Change in school nutrition-related laws from 2003 to 2008: evidence from the school nutrition-environment state policy classification system

The Impact of the National Nutrition Program 2017-2030 on People's Food Purchases: A Revenue-Based Perspective

The General Office of the State Council of China promulgated the National Nutrition Program 2017-2030 in 2017 to guide the people to improve their food supply and nutritional intake. This study uses qualitative and quantitative information which are analyzed to estimate the change in people's food purchases following the implementation of the National Nutrition Program 2017-2030, and puts forward measures that should be taken by the competent authorities and stakeholders. We use the translog revenue function of the food industry, and based on the data of listed companies of Chinese food enterprises from 2015 to 2020, and this study find that the National Nutrition Program 2017-2030 has had a positive impact on people's food purchases, and the impact is more obvious in people's food purchases from large food manufacturers. Finally, we also provide regulators with public policy implications, and provide food manufacturers with development suggestions.

State Wellness Policy Requirement Laws Matter for District Wellness Policy Comprehensiveness and Wellness Policy Implementation in the United States

Beginning with the school year 2006-2007, U.S. school districts participating in the federal Child Nutrition Programs were required to adopt and implement a local wellness policy (LWP) that included goals and/or standards for nutrition education, school meals, other foods sold or served in schools, and physical activity. A primary challenge with LWPs has been inconsistent implementation. This study examined whether state wellness policy requirement laws and district LWP comprehensiveness influence district level implementation, using law/policy data from the National Wellness Policy Study and school food authority (SFA)-reported district LWP implementation from the School Nutrition and Meal Cost Study. Generalized linear and structural equation models were used, controlling for SFA and district characteristics. SFAs in states with wellness policy requirement laws (vs. those in states without) reported implementing significantly more practices (59.56% vs. 44.57%, p < 0.01). State wellness policy requirement laws were associated with district LWP comprehensiveness (coeff.: 0.463; 95% CI: 0.123, 0.803) and district-level implementation (coeff.: 1.392; 95% CI: 0.299, 2.485). District LWP comprehensiveness was associated with district implementation (coeff.: 0.562; 95% CI: 0.072, 1.053), but did not mediate the state law-district implementation relationship. This study highlights the important role that state laws and district LWPs can play in facilitating wellness policy implementation.

High School Physical Activity and Nutrition Policy: Summarizing Changes Over Time Using Latent Class Analysis

INTRODUCTION

High school physical activity and nutrition policies can substantially affect student behavior and outcomes. Although public health officials and legislators have advocated for policy improvements, the extent to which policies have changed at local levels is not well understood. This study identifies latent classes of physical activity and nutrition policy environments and explores changes in prevalence of these classes from 2000 to 2016.

METHODS

Data from the School Health Policies and Practices Study, a repeated cross-sectional survey from the Centers for Disease Control and Prevention administered at the school district level in 2000, 2006, 2012, and 2016, were analyzed in 2018. Using latent class analysis, policy environment subgroups were identified, described, and then dichotomized based on satisfaction in meeting recommendations. Associations of latent classes with year and urbanicity were evaluated using logistic regression.

RESULTS

Five latent classes were identified each for physical activity and nutrition policy environments, all with distinct characteristics. Physical activity policies improved from 2000 to 2006 (p<0.001) and then plateaued until 2016, whereas nutrition policies improved consistently from 2000 to 2016 (p<0.001, p=0.011, p<0.001). Though significant disparities between urban and rural school districts were found, these disparities narrowed during the studied years, particularly for physical activity policies.

CONCLUSIONS

The estimated proportion of school districts with satisfactory physical activity and nutrition policy environments increased from 2000 to 2016, possibly because of legislative and policy advocacy efforts. However, many areas for improvement remain. Unsatisfactory latent classes that remained prevalent though 2016 may highlight policy domains that should be targeted by future interventions or subject to further research.

Appetite self-regulation: Environmental and policy influences on eating behaviors

OBJECTIVE

Appetite regulation is influenced by the environment, and the environment is shaped by food-related policies. This review summarizes the environment and policy research portion of an NIH Workshop (Bethesda, MD, 2015) titled "Self-Regulation of Appetite-It's Complicated."

METHODS

In this paper, we begin by making the case for why policy is an important tool in efforts to improve nutrition, and we introduce an ecological framework that illustrates the multiple layers that influence what people eat. We describe the state of the science on how policies influence behavior in several key areas: the federal food programs, schools, child care, food and beverage pricing, marketing to youth, behavioral economics, and changing defaults. Next, we propose novel approaches for multidisciplinary prevention and intervention strategies to promote breastfeeding, and examine interactions between psychology and the environment.

RESULTS

Policy and environmental change are the most distal influences on individual-level appetite regulation, yet these strategies can reach many people at once by changing the environment in which food choices are made. We note the need for more research to understand compensatory behavior, reactance, and how to effectively change social norms.

CONCLUSIONS

To move forward, we need a more sophisticated understanding of how individual psychological and biological factors interact with the environment and policy influences.

Association between state school nutrition laws and subsequent child obesity

Many states have enacted laws to improve school nutrition. We tested whether stronger state nutrition laws are associated with subsequently decreased obesity. We conducted a retrospective national multi-year panel data study (analyzed 2014-2016 at the Children's Hospital of Philadelphia). The predictors were 2010 laws regarding 9 nutrition categories from the Classification of Laws Associated with School Students, which grades the strength of state laws (none, weak, or strong). The outcome was weight status (healthy weight, overweight, or obese) in elementary, middle, and high school from the 2011/2012 National Survey of Children's Health. We tested the association between the strength of laws and weight using multinomial logistic regression. To further evaluate our main results, we conducted state-level longitudinal analyses testing the association between competitive food and beverage laws on the change in obesity from 2003-2011. In main analyses of 40,177 children ages 10-17years, we found strong state laws restricting the sale of competitive food and beverages in elementary school (OR: 0.68; 95% CI: 0.48, 0.96) and strong advertising laws across all grades (OR: 0.63; 95% CI: 0.46, 0.86) were associated with reduced odds of obesity. In longitudinal analyses, states with strong competitive food and beverage laws from 2003-2010 had small but significant decreases in obesity, compared to states with no laws. Although further research is needed to determine the causal effect of these laws, this study suggests that strong state laws limiting the sale and advertising of unhealthy foods and beverages in schools are associated with decreased obesity rates.

School District Policies and Adolescents' Soda Consumption

PURPOSE

Sugar-sweetened beverages (SSBs) are a significant source of calories and added sugars for youth ages 14-18 years in the United States. This study examined the relationship between district-level policies and practices and students' consumption of regular soda, one type of SSB, in 12 large urban school districts.

METHODS

Data from the 2012 School Health Policies and Practices Study and 2013 Youth Risk Behavior Surveillance System were linked by district. The outcome variable was soda consumption and exposure variables were district policies. We used multivariable logistic regression analyses to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) after controlling for student characteristics and district free/reduced-price meal eligibility.

RESULTS

About 18% of students reported consuming regular soda at least once per day. Most districts required high schools to have nutrition education, maintain closed campuses, and required/recommended that schools restrict promotional products and sale of beverages. Fewer districts required/recommended that schools offer healthful alternative beverages. Students in districts that restricted promotional products had lower odds of regular soda consumption (AOR = .84, 95% CI = .71-1.00), as did students in districts that restricted access to SSBs and offered healthful beverages when other beverages were available (AOR = .72, 95% CI = .54-.93, AOR = .76, 95% CI = .63-.91).

CONCLUSIONS

This study demonstrates that certain district-level policies are associated with student consumption of regular soda. These findings add to a growing consensus that policies and practices that influence the availability of healthier foods and beverages are needed across multiple settings.

Built environment assessment: Multidisciplinary perspectives

Context

As obesity has become increasingly widespread, scientists seek better ways to assess and modify built and social environments to positively impact health. The applicable methods and concepts draw on multiple disciplines and require collaboration and cross-learning. This paper describes the results of an expert team׳s analysis of how key disciplinary perspectives contribute to environmental context-based assessment related to obesity, identifies gaps, and suggests opportunities to encourage effective advances in this arena.

Evidence acquisition

A team of experts representing diverse disciplines convened in 2013 to discuss the contributions of their respective disciplines to assessing built environments relevant to obesity prevention. The disciplines include urban planning, public health nutrition, exercise science, physical activity research, public health and epidemiology, behavioral and social sciences, and economics. Each expert identified key concepts and measures from their discipline, and applications to built environment assessment and action. A selective review of published literature and internet-based information was conducted in 2013 and 2014.

Evidence synthesis

The key points that are highlighted in this article were identified in 2014–2015 through discussion, debate and consensus-building among the team of experts. Results focus on the various disciplines׳ perspectives and tools, recommendations, progress and gaps.

Conclusions

There has been significant progress in collaboration across key disciplines that contribute to studies of built environments and obesity, but important gaps remain. Using lessons from interprofessional education and team science, along with appreciation of and attention to other disciplines׳ contributions, can promote more effective cross-disciplinary collaboration in obesity prevention.

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Gaps in collaboration in studies of built environments and obesity remain.

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Lessons from interprofessional education can promote more effective collaboration.

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More attention to other disciplines’ contributions will yield greater health impact.

Socioeconomic Differences in the Association Between Competitive Food Laws and the School Food Environment

BACKGROUND

Schools of low socioeconomic status (SES) tend to sell fewer healthy competitive foods/beverages. This study examined whether state competitive food laws may reduce such disparities.

METHODS

School administrators for fifth- and eighth grade reported foods and beverages sold in school. Index measures of the food/beverage environments were constructed from these data. Schools were classified into SES tertiles based on median household income of students' postal zip code. Regression models were used to estimate SES differences in (1) Healthy School Food Environment Index (HSFEI) score, Healthy School Beverage Environment Index (HSBEI) score, and specific food/beverage sales, and (2) associations between state competitive food/beverage laws and HSFEI score, HSBEI score, and specific food/beverage sales.

RESULTS

Strong competitive food laws were positively associated with HSFEI in eighth grade, regardless of SES. Strong competitive beverage laws were positively associated with HSBEI particularly in low-SES schools in eighth grade. These associations were attributable to schools selling fewer unhealthy items, not providing healthy alternatives. High-SES schools sold more healthy items than low-SES schools regardless of state laws.

CONCLUSIONS

Strong competitive food laws may reduce access to unhealthy foods/beverages in middle schools, but additional initiatives are needed to provide students with healthy options, particularly in low-SES areas.

Mississippi Communities for Healthy Living: Implementing a nutrition intervention effectiveness study in a rural health disparate region

BACKGROUND

Intervention research in rural, health disparate communities presents unique challenges for study design, implementation, and evaluation. Challenges include 1) culturally appropriate intervention components, 2) participant recruitment and retention, 3) treatment cross-contamination, 4) intervention delivery and data collection, and 5) potential measurement reactivity.

PURPOSE

The purposes of this paper are to 1) detail the methods of the MCHL study and 2) report baseline demographic characteristics of study participants. The secondary aim is to determine if study participants were engaging in behavior changes after enrollment and prior to intervention initiation.

METHODS

MCHL was developed using the RE-AIM planning and evaluation framework (reach, effectiveness, adoption, implementation, maintenance). Intervention components were based on Roger's diffusion of innovation attributes that promote adoption of a new innovation as well as on the psychosocial constructs of social support, self-efficacy and decisional balance. Rolling enrollment data collection was used to acquire sufficient sample size and a second data collection just prior to intervention implementation assessed measurement reactivity effects. Participant outcomes included diet quality, blood pressure, weight status, and quality of life. Cluster stratified assignment to one of two treatment arms was utilized to minimize cross contamination. Generalized linear models were used to compare enrollment measures between the two treatment arms while mixed model linear regression was used to test for changes in diet quality outcomes from enrollment to pre-intervention baseline.

RESULTS

There were no significant differences in participant demographic, anthropometric or clinical measures between the two treatment arms at enrollment. With the exception of total vegetables, none of the diet quality indicators were significantly different between enrollment and baseline timepoints.

CONCLUSIONS

Conducting nutrition intervention research in a rural health disparate region requires flexibility in adapting the recruitment, retention, and data collection procedures while maintaining a high level of scientific rigor. Negligible research participation effects, such as measurement reactivity, were noted in this population. However, further research is needed to identify methods to successfully recruit and retain Caucasian females to participate in community-based nutrition interventions in this region.

The association of soda sales tax and school nutrition laws: a concordance of policies

OBJECTIVE

The current research examined the association between state disfavoured tax on soda (i.e. the difference between soda sales tax and the tax on food products generally) and a summary score representing the strength of state laws governing competitive beverages (beverages that compete with the beverages in the federally funded school lunch programme) in US schools.

DESIGN

The Classification of Laws Associated with School Students (CLASS) summary score reflected the strength of a state's laws restricting competitive beverages sold in school stores, vending machines, school fundraisers and à la carte cafeteria items. Bridging the Gap (BTG) is a nationally recognized research initiative that provided state-level soda tax data. The main study outcome was the states' competitive beverage summary scores for elementary, middle and high school grade levels, as predicted by the states' disfavoured soda tax. Univariate and multivariate analyses were conducted, adjusting for year and state.

SETTING

Data from BTG and CLASS were used.

SUBJECTS

BTG and CLASS data from all fifty states and the District of Columbia from 2003 to 2010 were used.

RESULTS

A higher disfavoured soda sales tax was generally associated with an increased likelihood of having strong school beverage laws across grade levels, and especially when disfavoured soda sales tax was >5 %.

CONCLUSIONS

These data suggest a concordance between states' soda taxes and laws governing beverages sold in schools. States with high disfavoured sales tax on soda had stronger competitive beverage laws, indicating that the state sales tax environment may be associated with laws governing beverage policy in schools.

State-level school competitive food and beverage laws are associated with children's weight status

BACKGROUND

This study attempted to determine whether state laws regulating low nutrient, high energy-dense foods and beverages sold outside of the reimbursable school meals program (referred to as "competitive foods") are associated with children's weight status.

METHODS

We use the Classification of Laws Associated with School Students (CLASS) database of state codified law(s) relevant to school nutrition. States were classified as having strong, weak, or no competitive food laws in 2005 based on strength and comprehensiveness. Parent-reported height and weight along with demographic, behavioral, family, and household characteristics were obtained from the 2007 National Survey of Children's Health. Bivariate and logistic regression analyses estimated the association between states' competitive food laws and children's overweight and obesity status (body mass index [BMI]-for-age ≥85th percentile). Children (N = 16,271) between the ages of 11-14 years with a BMI for age ≥5th percentile who attended public school were included.

RESULTS

Children living in states with weak competitive food laws for middle schools had over a 20% higher odds of being overweight or obese than children living in states with either no or strong school competitive food laws.

CONCLUSION

State-level school competitive food and beverage laws merit attention with efforts to address the childhood obesity epidemic. Attention to the specificity and requirements of these laws should also be considered.

Behavioral research in cancer prevention and control: a look to the future

Human behavior is central to the etiology and management of cancer outcomes and presents several avenues for targeted and sustained intervention. Psychosocial experiences such as stress and health behaviors including tobacco use, sun exposure, poor diet, and a sedentary lifestyle increase the risk of some cancers yet are often quite resistant to change. Cancer screening and other health services are misunderstood and over-utilized, and vaccination underutilized, in part because of the avalanche of information about cancer prevention. Coordination of cancer care is suboptimal, and only a small fraction of cancer patients enroll in clinical trials essential to the development of new cancer treatments. A growing population of cancer survivors has necessitated a fresh view of cancer as a chronic rather than acute disease. Fortunately, behavioral research can address a wide variety of key processes and outcomes across the cancer control continuum from prevention to end-of-life care. Here we consider effects at the biobehavioral and psychological, social and organizational, and environmental levels. We challenge the research community to address key behavioral targets across all levels of influence, while taking into account the many new methodological tools that can facilitate this important work.