The Role of Schools in Obesity Prevention

Effects of Physical Activity on Children's Executive Function: Contributions of Experimental Research on Aerobic Exercise

Executive function refers to the cognitive processes necessary for goal-directed cognition and behavior, which develop across childhood and adolescence. Recent experimental research indicates that both acute and chronic aerobic exercise promote children's executive function. Furthermore, there is tentative evidence that not all forms of aerobic exercise benefit executive function equally: Cognitively-engaging exercise appears to have a stronger effect than non-engaging exercise on children's executive function. This review discusses this evidence as well as the mechanisms that may underlie the association between exercise and executive function. Research from a variety of disciplines is covered, including developmental psychology, kinesiology, cognitive neuroscience, and biopsychology. Finally, these experimental findings are placed within the larger context of known links between action and cognition in infancy and early childhood, and the clinical and practical implications of this research are discussed.

Public health professionals as policy entrepreneurs: Arkansas's childhood obesity policy experience

In response to a nationwide rise in obesity, several states have passed legislation to improve school health environments. Among these was Arkansas's Act 1220 of 2003, the most comprehensive school-based childhood obesity legislation at that time. We used the Multiple Streams Framework to analyze factors that brought childhood obesity to the forefront of the Arkansas legislative agenda and resulted in the passage of Act 1220. When 3 streams (problem, policy, and political) are combined, a policy window is opened and policy entrepreneurs may advance their goals. We documented factors that produced a policy window and allowed entrepreneurs to enact comprehensive legislation. This historical analysis and the Multiple Streams Framework may serve as a roadmap for leaders seeking to influence health policy.

Sustainability of a Culturally Informed Community-Based Diabetes Prevention Program for Obese Latino Youth

Latino youth are disproportionately impacted by obesity and type 2 diabetes; however, few lifestyle interventions have targeted this population. Therefore, the purpose of this study was to assess the impact of a culturally informed lifestyle education program on nutrition and physical activity behaviors among obese Latino youth. A retrospective chart review of 67 youths was conducted with self-reported nutrition and physical activity assessed both immediately following the program and after long-term follow-up. Body mass index (BMI) was evaluated to determine the impact of behavior changes on adiposity. Healthy nutrition and physical activity changes were reported by 20%-59% of youths immediately following the program. However, most of these changes were attenuated over the 261 ± 49 day follow-up with reported walking (25.4%) and sports participation (34.3%) sustained to a greater extent than dietary changes (3.4–14.9%). Nonetheless, children who continued walking at follow-up exhibited significantly larger reductions in BMI compared with those who did not (−1.63 ± 0.56 vs. 0.44 ± 0.30 kg/m2, P < .05). Based on our pilot study, we conclude that community-based lifestyle education programs can support behavior modification and weight management in obese Latino youth. Ongoing support may be necessary to encourage sustained behavior change to facilitate greater weight loss.

Obesity prevention opinions of school stakeholders: a qualitative study

BACKGROUND

In general, schools are an important setting to implement current recommendations for obesity prevention in children because the vast majority of children attend school. This study investigated the opinions of different school stakeholders on the feasibility and acceptability of current obesity prevention strategies that could be implemented in Swiss schools.

METHODS

Research methods were comprised of a qualitative study which included school directors, physical education teachers, catering staff, school nurses and health educators, parents of young adolescents, and young adolescents interviewed (N = 40) categorized into 6 focus groups. Open-ended questions were used to determine the participants' opinion regarding current obesity prevention recommendations, and healthy eating and physical activity promotion strategies.

RESULTS

All participants approved the implementation of nutritional standards for food and drinks sold in schools, but thought that increasing the attractiveness of healthy options was the best strategy to improve eating habits. Enjoying participation in physical activity classes or after-school activities was stressed. Participants suggested offering classes for all students with poor physical condition, independent of weight status. Stakeholders called for governmental support and global coordination of interventions balanced with providing schools with enough autonomy to adapt programs relevant to their individual circumstances. They recommended integrating all school stakeholders in obesity prevention initiatives, with special attention to students and local authorities.

CONCLUSIONS

Participants agreed that schools are a crucial setting to implement childhood obesity prevention strategies. They called on school stakeholders to join efforts aiming to encourage healthy behaviors and to support and reinforce parents' efforts by spreading consistent and coherent health messages.

Overweight in Latino preschoolers: do parental health beliefs matter?

OBJECTIVE

To characterize the knowledge, attitudes, and beliefs (KAB) regarding childhood obesity among parents of Latino preschoolers.

METHODS

Three hundred sixty-nine Mexican immigrant parents of children ages 2-5 were interviewed. Children were weighed and measured.

RESULTS

Parents underestimated their own child's weight status and had high levels of perceived control over their children's eating and activity behaviors. Parents of overweight (>95%ile-for-age-and-sex BMI) versus nonoverweight (<95%ile BMI) children did not differ in their beliefs about ideal child body size.

CONCLUSION

Latino parents of overweight children did not differ from parents of nonoverweight children with respect to their KAB about childhood obesity.

The characteristics of the outdoor school environment associated with physical activity

The school is an important setting for physical activity. The purpose of the present study was to examine the association between physical environmental characteristics and participation in daily physical activity during school breaks. Data from 130 schools and 16 471 students (Grades 4-10) in Norway were obtained in 2004 through self-administered questionnaires to principals and students. Multilevel logistic regression models revealed that boys at secondary level with a larger number of outdoor facilities at school had 2.69 times [95% confidence interval (CI) = 1.21-5.98] and girls 2.90 times (95% CI = 1.32-6.37) higher odds of being physically active compared with students in schools with fewer facilities. Boys at secondary level with areas for hopscotch/skipping rope had 2.53 times (95% CI = 1.55-4.13), with a soccer field 1.68 times (95% CI = 1.15-2.45), with playground equipment 1.66 times (95% CI = 1.16-2.37) and with a sledding hill 1.70 times (95% CI = 1.23-2.35) higher odds to be physically active compared with students in schools without these facilities. A sledding hill was also associated with girls' physical activity participation in secondary school (odds ratio = 1.58, 95% CI = 1.11-2.24). Outdoor facilities in secondary schools are associated with students' daily physical activity participation during school breaks. Therefore, improving the outdoor environment should be considered in physical activity promotion school programs in secondary schools.

Farm-to-school programs: perspectives of school food service professionals

OBJECTIVE

This qualitative study used a case study approach to explore the potential of farm-to-school programs to simultaneously improve children's diets and provide farmers with viable market opportunities.

DESIGN

Semistructured interviews were the primary data collection strategy.

SETTING

Seven farm-to-school programs in the Upper Midwest and Northeast regions of the United States.

PARTICIPANTS

Seven school food service professionals, 7 farmers, and 4 food distributors recruited from 7 farm-to-school programs.

PHENOMENON OF INTEREST

Interviews probed why farmers, school food service professionals, and food distributors participate in farm-to-school programs and how they characterize the opportunities and challenges to local school food procurement.

ANALYSIS

Data were analyzed using thematic coding and data displays.

RESULTS

School food service professionals described 3 motivators for buying locally grown food for their cafeterias: (1) "The students like it," (2) "The price is right," and (3) "We're helping our local farmer." Students' preference for locally grown food was related to food quality, influence of school staff, and relationships with farmers. Buying food directly from farmers and wholesalers was associated with lower prices and flexible specifications, and the "local feel."

CONCLUSIONS AND IMPLICATIONS

Understanding school food service professionals' motivations for buying locally grown food is critical to the sustainability of farm-to-school programs.

Is childcare associated with the risk of overweight and obesity in the early years? Findings from the UK Millennium Cohort Study

BACKGROUND

A recent assessment of childcare in OECD (Organisation for Economic Co-operation and Development) countries highlighted the potential for childcare to widen inequalities. Although childcare offers a potential setting for obesity prevention, little research has analysed the association between childcare and overweight, particularly in different socio-economic groups.

OBJECTIVES

Our primary objective was to explore the association between childcare and overweight (including obesity), both overall and by socio-economic background, in a contemporary UK cohort of children at age 3 years (N=12 354). Our secondary objective was to explore infant feeding as a potential mediator between childcare in infancy and overweight at age 3 years.

RESULTS

After controlling for confounders, children who were cared for in informal childcare (75% grandparents) between the age of 9 months and 3 years were more likely to be overweight than those cared for only by a parent (adjusted risk ratio (aRR)=1.15, 95% confidence interval (CI) 1.04-1.27), particularly if they were in full-time childcare (aRR=1.34, 95% CI 1.15-1.57). When stratifying by socio-economic background, the increased risk of overweight in informal childcare (compared with parental care) was limited to children from more advantaged groups: those whose mother was from a managerial or professional background (aRR=1.23, 95% CI 1.02-1.47), had a degree (RR=1.43, 95% CI 1.13-1.83) or lived in a couple household (RR=1.18, 95% CI 1.06-1.32). There was no association between formal childcare and overweight. Infant feeding did not mediate the association between childcare use in infancy and overweight at age 3 years.

CONCLUSIONS

Children from more advantaged families who use informal childcare are at increased risk of overweight. The UK government's drive to support parents into paid employment should be accompanied by health-related information and support for both informal and formal carers. As the majority of informal carers were grandparents, the recent government announcement to provide grandparents with National Insurance credits for caring for grandchildren provides a potential opportunity for health promotion.

Understanding barriers to implementing the Norwegian national guidelines for healthy school meals: a case study involving three secondary schools

The main goal of the present study was to investigate the barriers to implementing the Norwegian national guidelines for healthy school meals as perceived by principals, project leaders, teachers and students. This study employed a multiple-case design using an explorative approach. Data were collected at three secondary schools in Norway participating in the intervention project Physical activity and healthy school meals. Individual interviews were conducted with school principals and project leaders, and focus group interviews were conducted separately with teachers and students. Four categories of barriers were identified: (1) lack of adaptation of the guidelines to the target group; (2) lack of resources and funding; (3) conflicting values and goals; and (4) access to unhealthy food outside school. The research identified differences in perceived barriers between the staff responsible for implementation and the students as the target group of the measures. All staff groups perceived barriers relating to both resources, and conflicting values and goals. The teachers were more concerned about issues of relevance for adaptation to the target groups than were the principals and project leaders. The students were concerned mostly with issues directly affecting their experience with items offered in the canteen.

Changes in school environments with implementation of Arkansas Act 1220 of 2003

Changes in school nutrition and physical activity policies and environments are important to combat childhood obesity. Arkansas Act 1220 of 2003 was among the first and most comprehensive statewide legislative initiatives to combat childhood obesity through school-based change. Annual surveys of principals and superintendents have been analyzed to document substantial and important changes in school environments, policies, and practices. For example, results indicate that schools are more likely to require that healthy options be provided for student parties (4.5% in 2004, 36.9% in 2008; P <or= 0.0001) and concession stands (1.6% in 2004, 19.6% in 2008; P <or= 0.0001), ban commercial advertising by food or beverage companies (31.7% in 2005, 42.6% in 2008; P <or= 0.0001), and offer skim milk options for students in cafeterias (white milk: 26.1% in 2004, 41.0% in 2008, P <or= 0.0001; chocolate milk: 9.0% in 2004, 24.0% in 2008, P <or= 0.0001). They are less likely to have vending machines available during the lunch period (72.3% in 2004, 37.2% in 2008; P <or= 0.0001) and to include sodas in vending machines (83.8% in 2004, 73.5% in 2008; P <or= 0.0001). Other changes were noted in foods and beverages offered in the cafeteria, in classrooms, and at school events, as well as in fund-raising and physical activity practices. A significant number of school districts have modified physical education requirements for elementary schools and developed policies prohibiting the use of physical activity as a punishment. We conclude that Arkansas Act 1220 of 2003 is associated with a number of changes in school environments and policies, resulting from both statewide and local initiatives spawned by the Act.

Differences in school environment, school policy and actions regarding overweight prevention between Dutch schools. A nationwide survey

Background

Schools are regarded as an important setting for the prevention of overweight. This study presents a nationally representative picture of the obesogenity of the school environment, the awareness of schools regarding overweight, and actions taken by the schools aiming at overweight prevention. In addition, differences between school levels were studied.

Methods

In 2006-2007, questionnaires were sent to all Dutch secondary schools (age group 12-18 years). Prevalences of the outcome variables were calculated for the schools in total and by school level. The association between school level and outcome variables were analysed by a log linear regression.

Results

Unhealthy foods and drinks are widely available at secondary schools. One third of the schools indicated that overweight has increased among students and half of the schools agreed that schools were (co)responsible for the prevention of overweight. Only 3% of the schools have a policy on overweight prevention. Small differences were observed between vocational education schools and higher education schools. The presence of vending machines did not differ by school level, but at vocational education schools, the content of the vending machines was less healthy.

Conclusion

This study describes the current situation at schools which is essential for the development and evaluation of future overweight prevention policies and interventions. In general, secondary schools are not actively involved in overweight prevention and the nutritional environment at most schools could be improved. The small differences between school levels do not give reason for a differential approach for a certain school level for overweight prevention.

Feasibility and impact of placing water coolers on sales of sugar-sweetened beverages in Dutch secondary school canteens

AIMS

The aim of this pilot study was to investigate the feasibility and effectiveness of placing water coolers on sugar-sweetened beverage sales at secondary schools (age 12-18 years) in the city of Zwolle, the Netherlands.

METHODS

Six schools, hosting 5,866 pupils, were divided in three intervention and three control schools. In the intervention schools, water coolers were placed in the canteen. Hidden observations were performed in one school to study the intervention's feasibility, and school personnel was interviewed. Beverage sales were monitored before and during the intervention. After the intervention period, 366 class 1 and 2 pupils completed a questionnaire about their drinking habits (response rate 81%).

RESULTS

Placement of water coolers appeared to be a feasible intervention at secondary schools. However, it did not affect sales of sugar-sweetened beverages at schools. Although mean intake of sugar-sweetened beverages at school was high, more than 500 ml/day for boys, and more than 250 ml/day for girls, only a minority of these quantities was purchased at school.

CONCLUSION

We conclude that placing water coolers as a single-issue intervention in secondary school canteens should not be prioritized in the combat against obesity.

Physical activity and sports team participation: associations with academic outcomes in middle school and high school students

BACKGROUND

Previous studies have found that higher physical activity levels are associated with greater academic achievement among students. However, it remains unclear whether associations are due to the physical activity itself or sports team participation, which may involve requirements for maintaining certain grades, for example. The purpose of this study is to examine the associations between sports team participation, physical activity, and academic outcomes in middle and high school students.

METHODS

Data were drawn from Project EAT (Eating Among Teens), a survey of middle and high school students (n = 4746). Students self-reported their weekly hours of physical activity, sports team participation, and academic letter grades. Two statistical models were considered: first, 2 separate regression analyses with grade point average (GPA) as the outcome and either sports team participation or physical activity as the predictor; second, a single regression with GPA as the outcome and both sports team participation and physical activity as the simultaneous predictors.

RESULTS

For high school girls, both physical activity and sports team participation were each independently associated with a higher GPA. For high school boys, only sports team participation was independently associated with a higher GPA. For middle school students, the positive association between physical activity and GPA could not be separated from the relationship between sports team participation and a higher GPA.

CONCLUSIONS

Regardless of whether academic success was related to the physical activity itself or to participation on sports teams, findings indicated positive associations between physical activity involvement and academic achievement among students.

School site visits for community-based participatory research on healthy eating

BACKGROUND

School nutrition policies are gaining support as a means of addressing childhood obesity. Community-based participatory research (CBPR) offers an approach for academic and community partners to collaborate to translate obesity-related school policies into practice. Site visits, in which trained observers visit settings to collect multilevel data (e.g., observation, qualitative interviews), may complement other methods that inform health promotion efforts. This paper demonstrates the utility of site visits in the development of an intervention to implement obesity-related policies in Los Angeles Unified School District (LAUSD) middle schools.

METHODS

In 2006, trained observers visited four LAUSD middle schools. Observers mapped cafeteria layout; observed food/beverage offerings, student consumption, waste patterns, and duration of cafeteria lines; spoke with school staff and students; and collected relevant documents. Data were examined for common themes and patterns.

RESULTS

Food and beverages sold in study schools met LAUSD nutritional guidelines, and nearly all observed students had time to eat most or all of their meal. Some LAUSD policies were not implemented, including posting nutritional information for cafeteria food, marketing school meals to improve student participation in the National School Lunch Program, and serving a variety of fruits and vegetables. Cafeteria understaffing and costs were obstacles to policy implementation.

CONCLUSIONS

Site visits were a valuable methodology for evaluating the implementation of school district obesity-related policies and contributed to the development of a CBPR intervention to translate school food policies into practice. Future CBPR studies may consider site visits in their toolbox of formative research methods.

Local school policies increase physical activity in Norwegian secondary schools

The implementation of school policies to support the adoption of physical activity is one of the main strategies recommended to increase physical activity levels among this age group. However, documentation of the effect of such policies is so far limited. The purpose of this study was to explore policy-related practices to support physical activity in Norwegian secondary schools and their association with recess physical activity. Emphasis was given to examine the association between policies and physical activity, over and beyond, individual level interests and environmental factors and to examine cross-level interaction effects. This cross-sectional study was based on a nationally representative sample of Norwegian secondary schools and grade 8 students who participated in the Health Behaviour in School-aged Children (HBSC) 2005/06 study. The final sample comprised 68 schools and 1347 students. Data were collected through questionnaires. The results showed that schools with a written policy for physical activity and schools offering organized non-curricular physical activity several times a week had a higher proportion of students reporting daily participation in recess physical activity. Multilevel logistic regression analysis demonstrated a cross-level main effect of the policy index after controlling for sex, socio-economic status, individual-level interests and the physical environment. A significant contribution of adding the policy index to the prediction of recess physical activity above that provided by the individual-level interests and the physical environment was demonstrated. The results are encouraging and give scientific support to policy documents recommending the implementation of school policies to increase physical activity.

What is a healthy body weight? Perspectives of overweight youth

PURPOSE

A qualitative assessment was completed of overweight/obese youths' perceptions of the meaning of "healthy body weight," barriers and facilitators to healthy body weight attainment, and what would effectively enhance and support their healthy body weight behaviours.

METHODS

This qualitative study targeted a sample of overweight and obese youth, aged 14 to 16 years. An experienced interviewer conducted 11 in-depth interviews. Interviews were audio-recorded and transcribed verbatim. Three qualitative researchers conducted independent and simultaneous inductive content analysis to facilitate confirmability. Data trustworthiness was supported via member checking, peer debriefing, and reflexive journalling.

RESULTS

Most participants characterized healthy body weight as a combination of healthy eating and regular physical activity. Some included a psychological dimension in the definition. Perceived facilitators of a healthy body weight included family support, access to nutritious food at home, physical activity encouragement, and a physical activity environment at school. Perceived barriers included lack of family support, a poor nutrition environment, an unsupportive school environment, time, self-esteem, and bullying. Participants identified preferences for an intervention that would include opportunities for unstructured coeducational recreational activities, coeducational nutrition education sessions, and a gender-specific discussion forum.

CONCLUSIONS

Participants provided a wealth of information to form the foundation of future youth-focused efficacious healthy body weight interventions.

Evaluation of a multiple ecological level child obesity prevention program: Switch what you Do, View, and Chew

BACKGROUND

Schools are the most frequent target for intervention programs aimed at preventing child obesity; however, the overall effectiveness of these programs has been limited. It has therefore been recommended that interventions target multiple ecological levels (community, family, school and individual) to have greater success in changing risk behaviors for obesity. This study examined the immediate and short-term, sustained effects of the Switch program, which targeted three behaviors (decreasing children's screen time, increasing fruit and vegetable consumption, and increasing physical activity) at three ecological levels (the family, school, and community).

METHODS

Participants were 1,323 children and their parents from 10 schools in two states. Schools were matched and randomly assigned to treatment and control. Measures of the key behaviors and body mass index were collected at baseline, immediately post-intervention, and 6 months post-intervention.

RESULTS

The effect sizes of the differences between treatment and control groups ranged between small (Cohen's d = 0.15 for body mass index at 6 months post-intervention) to large (1.38; parent report of screen time at 6 months post-intervention), controlling for baseline levels. There was a significant difference in parent-reported screen time at post-intervention in the experimental group, and this effect was maintained at 6 months post-intervention (a difference of about 2 hours/week). The experimental group also showed a significant increase in parent-reported fruit and vegetable consumption while child-reported fruit and vegetable consumption was marginally significant. At the 6-month follow-up, parent-reported screen time was significantly lower, and parent and child-reported fruit and vegetable consumption was significantly increased. There were no significant effects on pedometer measures of physical activity or body mass index in the experimental group. The intervention effects were moderated by child sex (for fruit and vegetable consumption, physical activity, and weight status), family involvement (for fruit and vegetable consumption), and child body mass index (for screen time). The perception of change among the experimental group was generally positive with 23% to 62% indicating positive changes in behaviors.

CONCLUSION

The results indicate that the Switch program yielded small-to-modest treatment effects for promoting children's fruit and vegetable consumption and minimizing screen time. The Switch program offers promise for use in youth obesity prevention.

The need for bold action to prevent adolescent obesity

Record levels of obesity in children and adolescents are predictable in light of powerful conditions that promote high consumption of calorie-dense, nutrient-poor foods and discourage physical activity. Default conditions for youth are dangerous, and include multiple and relentless forms of marketing, poor foods promoted in schools, and a variety of other conditions that undermine personal resources, individual responsibility, and parental authority. This article discusses how optimal defaults can be created using five issues as examples: framing of the obesity issue, treating versus preventing obesity, nutrition in schools, marketing, and addressing weight bias and discrimination. By adopting a public health approach that addresses the conditions causing obesity, there is hope of reversing troubling trends in prevalence.

The role of culture in the context of school-based BMI screening

The high prevalence of overweight and obesity is a significant public health concern in the United States. Minority populations are disproportionately affected, and the impact of obesity on minority children is especially alarming. In this article we discuss school-based BMI reporting, which is intended to increase parental awareness of their children's weight status. This information could potentially lead parents of overweight and obese children to carefully examine and possibly change their children's diet and activity patterns. However, any program related to child weight status must consider culturally defined aspects of body size and shape. In other words, the cultural context in which information on child BMI is presented to and received by parents must be considered. In this article we review parental perceptions of child weight. Multiple studies have shown that parents of overweight or obese children often fail to correctly perceive their children as overweight. Possible reasons for, and implications of, this misperception of child weight status among minority parents are then explored within a cultural framework. The PEN-3 model is used to examine influences on health behaviors and could help inform the development of a culturally sensitive BMI-notification program for minority parents. Reporting materials congruent with the social and cultural values and practices of the target audience are likely to maximize program effectiveness. A culturally based BMI-notification program should be conceptualized as a small step in a comprehensive plan to reduce childhood obesity and improve the current and future health of minority children.

Obesity as a social problem in the United States: application of the public arenas model

Obesity rates in the United States have been rising over the past 35 years, resulting in a subsequent increase in nutrition-related chronic disease morbidity and mortality and significant burdens to families, communities, and health care systems. In working to formulate effective public health policy solutions that address the obesity epidemic, it is important to analyze how obesity has been defined and accepted as a social problem. This article applies Hilgartner and Bosk's public arenas model to examine how obesity is defined in the public arena, how competition plays a role in "framing" the obesity issue, and how operatives influence the ways in which obesity is viewed and understood. Implications for nurses and policy makers are addressed in the context of using the public arenas model as a tool to analyze the social problem of obesity.

Associations of various family characteristics and time use with children's body mass index

This study used multiple regression models to estimate associations of various family characteristics and time use with the body mass index (BMI) z-scores of 734 boys and 725 girls aged 5-18y from the Panel Study of Income Dynamics Child Development Supplement 2003. The strongest relationship in the data was between the BMI of the head of household and a child's BMI z-score (p < 0.001). Time spent sleeping, performing sedentary behaviors, and participating in physical activities was not associated with a child's BMI z-score. This suggests that a family-oriented approach to prevent and treat childhood and adolescent overweight is required.

The food and beverage vending environment in health care facilities participating in the healthy eating, active communities program

BACKGROUND

Little has been done to ensure that the foods sold within health care facilities promote healthy lifestyles. Policies to improve school nutrition environments can serve as models for health care organizations.

OBJECTIVE

This study was designed to assess the healthfulness of foods sold in health care facility vending machines as well as how health care organizations are using policies to create healthy food environments.

METHODS

Food and beverage assessments were conducted in 19 California health care facilities that serve children in the Healthy Eating, Active Communities sites. Items sold in vending machines were inventoried at each facility and interviews conducted for information on vending policies. Analyses examined the types of products sold and the healthfulness of these products.

RESULTS

Ninety-six vending machines were observed in 15 (79%) of the facilities. Hospitals averaged 9.3 vending machines per facility compared with 3 vending machines per health department and 1.4 per clinic. Sodas comprised the greatest percentage of all beverages offered for sale: 30% in hospital vending machines and 38% in clinic vending machines. Water (20%) was the most prevalent in health departments. Candy comprised the greatest percentage of all foods offered in vending machines: 31% in clinics, 24% in hospitals, and 20% in health department facilities. Across all facilities, 75% of beverages and 81% of foods sold in vending machines did not adhere to the California school nutrition standards (Senate Bill 12). Nine (47%) of the health care facilities had adopted, or were in the process of adopting, policies that set nutrition standards for vending machines.

CONCLUSIONS

According to the California school nutrition standards, the majority of items found in the vending machines in participating health care facilities were unhealthy. Consumption of sweetened beverages and high-energy-density foods has been linked to increased prevalence of obesity. Some health care facilities are developing policies that set nutrition standards for vending machines. These policies could be effective in increasing access to healthy foods and beverages in institutional settings.

Competitive foods in schools: availability and purchasing in predominately rural small and large high schools

OBJECTIVES

Schools have an important role to play in obesity prevention, but little is known about the food environment in small, predominately rural schools. The primary purpose of this study was to compare the availability and student purchasing of foods sold outside of the reimbursable meals program through à la carte or vending (ie, competitive foods) in small (n=7) and large (n=6) Kansas high schools.

METHODS

A cross-sectional observational study design was used to capture the number of à la carte and vending items available and purchased, and the fat and energy content of all available and purchased items on a single school day between January and May 2005.

RESULTS

Small schools had significantly fewer vending machines than large schools (median 3.0 [range 2.0 to 5.0] vs 6.5 [range 4.0 to 8.0], P<0.01]. Vending and à la carte items at small schools contained a median of 2.3 fewer fat grams per item (P< or =0.05), whereas vending products contained a median of 25 kcal fewer per item (P< or =0.05) than at large schools. Significantly less fat (median -15.4 g/student) and less energy (median -306.8 kcal/student) were purchased per student from all competitive food sources and from à la carte (median -12.9 g fat and -323.3 kcal/student) by students in small schools compared to students in large schools (P< or =0.05).

CONCLUSIONS

The findings, which highlight less availability and lower energy content from competitive foods at small compared to large schools, have implications for understanding how small schools support their foodservice programs with limited dependence on competitive foods and the influence that food and nutrition professionals can have on school environments by providing more oversight into the nutritional quality of foods available.

The politics of obesity: a current assessment and look ahead

CONTEXT

The continuing rise in obesity rates across the United States has proved impervious to clinical treatment or public health exhortation, necessitating policy responses. Nearly a decade's worth of political debates may be hardening into an obesity issue regime, comprising established sets of cognitive frames, stakeholders, and policy options.

METHODS

This article is a survey of reports on recently published studies.

FINDINGS

Much of the political discussion regarding obesity is centered on two "frames," personal-responsibility and environmental, yielding very different sets of policy responses. While policy efforts at the federal level have resulted in little action to date, state and/or local solutions such as calorie menu labeling and the expansion of regulations to reduce unhealthy foods at school may have more impact.

CONCLUSIONS

Obesity politics is evolving toward a relatively stable state of equilibrium, which could make comprehensive reforms to limit rising obesity rates less feasible. Therefore, to achieve meaningful change, rapid-response research identifying a set of promising reforms, combined with concerted lobbying action, will be necessary.

Schools and obesity prevention: creating school environments and policies to promote healthy eating and physical activity

CONTEXT

Research consistently shows that the majority of American children do not consume diets that meet the recommendations of the Dietary Guidelines for Americans, nor do they achieve adequate levels of daily physical activity. As a result, more children are overweight today than at any other time in U.S. history. Schools offer many opportunities to develop strategies to prevent obesity by creating environments in which children eat healthfully and engage regularly in physical activity.

METHODS

This article discusses the role of schools in obesity prevention efforts. Current issues in schools' food and physical activity environments are examined, as well as federal, state, and local policies related to food and physical activity standards in schools. The article is organized around four key areas: (1) school food environments and policies, (2) school physical activity environments and policies, (3) school body mass index measurements, and (4) school wellness policies. Recommendations for accelerating change also are addressed.

FINDINGS

The article found that (1) competitive foods (foods sold outside of federally reimbursed school meals) are widely available in schools, especially secondary schools. Studies have related the availability of snacks and drinks sold in schools to students' high intake of total calories, soft drinks, total fat and saturated fat, and lower intake of fruits and vegetables; (2) physical activity can be added to the school curriculum without academic consequences and also can offer physical, emotional, and social benefits. Policy leadership has come predominantly from the districts, then the states, and, to a much lesser extent, the federal government; (3) few studies have examined the effectiveness or impact of school-based BMI measurement programs; and (4) early comparative analyses of local school wellness policies suggest that the strongest policies are found in larger school districts and districts with a greater number of students eligible for a free or reduced-price lunch.

CONCLUSIONS

Studies show that schools have been making some progress in improving the school food and physical activity environments but that much more work is needed. Stronger policies are needed to provide healthier meals to students at schools; limit their access to low-nutrient, energy-dense foods during the school day; and increase the frequency, intensity, and duration of physical activity at school.

School food environments and practices affect dietary behaviors of US public school children

BACKGROUND

Changes to school food environments and practices that lead to improved dietary behavior are a powerful strategy to reverse the childhood obesity epidemic.

OBJECTIVES

To estimate the effects of school food environments and practices, characterized by access to competitive foods and beverages, school lunches, and nutrition promotion, on children's consumption of sugar-sweetened beverages, low-nutrient energy-dense foods, and fruits/vegetables at school.

DESIGN

Cross-sectional study using data from the third School Nutrition Dietary Assessment Study, a nationally representative sample of public school districts, schools, and children in school year 2004-2005. Data from school principals and foodservice directors, school menu analysis, and on-site observations were used to characterize school food environments and practices. Dietary intake was assessed using 24-hour recalls.

SUBJECTS/SETTING

The sample consists of 287 schools and 2,314 children in grades one through 12.

STATISTICAL ANALYSES PERFORMED

Ordinary least squares regression was used to identify the association between school food environments and practices (within elementary, middle, and high schools) and dietary outcomes, controlling for other school and child/family characteristics.

RESULTS

Sugar-sweetened beverages obtained at school contributed a daily mean of 29 kcal in middle school children and 46 kcal in high school children across all school children. Attending a school without stores or snack bars was estimated to reduce sugar-sweetened beverage consumption by 22 kcal per school day in middle school children (P<0.01) and by 28 kcal in high school children (P<0.01). The lack of a pouring rights contract in a school reduced sugar-sweetened beverage consumption by 16 kcal (P<0.05), and no à la carte offerings in a school reduced consumption by 52 kcal (P<0.001) in middle school children. The most effective practices for reducing energy from low-energy, energy-dense foods were characteristics of the school meal program; not offering french fries reduced low-nutrient, energy-dense foods consumption by 43 kcal in elementary school children (P<0.01) and sugar-sweetened beverage consumption by 41 kcal in high school children (P<0.001).

CONCLUSIONS

To improve children's diet and reduce obesity continued changes to school food environments and practices are essential. Removing sugar-sweetened beverages from school food stores and snack bars, improving à la carte choices, and reducing the frequency of offering french fries merit testing as strategies to reduce energy from low-nutrient, energy-dense foods at school.

Availability and consumption of competitive foods in US public schools

BACKGROUND

With ongoing efforts to develop and implement school wellness policies, there is a need for information about the availability and consumption of competitive foods in schools.

OBJECTIVE

To describe the availability of competitive foods in US public schools, consumption of competitive foods by children, and contributions of competitive foods to energy intakes.

DESIGN

The study used data from the third School Nutrition Dietary Assessment Study, a cross-sectional study that included a national sample of public school districts, schools, and children in the 2004-2005 school year. On-site observations were used to document the availability of competitive foods and a 24-hour recall was used to assess children's consumption of competitive foods.

SUBJECTS/SETTING

The study included 287 schools and 2,314 children in grades 1 through 12.

STATISTICAL ANALYSES PERFORMED

Most analyses were limited to estimation of means and proportions. Two-tailed t tests were used to test the significance of differences between children who did and did not eat a school lunch.

RESULTS

In school year 2004-2005, competitive foods were widely available in public schools. Overall, 40% of children consumed one or more competitive foods on a typical school day. The most commonly consumed competitive foods were foods and beverages that were low in nutrients and energy-dense. Children who ate a school lunch were significantly less likely than children who did not eat a school lunch to consume competitive foods (36% vs 45%; P<0.01); however, the leading competitive food choices for both groups of children were foods that were low in nutrients and energy-dense. On average, competitive food consumers who ate school lunches obtained 159 calories from competitive foods that were low in nutrients and energy-dense, compared with 201 calories for competitive food consumers who did not eat school lunches (P<0.05).

CONCLUSIONS

In school year 2004-2005, competitive foods were widely available and consumed in US public schools and the most commonly consumed competitive foods were low in nutrients and energy-dense. These data support the need for improvements in school food environments and policies and provide a useful baseline for monitoring change as schools work to make these improvements.

Meals offered and served in US public schools: do they meet nutrient standards?

BACKGROUND

Concerns about the diets of school-aged children and new nutrition recommendations for the US population have increased interest in the nutritional quality of meals available through the National School Lunch Program and School Breakfast Program.

OBJECTIVE

This article updates national estimates of the food energy and nutrient content of school meals and compares these estimates to federal nutrient standards established under the 1995 School Meals Initiative for Healthy Children.

DESIGN

Data were collected as part of the third School Nutrition Dietary Assessment Study, a nationally representative cross-sectional study fielded during school year 2004-2005. Menu and recipe data for a typical school week were collected in a mail survey with telephone assistance. Nutrient information for common commercially prepared food items was obtained from manufacturers, to supplement the Food and Nutrient Database for Dietary Studies used to analyze the data. Analyses were conducted for meals offered and meals served to (selected by) children.

SUBJECTS/SETTING

Samples of 130 public school districts that offered federally subsidized school meals, and 398 schools within those districts, participated in the study. Foodservice managers in each school completed a menu survey.

STATISTICAL ANALYSES PERFORMED

Descriptive tabulations present weighted means, proportions, and standard errors for elementary, middle, and high schools, and for all schools combined.

RESULTS

Most schools offered and served meals that met the standards for protein, vitamins, and minerals. Fewer than one third of schools met the standards for energy from fat or saturated fat in the average lunch, whereas three fourths or more met the fat standards in school breakfasts. For both meals, average levels of sodium were high and fiber was low relative to Dietary Guidelines for Americans 2005 recommendations.

CONCLUSIONS

For school meals to meet nutrient standards and promote eating behaviors consistent with the Dietary Guidelines, future policy, practice, and research should focus on reducing levels of fat and sodium and increasing fiber.

Consumption of low-nutrient, energy-dense foods and beverages at school, home, and other locations among school lunch participants and nonparticipants

BACKGROUND

Access to foods and beverages on school campuses, at home, and other locations affects children's diet quality, energy intake, and risk of obesity.

OBJECTIVES

To describe patterns of consumption of "empty calories"--low-nutrient, energy-dense foods, including sugar-sweetened beverages--by eating location among National School Lunch Program (NSLP) participants and nonparticipants.

DESIGN

Cross-sectional study using 24-hour dietary recall data from the 2004-2005 third School Nutrition Dietary Assessment Study.

SUBJECTS/SETTING

A nationally representative sample of 2,314 children in grades one through 12, including 1,386 NSLP participants.

STATISTICAL ANALYSES PERFORMED

Comparisons, using t tests, of the proportion of children consuming low-nutrient, energy-dense foods and beverages, mean daily energy and energy from low-nutrient, energy-dense foods, and energy density by NSLP participation status.

RESULTS

On a typical school day, children consumed 527 "empty calories" during a 24-hour period. Eating at home provided the highest mean amount of energy from low-nutrient, energy-dense foods (276 kcal vs 174 kcal at school and 78 kcal at other locations). NSLP participants consumed less energy from sugar-sweetened beverages at school than nonparticipants (11 kcal vs 39 kcal in elementary schools and 45 kcal vs 61 kcal in secondary schools, P<0.01), but more energy from low-nutrient, energy-dense solid foods such as french fries and higher-fat baked goods in secondary schools (157 kcal vs 127 kcal, P<0.01). Participants were not more likely to consume sugar-sweetened beverages or low-nutrient, energy-dense foods at home or other locations. School lunch participants' consumption at school was less energy-dense than nonparticipants' consumption at school (P<0.01). Energy density was highest for consumption at locations away from home and school.

CONCLUSIONS

Improving home eating behaviors, where the largest proportion of total daily and energy from low-nutrient, energy-dense foods are consumed (especially from sugar-sweetened beverages, chips, and baked goods) is warranted. At schools, consumption of energy from low-nutrient, energy-dense foods may be reduced by limiting access to competitive foods and beverages, enforcing strong school wellness policies, and minimizing the frequency of offering french fries and similar potato products and higher-fat baked goods in school meals or à la carte.

Examining the interaction between food outlets and outdoor food advertisements with primary school food environments

Schools are commonly seen as a site of intervention to improve children's nutrition, and prevent excess weight gain. Schools may have limited influence over children's diets; however, with home and community environments also exerting an influence within schools. This study considered the environment of food outlets and outdoor food advertisements surrounding four case study primary schools in New Zealand, and the impact of that external environment on within-school food environments. The shortest travel route between school and home addresses, and the number of food outlets and advertisements passed on that route, was calculated for each student. Interviews with school management were conducted. The schools with a higher percentage of students passing food outlets and advertisements considered that their presence impacted on efforts within schools to improve the food environment. Limiting students' exposure to food outlets and outdoor food adverts through travel route planning, reducing advertising, or limiting the location of food outlets surrounding schools could be explored as intervention options to support schools in promoting nutrition.

Improving laws and legal authorities for obesity prevention and control

This paper is one of four interrelated action papers resulting from the 2008 National Summit on Legal Preparedness for Obesity Prevention and Control. Summit participants engaged in discussions on the current state of the law with respect to obesity, nutrition and food policy, physical activity, and physical education. Participants also identified gaps in the law at all jurisdictional levels and relevant to numerous sectors and disciplines that have a stake in obesity prevention and control.

The companion paper, “Assessment of Laws and Legal Authorities for Obesity Prevention and Control,”identified numerous laws and policies enacted to target the three domains of healthy lifestyles, healthy places, and healthy societies. That paper identified several gaps in the law that require attention and action. This paper addresses those gaps and presents applicable laws and legal authorities that public health professionals and lawyers can consider to implement to close the gaps.

A public health approach to winning the war against cancer

The "war on cancer" in the United States has been viewed primarily as an effort to develop and disseminate cancer cures, but cancer is far more easily prevented than cured. There are three major approaches to cancer prevention: Primary prevention, through reduction in risk factors and changes to the environment that reduce human exposure to widely-consumed cancer-promoting agents. The most important actions for primary prevention of cancer are those that reduce tobacco use through taxation, smoke-free environment policies, advertising restrictions, counter-advertising, and cessation programs. The World Health Organization's MPOWER package outlines these actions, each of which covered less than 5% of people in the world in 2007. Similarly, cancer can be prevented by reducing alcohol consumption through policies such as alcohol taxes and limits on alcohol sales, and restoring caloric balance through policies such as creating healthier food environments and engineering the built environment to increase opportunities for physical activity. Vaccination is an effective approach to preventing specific virus-associated cancers, such as using human papillomavirus vaccine to prevent cervical cancer and hepatitis B virus vaccine to prevent hepatocellular cancer. Secondary prevention reduces cancer mortality through screening and early treatment; this approach has been used successfully for breast and cervical cancer but is still underused against colon cancer. Progress can be made in all three approaches to cancer prevention, but will require a greater emphasis on public health programs and public policy. Winning the war on cancer will require a much larger investment in prevention to complement efforts to improve treatment.

Children's Nutritional Health: Running on Empty?

This review discusses evidence-based perspectives on promoting children's nutritional health. Future directions for inquiry and empirically driven public policy initiatives also are addressed.

Avaliação de um programa para promoção de hábitos alimentares saudáveis em escolares de Florianópolis, Santa Catarina, Brasil

OBJETIVOS: avaliar os resultados de um programa de intervenção nutricional visando à promoção de hábitos alimentares saudáveis em escolares do ensino fundamental. MÉTODOS: estudo de intervenção não controlado desenvolvido com 162 escolares de terceira e quarta séries de duas instituições de ensino (pública e privada), em Florianópolis, Santa Catarina, Brasil. O programa de educação nutricional de curta duração foi distribuído em sete encontros. Aplicou-se um questionário de consumo alimentar e aferiu-se peso e estatura antes e um mês após o término da intervenção. RESULTADOS embora não tenham sido detectadas mudanças no perfil nutricional dos escolares, percebeu-se na escola privada redução significativa nos percentuais de bolachas recheadas trazidas de casa pelos meninos e na escola pública aumentou significativamente o consumo da merenda escolar e aceitação por frutas. CONCLUSÕES: após a intervenção, verificou-se aumento da freqüência de algumas atitudes e práticas alimentares mais saudáveis. O tempo entre a conclusão do programa e a realização do segundo exame antropométrico pode não ter sido suficiente para provocar mudanças no índice de massa corporal. Essa experiência pode ser aplicada em outras instituições e, para sua maior efetividade, deve contar com a participação da comunidade escolar (especialmente pais e professores).

What's law got to do with it Part 2: Legal strategies for healthier nutrition and obesity prevention

This article is the second in a two-part review of law's possible role in a regulatory approach to healthier nutrition and obesity prevention in Australia. As discussed in Part 1, law can intervene in support of obesity prevention at a variety of levels: by engaging with the health care system, by targeting individual behaviours, and by seeking to influence the broader, socio-economic and environmental factors that influence patterns of behaviour across the population. Part 1 argued that the most important opportunities for law lie in seeking to enhance the effectiveness of a population health approach.

Part 2 of this article aims to provide a systematic review of the legal strategies that are most likely to emerge, or are worth considering, as part of a suite of policies designed to prevent population weight gain and, more generally, healthier nutrition. While the impact of any one intervention may be modest, their cumulative impact could be significant and could also create the conditions for more effective public education campaigns. This article addresses the key contenders, with particular reference to Australia and the United States.

School level contextual factors are associated with the weight status of adolescent males and females

OBJECTIVE

To determine whether school context influences the BMI of adolescent males and females.

METHODS AND PROCEDURES

Our sample was 17,007 adolescents (aged 12-19) from the National Longitudinal Study of Adolescent Health (Add Health). We used gender-stratified multilevel modeling to examine the contribution of schools to the overall variance in adolescent BMIs, calculated from self-reported weight and height. We then examined the associations of individual attributes with BMI after controlling for the average BMI of the school and the association of two school-level variables with BMI.

RESULTS

Participants attended schools that were segregated by race/ethnicity and socioeconomic status (SES). In females, when controlling only for individual-level attributes, individual household income was inversely associated (beta = -0.043, P = 0.01) while Hispanic (beta = 0.89, P < 0.001) and black (beta = 1.61, P < 0.001) race/ethnicity were positively associated with BMI. In males, Hispanic (beta = 0.67, P < 0.001) race/ethnicity was positively associated with BMI; there was no difference in the BMIs of blacks compared with whites (beta = 0.24, P = 0.085). After controlling for the school racial/ethnic makeup and the school level median household income, the relationship between individual race/ethnicity and BMI was attenuated in both male and female adolescents. Higher school level median household income was associated with lower individual BMIs in adolescent girls (gamma = -0.37, P < 0.001) and boys (gamma = -0.29, P < 0.001) suggesting a contextual effect of the school.

DISCUSSION

Male and female adolescents attending schools with higher median household incomes have on average lower BMIs. Resources available to or cultural norms within schools may constitute critical mechanisms through which schools impact the BMI of their students.

Away-from-home food intake and risk for obesity: examining the influence of context

OBJECTIVE

This study examined sociodemographic and cultural determinants of away-from-home food consumption in two contexts and the influence of frequency of away-from-home food consumption on children's dietary intake and parent and child weight status.

METHODS AND PROCEDURES

Parents of children (N=708) in grades K-2 were recruited from 13 elementary schools in Southern California. Parents were asked through a questionnaire the frequency with which they eat meals away from home and the restaurant they frequented most often. The height and weight of the parents and their children were measured to calculate BMI.

RESULTS

Consuming foods at least once a week from relatives/neighbors/friends (RNF) homes was associated with children's dietary intake and children's risk for obesity. For example, children of parents with weekly or greater RNF food consumption drank more sugar-sweetened beverages. Parents of families who ate at restaurants at least weekly reported that their children consumed more sugar-sweetened beverages, more sweet/savory snacks, and less water compared with families who did not frequent restaurants this often. The type of restaurant visited did not affect diet intake or obesity. More acculturated families exhibited less healthy dietary behaviors than less acculturated families.

DISCUSSION

Restaurants remain an important setting for preventing child and adult obesity, but other settings outside the home need to be considered in future intervention research. This may especially involve eating in the homes of RNF.

Is school-based height and weight screening of elementary students private and reliable?

The Institute of Medicine recommends school-based body mass index (BMI) screening as an obesity prevention strategy. While school nurses have provided height/weight screening for years, little has been published describing measurement reliability or process. This study evaluated the reliability of height/weight measures collected by school nurses and the privacy of the measurement process. Interrater reliability for height/weight measures was computed on 70 elementary students, comparing measurements collected by a trained researcher to those collected by 7 school nurses. Students arrived in small groups to private measurement spaces. Height agreement was 80% for younger and 85% for older students. Agreement for weight was 97% and 100%, respectively. Reliability for weight was very good. Reliability for height was good, but results suggest careful attention to the collection process is required. Nurses may benefit from regular training on measurement procedures. The results of this study suggest that school nurses provide BMI screening that is private and reliable.

Recommendations for prevention of childhood obesity

The majority of US youth are of healthy weight, but the majority of US adults are overweight or obese. Therefore, a major health challenge for most American children and adolescents is obesity prevention-today, and as they age into adulthood. In this report, we review the most recent evidence regarding many behavioral and practice interventions related to childhood obesity, and we present recommendations to health care providers. Because of the importance, we also suggest approaches that clinicians can use to encourage obesity prevention among children, including specific counseling strategies and practice-based, systems-level interventions. In addition, we suggest how clinicians may interact with and promote local and state policy initiatives designed to prevent obesity in their communities.