Evaluating the Usability of the Wellness School Assessment Tool Whole School, Whole Community, Whole Child (WellSAT WSCC): A School Wellness Policy Assessment Tool

BACKGROUND

Adoption of the Whole School, Whole Community, Whole Child (WSCC) model has been slowed by a lack of available tools to support implementation. The Wellness School Assessment Tool (WellSAT) WSCC is an online assessment tool that allows schools to evaluate the alignment of their policies with the WSCC model. This study assesses the usability of the WellSAT WSCC.

METHODS

Using a convergent mixed methods design, we collected qualitative and quantitative data from 5 school-based participants with roles in development and evaluation of policy. Participants explored the platform while engaging in a think-aloud procedure and scored a sample policy using the platform. They also completed the System Usability Scale and responded to open-ended questions about the usability of the platform.

RESULTS

Participants rated the WellSAT WSCC as an above-average user experience, but data suggested several areas for improvement, including improved instructions, enhanced visual design of the platform, and guidance for subsequent policy changes.

CONCLUSION

The WellSAT WSCC provides an above-average user experience but can be improved to increase user experience. These improvements increase the potential for greater use to facilitate integration of the WSCC model into school policy.

Transcription factor DREF regulates expression of the microRNA gene bantam in Drosophila melanogaster

The bantam gene encodes a vital microRNA and has a complex expression pattern in various tissues at different stages of Drosophila development. This microRNA is involved in the control of normal development of the ocular and wing imaginal discs, the central nervous system, and also in maintaining the undifferentiated state of stem cells in the ovaries of adult females. At the cellular level, bantam stimulates cell proliferation and prevents apoptosis. The bantam gene is a target of several conserved signaling cascades, in particular, Hippo. At the moment, at least ten proteins are known to directly regulate the expression of this gene in different tissues of Drosophila. In this study, we found that the bantam regulatory region contains motifs characteristic of binding sites for DREF, a transcription factor that regulates the expression of Hippo cascade genes. Using transgenic lines containing a full-length bantam lethality-rescuing deletion fragment and a fragment with a disrupted DREF binding site, we show that these motifs are functionally significant because their disruption at the bantam locus reduces expression levels in the larvae and ovaries of homozygous flies, which correlates with reduced vitality and fertility. The effect of DREF binding to the promoter region of the bantam gene on its expression level suggests an additional level of complexity in the regulation of expression of this microRNA. A decrease in the number of eggs laid and a shortening of the reproductive period in females when the DREF binding site in the regulatory region of the bantam gene is disrupted suggests that, through bantam, DREF is also involved in the regulation of Drosophila oogenesis.

USDA's Summer Meals During the COVID-19 Pandemic: A Mixed-Methods Examination of Participants and Non-Participants in 2021

BACKGROUND

The US Department of Agriculture's school meal programs have wide reach during the school year, but food insufficiency among households with children increases during summer months. The US Department of Agriculture summer meal programs are designed to fill this gap, yet participation has historically been low.

OBJECTIVE

To examine the facilitators and barriers to participation in a 2021 summer meal program while the COVID-19 pandemic regulation waivers were in place.

DESIGN

Cross-sectional mixed-methods survey research.

PARTICIPANTS/SETTING

All parents/guardians of children enrolled in a school district in Connecticut were invited to participate in an online survey in December 2021. The respondents included summer meal participants (n = 622) and nonparticipants (n = 294).

MAIN OUTCOME MEASURES

Survey respondents reported demographic variables, current food sufficiency, communication preferences, satisfaction with the program, reasons for using or not using the program, and whether they found the program helpful financially. The survey included three open-ended questions about barriers to participation.

RESULTS

Respondents who used the summer meal program indicated that the pandemic-related regulatory waivers were key to their decision to participate. Reported barriers included lack of awareness of the program, inability to travel to sites during the times they were open, lack of transportation, concerns about dietary restrictions, and lack of variety in the menu, and concerns about wasting food. Parents/guardians expressed strong preferences for receiving communication about summer meals directly from their child's school and being able to access meals outside of typical work hours.

CONCLUSIONS

The pandemic waivers allowed sponsors to test different models of distribution. Parents/guardians responded positively to the opportunity to access grab-and-go meals, multiple meals at once, and meals without a child present. These findings can be used to inform potential policy changes to reduce barriers and increase participation.

Parent Perceptions of School Meals Influence Student Participation in School Meal Programs

OBJECTIVE

To evaluate if parent perceptions of school meals influence student participation.

DESIGN

In May 2022, an online survey was used to evaluate parents' perceptions of school meals and their children's participation.

PARTICIPANTS

A total of 1,110 California parents of kindergarten through 12th-grade students.

MAIN OUTCOME MEASURES

Student participation in school lunch and breakfast.

ANALYSIS

Principal component analysis and Poisson regression models.

RESULTS

Three groups of parental perceptions were identified: (1) positive perceptions (eg, liking school meals and thinking that they are tasty and healthy), (2) perceived benefits to families (eg, school meals save families money, time, and stress), and (3) negative (eg, concerns about the amount of sugar in school meals and stigma). More positive parental perceptions about school meals and their benefits to families were associated with greater student meal participation. In contrast, more negative parental perceptions were associated with reduced student participation in school meals (P < 0.05).

CONCLUSION AND IMPLICATIONS

Parent perceptions of school meals may affect student participation in school meal programs. Working to ensure parents are familiar with the healthfulness and quality of school meals and the efforts schools are making to provide high-quality, appealing meals may be critical for increasing school meal participation rates.

Participation in the US Department of Agriculture's Summer Meal Programs: 2019-2021

BACKGROUND

The US Department of Agriculture's (USDA) summer meal programs are designed to provide meals at no cost while school is out of session. In response to the COVID-19 pandemic, several regulatory waivers were enacted to facilitate meal distribution. The aim of this study was to assess the rates of meal distribution before and after these waivers were in effect.

METHODS

Meal distribution patterns for 2019, 2020, and 2021 were examined through (1) a descriptive comparison of the number of participating districts, sponsors, meal sites, and meals distributed statewide, and (2) repeated measures ANOVAs to examine changes among districts in operation all years.

RESULTS

The waivers were associated with an increase in the total number of participating districts, sponsors, and meal sites; an increase in the total number of meals distributed to children during the summer months; and an increase in meal distribution among sponsors that had been in place since 2019.

CONCLUSION

Expanding the area eligibility criteria and enabling flexibility in meal distribution methods increased the number of meals provided. This study provides important preliminary evidence to suggest that the USDA should consider permanent regulatory changes to this program to maximize its reach.

Competitive Foods' Nutritional Quality and Compliance with Smart Snacks Standards: An Analysis of a National Sample of U.S. Middle and High Schools

Snacks and beverages are often sold in addition to meals in U.S. schools ("competitive foods"), but their current nutritional quality and compliance with national Smart Snacks standards are unknown. This study assessed competitive foods in a national sample of 90 middle and high schools. Differences in compliance by school characteristics were measured using mixed methods analysis of variance. Overall, 80% of the schools in the sample sold competitive foods; but they were less commonly available in schools with universal free school meal (UFSM) policies. A total of 840 unique products were documented and, on average, 75% were compliant with Smart Snacks standards. A total of 56% aligned with recommended added sugar limits (<10% of calories); and 340 unique products (40%) aligned with both sugar and Smart Snacks standards. Approximately one-fifth of competitive foods contained synthetic dyes, and 31% of beverages contained artificial sweeteners. Smart Snacks standards compliance was greater when competitive foods were overseen by food service departments, in comparison with others (e.g., principals, student organizations, or outside vendors [77% vs. 59% compliance; p = 0.003]). Therefore, district wellness policies should consider requiring food service departments to oversee competitive foods. Federal and state policies should limit added sugars, artificial sweeteners, and synthetic dyes. This appears to be highly feasible, given the substantial number of products that meet these criteria. UFSM policies should also be considered to support healthier school meal environments more broadly.

An Examination of Parental Weight Stigma and Weight Talk Among Socioeconomically and Racially/Ethnically Diverse Parents

Parental communication about body weight can influence children's emotional well-being and eating behaviors. However, little is known about the role of parental self-stigma concerning weight and social position variables (ie, race/ethnicity, income, and gender) in weight communication. This study examined how parents' self-stigmatization for their own weight (ie, weight bias internalization) and self-stigmatization for their child's weight (ie, affiliate stigma) relates to weight talk frequency with their children, and whether these associations vary across parental race/ethnicity, income, and gender. Parents (n = 408) completed a cross-sectional, online survey about their weight communication and self-stigmatization. Linear regression was used to examine the relationships among these variables, including interactions between the stigma variables and social position variables in predicting weight talk. Higher levels of weight bias internalization and affiliate stigma were strongly associated with increased parental weight talk frequency; parents who endorsed higher levels of internalized bias about their own weight expressed greater affiliate stigma for their child's weight, regardless of demographic characteristics or weight status. Associations between the stigma variables and weight talk outcomes were stronger among fathers and parents of higher income. Findings highlight the importance of considering weight stigma variables in parental weight communication research.

Parental Reasons for Engaging in or Avoiding Weight Talk With Children

Parental weight talk with children can have negative consequences; yet, it is not well understood why parents engage in it and if demographic differences exist. Utilizing the extant qualitative literature, we developed two scales to quantitatively examine parental reasons for engaging in and avoiding weight talk. An Internet sample of 408 US parents (64% mothers; 34% White, 33% Black, and 32% Hispanic/Latinx) completed the scales. Parents cited concern for their child's health as a primary reason for weight talk, whereas avoidance stemmed from not wanting their child to be weight-obsessed. White and Hispanic vs. Black parents, and parents with experienced weight stigma, were more likely to cite personal struggles with body weight as reasons to both engage in and avoid weight talk. Fathers vs. mothers were more likely to cite protecting their child from weight-based bullying as a reason for weight talk. Understanding these parental motivations can inform health interventions.

Predictors of Participation in the U.S. Department of Agriculture Summer Meal Programs: An Examination of Outreach Strategies and Meal Distribution Methods During COVID-19

Introduction

Significantly fewer children participate in the U.S. Department of Agriculture-sponsored summer meal programs than in the federal school meal programs during the academic year. During the summer of 2021, several pandemic-related waivers supported more flexible operations for summer meal programs, such as allowing grab-and-go meals and the distribution of meals for multiple days at once. This study assessed how summer meal site characteristics and geographically targeted outreach methods were associated with summer meals served in 2021 in Connecticut.

Methods

Weekly meal count data were requested from all sponsors of the Summer Food Service Program and the National School Lunch Program Seamless Summer Option. Data were received from 78 sponsors with 763 sites. Geographically targeted outreach (e.g., billboards, bus ads, and flyers) was tracked by location each week. Mixed methods ANOVA was used to examine the predictive value of outreach efforts, program characteristics, and meal distribution methods on meals served each week. The program characteristics examined included the hours open per week, the number of weeks serving meals, the maximum number of meals distributed at one time, and the number of open and closed sites in a school district.

Results

Between June 21 and August 20, 2021, a total of 1,188,669 breakfasts and 1,389,347 lunches were served. Sites that were open more hours per week (mean=7.60 hours per week; range=0.17-35) and gave multiple meals to parents at each visit (mean=4.68 meals; range=1-15) reported greater rates of meal distribution. The outreach efforts assessed were not significantly associated with changes in meal distribution at nearby sites.

Conclusions

The U.S. Department of Agriculture's waivers in response to COVID-19 permitted extended operating hours and multiple-meal distribution. These operational flexibilities should be considered for permanent regulation changes owing to their positive association with summer meal participation.

Construct validity of the Charitable Food Nutrition Index

Background

Food pantries are an important source of food for those facing food insecurity. The Charitable Food Nutrition Index (CFNI) was developed for research and practice to measure the nutritional quality of assortments of foods in this setting.

Objective

The study assessed the construct validity of the CFNI using secondary data from a group-randomized food pantry intervention in Minnesota.

Methods

The CFNI was calculated for each client cart post-intervention (n = 187; 85 intervention, 102 control). CFNI scores were based on the proportion of items in each client cart ranked "green," "yellow," or "red" using the Healthy Eating Research Nutrition Guidelines for the Charitable Food System. An implementation score assessing intervention fidelity was measured for each pantry (n = 11; 5 intervention, 6 control) based on the four intervention subcomponents: aesthetics/use of space; healthy food prominence and appeal; unhealthy food de-emphasis; and stocking standards. Mixed linear models were used to test whether: (a) client carts from pantries in the intervention condition had higher CFNI scores than those in the control condition, and (b) higher implementation scores were associated with higher CFNI scores.

Results

In adjusted models, clients from intervention group pantries had higher CFNI scores, reflecting a healthier assortment of foods compared with clients from control group pantries (p = 0.022). CFNI scores were positively associated with greater fidelity to the intervention (p = 0.020).

Conclusions

The CFNI was sensitive enough to detect the effects of the intervention in the expected directions. These findings support its construct validity and utility as a measure in the charitable food system.

Mediation of the association between social environmental characteristics of family childcare home and weight status in children by diet quality

BACKGROUND

The food and beverages served in family childcare homes (FCCHs) may play an important role in the development of childhood overweight and obesity. This analysis examines whether children's diet quality mediates the relationship between foods and beverages served in FCCHs and preschool-aged children's weight status.

METHODS

Trained and certified staff conducted observations for two days in each FCCH, using the Environment and Policy Assessment and Observation (EPAO) measure to determine the foods and beverages served to children (N = 370) in FCCHs (N = 120). They also used the Dietary Observation in Child Care (DOCC) protocol to assess children's food and beverage intake during childcare, from which we calculated the Healthy Eating Index-2015 (HEI), a measure of diet quality. Height and weight were measured for each child with parent consent from which the child's body mass index (BMI) z-scores were calculated. A multilevel mediation analysis was conducted to indicate whether children's diet quality mediates the relations between food and beverage served in FCCHs and preschool-aged children's weight status.

RESULTS

Children's total HEI scores significantly mediated the relationship between the EPAO subscale Food Provided and children's BMI z-scores (B=-0.01, p < .05, 95% CI = [-0.03, - 0.002]). Further, the EPAO subscale Food Provided was positively associated with the total HEI score (B = 0.75, p < .01, 95% CI = [0.32, 1.18]). Total HEI scores were negatively associated with BMI z-score (B=-0.01, p < .05, 95% CI = [-0.02, - 0.001]).

CONCLUSION

Children's diet quality did significantly mediate the relationship between the food served in FCCHs and children's weight status. More longitudinal studies with longer follow-up periods need to be conducted to confirm these relationships. Further, future studies need to examine the relationships between a broader spectrum of FCCH environmental characteristics and home environment with children's weight status, as well as other mediators including physical activity.

Mediation of the Association between Social Environmental Characteristics of Family Childcare Home and Weight Status in Children by Diet Quality

Background

The food and beverages served in family childcare homes (FCCHs) may play an important role in the development of childhood overweight and obesity. This analysis examines whether children's diet quality mediates the relationship between foods and beverages served in FCCHs and preschool-aged children's weight status.

Methods

Trained and certified staff conducted observations for two days in each FCCH, using the Environment and Policy Assessment and Observation (EPAO) measure to determine the foods and beverages served to children (N=370) in FCCHs (N=120). They also used the Dietary Observation in Child Care (DOCC) protocol to assess children's food and beverage intake during childcare, from which we calculated the Healthy Eating Index-2015 (HEI), a measure of diet quality. Height and weight were measured for each child with parent consent from which the child's body mass index (BMI) z-scores were calculated from. A multilevel mediation analysis was conducted to indicate whether children's diet quality mediates the relations between food and beverage served in FCCHs and preschool-aged children's weight status.

Results

Children's total HEI scores significantly mediated the relationship between the EPAO subscale "Food provided" and children's BMI z-scores (B=-.01, p<.05, 95% CI = [-.03, -.002]). Further, the EPAO subscale "Food provided" was positively associated with the total HEI score (B=.75, p<.01, 95% CI = [.32, 1.18]). Total HEI scores were negatively associated with BMI z-score (B=-.01, p<.05, 95% CI = [-.02, -.001]).

Conclusion

Children's diet quality did significantly mediate the relationship between the food served in FCCHs and children's weight status. More longitudinal studies with longer follow-up periods need to be conducted to confirm these relationships. Further, future studies need to examine the relationships between a broader spectrum of FCCH environmental characteristics and home environment with children's weight status, as well as other mediators including physical activity.

Effect of Applying Best Practices for Physical Activity and Screen Time to Family Childcare Homes

INTRODUCTION

Early childcare has been identified as an influential setting for children's physical activity. Our objective was to determine whether children aged 2 to 5 years had more accelerometer-measured minutes of physical activity when caregivers in their family childcare home (FCCH) adhered to best practices for physical activity and screen time.

METHODS

We analyzed baseline 2-day observation data collected by using the Environment and Policy Assessment and Observation measure from a cluster-randomized trial. Multilevel linear regression models assessed the association between caregivers' meeting best practices for physical activity and screen time and children's time spent sedentary or in moderate-to-vigorous physical activity (MVPA).

RESULTS

All FCCH caregivers (N = 120) in our study were female, and 67.5% were Hispanic. Participating children (N = 349) were 52.1% female and 57.4% Hispanic. A higher score among caregivers for physical activity best practices was associated with more MVPA (B = 0.79; 95% CI, 0.02 to 1.56; P = .04) for children and less sedentary time (B = -2.07; 95% CI, -3.94 to -0.19; P = .04). A higher caregiver score for screen time best practices was associated with less sedentary time (B = -2.07; 95% CI, -3.94 to -0.19; P = .04) and more MVPA time (B = 0.65; 95% CI, 0.03 to .27; P = .04). Children in homes where caregivers offered them 60 minutes or more of outdoor play and participated in outdoor physical activity had more MVPA and less sedentary time. We found no association between various screen-time best practices and children's sedentary time.

DISCUSSION

Children with caregivers who used more best practices for physical activity and screen time had higher activity levels and spent less time sedentary. These findings could help policy makers and people caring for young children modify existing policies and develop programs to help early childhood caregivers implement best practices to promote children's physical activity.

Nutrition Practices of Family Child Care Home Providers and Children's Diet Quality

OBJECTIVE

To examine the relationship between the diet quality of children aged 2-5 years cared for in family child care homes (FCCHs) with provider adherence to nutrition best practices.

DESIGN

Cross-sectional analysis.

PARTICIPANTS

Family child care home providers (n = 120, 100% female, 67.5% Latinx) and children (n = 370, 51% female, 58% Latinx) enrolled in a cluster-randomized trial.

MAIN OUTCOME MEASURES

Data were collected over 2 days at each FCCH. The Environment and Policy Assessment and Observation tool was used to document whether providers exhibited nutrition practices on the basis of the Nutrition and Physical Activity Self-Assessment for Child Care. Each practice was scored as either present or absent. Children's food intake was observed using Diet Observation at Child Care and analyzed with the Healthy Eating Index-2015.

ANALYSIS

Multilevel linear regression models assessed the association between providers exhibiting best practices regarding nutrition and children's diet quality. The model accounted for clustering by FCCH and controlled for provider ethnicity, income level, and multiple comparisons.

RESULTS

Children in FCCHs in which more of the best practices were implemented had higher diet quality (B = 1.05; 95% confidence interval [CI], 0.12-1.99; P = 0.03). Specifically, children whose providers promoted autonomous feeding (B = 27.52; 95% CI, 21.02-34.02; P < 0.001) and provided nutrition education (B = 7.76; 95% CI, 3.29-12.23; P = 0.001) had higher total Healthy Eating Index scores.

CONCLUSIONS AND IMPLICATIONS

Future interventions and policies could support FCCH providers in implementing important practices such as autonomy feeding practices, talking informally to children about nutrition, and providing healthful foods and beverages.

Knowing Is Not Doing: A Qualitative Study of Parental Views on Family Beverage Choice

OBJECTIVE

Sugary drink consumption is associated with adverse health outcomes in children, highlighting the need for scalable family interventions that address barriers to water consumption. To inform development of a scalable, health-care-system-based intervention targeting family beverage choice, a formative qualitative study was conducted using semi-structured interviews with parents whose children were identified as over-consuming sugar-sweetened beverages (SSB) and/or fruit juice (FJ). The first goal of these interviews was to understand, in a diverse real-world patient population, what parents viewed as the primary drivers of their family's beverage choices, and explore how these drivers might need to be addressed in order to make changes to beverage consumption. A second goal was to explore parental preferences for planned intervention components. An exploratory goal of the interviews was to examine whether knowledge, attitudes, and beliefs around family beverage choice differed across racial and ethnic groups in this sample.

DESIGN

Semi-structured phone interviews were conducted and interviews audio-recorded and transcribed.

PARTICIPANTS

39 parents/caregivers of children ages 1-8 who over-consumed sugary drinks as determined by screenings at pediatric visits.

PHENOMENON OF INTEREST

Parents were interviewed about family beverage choices and preferences to inform development of a multi-component intervention.

ANALYSIS

Thematic analysis was performed, including comparison of themes across racial/ethnic groups.

RESULTS

Parents expressed that sugary drinks were unhealthy and water was a better alternative. Most were familiar with the health consequences of excess sugar consumption. They identified many reasons why sugary drinks are chosen over water despite this knowledge. One common reason was concern about tap water safety. Few differences were noted across racial and ethnic groups in our sample. Parents were enthusiastic about a technology-based intervention to be delivered through their child's doctor's office.

CONCLUSIONS AND IMPLICATIONS

Knowledge is not enough to change behavior. Beverage interventions need to be easy to access, make water more appealing, and elevate beverage choice above the "white noise" of everyday life. Delivering an intervention in a clinical setting could provide an extra level of care, while technology would reduce the amount of live contact and decrease the burden for clinicians and parents.

Family-based weight stigma and psychosocial health: A multinational comparison

OBJECTIVE

Family-based weight stigma can be expressed as criticism, judgment, teasing, and mistreatment by family members because of an individual's body weight. The current study compared the prevalence and psychosocial correlates of family-based weight stigma among adult members of a weight-management program living in Australia, Canada, France, Germany, the UK, and the US.

METHODS

Participants (N = 8100 adults who reported having ever experienced weight stigma; 95% female; 94% White) completed an identical online survey in their country's dominant language that assessed their experiences of weight stigma from 16 different family member sources, as well as internalized weight bias, body image, eating behaviors, perceived stress, and self-rated health.

RESULTS

Family-based weight stigma, especially from mothers (49%-62%), spouses/romantic partners (40%-57%), and fathers (35%-48%), was highly prevalent across countries. Weight stigma from one's immediate family members was associated with indices of poorer psychosocial health across the six countries (β coefficients = |0.08-0.13|).

CONCLUSIONS

Findings highlight the need for weight stigma-reduction efforts to help family members distinguish between supportive, encouraging discourse and potentially weight-stigmatizing communication. Future research should examine the prevalence and correlates of family-based weight stigma in more diverse community samples, including among racially/ethnically and gender diverse adults, and in non-Western countries.

Effects of Sugary Beverage Text and Pictorial Warnings: A Randomized Trial

INTRODUCTION

Multiple U.S. localities have introduced legislation requiring sugar-sweetened beverage (SSB) warnings. This study effects of different warning designs on beverage selections and perceptions.

STUDY DESIGN

The study was an RCT.

SETTING/PARTICIPANTS

An online virtual convenience store and survey were used with a nationally representative sample of primary caregivers of 6-11-year-olds (n=961). Data were collected in January 2020 and analyzed in May-July 2020.

INTERVENTION

Participants were randomized to view SSBs with 1 of 4 front-of-package label designs: (1) no-warning control, (2) health-related text warning, (3) sugar pictorial warning (image of beverage sugar content in cubes/teaspoons/packets with health-related warning text), or (4) health pictorial warning (image of possible health consequences of overconsuming SSBs with health-related warning text).

MAIN OUTCOME MEASURES

Outcomes included participants' beverage choice for their child and perceptions of beverages, their assigned labels, and warning policies.

RESULTS

Proportionally fewer participants chose a SSB in the sugar pictorial warning condition (-13.4 percentage points; 95% CI= -21.6 to -0.1 percentage points; p=0.007) and in the health pictorial warning condition (-14.7 percentage points; 95% CI= -22.8 to -0.1 percentage points; p=0.004) compared to the control. Sugar pictorial warnings led to more accurate added-sugar content estimates than all conditions and greater label trust and support for sugar-sweetened beverage warning policies than health pictorial warnings.

CONCLUSIONS

SSB warning policies may be most effective if they mandate images of beverages' added sugar content accompanied by warning text.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT03648138.

A Technology-Driven, Healthcare-Based Intervention to Improve Family Beverage Choices: Results from a Pilot Randomized Trial in the United States

Background: Healthcare-based interventions to address sugary beverage intake could achieve broad reach, but intensive in-person interventions are unsustainable in clinical settings. Technology-based interventions may provide an alternative, scalable approach. Methods: Within an academic health system in the United States that already performs electronic health record-based sugary drink screening, we conducted a pilot randomized trial of a technology-driven family beverage choice intervention. The goal of the intervention was to reduce sugar-sweetened beverage (SSB) and fruit juice (FJ) consumption in 60 parent-child dyads, in which children were 1-8 years old. The pediatrician-initiated intervention consisted of a water promotion toolkit, a video, a mobile phone application, and 14 interactive voice-response phone calls to parents over 6 months. The study was conducted between June 2021 and May 2022. The aim of the pilot study was to assess the potential feasibility and efficacy of the newly developed intervention. Results: Intervention fidelity was excellent, and acceptability was high for all intervention components. Children in both the intervention and the control groups substantially decreased their consumption of SSB and FJ over follow-up (mean combined baseline 2.5 servings/day vs. 1.4/day at 6 months) and increased water consumption, but constrained linear mixed-effects models showed no differences between groups on these measures. Compared to parents in the control group, intervention parents had larger decreases in SSB intake at 3 months (-0.80 (95% CI: -1.54, -0.06, p = 0.03) servings daily), but these differences were not sustained at 6 months. Conclusion: These findings suggest that, though practical to implement in a clinical care setting and acceptable to a diverse participant group, our multicomponent intervention may not be universally necessary to achieve meaningful behavior changes around family beverage choice. A lower-intensity intervention, such as EHR-based clinical screening alone, might be a less resource-intense way for health systems to achieve similar behavioral outcomes. Future studies might therefore explore whether, instead of applying a full intervention to all families whose children overconsume SSB or FJ, a stepped approach, starting with clinical screening and brief counseling, could be a better use of health system resources.

Expanding school wellness policies to encompass the Whole School, Whole Community, Whole Child model

Schools influence children’s developmental outcomes across multiple domains, including academic, social, emotional, behavioral, and physical. School district wellness policies are powerful mechanisms that set clear expectations for health-related practices in school buildings and the surrounding community. A current challenge is that many health-related school policies are narrow, siloed, and reactive instead of proactive. In this paper, we: (a) describe how written food, nutrition, and physical activity district and state policies were strengthened in the United States in response to specific concerns about childhood obesity; (b) present how schools have historically addressed policies concerning children’s social, emotional, and behavioral health; and (c) propose using the Whole School, Whole Community, Whole Child (WSCC) model to strengthen the coordination and integration of school wellness policies. We conclude by describing recently developed tools to assist school districts in implementing the WSCC model. The Wellness School Assessment Tool (WellSAT) WSCC is a quantitative measure that districts can use to code their current written policies for alignment with the WSCC model. The WSCC Policy and Practice Blueprints are action planning tools that lead school and district leaders through a series of activities to strengthen the implementation of coordinated and integrated policies and practices. By using the WSCC model and accompanying implementation tools, schools can support the development of the whole child.

Evaluation of US Department of Agriculture Foods Programs for Households Using Nutrition Guidelines for the Charitable Food System

BACKGROUND

US Department of Agriculture (USDA) Foods programs for households (ie, The Emergency Food Assistance Program, Food Distribution Program on Indian Reservations, and Commodity Supplemental Food Program) are designed to provide nutritious foods at no cost to income-eligible individuals in the United States.

OBJECTIVE

Our aim was to evaluate the nutritional quality of the foods available from 3 USDA Foods programs for households (ie, The Emergency Food Assistance Program, Food Distribution Program on Indian Reservations, and Commodity Supplemental Food Program) according to the Healthy Eating Research (HER) Guidelines for the Charitable Food System.

DESIGN

Review of the nutritional information of the foods available from USDA Foods programs for households was performed. Using the HER Guidelines, foods were categorized into a 3-tiered system (ie, choose often/green; choose sometimes/yellow; choose rarely/red) based on levels of saturated fat, sodium, and added sugar per serving, and presence of whole grains.

SETTING

All unique foods available from The Emergency Food Assistance Program, Food Distribution Program on Indian Reservations, and Commodity Supplemental Food Program (n = 152) for fiscal year 2022 were evaluated.

MAIN OUTCOME MEASURES

Nutritional quality of the foods available from USDA Foods programs for households according to the HER guidelines was measured. Foods were ranked green, yellow, red, or not ranked.

STATISTICAL ANALYSES PERFORMED

The proportion of foods in each HER Guidelines' rank was calculated across the 3 USDA Foods programs for households and by each program.

RESULTS

The majority of USDA Foods were ranked green (57.3%) or yellow (35.5%). A small number of items were ranked red (3.3%) or were unranked condiments or cooking staples (3.9%).

CONCLUSIONS

The USDA Foods available in the household programs were primarily fruits and vegetables; lean proteins; whole grains; and low-fat dairy products that were consistent with national dietary guidelines. There is some room for improvement, and adjustments in the specifications for certain items are recommended to strengthen the nutritional value of the foods provided through these important federal programs.

Implementation of Universal School Meals during COVID-19 and beyond: Challenges and Benefits for School Meals Programs in Maine

School meals play a major role in supporting children’s diets and food security, and policies for universal school meals (USM) have the potential to contribute to positive child health outcomes. During the COVID-19 pandemic, schools provided free school meals to all students in the United States, but this national USM policy ended in school year (SY) 2022–2023; however, a few states have adopted policies to continue USM statewide for SY 2022–2023. Research examining the challenges and strategies for successful continuation of USM is essential, along with studying pandemic-related challenges that are likely to persist in schools. Therefore, we conducted a study in Maine (with a USM policy) to evaluate the impact of COVID-19 and the concurrent implementation of USM, as well as examine differences in implementation by school characteristics, throughout the state. A total of n = 43 school food authorities (SFAs) throughout Maine completed surveys. SFAs reported multiple benefits of USM including increased school meal participation; reductions in the perceived stigma for students from lower-income households and their families; and no longer experiencing unpaid meal charges and debt. SFAs also experienced challenges due to the COVID-19 pandemic, particularly regarding costs. When considering future challenges, most respondents were concerned with obtaining income information from families, product and ingredient availability, and the costs/financial sustainability of the school meal programs. Overall, USM may have multiple important benefits for students and schools, and other states should consider implementation of a USM policy.

Retail Soda Purchases Decrease and Water Purchases Increase: 6-Year Results From a Community-Based Beverage Campaign

Introduction

This study aimed to document the long-term impacts on beverage sales of a 6-year intervention campaign to reduce consumption of sugar-sweetened beverages.

Methods

In 2013, a multicomponent intervention campaign designed to reduce the intake of sugary drinks was launched in Howard County, Maryland. A difference-in-differences regression approach was used to compare data on Howard County supermarket beverage sales (in ounces) from 2013 to 2018 with a set of control supermarkets. Outcome variables were average weekly sales by store of top brands of sugar-sweetened beverages (regular soda, sports drinks, fruit drinks) as well as diet soda and 100% juice. Trends in the sales of water products from 2016 to 2018 were estimated separately using a linear regression model.

Results

In Howard County, the sales of regular soda, fruit drinks, and 100% juice decreased significantly more than predicted each year. These changes correspond to a 29.7% decrease in sales for regular soda, a 7.5% decrease for fruit drinks, and a 33.5% drop for 100% juice between 2012 and 2018 in Howard County stores. There was a significant trend such that the net reduction in regular soda sales in Howard County stores became larger over time. The amount of plain water sold in Howard County increased significantly from 2016 to 2018.

Conclusions

Multicomponent efforts by local government, nonprofit organizations, and other community-based organizations are needed to decrease sugar-sweetened beverage consumption at the population level. Substantial and sustained improvements in retail beverage sales can be achieved through coordinated messaging, community organizing, and targeted advocacy for policy changes.

Assessing District Policy Alignment with the Whole School, Whole Community, Whole Child Model in Connecticut, 2019 to 2020

BACKGROUND

The Whole School, Whole Community, Whole Child (WSCC) model offers a comprehensive framework for creating safe, healthy, and supportive school environments. However, few studies to date have examined the degree to which school policies represent a comprehensive and integrated approach to this goal beyond nutrition and physical activity. Therefore, the purpose of this study was to provide a baseline evaluation of the alignment of district-level policies with the WSCC model within one state.

METHODS

Fifty-four Connecticut public school districts' policies were evaluated using the WellSAT WSCC, a new measure of how well district-level policies address topic areas within each domain of the WSCC model. The comprehensiveness and strength of each district's policies were calculated and then averaged across districts to assess areas of strength and need.

RESULTS

Districts' policies were most comprehensive in the domains of Social and Emotional Climate; Behavioral Supports (Counseling, Psychological, and Social Services); and Family Engagement. Policies were strongest for Safe Environment (Physical Environment); Behavioral Supports; and Health Services.

CONCLUSIONS

School district policy coverage of the WSCC model within Connecticut varies by domain and is often fragmented. Comprehensive and coordinated policies modeled from WSCC domains are needed to better support safe, healthy, and supportive school environments.

Strengthening US Food Policies and Programs to Promote Equity in Nutrition Security: A Policy Statement From the American Heart Association

Nutritionally inadequate dietary intake is a leading contributor to chronic cardiometabolic diseases. Differences in dietary quality contribute to socioeconomic and racial and ethnic health disparities. Food insecurity, a household-level social or economic condition of limited access to sufficient food, is a common cause of inadequate dietary intake. Although US food assistance policies and programs are designed to improve food security, there is growing consensus that they should have a broader focus on nutrition security. In this policy statement, we define nutrition security as an individual or household condition of having equitable and stable availability, access, affordability, and utilization of foods and beverages that promote well-being and prevent and treat disease. Despite existing policies and programs, significant gaps remain for achieving equity in nutrition security across the life span. We provide recommendations for expanding and improving current food assistance policies and programs to achieve nutrition security. These recommendations are guided by several overarching principles: emphasizing nutritional quality, improving reach, ensuring optimal utilization, improving coordination across programs, ensuring stability of access to programs across the life course, and ensuring equity and dignity for access and utilization. We suggest a critical next step will be to develop and implement national measures of nutrition security that can be added to the current US food security measures. Achieving equity in nutrition security will require coordinated and sustained efforts at the federal, state, and local levels. Future advocacy, innovation, and research will be needed to expand existing food assistance policies and programs and to develop and implement new policies and programs that will improve cardiovascular health and reduce disparities in chronic disease.

Assessing the Effects of a Statewide Training Initiative on Local School Wellness Policies

Local district wellness policies are designed to ensure that schools support student health by providing a healthy nutrition environment and opportunities for physical activity. The Kansas State Department of Education (KSDE) developed a 5-year initiative to strengthen wellness policies across their state by offering regional wellness workshops and providing coaches to work with individual districts. KSDE also developed the Wellness Impact Tool (WIT), a self-report measure districts use to document their practices at each school level related to Nutrition, Nutrition Promotion, Physical Activity, and Integrated School-Based Wellness. Kansas districts (N = 286) completed the WIT annually over a 5-year period. The current study evaluates the KSDE wellness initiative by examining the changes in WIT scores over time and by school level, and testing whether greater engagement with wellness supports (i.e., workshops attended and coaching sessions received) predicts higher WIT scores. The findings indicate that district WIT scores increased over the 5-year initiative. Overall, high schools scored higher than elementary or middle schools on Nutrition items, and elementary schools scored higher than other school levels in the domains of Nutrition Promotion, Physical Activity, and Integrated School-Based Wellness. The number of wellness supports utilized by districts each year were significant predictors of subsequent WIT scores. The KSDE's initiative to support Kansas school districts was associated with significant improvements in the quality of wellness practices across the state and provides a model for consideration by other states.

Stakeholders' Perspectives on the Current Status of Partnerships between the Food Banking and Healthcare Systems to Address Food Insecurity in the U.S

One in eight people in the U.S. experience food insecurity (FI). To date, the food banking sector has been at the forefront of efforts to address FI, but the healthcare sector is becoming increasingly involved in such efforts. The extent of collaboration between the two sectors remains unclear. We explored food banking stakeholders’ views on the current state of partnerships between the two sectors. We used purposive sampling to recruit ten key informants for semi-structured interviews. We also conducted a national online survey to gather data from food bank directors (n = 137). Thematic analysis generated two major themes: (1) Healthcare and food banking stakeholders are coordinating to achieve collective impact, and (2) Food banking-healthcare partnerships are leveraging various resources and vested interests within the medical community. We found evidence of ongoing partnerships between the two sectors and opportunities to strengthen these partnerships through the support of backbone organizations.

Strategies to Improve School Meal Consumption: A Systematic Review

School meals can play an integral role in improving children's diets and addressing health disparities. Initiatives and policies to increase consumption have the potential to ensure students benefit from the healthy school foods available. This systematic review evaluates studies examining initiatives, interventions, and policies to increase school meal consumption. Following PRISMA guidelines, this review was conducted using four databases and resulted in a total of 96 studies. The research evidence supports the following strategies to increase school meal consumption: (1) offering students more menu choices; (2) adapting recipes to improve the palatability and/or cultural appropriateness of foods; (3) providing pre-sliced fruits; (4) rewarding students who try fruits and vegetables; (5) enabling students to have sufficient time to eat with longer (~30 min) lunch periods; (6) having recess before lunch; and (7) limiting students' access to competitive foods during the school day. Research findings were mixed when examining the impact of nutrition education and/or offering taste tests to students, although multiple benefits for nutrition education outside the cafeteria were documented. There is some evidence that choice architecture (i.e., "Smarter Lunchroom") techniques increase the proportion of students who select targeted meal components; however, there is not evidence that these techniques alone increase consumption. There were limited studies of the impact of increasing portion sizes; serving vegetables before other meal components; and strengthening local district and/or school wellness policies, suggesting that further research is necessary. Additionally, longer-term studies are needed to understand the impact of policies that limit students' access to flavored milk. Several studies found increases in students' meal consumption following the Healthy Hunger-Free Kids Act (HHFKA) and concerns regarding an increase in food waste following the HHFKA were not supported. Overall, there are a range of effective strategies to increase school meal consumption that can be implemented by schools, districts, and policymakers at the local, state, and federal levels (PROSPERO registration: CRD42021244688).

A pilot examination of the inter-rater reliability of the 18-item Household Food Security Module between cohabiting mothers and fathers

Food insecurity, defined as the inability to access sufficient food for an active, healthy life, affects 11.1% of the US population and is primarily assessed using the United States Department of Agriculture's (USDA) 18-item Household Food Security Survey Module (HFSSM). The HFSSM is a self-report measure presumed to represent all household members, but it is unknown if cohabiting parents report food security differently. This pilot study aimed to determine (i) the inter-rater reliability of the HFSSM; (ii) the direction of any difference between responses to the HFSSM; and (iii) the item-level response similarities and differences among mothers and fathers of young children. Twenty-five pairs of low-income, food-insecure cohabiting parents of 2.5- to 10-year-old children participated in cognitive interviews assessing their level of food security using the USDA's HFSSM and completed related questionnaires. Intraclass correlations were computed to compare the responses of each dyad on the HFSSM overall and by item. Results revealed that overall report of food security was significantly but weakly correlated (r = .40, p = .02) within dyads. The majority of fathers (60%) reported higher food security scores on the HFSSM than their respective female partners. Furthermore, item-level intraclass correlations revealed that some HFSSM questions had poor reliability between cohabiting parents. This research identifies that a potential shortcoming of the HFSSM is the under-reporting of food insecurity by fathers compared with mothers within the household. These findings have implications for the utility of this measure used in national monitoring of the nation's food security.

Understanding the process of implementing nutrition and physical activity policies in a large national child care organization: a mixed-methods study

Learning Care Group made a three-year commitment with the Partnership for a Healthier America to implement several evidence-based nutrition and physical activity policies in over 900 child care centers. New practices included serving more fruits and vegetables; eliminating sugary drinks and juice; family-style dining; healthier celebrations; limiting screen time; increasing outdoor play time; and supporting breastfeeding. A sequential convergent mixed-methods design was used to describe changes in center practices over time; organizational support for changes; and center director perceptions of the implementation process. Data were collected through an interview with organizational leadership; document review; and online center director surveys at 6, 18, and 36 months. The final center director survey included open-ended questions about policy implementation. Written responses were coded and overall themes were extracted by integrating the qualitative and quantitative data. The five overall themes were to: take a comprehensive approach; build the initiative over time; provide structural supports; replace old practices with new ones; and communicate thoroughly. Center leaders reported primarily positive reactions to healthier menus, juice removal, and increased physical activity. The most controversial policy concerned healthier celebrations. Center directors reported that the staff and children adapted quickly to changes, while some families required more assistance. The experience of this large child care organization can inform other efforts to implement early care and education wellness policies.

Race, Ethnicity, and Neighborhood Food Environment Are Associated with Adolescent Sugary Drink Consumption During a 5-Year Community Campaign

Background

A multi-level county-wide campaign to reduce sugary drink consumption was associated with significant decreases in retail sales of soda and fruit drinks. The aim of the current study was to examine changes in adolescent beverage consumption during the campaign by race/ethnicity and neighborhood food environment.

Methods

Beverage consumption among adolescents was evaluated at four time points in a repeated cross-sectional survey of a racially and ethnically diverse sample of sixth graders (N = 13,129) from public middle schools in the county. Each school’s surrounding attendance zone (i.e., neighborhoods where students live) was characterized as providing high or low exposure to unhealthy food retail (e.g., convenience stores, fast-food restaurants). Logistic and multiple linear regression models were used to evaluate changes in beverage consumption over time by student race/ethnicity and high versus low unhealthy food exposure.

Results

Over the 5 years, there were significant declines in the overall share of students who reported daily sugary drink consumption (49.4 to 36.9%) and their reported daily calories from these products (220 to 158 calories). However, disparities were observed, with higher levels of consumption among Black and Hispanic youth and among youth living in neighborhoods with more unhealthy food retail. Notably, Black students living in healthier neighborhood food environments reported significant decreases in daily consumption and calories after 5 years, while Black students living in neighborhoods with more convenience stores and fast-food outlets did not.

Conclusion

These findings suggest that both race/ethnicity and neighborhood food environments are important considerations when designing interventions to reduce sugary drink consumption among adolescents.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40615-021-01074-9.

Abstract MP54: Retail Soda Purchases Decrease And Water Purchases Increase After Six Years Of A Healthy Beverage Campaign

Introduction: Sugary drink consumption is a major risk factor for excess weight gain. In 2013, Howard County, MD launched a multi-component campaign to decrease sugary drink consumption. A previously published difference-in-differences (DID) analysis of supermarket retail beverage sales from 2012 (baseline) to 2015 documented a significant decrease in regular soda and fruit drinks sales in intervention stores compared to matched control stores. The present study extends this evaluation through 2018.

Hypothesis: Sugary drink sales will continue to decrease and sales of non-sugary drinks will increase through 2018.

Methods: Prior to the intervention, a retail sales tracking company identified a sample of supermarkets (N=15) in Howard County (Intervention stores) and assessed 52-weeks of top brand sales for each beverage category. These data were used to identify a set of matched Control stores (N=17) in an adjacent state. DID analyses were used to compare the weekly volume sales of each product (brand and package size) within each beverage category in the Intervention and Control stores from baseline (2012) to Year 6 (2018). Models were adjusted for relevant variables, including average price/ounce; average competitor price/ounce; and weekly local temperature.

Results: DID analyses identified a significantly larger net decrease in average weekly volume sales of regular soda, fruit drinks, and 100% juice in the Intervention stores compared to the Control stores over six years (p < .001). See Figure for regular soda sales. After 2015, intervention stores also exhibited significant increases in sales of plain bottled water (p < .0001) and carbonated water (p < .001). In contrast, sports drinks, diet soda, and flavored waters did not consistently differ between conditions.

Conclusion: A locally implemented, multi-component campaign reduced regular soda and fruit drink sales over six years. Additional efforts to reduce sales of sports drinks are warranted.

Messages Promoting Healthy Kids' Meals: An Online RCT

INTRODUCTION

Calorie labeling is now required on all large U.S. chain restaurant menus, but its influence on consumer behavior is mixed. This study examines whether different parent-targeted messages encourage parents to order lower-calorie meals for their children in a hypothetical online setting.

METHODS

An online RCT was conducted with sociodemographically diverse primary caregivers of children aged 6-12 years (data collected and analyzed in 2017-2019). Participants (N=2,373) were randomized to see 1 of 4 messages: (1) nonfood control, (2) kids' meals are the right size for children, (3) doctors recommend a 600 kcal per meal limit for kids, or (4) 600 kcal per meal is a generally recommended limit for kids. Participants ordered hypothetical meals for their children and themselves and rated meal and message perceptions.

RESULTS

There were no significant differences between conditions in calories ordered for children at either restaurant, although all 3 food message conditions ordered fewer calories for their children than the control (full service: 27-68 fewer kcal, fast food: 18-64 fewer kcal). The general 600 kcal/meal limit message consistently performed best across outcomes, encouraging parents to order the fewest calories for their children at both restaurants (5%-7% fewer) and significantly increasing their understanding of calorie recommendations for kids' meals. It also significantly reduced fast-food calories parents ordered for themselves compared with the control (-106 kcal, p=0.042).

CONCLUSIONS

Although no statistically significant differences were detected, messages with specific calorie recommendations for kids led parents to order lower-calorie restaurant meals for their children, suggesting that additional real-world studies with larger sample sizes are warranted.

A Qualitative Study of Parents With Children 6 to 12 Years Old: Use of Restaurant Calorie Labels to Inform the Development of a Messaging Campaign

BACKGROUND

US law mandates that chain restaurants with 20 or more locations post calorie information on their menus to inform consumers and encourage healthy choices. Few qualitative studies have assessed how parents perceive and use this information when ordering for their children and what types of accompanying messages might increase use of calorie labels when ordering food.

OBJECTIVE

We aimed to better understand parents' perceptions and use of calorie labeling and the types of messages that might increase use.

DESIGN

We conducted 10 focus groups (n = 58) and 20 shop-along interviews (n = 20). Focus group participants discussed their hypothetical orders and restaurant experiences when dining with their children, and shop-along participants verbalized their decision processes while ordering at a restaurant. Both groups gave feedback on 4 public service messages aimed to increase healthier ordering for children. All interviews were voice-recorded and transcribed.

PARTICIPANTS/SETTING

Participants were primary caregivers of at least 1 child between 6 and 12 years who reported having less than a college education at the time of screening and who commonly ate at chain restaurants. Focus groups were conducted in a conference room, and shop-alongs were conducted in quick-serve and full-service chain restaurants around Philadelphia between August 2016 and May 2017.

ANALYSES

A modified grounded theory approach was used to extract themes from transcripts.

RESULTS

Thematic analysis of transcripts revealed 5 key themes: (1) parents' use of calorie labels; (2) differences across restaurant settings; (3) nonjudgmental information; (4) financial value and enjoyment of food; and (5) message preferences. These themes suggested that nonjudgmental, fact-based messages that highlight financial value, feelings of fullness, and easy meal component swaps without giving up the treatlike aspect of eating out may be particularly helpful for consumers.

CONCLUSIONS

These findings can inform current US Food and Drug Administration campaign efforts to support consumer use of calorie labels on menus.

Universal School Meals and Associations with Student Participation, Attendance, Academic Performance, Diet Quality, Food Security, and Body Mass Index: A Systematic Review

The school environment plays an important role in children's diets and overall health, and policies for universal free school meals have the potential to contribute to positive child health outcomes. This systematic review evaluates studies examining the association between universal free school meals and students' school meal participation rates, diets, attendance, academic performance, and Body Mass Index (BMI), as well as school finances. The search was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). A search for studies published in economically developed countries published through December 2020 was performed in PubMed, Education Resources Information Center (ERIC), Thomson Reuters' Web of Science, and Academic Search Ultimate, followed by examining the references in the resultant literature. A total of 47 studies were identified and the Newcastle-Ottawa Scale (NOS) was applied to assess bias. Nearly all studies examining universal free school meals found positive associations with school meal participation. Most studies examining universal free school meals that included free lunch found positive associations with diet quality, food security, and academic performance; however, the findings of studies examining only universal free breakfast were mixed. Research findings were similarly mixed when examining attendance as an outcome. Concerns about adverse outcomes on student BMI were not supported by the literature; in fact, several studies detected a potentially protective effect of universal free school meals on BMI. Research examining the impact of universal free meals on school finances was limited, but suggest that lower-income school districts in the U.S. may have positive financial outcomes from participation in universal free school meal provisions. Additionally, providing free meals to students may be associated with improved household incomes, particularly among lower-income families with children. Further research is needed to examine the financial implications of universal free meals for both school districts and families. Overall, universal free school meals may have multiple benefits for students and countries should consider universal free school meal provisions with strong nutrition guidelines. (PROSPERO registration: CRD42020221782).

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.

Association between Nutrition Policies and Student Body Mass Index

In response to concerns about childhood obesity, many US states have implemented policies to limit the sale of unhealthy foods and beverages (e.g., snacks, desserts, and sugary drinks) sold in competition with school meal programs (i.e., competitive foods) in order to improve the nutritional environment of schools and support student health. This study measured state-level competitive food and beverage policies that require foods and beverages sold in à la carte lines, vending machines, and school stores to meet strong nutrition standards and tested the hypothesis that students living in states with stronger laws would have lower body mass index (BMI)-for-age percentiles. BMI data from a national sample of 1625 students attending 284 schools from the School Nutrition and Meal Cost Study were linked to state laws coded as part of the National Wellness Policy Study. A survey-adjusted linear regression model accounting for student and school-level characteristics showed that stronger state nutrition policies were associated with lower student BMI scores (coefficient: -0.06, 95% CI: -0.12, -0.00). Additional models indicated that stronger state policies were significantly associated with fewer unhealthy foods and beverages available in schools. These findings suggest that strong regulations on competitive foods and beverages may lead to improvements in the nutritional quality of the school environment and student BMI. Thus, current federal standards regulating snacks in US schools (i.e., Smart Snacks) are an important element of a comprehensive strategy to improve the school nutrition environment and reduce rates of childhood obesity.

Development of a Comprehensive Tool for School Health Policy Evaluation: The WellSAT WSCC

BACKGROUND

Stakeholders increasingly recognize the role of policy in implementing Whole School, Whole Community, Whole Child (WSCC) frameworks in schools; however, few tools are currently available to assess alignment between district policies and WSCC concepts. The purpose of this study was to expand the Wellness School Assessment Tool (WellSAT) for evaluation of policies related to all 10 domains of the WSCC model.

METHODS

Developing the WellSAT WSCC was an iterative process that involved (1) identifying items for each domain based on key concepts and best practice recommendations; (2) expert review of the draft measure; (3) cognitive pre-testing; (4) developing scoring criteria; and (5) pilot-testing the measure.

RESULTS

Ratings from expert reviewers indicated that the tool included items that were both relevant and important to each of the 10 WSCC domains. Results of cognitive pre-testing indicated that the items were understood as intended. Feedback from expert reviews, cognitive pre-testing, and pilot-testing was used to further revise and refine the measure and develop a final version of the tool. Acceptable interrater reliability was established for the final selection of items.

CONCLUSIONS

The WellSAT WSCC provides a reliable means for assessing integration and alignment between WSCC model concepts and district policies.

The hunger-obesity paradox: Exploring food banking system characteristics and obesity inequities among food-insecure pantry clients

Purpose

Heightened obesity risk among food-insecure food pantry clients is a health equity issue because the co-occurrence of obesity and hunger is deeply-rooted in systematic social disadvantage and historical oppression. This qualitative study examined key stakeholders’ perspectives of the relationship between the U.S. food banking system and obesity disparities among food insecure clients.

Methods

We conducted in-depth, semi-structured interviews with 10 key stakeholders (e.g., food bank director, food bank board member, advocate) who are familiar with food bank operations. Data were transcribed verbatim, coded in NVivo [v11], and analyzed using thematic analysis.

Results

Multiple themes emerged drawing linkages between structural characteristics of the food banking system and disparities in the dual burden of food insecurity and obesity: [a] access to unhealthy food from donors; [b] federal emergency food policy and programming; [c] state-level emergency food policy and programming; [d] geography-based risk profiles; and [e] inadequate food supply versus client need. Interviewees also identified social challenges between system leaders and clients that maintain disparities in obesity risk among individuals with very low food security including: [a] media representation and stereotypes about food pantry clients; [b] mistrust in communities of color; [c] lack of inclusion/representation among food bank system leaders; and [d] access to information.

Conclusion

Future efforts to alleviate obesity inequities among clients chronically burdened by food insecurity, especially among certain subpopulations of clients, should prioritize policy, systems, and environmental strategies to overcome these structural and social challenges within the food banking system.

Childhood Obesity Evidence Base Project: A Systematic Review and Meta-Analysis of a New Taxonomy of Intervention Components to Improve Weight Status in Children 2-5 Years of Age, 2005-2019

Objective: To evaluate the efficacy of childhood obesity interventions and conduct a taxonomy of intervention components that are most effective in changing obesity-related health outcomes in children 2-5 years of age. Methods: Comprehensive searches located 51 studies from 18,335 unique records. Eligible studies: (1) assessed children aged 2-5, living in the United States; (2) evaluated an intervention to improve weight status; (3) identified a same-aged comparison group; (4) measured BMI; and (5) were available between January 2005 and August 2019. Coders extracted study, sample, and intervention characteristics. Effect sizes [ESs; and 95% confidence intervals (CIs)] were calculated by using random-effects models. Meta-regression was used to determine which intervention components explain variability in ESs. Results: Included were 51 studies evaluating 58 interventions (N = 29,085; mean age = 4 years; 50% girls). Relative to controls, children receiving an intervention had a lower BMI at the end of the intervention (g = 0.10, 95% CI = 0.02-0.18; k = 55) and at the last follow-up (g = 0.17, 95% CI = 0.04-0.30; k = 14; range = 18-143 weeks). Three intervention components moderated efficacy: engage caregivers in praise/encouragement for positive health-related behavior; provide education about the importance of screen time reduction to caregivers; and engage pediatricians/health care providers. Conclusions: Early childhood obesity interventions are effective in reducing BMI in preschool children. Our findings suggest that facilitating caregiver education about the importance of screen time reduction may be an important strategy in reducing early childhood obesity.

Childhood Obesity Evidence Base Project: Methods for Taxonomy Development for Application in Taxonomic Meta-Analysis

Meta-analysis has been used to examine the effectiveness of childhood obesity prevention efforts, yet traditional conventional meta-analytic methods restrict the kinds of studies included, and either narrowly define mechanisms and agents of change, or examine the effectiveness of whole interventions as opposed to the specific actions that comprise interventions. Taxonomic meta-analytic methods widen the aperture of what can be included in a meta-analysis data set, allowing for inclusion of many types of interventions and study designs. The National Collaborative on Childhood Obesity Research Childhood Obesity Evidence Base (COEB) project focuses on interventions intended to prevent childhood obesity in children 2-5 years old who have an outcome measure of BMI. The COEB created taxonomies, anchored in the Social Ecological Model, which catalog specific outcomes, intervention components, intended recipients, and contexts of policies, initiatives, and interventions conducted at the individual, interpersonal, organizational, community, and societal level. Taxonomies were created by discovery from the literature itself using grounded theory. This article describes the process used for a novel taxonomic meta-analysis of childhood obesity prevention studies between the years 2010 and 2019. This method can be applied to other areas of research, including obesity prevention in additional populations.

Wellness School Assessment Tool Version 3.0: An Updated Quantitative Measure of Written School Wellness Policies

Schools play an important role in promoting student wellness. As directed by the Healthy Hunger-Free Kids Act, the US Department of Agriculture updated the requirements for written school wellness policies in 2016. The WellSAT (Wellness School Assessment Tool) is an online tool that provides a quantitative score for wellness policy comprehensiveness and strength. The WellSAT has been updated 3 times over the past decade to remain current with federal law and best practices. In this article, we describe the process of updating to WellSAT 3.0. The steps included: reviewing the language of each item linked to a federal provision; adding and deleting items based on frequencies from the National Wellness Policy Study and the empirical support for specific policies; gathering feedback from a survey of experts (N = 77) about best practices and measure usability; and establishing intercoder reliability in a national sample (N = 50) of policies. We conclude with recommendations and guidance for the use of WellSAT 3.0.

The Relationship between Written District Policies and School Practices among High-Need Districts in New York State

BACKGROUND

This study tested the hypothesis that written district wellness policies are associated with higher rates of implementation of nutrition and physical activity practices.

METHODS

Written wellness policies and building level practices were assessed for schools (N = 295) within high-need districts (N = 70) in New York State. The relationship between policies and practices was measured using multi-level mixed-effects logistic regressions.

RESULTS

Overall, stronger written district policies significantly increase the likelihood of practice implementation in schools. This relationship is strongest for physical education and physical activity items, followed by nutrition standards for competitive foods in middle and high schools. Most elementary schools implemented nutrition practices with or without a policy and there were differences in implementation rates between elementary and middle/high schools. When examined separately, policies were for the most part not significantly associated with implementation of corresponding practices.

CONCLUSIONS

Strong and comprehensive written policies are associated with higher rates of practice implementation overall, but the consistency of this relationship varies by policy-practice domain. The newer policy topics areas of school wellness promotion and marketing were less frequently included in written policies. Future research should examine whether districts that strengthen their written policies achieve greater implementation over time.