National School Lunch Program participation and sex differences in body mass index trajectories of children from low-income families

U.S. Nutrition Assistance Program Participation and Childhood Obesity: The Early Childhood Longitudinal Study 2011

INTRODUCTION

The Supplemental Nutrition Assistance Program; Free/Reduced Priced Lunch Program; and Special Supplemental Nutrition Program for Women, Infants, and Children reduce food insecurity for millions of Americans with lower incomes. However, critics have questioned whether they increase obesity. This study examined whether program participation was associated with BMI z-score from kindergarten to fifth grade.

METHODS

Data from 4,457 primary-grade students whose household incomes were equal to or below 200% of the federal poverty level from kindergarten to fifth grade as part of the Early Childhood Longitudinal Study, Kindergarten Class of 2010‒2011 were analyzed. Marginal structural models with inverse probability of treatment/censoring weights were used to estimate associations between Supplemental Nutrition Assistance Program/Free and Reduced Priced Lunch participation over time and fifth-grade BMI z-score, accounting for lost-to-follow-up and time-varying confounders. Weighted generalized estimating equations were used to examine associations between Special Supplemental Nutrition Program for Women, Infants, and Children participation and BMI z-score trends. All analyses incorporated sampling weights. The Early Childhood Longitudinal Study, Kindergarten Class of 2010‒2011 data were collected from 2010-2016; analyses were conducted in 2021 and 2022.

RESULTS

At baseline, 2,419 (54.3%) respondents participated in the Supplemental Nutrition Assistance Program, 3,993 (89.6%) participated in Free/Reduced Priced Lunch, and 3,755 (84.2%) reported past participation in the Special Supplemental Nutrition Program for Women, Infants, and Children. No associations were found between any program and fifth-grade BMI z-score or between Special Supplemental Nutrition Program for Women, Infants, and Children participation and BMI z-score trend.

CONCLUSIONS

Previous findings of relationships between program participation and BMI may have been because of weaker study designs and uncontrolled confounding. Participation in the Supplemental Nutrition Assistance Program; Free/Reduced Priced Lunch; and Special Supplemental Nutrition Program for Women, Infants, and Children was not associated with increased risk of childhood obesity in this recently conducted longitudinal study.

Parental and family predictors of fruits and vegetables in elementary school children's home-packed lunches across a school week

Home-packed lunches have been found to be of lower nutritional quality than school-bought lunches, yet little is known about family-based factors associated with lunch packing. The current exploratory study examines parental and family predictors of fruits and vegetables packed in lunches, hypothesizing parents' nutrition knowledge and authoritative parenting as well as children's involvement in lunch decisions would relate to packing more fruits and vegetables, while financial difficulties would relate to packing fewer. Ninety parent-child dyads from 4th-6th grade participated for 5 consecutive school days. Lunch contents were recorded using a digital imaging procedure to capture the number of days a fruit or vegetable was packed, and servings of fruits and vegetables in lunches each day. Parents completed family and parenting questionnaires and daily reports of child involvement in lunch decisions. Count-based regression models and longitudinal analyses within a multilevel modeling framework were used to examine predictors of lunch contents. Higher nutrition knowledge was associated with packing more fruit across the week and more vegetables on Monday. Authoritative parenting was associated with packing fewer vegetables on Monday, but more servings across the week. Financial stress was related to higher rates of never packing vegetables and when vegetables were packed including fewer servings, while child involvement in lunch decisions was associated with packing more fruits across the week, packing vegetables on more days and more servings of vegetables on Monday. Findings suggest parental and family factors impact the foods in packed lunches, with implications for children's dietary intake at school. Outreach programs can help parents pack more fruits and vegetables by providing nutrition education and suggestions for affordable, healthy lunch options as well as encouraging child involvement in the lunch packing process.

Alimentação Escolar no Brasil e Estados Unidos: uma revisão integrativa

Resumo Trata-se de uma revisão integrativa da literatura que teve como objetivo identificar os fatores que influenciam a adesão e a aceitação da alimentação escolar entre estudantes brasileiros e americanos, e apontar as principais diferenças entre os programas desses dois países. A busca dos trabalhos científicos foi realizada nas bases de dados da Literatura Latino-Americana e do Caribe em Ciências da Saúde (Lilacs), Pubmed, Scientific Eletronic Library Online (SciELO) e Science Direct. Os dados foram coletados no período de julho a agosto de 2015, utilizando os seguintes descritores em português e inglês: “adesão à alimentação escolar” (adherence of school feeding), “aceitação à alimentação escolar” (accepting of school feeding), “Programa Nacional de Alimentação Escolar” e “National School Lunch Program”. A busca resultou em 07 artigos brasileiros e 07 artigos americanos, publicados entre os períodos de 2004 a 2014, além das legislações vigentes de cada programa, selecionadas nos sites eletrônicos dos órgãos responsáveis pelo gerenciamento dos mesmos. Após análise descritiva e comparativa, os resultados demonstraram que a adesão e a aceitação foram baixas em ambos os programas, e que são influenciadas por fatores socioeconômicos, alimentos competitivos presentes no ambiente escolar e pelas preferências alimentares dos alunos.

Unidirectional or Bidirectional Relationships of Behaviors: The Importance of Positive Behavioral Momentum

Theoretically based behavioral interventions provide the most evidence for successful change; however, several issues should be considered when applying these interventions. For example, school-based obesity prevention programs can be used to teach children how to adopt healthy lifestyle behaviors from an early age. Ecological systems theory provides a framework to design, implement, and evaluate school-based obesity prevention programs. An ecological framework emphasizes that the characteristics within and between systems place children at risk for obesity. Although this developmental process is considered to occur continuously and simultaneously, in practice, we tend to consider the relationships to be unidirectional. Using a positive behavioral momentum approach in practice may assist in addressing these complexities.

Deconstructing race and gender differences in adolescent obesity: Oaxaca-blinder decomposition

OBJECTIVE

To analyze sources of racial and gender disparities in adolescent obesity prevalence in the United States using Oaxaca-Blinder decomposition.

METHODS

Data were obtained from the National Youth Physical Activity and Nutrition Study, a 2010 nationally representative study of 9th-12th grade students. Obesity status was determined from objective height and weight data; weight-related behaviors and school, home, and environmental data were collected via questionnaire. Oaxaca-Blinder decomposition was used to independently analyze racial and gender obesity prevalence differences (PD), i.e., comparing Black girls to White girls, and Black girls to Black boys.

RESULTS

Overall, measured characteristics accounted for 46.8% of the racial PD but only 11.9% of the gender PD. Racial PD was associated with Black girls having less fruit/vegetable access at home, obtaining lunch at school more often, and playing fewer sports than White girls. Gender PD was associated with differential associations between physical activity (PA) measures-including total activities in the past year and days of moderate to vigorous physical activity (MVPA) in the past week-and obesity.

CONCLUSIONS

School lunch and home food environmental variables accounted for racial disparities, but not gender disparities, in obesity prevalence. Gender differences in mechanisms between PA and obesity should be explored further.

Postpartum Teens' Perception of the Food Environments at Home and School

BACKGROUND

An environment that supports healthy eating is one factor to prevent obesity. However, little is known about postpartum teen's perceptions of their home and school environments and how this relates to dietary behaviors.

PURPOSE

This study explores the relationship between home and school environments and dietary behaviors for postpartum teens.

DESIGN

Conducted cross-sectionally during 2007-2009 across 27 states and included 889 postpartum teens enrolled in Parents as Teachers Teen Program. Data included measures of sociodemographics and perceptions of school and home food environments. A 7-day recall of snack and beverage frequency assessed dietary behaviors. Logistic regression explored associations between baseline environment measures and dietary behaviors at baseline and postintervention (approximately 5 months after baseline) for the control group.

RESULTS

Respondents reported greater access and selection (i.e., variety of choices) of healthy foods and beverages at home than school. At baseline, fruit and vegetable intake was associated with home selection (1.9, 95% confidence interval [CI: 1.3, 2.9]) and availability (1.8, 95% CI [1.3, 2.6]), sweet snack consumption was associated with selection (1.5, 95% CI [1.0, 2.1]), and total snack consumption and sugar-sweetened beverage intake were associated with selection (snack: 2.1, 95% CI [1.5, 3.0]; beverage: 1.7, 95% CI [1.2, 2.4]) and availability (snack: 2.1, 95% CI [1.4, 3.1]; beverage: 1.5, 95% CI [1.0, 2.3]). Water intake at baseline and at the postintervention for control group teens was associated with selection (1.6, 95% CI [1.1, 2.2]). No significant associations were identified between the school environment and dietary behaviors.

CONCLUSIONS

Interventions should target improvements in the home environment for high-risk, postpartum teens.

School food reduces household income disparities in adolescents' frequency of fruit and vegetable intake

OBJECTIVE

The aim of this study is to examine whether school food attenuates household income-related disparities in adolescents' frequency of fruit and vegetable intake (FVI).

METHOD

Telephone surveys were conducted between 2007 and 2008 with adolescent-parent dyads from Northern New England; participants were randomly assigned to be surveyed at different times throughout the year. The main analysis comprised 1542 adolescents who typically obtained breakfast/lunch at school at least once/week. FVI was measured using 7-day recall of the number of times adolescents consumed fruits and vegetables. Fully adjusted linear regression was used to compare FVI among adolescents who were surveyed while school was in session (currently exposed to school food) to those who were surveyed when school was not in session (currently unexposed to school food).

RESULTS

Mean FVI was 8.0 (SD=5.9) times/week. Among adolescents unexposed to school food, household income and FVI were strongly, positively associated. In contrast, among adolescents exposed to school food, FVI was similar across all income categories. We found a significant cross-over interaction between school food and household income in which consuming food at school was associated with higher FVI among adolescents from low-income households versus lower FVI among adolescents from high-income households.

CONCLUSION

School food may mitigate income disparities in adolescent FVI. The findings suggest that the school food environment positively influences FVI among low-income adolescents.

Investigating the historic long-term population health impact of the US National School Lunch Program

OBJECTIVE

The present research aimed to compare historic participation in the US National School Lunch Program (NSLP) during childhood and subsequent prevalence of overweight and obesity among adults at the population level.

DESIGN

Regression models examined cross-sectional, state- and age-based panel data constructed from multiple sources, including the Behavioural Risk Factor Surveillance System, US Congressional Record, US Census and the US Department of Agriculture. Models controlled for cohorts' racial/ethnic composition and state poverty rates.

SUBJECTS

Adult-age cohorts (18-34, 35-49, 50-64 and 18-64 years) by US state over a 25-year period (1984-2008).

SETTING

The cohorts' prevalence of overweight and obesity was compared with the cohorts' estimated NSLP participation during schooling (1925-2007; the NSLP began in 1946).

RESULTS

Among adults aged 18-64 years, a one percentage-point increase in estimated NSLP participation during schooling between 1925 and 2007 was significantly associated with a 0·29 percentage-point increase in the cohort's later prevalence of overweight and obesity. Analysis of narrower age cohorts and different schooling periods produced mixed results.

CONCLUSIONS

The NSLP might have influenced population health historically. Longitudinal analysis of individuals from studies now underway will likely facilitate more robust conclusions about the NSLP's long-term health impact based on more recent experiences.

Misclassification of fourth-grade children's participation in school-provided meals based on parental responses relative to administrative daily records

Although many studies have relied on parental responses concerning children's school-meal participation, few studies have evaluated parental response accuracy. We investigated misclassification of fourth-grade children's participation in school-meal programs based on parental responses relative to administrative daily records using cross-sectional study data collected for 3 school years (2004-05, 2005-06, and 2006-07) for 1,100 fourth-grade children (87% black; 52% girls) from 18 schools total in one district. Parents reported children's usual school-meal participation on paper consent forms. The district provided administrative daily records of individual children's school-meal participation. Researchers measured children's weight and height. "Usual participation" in breakfast/lunch was defined as ≥50% of days. Parental responses misclassified 16.3%, 12.8%, 19.8%, and 4.7% of children for participation in breakfast, classroom breakfast, cafeteria breakfast, and lunch, respectively. Parental responses misclassified more children for participation in cafeteria than classroom breakfast (P=0.0008); usual-participant misclassification probabilities were less than nonusual-participant misclassification probabilities for classroom breakfast, cafeteria breakfast, and lunch (P<0.0001 for each) (two-proportion z tests). Parental responses concerning children's participation were more accurate for lunch than breakfast; parents overstated breakfast participation (both classroom and cafeteria) and lunch participation. Breakfast participation misclassification was not related to body mass index (P=0.41), sex (P=0.40), age (P=0.63), or socioeconomic status (P=0.21) (multicategory logistic regression controlling for school year, breakfast location, and school). Relying on parental responses concerning children's school-meal participation may hamper researchers' abilities to detect relationships that have policy implications for the child nutrition community. The use of administrative daily records of children's school-meal participation is recommended.

Growth disorders among 6-year-old Iranian children

Background:

Sociodemographic factors are important determinants of weight disorders. National representative studies provide a view on this health problem at national and regional levels.

Objectives:

This study aimed to assess the distribution of growth disorders in terms of body mass index (BMI) and height in 6-year-old Iranian children using geographical information system (GIS).

Materials and Methods:

In this cross-sectional nationwide survey, all Iranian children entering public and private elementary schools were examined in a mandatory national screening program in 2009. Descriptive analysis was used to calculate the prevalence of underweight, overweight, obesity, and short stature. Then, ArcGIS software was used to draw the figures.

Results:

The study population consisted of 955388 children (48.5% girls and 76.5% urban). Overall, 20% of children were underweight, and 14.3% had high BMI, consisted of 10.9% overweight and 3.4% obese. The corresponding figure for short stature was 6.6%; however, these growth disorders were not equally distributed across various provinces.

Conclusions:

Our results confirmed unequal distribution of BMI and height of 6-year-old children in Iran generally and in most of its provinces particularly. The differences among provinces cannot be fully explained by the socioeconomic pattern. These findings necessitate a comprehensive national policy with provincial evidence-based programs.

Food insecurity, food assistance and weight status in US youth: new evidence from NHANES 2007-08

OBJECTIVE

To investigate food assistance participation as a risk factor for overweight and obesity in youth, and food insecurity as an effect modifier.

METHODS

The sample included youth ages 4-17, in families ≤200% of the federal poverty line in the 2007-2008 National Health and Nutrition Examination Survey (n = 1321). Food insecurity was measured with the US Department of Agriculture survey module. Food assistance participation was assessed for Supplemental Nutrition Assistance Program, Special Supplemental Nutrition Program for Women, Infants and Children and school meals. Body size was classified by age- and sex-specific body mass index (BMI) percentile, BMI z-score and waist circumference percentile. Regression models with direct covariate adjustment and programme-specific propensity scores, stratified by food insecurity, estimated associations between food assistance participation and body size.

RESULTS

Food assistance participation was not associated with increased body size among food-insecure youth in models with direct covariate adjustment or propensity scores. Compared with low-income, food-secure youth not participating in food assistance, BMI z-scores were higher among participants in models with direct covariate adjustment (0.27-0.38 SD and 0.41-0.47 SD, for boys and girls, respectively). Using propensity scores, results were similar for boys, but less so for girls.

CONCLUSIONS

Food assistance programme participation is associated with increased body size in food-secure youth, but not food-insecure youth. Using both direct covariate adjustment and a propensity score approach, self-selection bias may explain some, but not all, of the associations. Providing healthy food assistance that improves diet quality without contributing to excessive intake remains an important public health goal.

Systematic review and meta-analysis of the association between childhood overweight and obesity and primary school diet and physical activity policies

Obesity is a major public health concern and there are increasing calls for policy intervention. As obesity and the related health conditions develop during childhood, schools are being seen as important locations for obesity prevention, including multifaceted interventions incorporating policy elements. The objective of this systematic review was to evaluate the effects of policies related to diet and physical activity in schools, either alone, or as part of an intervention programme on the weight status of children aged 4 to 11 years. A comprehensive and systematic search of medical, education, exercise science, and social science databases identified 21 studies which met the inclusion criteria. There were no date, location or language restrictions. The identified studies evaluated a range of either, or both, diet and physical activity related policies, or intervention programmes including such policies, using a variety of observational and experimental designs. The policies were clustered into those which sought to affect diet, those which sought to affect physical activity and those which sought to affect both diet and physical activity to undertake random effects meta-analysis. Within the diet cluster, studies of the United States of America National School Lunch and School Breakfast Programs were analysed separately; however there was significant heterogeneity in the pooled results. The pooled effects of the physical activity, and other diet related policies on BMI-SDS were non-significant. The multifaceted interventions tended to include policy elements related to both diet and physical activity (combined cluster), and although these interventions were too varied to pool their results, significant reductions in weight-related outcomes were demonstrated. The evidence from this review suggests that, when implemented alone, school diet and physical activity related policies appear insufficient to prevent or treat overweight or obesity in children, however, they do appear to have an effect when developed and implemented as part of a more extensive intervention programme. Additional evidence is required before recommendations regarding the focus of policies can be made and therefore, increased effort should be made to evaluate the effect of policies and policy containing intervention programmes upon weight status.

Association between state laws governing school meal nutrition content and student weight status: implications for new USDA school meal standards

IMPORTANCE

This study assessed whether stronger school meal nutrition standards may improve student weight status. Results have immediate implications because of the ongoing implementation of new nutrition standards for the National School Lunch Program. OBJECTIVE To determine if state laws with stricter school meal nutrition standards are inversely associated with adolescent weight status, while controlling for unmeasured state-level confounders.

DESIGN

Quasi-experiment.

SETTING

Public schools.

PARTICIPANTS

Four thousand eight hundred seventy eighth-grade students in 40 states. Students were categorized by type of school lunch they usually obtained (free/reduced price, regular price, or none). INTERVENTIONS State laws governing school meal nutrition standards. States with standards that exceeded US Department of Agriculture (USDA) school meal standards were compared with states that did not exceed USDA standards. The parameter of interest was the interaction between state laws and student lunch participant status, ie, whether disparities in weight status between school lunch participants and nonparticipants were smaller in states with stricter standards.

MAIN OUTCOME MEASURES

Body mass index percentile and obesity status.

RESULTS

In states that exceeded USDA standards, the difference in obesity prevalence between students who obtained free/reduced-price lunches and students who did not obtain school lunches was 12.3 percentage points smaller (95% CI, -21.5 to -3.0) compared with states that did not exceed USDA standards. Likewise, differences in mean body mass index percentile between those student populations were 11 units smaller in states that exceeded USDA standards (95% CI, -17.7 to -4.3). There was little evidence that students compensated for school meal laws by purchasing more sweets, salty snacks, or sugar-sweetened beverages from other school venues (eg, vending machines) or other sources (eg, fast food).

CONCLUSIONS AND RELEVANCE

Stringent school meal standards that reflect the latest nutrition science may improve weight status among school lunch participants, particularly those eligible for free/reduced-price lunches.

Trends in body mass index among Ohio's third-grade children: 2004-2005 to 2009-2010

Substantial variation across states in the prevalence and trends in childhood overweight and obesity indicate a need for state-specific surveillance to make state comparisons to national estimates and identify high-risk populations. The purpose of this study was to examine body mass index (BMI) trends among third-grade children in Ohio between the 2004-2005 and 2009-2010 school years and examine changes in prevalence of obesity by specific demographic subgroups. Third-grade children (n=33,672) were directly weighed and measured throughout the school years by trained health care professionals. Trends in overweight/obesity (≥85th percentile of BMI by age/sex), obesity (≥95th percentile), and obesity level 2 (≥97th percentile) over five time periods (2004-2005, 2006-2007, 2007-2008, 2008-2009, 2009-2010) were modeled using logistic regression, accounting for the survey design and adjusting for sex, race/ethnicity, National School Lunch Program (NSLP) participation, and age. Differences in these BMI categories were also examined by these subgroups. BMI estimates did not demonstrate a statistically significant trend over the five time periods for overweight/obesity (34% to 36%), obesity (18% to 20%), or obesity level 2 (12% to 14%). However, increases in overweight/obesity prevalence were found in Hispanic children (37.8% vs 53.1%; P<0.01). Decreases in obesity (16.6% vs 14.1%; P=0.02) and obesity level 2 (11.3% vs 9.3%; P=0.02) were found among children not participating in NSLP and residing in suburban counties (obesity [17.3% vs 14.7%; P=0.03] and obesity level 2 [11.8% vs 9.8%; P=0.05]). Finally, decreases in overweight/obesity and obesity level 2 among boys were observed (15% vs 12.9%; P=0.02). Despite no significant overall trends in overweight/obesity, obesity, or obesity level 2 between 2004 and 2010, prevalence changed among specific subgroups. Obesity prevention efforts should be widespread and include special emphasis on groups experiencing increases or no change in prevalence.

Inequality in School Readiness and Autism among 6-Year-Old Children across Iranian Provinces: National Health Assessment Survey Results

OBJECTIVE

To assess the national inequality of school readiness and autism among 6-year-old Iranian children before school entry using a national health assessment survey.

METHODS

In a cross-sectional nationwide survey, all Iranian children entering public and private elementary schools were asked to participate in a mandatory national screening program in Iran in 2009 in two levels of screening and diagnostic levels.

FINDINGS

The study population consisted of 955388 children (48.5% girls and 76.1% urban residents). Of the whole children, 3.1% of the 6-year-old children had impaired vision. In addition, 1.2, 1.8, 1.4, 7.6, 0.08, 10, 10.9, 56.7, 0.7, 0.8 and 0.6 percent had color blindness, hearing impaired, speech disorder, school readiness, autism, height to age retardation, body mass index extremes, decayed teeth, disease with special needs, spinal disorders, and hypertension, respectively. The distribution of these disorders was unequally distributed across provinces.

CONCLUSION

Our results confirmed that there is an inequality in distribution of school readiness and autism in 6-year-old children across Iranian provinces. The observed burden of these distributions among young children needs a comprehensive national policy with evidence-based province programs to identify the reason for different inequality among provinces.

Prevalence study of clinical disorders in 6-year-old children across Iranian provinces: Findings of Iranian national health assessment survey

OBJECTIVE

To assess the national prevalence of clinical disorders in 6-year-old Iranian children before school entry using a national health assessment survey.

MATERIALS AND METHODS

In a cross-sectional nationwide survey, all Iranian children entering public and private elementary schools were asked to participate in a mandatory national screening program in Iran in 2009 in two levels of screening and diagnostic levels.

RESULTS

The study population consisted of 955388 children (48.5% girls and 76.1% urban). Of the whole children, 3.1% of the 6-year-old children had impaired vision. In addition, 1.2, 1.8, 1.4, 10, 10.9, 56.7, 0.7, 0.8 and 0.6% had color blindness, hearing impaired, speech disorder, height to age retardation, body mass index extremes, decayed teeth, having disease with special needs, spinal disorders, and hypertension, respectively. The distribution of these disorders was unequally distributed across provinces.

CONCLUSIONS

Our results confirmed that the prevalence of clinical disorders among 6-year-old children across Iranian provinces was not similar. The observed burden of these distributions among young children needs a comprehensive national policy with evidence-based province programs to identify the reason for different distribution among provinces.