1) ES is associated with body mass index (BMI) through EE and/or dietary patterns, 2) PA moderates these relationships, and 3) these patterns differ by race/ethnicity and gender. METHODS: Adult participants (N = 1674) of the Family Life, Activity, Sun, Health, and Eating study completed modified versions of the Emotion Regulation, Eating in the Absence of Hunger, and International Physical Activity Questionnaires; a validated dietary assessment; and items on demographics, height, and weight. RESULTS: Analyses revealed a serial mediation pathway in the full sample where greater ES was associated with higher BMI through greater EE and lower fruit and vegetable (F&V) intake (B = 0.0017, CI 95% [0.0001, 0.0042]) after controlling for age, gender, and education. Hedonic snack food (HSF) intake was not a significant mediator of the ES-BMI association. Greater PA attenuated associations of ES and EE with dietary intake and BMI. The serial pathway remained significant for non-Hispanic White women only in subgroup analyses. EE was a significant mediator among women, and PA effects were largely found among Hispanics and men. CONCLUSIONS: ES was associated with higher BMI through greater EE and lower F&V, but not HSF intake. PA attenuated these associations. Differences in patterns of coping strategies may help to explain disparities in obesity-related health behavior.

Evidence Gaps in Cancer Survivorship Care: A Report From the 2019 National Cancer Institute Cancer Survivorship Workshop.

Today, there are more than 16.9 million cancer survivors in the United States; this number is projected to grow to 22.2 million by 2030. Although much progress has been made in describing cancer survivors' needs and in improving survivorship care since the seminal 2006 Institute of Medicine report "From Cancer Patient to Cancer Survivor: Lost in Transition," there is a need to identify evidence gaps and research priorities pertaining to cancer survivorship. Thus, in April 2019, the National Cancer Institute convened grant-funded extramural cancer survivorship researchers, representatives of professional organizations, cancer survivors, and advocates for a 1-day in-person meeting. At this meeting, and in a subsequent webinar aimed at soliciting input from the wider survivorship community, evidence gaps and ideas for next steps in the following 6 areas, identified from the 2006 Institute of Medicine report, were discussed: surveillance for recurrence and new cancers, management of long-term and late physical effects, management of long-term and late psychosocial effects, health promotion, care coordination, and financial hardship. Identified evidence gaps and next steps across the areas included the need to understand and address disparities among cancer survivors, to conduct longitudinal studies as well as longer-term (>5 years postdiagnosis) follow-up studies, to leverage existing data, and to incorporate implementation science strategies to translate findings into practice. Designing studies to address these broad evidence gaps, as well as those identified in each area, will expand our understanding of cancer survivors' diverse needs, ultimately leading to the development and delivery of more comprehensive evidence-based quality care.

Perceived Usefulness and Recall of Sunscreen Label Information by Consumers.

Importance: In February 2019, the US Food and Drug Administration issued a proposed rule (84 FR 6204), an amendment to the Sunscreen Innovation Act of 2014, that would require listing active ingredients on the principal display panel of sunscreens to allow consumers to "more readily compare products and either select or avoid a given product accordingly." Objective: To understand consumers' perceived importance of active ingredients in sunscreen and their ability to recall these ingredients when comparing, avoiding, or selecting sunscreen products. Design, Setting, and Participants: In this qualitative study, participants were recruited from Fors Marsh Group and User Works, Inc consumer panels and interviewed in person in November and December 2019. Eligible participants were 18 years or older, reported sunscreen use in the past 12 months, and were residents of the Washington, DC, area. After viewing 2 mock sunscreen labels (1 that meets current US Food and Drug Administration requirements and 1 designed to meet proposed requirements), participants were asked questions to assess their perceived importance of active ingredients in sunscreen products, whether they could recall any of the active ingredients on the labels, and whether they typically looked for active ingredients on a sunscreen label. Main Outcomes and Measures: The main outcomes were the sunscreen label information used by participants to select a sunscreen and their ability to recall the active ingredients after viewing 2 mock sunscreen labels. Results: The mean (SD) age of the 47 participants was 42.8 (13.6) years, 32 (68%) were women, and 40 (85%) had a bachelor's or graduate degree. Of the total, 13 (28%) participants stated that sunscreen ingredients influenced their sunscreen selection, but only 5 (11%) said it was the most important information. Instead, 34 (72%) participants stated that the sun protection factor rating was the most important information. After viewing the mock sunscreen labels, only 5 (11%) participants recalled any of the active ingredients, although 10 (21%) reported typically looking at active ingredients when choosing a sunscreen. Conclusions and Relevance: This qualitative study investigated the US Food and Drug Administration's proposed new rule requiring that active ingredients be listed on the front of sunscreen labels to facilitate product comparison for consumers. However, active ingredients were not reported to be a primary reason for consumers' sunscreen selection. Recall of active ingredients was low, and few consumers reported typically looking at the active ingredients, which were more commonly used to avoid ingredients rather than to select a sunscreen. Therefore, listing active ingredients on the front label alone may not have the intended usefulness for consumers.

The Context of Sunburn Among U.S. Adults: Common Activities and Sun Protection Behaviors.

INTRODUCTION: Sunburn increases skin cancer risk and is common among U.S. adults. However, little is known about the contexts in which sunburns often occur. The purpose of this study is to examine the contextual factors surrounding sunburns among U.S. adults. METHODS: Cross-sectional data from a 2018 online panel survey were analyzed. A total of 4,088 panel members were recruited by mail using probability-based, random sampling by address. Respondents were asked about their most recent sunburn, and analyses were limited to those who remembered their most recent sunburn (N=3,106). Data were weighted to match the U.S. Current Population Survey proportions; analyses were conducted in 2018 and 2019. RESULTS: Participants' age ranged from 18 to 93 years. About half (50.8%) were women, and most (82.3%) were non-Hispanic White adults. Swimming or spending time in water (32.5%), working outside at home (26.2%), traveling/vacationing (20.7%), and engaging in nonswimming physical activity (14.2%) were the most frequently reported activities. Using sunscreen on the face, neck, and chest (38.8%) and on the body (19.9%) and wearing sunglasses (34.2%) were the most frequently reported sun safety behaviors. Wearing clothes to the ankles (6.6%) and a long-sleeved shirt (4.5%) were least frequently reported. CONCLUSIONS: This study provides new information about the contexts in which adult sunburns often occur, especially about contexts unrelated to intentional tanning, which was relatively infrequent. The results suggest the need to promote multiple forms of sun protection tailored to specific outdoor activities and develop innovative solutions for outdoor physical and aquatic activities, which present unique sun safety challenges.

State laws matter when it comes to school provisions for structured PE and daily PE participation.

The physical and mental benefits children receive from physical activity have been well documented, and physical education is a key way to ensure that physical activity opportunities are available during the school day. This study evaluates whether state PE laws are associated with school-level practices of requiring structured PE classes and whether students take PE classes daily. State laws were obtained as part of the National Cancer Institute's Classification of Laws Associated with School Students (CLASS) and were compiled for all 50 states and District of Columbia using Boolean keyword searches in LexisAdvance and WestlawNext. PE time requirements and state daily PE requirements in the laws were subsequently linked to school-required structured PE classes and daily PE in the School Nutrition and Meal Cost Study (SNMCS) Principal Survey. Logistic regression analyses were conducted while controlling for grade level, district child poverty rate, district race/ethnicity, school urbanicity, and school size. The state daily PE analysis also controlled for region. Schools located in a state that required at least 90 min of PE per week at the elementary level or 150 min of PE per week at the middle or high school levels had almost seven times higher odds of requiring structured PE. Schools located in a state that required daily participation of PE had almost five times higher odds of at least some students taking PE daily. State policymakers can utilize these findings to promote laws that require time for PE every week, daily if possible.

Strategies to Prevent or Remediate Cancer and Treatment-Related Aging.

Up to 85% of adult cancer survivors and 99% of adult survivors of childhood cancer live with an accumulation of chronic conditions, frailty, and/or cognitive impairments resulting from cancer and its treatment. Thus, survivors often show an accelerated development of multiple geriatric syndromes and need therapeutic interventions. To advance progress in this area, the National Cancer Institute convened the second of 2 think tanks under the auspices of the Cancer and Accelerated Aging: Advancing Research for Healthy Survivors initiative. Experts assembled to share evidence of promising strategies to prevent, slow, or reverse the aging consequences of cancer and its treatment. The meeting identified research and resource needs, including geroscience-guided clinical trials; comprehensive assessments of functional, cognitive, and psychosocial vulnerabilities to assess and predict age-related outcomes; preclinical and clinical research to determine the optimal dosing for behavioral (eg, diet, exercise) and pharmacologic (eg, senolytic) therapies; health-care delivery research to evaluate the efficacy of integrated cancer care delivery models; optimization of intervention implementation, delivery, and uptake; and patient and provider education on cancer and treatment-related late and long-term adverse effects. Addressing these needs will expand knowledge of aging-related consequences of cancer and cancer treatment and inform strategies to promote healthy aging of cancer survivors.

"Waiving" Goodbye to PE: State Law and School Exemption and Substitution Practices in the United States.

Purpose: The importance of schools providing physical education (PE) and promoting physical activity (PA) and the benefits of PA for children are well documented. However, a majority of students do not get the nationally recommended 60 min of daily PA. Many states grant waivers, substitutions, or exemptions from PE despite national recommendations. This study examined the association between state laws allowing for the use of PE substitutions and exemptions and school-level substitution and exemption practices. Methods: School-level PE exemption and substitution data from the 2014 School Health Policies and Practices Study were linked to state law data from the National Wellness Policy Study and the National Cancer Institute's 2013 Classification of Laws Associated with School Students. The analytic sample included 320 schools located in 42 states. Separate multivariable logistic regression models linked five types of school PE exemptions/substitutions to corresponding state laws, controlling for school characteristics. Results: Overall, 24 of the 42 states had laws addressing PE waivers, exemptions, or substitutions. Schools had higher odds of allowing PE substitutions for school sports (adjusted odds ratio (AOR), 3.59; 95% confidence interval (CI), 1.33-9.68), other school activities (AOR, 8.52; 95% CI, 2.90-25.03), and community sports (AOR, 4.30; 95% CI, 1.43-12.96) and allowing exemptions for fitness test scores (AOR, 4.67; 95% CI, 1.49-14.62) or vocational training (AOR, 5.92; 95% CI, 1.04-33.68) if state law allowed it, compared with schools in states that did not allow such practices. Conclusions: Given the connection between PA and beneficial outcomes for children, decision makers, school administrators, practitioners, advocates, and researchers should consider and further examine how PE waiver, exemption, and substitution policies and practices may affect students' PA and related outcomes.

Standards-based physical education in schools: The role of state laws.

Purpose: Examine the association of state physical education (PE) laws (https://class.cancer.gov) with school policies addressing motor skill development, physical activity (PA) participation, and health-enhancing physical fitness (https://www.cdc.gov/healthyyouth/data/shpps/data.htm). Methods: National school-level data on PE standards were obtained from the 2014 School Health Policies and Practices Study (SHPPS) of US schools for analytical samples of 408-410 schools in 43 states. These data were linked to Classification of Laws Associated with School Students (CLASS) data, which reflect the strength of state-PE curriculum laws and the associated state PE curriculum standards. Logistic regressions and generalized linear models with a complementary log-log link examined associations between state law and school-level standards. Results: Compared to having no state law, weak law (OR: 5.07, 95% CI: 1.02-25.27) or strong law (OR: 2.96, 95% CI: 1.04-8.37) was associated with higher odds of school PE standards addressing motor skill development, while only strong state law was associated with higher prevalence of addressing achievement and maintenance of physical fitness (coefficient: 0.63, 95% CI: 0.12, 1.14). State laws were not associated with addressing PA participation. Conclusions: Schools were more likely to address motor skills and physical fitness development when states had strong PE laws.

Associations between ultraviolet radiation, tree cover and adolescent sunburns.

BACKGROUND: Sunburn is the strongest risk factor for melanoma and non-melanoma skin cancers. Adolescent sunburns are related to higher risk of developing melanoma later in life. Little is known about the association of sunburns and shade, particularly tree cover, around adolescent homes and schools. This linkage study assessed associations of adolescent self-reported sunburns with ambient ultraviolet radiation (UV) and tree cover. METHODS: We analyzed a U.S. national sample of parent-child dyads (n = 1333) from the 2014 Family Life, Activity, Sun, Health, and Eating (FLASHE) study conducted by the National Cancer Institute. The outcome was adolescent sunburns reported for the previous 12 months. GIS buffers around geocoded home and school addresses were used to summarize UV and tree cover. A sensitivity analysis assessed different UV measures and tree cover buffer distances. Logistic regression models estimated the adjusted odds of any sunburns for five models: (1) no environmental variables; (2) spatial variables of latitude and longitude; (3) UV; (4) tree cover; and, (5) a combined model with UV and tree cover. Covariates included common sunburn-related items such as sun protective behaviors, socio-demographics, and latitude. Model residuals were assessed for spatial dependency and clustering. RESULTS: Overall, 44% of adolescents reported any sunburns in the previous 12 months. For the bivariate associations, lower categories of UV were associated with any reported sunburns (p-trend = 0.002). Home tree cover was not associated with any reported sunburns (p-trend = 0.08), whereas schools with lower categories of tree cover were associated with sunburns (p-trend = 0.008). The adjusted odds of any sunburns by UV tertiles, as a linear tread, was 0.89 (0.76-1.05) (p = 0.17); school tree cover was: 0.91 (0.78-1.07) (p = 0.25). Neither UV nor tree cover, in a combined model, were significant. Sensitivity analyses resulted in the optimal buffer size of 200 m for summarizing tree cover. Spatial dependence of residuals was not significant and clustering was significant for about 6% or less of the sample in each model. CONCLUSIONS: We did not find significant relationships between UV or tree cover and adolescent sunburns, when adjusted by sunburn-related covariates. Better contextual data about where sunburns occurred is needed to identify environmental correlates of sunburn.