Search

Providing interventions that facilitate improvement of dietary intake and other health behaviors can improve nutrition-related outcomes in adults with overweight or obesity. Medical nutrition therapy (MNT) behavioral interventions require expertise from registered dietitian nutritionists or international equivalents (dietitians), which no other health care provider can provide for adults with obesity. Current evidence supports the role of MNT behavioral interventions for adults with overweight or obesity as an effective treatment option, when appropriate for and desired by the client. This Academy of Nutrition and Dietetics Position Paper describes potential benefits and concerns regarding dietitian-provided MNT behavioral interventions for adults with overweight and obesity and informs dietitians about implications for practice. This Position Paper is supported by a systematic review examining effectiveness of MNT interventions provided by dietitians and by an evidence-based practice guideline. It is the position of the Academy of Nutrition and Dietetics that MNT behavioral interventions for adults (aged 18 years and older) with overweight or obesity should be a treatment option, when appropriate and desired by the client, to improve cardiometabolic, quality of life, and anthropometric outcomes. Dietitians providing MNT recognize the complex contributors to overweight and obesity, and thus individualize interventions, based on a shared decision-making process, and deliver interventions in an inclusive, compassionate, and client-centered manner. Interventions should include collaboration with an interprofessional team when needed. Dietitians strive to increase health equity and reduce health disparities by advocating and providing opportunities for increased access to effective nutrition care services. This position remains in effect until December 31, 2031., (Copyright © 2024 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: Obesity is associated with a multitude of comorbidities and considerable health care costs., Objective: The objective of this review was to examine the efficacy of weight management interventions provided by a registered dietitian or international equivalent (referred to as "dietitian")., Methods: This systematic review and meta-analysis of randomized controlled trials (RCTs) examined the effect of weight management interventions provided by a dietitian, compared with usual care or no intervention, on several cardiometabolic outcomes and quality of life in adults with overweight or obesity. MEDLINE, Embase, PsycINFO, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and CINAHL databases were searched for eligible RCTs published between January 2008 and January 2021 in the English language. Meta-analyses were conducted using a random-effects model, publication bias was assessed using funnel plots and Egger's statistics, and heterogeneity was assessed by interpreting I 2 values. Efficacy of intervention components, such as telehealth or group contacts, were explored in sub-group analyses. Version 2 of the risk-of-bias tool for RCTs was used to assess risk of bias. The Grading of Recommendations Assessment, Development and Evaluation method was used to determine certainty of evidence., Results: This systematic review included 62 RCTs. Compared with control conditions, weight management interventions provided by a dietitian resulted in improved body mass index (mean difference [MD] -1.5; 95% CI -1.74 to -1.26; moderate evidence certainty); percent weight loss (MD -4.01%; 95% CI -5.26% to -2.75%; high evidence certainty); waist circumference (MD -3.45 cm; 95% CI -4.39 to -2.51 cm; high evidence certainty); blood pressure (MD -3.04 mm Hg; 95% CI -5.10 to -0.98 mm Hg and MD -1.99 mm Hg; 95% CI -3.02 to -0.96 mm Hg for systolic blood pressure and diastolic blood pressure, respectively; moderate and low evidence certainty); and quality of life using the 36-Item Short Form Survey (MD 5.84; 95% CI 2.27 to 9.41 and 2.39; 95% CI 1.55 to 3.23 for physical and mental quality of life, respectively; low and moderate evidence certainty)., Conclusions: For adults with overweight or obesity, weight management interventions provided by a dietitian are efficacious for improving several examined cardiometabolic outcomes and quality of life., (Copyright © 2023 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Overweight and obesity affect most adults living in the United States and are causally linked to several adverse health outcomes. Registered dietitian nutritionists or international equivalents (dietitians) collaborate with each client and other health care professionals to meet client-centered goals, informed by the best available evidence, and translated through a lens of clinical expertise and client circumstances and preferences. Since the last iteration of the Academy of Nutrition and Dietetics guideline on adult weight management in 2014, considerable research has been conducted and circumstances confronting dietitians have evolved. Thus, updated guidance is needed. The objective of this evidence-based practice guideline is to provide recommendations for dietitians who deliver medical nutrition therapy behavioral interventions for adults (18 years and older) with overweight and obesity to improve cardiometabolic outcomes, quality of life, and weight outcomes, when appropriate for and desired by the client. Recommendations in this guideline highlight the importance of considering complex contributors to overweight and obesity and individualizing interventions to client-centered goals based on specific needs and preferences and shared decision making. The described recommendations have the potential to increase access to care and decrease costs through utilization of telehealth and group counseling as effective delivery methods, and to address other barriers to overweight and obesity management interventions. It is essential for dietitians to collaborate with clients and interprofessional health care teams to provide high-quality medical nutrition therapy interventions using the nutrition care process to promote attainment of client-centered outcomes for adults with overweight or obesity., (Copyright © 2023 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Although many studies have relied on parental responses concerning children's school-meal participation, few studies have evaluated parental response accuracy. We investigated misclassification of fourth-grade children's participation in school-meal programs based on parental responses relative to administrative daily records using cross-sectional study data collected for 3 school years (2004-05, 2005-06, and 2006-07) for 1,100 fourth-grade children (87% black; 52% girls) from 18 schools total in one district. Parents reported children's usual school-meal participation on paper consent forms. The district provided administrative daily records of individual children's school-meal participation. Researchers measured children's weight and height. "Usual participation" in breakfast/lunch was defined as ≥50% of days. Parental responses misclassified 16.3%, 12.8%, 19.8%, and 4.7% of children for participation in breakfast, classroom breakfast, cafeteria breakfast, and lunch, respectively. Parental responses misclassified more children for participation in cafeteria than classroom breakfast (P=0.0008); usual-participant misclassification probabilities were less than nonusual-participant misclassification probabilities for classroom breakfast, cafeteria breakfast, and lunch (P<0.0001 for each) (two-proportion z tests). Parental responses concerning children's participation were more accurate for lunch than breakfast; parents overstated breakfast participation (both classroom and cafeteria) and lunch participation. Breakfast participation misclassification was not related to body mass index (P=0.41), sex (P=0.40), age (P=0.63), or socioeconomic status (P=0.21) (multicategory logistic regression controlling for school year, breakfast location, and school). Relying on parental responses concerning children's school-meal participation may hamper researchers' abilities to detect relationships that have policy implications for the child nutrition community. The use of administrative daily records of children's school-meal participation is recommended., (Copyright © 2014 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: Qualitative methods were used to better understand how to obtain interviewer-administered recalls of physical activity from children., Methods: Subjects were 24 third- and fifth-grade children from 1 school in Columbia, South Carolina. Cognitive interviews targeted different retention intervals (about the same or previous school day). Round 1's protocols used an open format and had 4 phases (obtain free recall, review free recall, obtain details, review details). Round 2's protocols used a chronological format and had 3 phases (obtain free recall, obtain details, review details). Trained coders identified discrepancies across interview phases in children's recalls of physical activity at physical education (PE) and recess. Based on the school's schedule, children's reports of PE and recess were classified as omissions (scheduled but unreported) or intrusions (unscheduled but reported)., Results: Across interview phases, there were numerous discrepancies for Round 1 (regardless of grade, sex, or retention interval) but few discrepancies for Round 2. For Rounds 1 and 2, respectively, 0% and 0% of children omitted PE, while 33% and 0% intruded PE; 44% and 56% of children omitted recess, while 33% and 0% intruded recess., Conclusions: Results provide important information for facilitating interviewer-administered recalls of physical activity with elementary-age children.

Purpose/objectives: Analyses were conducted to examine variations in fourth-grade children's participation in school-breakfast and school-lunch programs by weekday, month, socioeconomic status, absenteeism, sex, and school-breakfast location., Methods: Fourth-grade children were participants in a dietary-reporting validation study during the 2005-2006 or 2006-2007 school years in 17 or 8 schools, respectively, in one South Carolina school district. For the two respective school years, school-breakfast location was the classroom for six and seven schools, and for the remaining schools, the cafeteria. District administrative records provided information about 180 possible days of participation in the school-breakfast and school-lunch programs for each of 1,060 children (91% Black, 52% girls). The state's Office of Research and Statistics linked data on school-meal participation with information about individual children's socioeconomic status (eligibility for free or reduced-price school meals) and annual absenteeism from school., Results: For school-provided breakfast, logistic regression showed participation rate differences by weekday (smallest for Monday [56.1%], largest for Wednesday [57.8%], p<0.0001), month (smallest for April [53.5%], largest for September [60.8%], p<0.0001), socioeconomic status (smallest for full-price status [27.5%], largest for free-meal status [63.4%], p<0.0001), school-breakfast location (smaller for breakfast located in the cafeteria [38%] than classroom [71%], p<0.0001), and absenteeism (p<0.0001). For school-provided lunch, logistic regression showed participation rate differences by weekday (smallest for Friday [81.9%], largest for Thursday [83.3%], p<0.0001), month (smallest for May [78.7%], largest for August [86.0%], p<0.0001), socioeconomic status (smallest for full-price status [72.1%], largest for free-meal status [84.9%], p<0.0001), and absenteeism (p<0.0001). There were no differences in participation rate by sex., Applications for Child Nutrition Professionals: Administrative participation records are used for forecasting purchasing and production. Using such records in research studies may provide insight into aspects of children's participation in school-provided meals. Districts and managers are encouraged to share administrative records of children's participation in school-provided meals with researchers.

Results from a 2012 article showed a positive relationship between children's body mass index (BMI) and energy intake at school-provided meals. To help explain that positive relationship, secondary analyses investigated (1) whether the relationship differed by sex and race and (2) the relationship between BMI and 6 aspects of school-provided meals--amounts eaten of standardized portions, energy content given in trades, energy intake received in trades, energy intake from flavored milk, energy intake from a la carte ice cream, and breakfast type. Data were from 4 studies conducted 1 per school year (1999-2000 to 2002-2003). Fourth-grade children (n = 328; 50% female; 54% black) from 13 schools total were observed eating school-provided breakfast and lunch on 1 to 3 days per child for 1178 total meals (50% breakfast). Children were weighed and measured. Marginal regression models were fit using BMI as the dependent variable. For purpose 1, independent variables were energy intake at school-provided meals, sex, race, age, and study; additional models included interaction terms involving energy intake and sex/race. For purpose 2, independent variables were the 6 aspects of school-provided meals, sex, race, age, and study. The relationship between BMI and energy intake at school-provided meals differed by sex (P < .0001; stronger for females) and race (P = .0063; stronger for black children). BMI was positively related to amounts eaten of standardized portions (P < .0001) and negatively related to energy content given in trades (P = .0052). Explaining the positive relationship between BMI and energy intake at school-provided meals may contribute to school-based obesity prevention efforts., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: This article investigated (1) parental response accuracy of fourth-grade children's school-meal participation and whether accuracy differed by children's body mass index (BMI), sex, and race, and (2) the relationship between BMI and school-meal participation (based on parental responses)., Methods: Data were from four cross-sectional studies conducted from fall 1999 to spring 2003 with fourth-grade children from 13 schools total. Consent forms asked parents to report children's usual school-meal participation. As two studies' consent forms did not ask about lunch participation, complete data were available for breakfast on 1,496 children (51% Black; 49% boys) and for lunch on 785 children (46% Black; 48% boys). Researchers compiled nametag records (during meal observations) of meal participation on randomly selected days during children's fourth-grade school year for breakfast (average nametag days across studies: 7-35) and for lunch (average nametag days across studies: 4-10) and categorized participation as "usually" (≥ 50% of days) or "not usually" (< 50% of days). Weight and height were measured. Concerning parental response accuracy, marginal regression was used with agreement between parental responses and nametag records as the dependent variable; independent variables were BMI, age, sex, race, and study. Concerning a relationship between BMI and school-meal participation, marginal regression was used with BMI as the dependent variable; independent variables were breakfast participation, lunch participation, age, sex, race, and study., Results: Concerning breakfast participation and lunch participation, 74% and 92% of parents provided accurate responses, respectively. Parental response accuracy was better for older children for breakfast and lunch participation, and for Black than White children for lunch participation. Usual school-meal participation was significantly related to children's BMI but in opposite directions -- positively for breakfast and inversely for lunch., Conclusions: Parental response accuracy of children's school-meal participation was moderately high; however, disparate effects for children's age and race warrant caution when relying on parental responses. The BMI results, which showed a relationship between school-meal participation (based on parental responses) and childhood obesity, conflict with results from a recent article that used data from the same four studies and found no significant relationship when participation was based on nametag records compiled for meal observations.

Data from four cross-sectional studies involving fourth-grade children were analyzed to investigate the relationship between participation in school-provided meals and body mass index (BMI), and the effect observed energy intake has on that relationship. Participation and BMI data were available on 1,535 children (51% black; 51% girls) for 4 school years (fall 1999 to spring 2003; one study per school year) at 13 schools total. Direct meal observations were available for a subset of 342 children (54% black; 50% girls) for one to three breakfasts and one to three lunches per child for a total of 1,264 school meals (50% breakfast). Participation in breakfast, lunch, and combined (both meals on the same day) was determined from nametag records compiled for meal observations for each study. Weight and height were measured. A marginal regression model was fit with BMI as the dependent variable; independent variables were breakfast participation, lunch participation, combined participation, sex, age, race, and study. For the subset of children, observed energy intake at breakfast, lunch, and combined was included in additional analyses. Participation in breakfast, lunch, and combined was not significantly associated with BMI regardless of whether analyses included observed energy intake (P values >0.181). The relationship between observed energy intake at breakfast and lunch, separately and combined, with BMI was positive (P values <0.01). In conclusion, these results do not support a relationship between school-meal participation and BMI but do support a relationship between observed energy intake at school meals and BMI during fourth grade., (Copyright © 2012 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Due to changing recommendations for fruit and vegetable (F/V) intake, public health and private organizations recognized the need to revise communications and programs that promote F/V consumption. This article describes formative research conducted in 2005 to develop a new identity for the 5 A Day Program, updated to the Fruits & Veggies--More Matters program. The objective was to re-brand the 5 A Day Program's campaign message to be adaptable, sustainable, and compelling, while leveraging the program's existing message dissemination infrastructure. Formative research included interviews with representatives from government, nonprofit organizations, and industry, and consumer perspectives from interviews, focus groups, and an online survey. Public health and private organizations agreed that a compelling emotional benefit was needed to motivate consumers to eat more F/V and that messaging needed to be used consistently among national, state, and local programs. Interviews and focus groups targeted mothers who believed they and their families were getting enough F/V, knew they could eat more, but needed to be convinced why they should do so. The most effective messages appealed to mothers' emotional needs to be responsible, leveraged functional intrinsic values of F/V, did not try to quantify "enough," and focused on small steps. When the Fruits & Veggies-More Matters slogan and graphic were viewed together, the majority (62%) said it increased their interest in eating more F/V. The Fruits & Veggies-More Matters brand offers numerous opportunities for promoting F/V consumption through this public health initiative., (Copyright © 2011 American Dietetic Association. Published by Elsevier Inc. All rights reserved.)

Children's dietary intake is a key variable in evaluations of school-based interventions. Current methods for assessing children's intake, such as 24-hour recalls and meal observations, are time- and resource-intensive. As part of a study to evaluate the impact of farm-to-school programs, the school lunch recall was developed from a need for a valid and efficient tool to assess school lunch intake among large samples of children. A self-administered paper-and-pencil questionnaire, the school lunch recall prompts for school lunch items by asking children whether they chose a menu item, how much of it they ate, how much they liked it, and whether they would choose it again. The school lunch recall was validated during summer school in 2008 with 18 third- to fifth-grade students (8 to 11 years old) in a North Carolina elementary school. For 4 consecutive days, trained observers recorded foods and amounts students ate during school lunch. Students completed the school lunch recall immediately after lunch. Thirty-seven total observation school lunch recall sets were analyzed. Comparison of school lunch recalls against observations indicated high accuracy, with means of 6% for omission rate (items observed but unreported), 10% for intrusion rate (items unobserved but reported), and 0.63 servings for total inaccuracy (a measure that combines errors for reporting items and amounts). For amounts, accuracy was high for matches (0.06 and 0.01 servings for absolute and arithmetic differences, respectively) but lower for omissions (0.47 servings) and intrusions (0.54 servings). In this pilot study, the school lunch recall was a valid, efficient tool for assessing school lunch intake for a small sample of third- to fifth-grade students., (Copyright © 2011 American Dietetic Association. Published by Elsevier Inc. All rights reserved.)

A validation study of children's dietary reporting provided an opportunity to investigate whether cognitive ability is a source of systematic error in dietary recalls. From the fall of 2004 through the spring of 2007, fourth-grade children (n = 374) in Columbia, South Carolina, were observed eating school meals and interviewed to obtain 24-hour dietary recalls; subsequently, measures of dietary reporting error were calculated. The common factor extracted from 4 subject-area achievement tests (scores on which were provided by the school district for 362 children) was used as a measure of cognitive ability. For the 325 children who reported school meals that met the criteria to be reports about school meals, as cognitive ability increased, dietary reporting error decreased; the relation between cognitive ability and dietary reporting performance was stronger among girls than among boys. The mean cognitive ability for 37 children who reported no meals that satisfied the criteria for being reports about school meals was significantly lower than that for the 325 children who reported meals that satisfied these criteria. These findings indicate that cognitive ability is a source of systematic error in children's dietary recalls. More generally, the quality of epidemiologic survey data may depend systematically on the cognitive ability of respondents.

Background: Accurate information about children's intake is crucial for national nutrition policy and for research and clinical activities. To analyze accuracy for reporting energy and nutrients, most validation studies utilize the "conventional approach," which was not designed to capture errors of reported foods and amounts. The "reporting-error-sensitive approach" captures errors of reported foods and amounts., Objective: To extend results to energy and macronutrients for a validation study concerning retention interval (elapsed time between to-be-reported meals and the interview) and accuracy for reporting school-meal intake, the conventional and reporting-error-sensitive approaches were compared. DESIGN AND PARTICIPANTS/SETTING: Fourth-grade children (n=374) were observed eating two school meals, and interviewed to obtain a 24-hour recall using one of six interview conditions from crossing two target periods (prior 24 hours and previous day) with three interview times (morning, afternoon, and evening). Data were collected in one district during three school years (2004-2005, 2005-2006, and 2006-2007)., Main Outcome Measures: Report rates (reported/observed), correspondence rates (correctly reported/observed), and inflation ratios (intruded/observed) were calculated for energy and macronutrients., Statistical Analyses Performed: For each outcome measure, mixed-model analysis of variance was conducted with target period, interview time, their interaction, and sex in the model; results were adjusted for school year and interviewer., Results: With the conventional approach, report rates for energy and macronutrients did not differ by target period, interview time, their interaction, or sex. With the reporting-error-sensitive approach, correspondence rates for energy and macronutrients differed by target period (four P values <0.0001) and the target period by interview-time interaction (four P values <0.0001); inflation ratios for energy and macronutrients differed by target period (four P values <0.0001), and inflation ratios for energy and carbohydrate differed by the target period by interview-time interaction (both P values <0.005)., Conclusions: Shortening the retention interval of dietary recalls increases accuracy for reporting energy and macronutrients. For validation studies, it is best to obtain reference information from a method that provides details about foods and amounts consumed and to use an analytic approach that captures errors of reported foods and amounts., (2010 American Dietetic Association. Published by Elsevier Inc. All rights reserved.)

Background: Data from a dietary-reporting validation study with fourth-grade children were analyzed to investigate a possible relationship of body mass index (BMI) with daily participation in school meals and observed energy intake at school meals, and whether the relationships differed by breakfast location (classroom; cafeteria)., Methods: Data were collected in 17, 17, and 8 schools during three school years. For the three years, six, six, and seven of the schools had breakfast in the classroom; all other schools had breakfast in the cafeteria. Information about 180 days of school breakfast and school lunch participation during fourth grade for each of 1,571 children (90% Black; 53% girls) was available in electronic administrative records from the school district. Children were weighed and measured, and BMI was calculated. Each of a subset of 465 children (95% Black; 49% girls) was observed eating school breakfast and school lunch on the same day. Mixed-effects regression was conducted with BMI as the dependent variable and school as the random effect; independent variables were breakfast participation, lunch participation, combined participation (breakfast and lunch on the same day), average observed energy intake for breakfast, average observed energy intake for lunch, sex, age, breakfast location, and school year. Analyses were repeated for BMI category (underweight/healthy weight; overweight; obese; severely obese) using pooled ordered logistic regression models that excluded sex and age., Results: Breakfast participation, lunch participation, and combined participation were not significantly associated with BMI or BMI category irrespective of whether the model included observed energy intake at school meals. Observed energy intake at school meals was significantly and positively associated with BMI and BMI category. For the total sample and subset, breakfast location was significantly associated with BMI; average BMI was larger for children with breakfast in the classroom than in the cafeteria. Significantly more kilocalories were observed eaten at breakfast in the classroom than in the cafeteria., Conclusions: For fourth-grade children, results provide evidence of a positive relationship between BMI and observed energy intake at school meals, and between BMI and school breakfast in the classroom; however, BMI and participation in school meals were not significantly associated.

Objective: To use data from a published validation study concerning retention interval and school food-service production records to examine intrusions (uneaten items reported eaten) in the school-meal parts of 24 h recalls., Design: For that study, children were observed eating two school meals (breakfast, lunch) and interviewed under one of six conditions from two target periods (previous day (PDTP), prior 24 h (24TP)) crossed with three interview times (morning, afternoon (AIT), evening). For the present article, a catalogue was constructed of foods available for that study's school meals. The study's intrusions were classified as stretches (on children's meal trays but uneaten), internal confabulations (in children's school food-service environments for that meal but not on children's trays) or external confabulations (not in children's school food-service environments for that meal). Occurrence, types and amounts of intrusions were investigated., Setting/subjects: Six schools; sixty fourth-grade children (ten per condition)., Results: For breakfast, for the 24TP v. PDTP, reported items were less likely to be intrusions, internal confabulations and external confabulations; and intrusions were more likely to be stretches. For lunch, for the 24TP-AIT condition v. the other five conditions, reported items were less likely to be intrusions and external confabulations. Mean amounts reported eaten were smaller for stretches than for internal confabulations or external confabulations at breakfast, and for stretches than for internal confabulations at lunch., Conclusions: Accuracy was better for the 24TP (with fewer intrusions of which proportionally more were stretches which had smaller amounts reported eaten) than for the PDTP. Studies with 24 h recalls should minimize retention interval to improve accuracy.

Objective: To investigate whether school-meal observations influenced children's 24-hour dietary recalls., Study Design and Setting: Over three school years, 555 randomly selected fourth-grade children were interviewed to obtain a 24-hour dietary recall; before being interviewed, 374 children were observed eating two school meals (breakfast, lunch), and 181 children were not observed. Within observation-status groups (observed, unobserved), children were randomized within sex to one of six combinations from two target periods (prior 24 hours, previous day) crossed with three interview times (morning, afternoon, evening)., Results: For each of the five variables (interview length, meals/snacks, meal components, items, kilocalories), naïve and adjusted equivalence tests rejected that observation-status groups were different, indicating that school-meal observations did not influence children's 24-hour dietary recalls. There was a target-period effect on length (P<0.0001) (longer for prior-24-hour recalls), a school year effect on length (P=0.0002) (longer for third year), and a target period-interview time interaction on items (P=0.0110) and kilocalories (P=0.0047) (both smaller for previous-day recalls in the afternoon than prior-24-hour recalls in the afternoon and previous-day recalls in the evening), indicating that variables were sufficiently sensitive and psychometrically reliable., Conclusion: Conclusions about 24-hour dietary recalls by fourth-grade children observed eating school meals in validation studies are generalizable to 24-hour dietary recalls by comparable but unobserved children in nonvalidation studies.

Background: For a 24-hour dietary recall, two possible target periods are the prior 24 hours (24 hours immediately preceding the interview time) and previous day (midnight to midnight of the day before the interview), and three possible interview times are morning, afternoon, and evening. Target period and interview time determine the retention interval (elapsed time between to-be-reported meals and the interview), which, along with intervening meals, can influence reporting accuracy., Objective: The effects of target period and interview time on children's accuracy for reporting school meals during 24-hour dietary recalls were investigated. DESIGN AND SUBJECTS/SETTING: During the 2004-2005, 2005-2006, and 2006-2007 school years in Columbia, SC, each of 374 randomly selected fourth-grade children (96% African American) was observed eating two consecutive school meals (breakfast and lunch) and interviewed to obtain a 24-hour dietary recall using one of six conditions defined by crossing two target periods with three interview times. Each condition had 62 or 64 children (half boys)., Main Outcome Measures: Accuracy for reporting school meals was quantified by calculating rates for omissions (food items observed eaten but unreported) and intrusions (food items reported eaten but unobserved); a measure of total inaccuracy combined errors for reporting food items and amounts., Statistical Analyses Performed: For each accuracy measure, analysis of variance was conducted with target period, interview time, their interaction, sex, interviewer, and school year in the model., Results: There was a target-period effect and a target-period by interview-time interaction on omission rates, intrusion rates, and total inaccuracy (six P values <0.004). For prior-24-hour recalls compared to previous-day recalls, and for prior-24-hour recalls in the afternoon and evening compared to previous-day recalls in the afternoon and evening, omission rates were better by one third, intrusion rates were better by one half, and total inaccuracy was better by one third., Conclusions: To enhance children's dietary recall accuracy, target periods and interview times that minimize the retention interval should be chosen.

Using previously collected data of fourth-grade children observed eating school meals and then interviewed, we categorized intrusions (food items reported but not observed eaten) as stretches (on the child's tray) or confabulations (not on the child's tray). We investigated intrusions, confabulations, and stretches, and the role of liking, at different retention intervals (morning interviews about the previous day's intake; evening interviews about that day's intake) and under different reporting-order prompts (forward; reverse). As retention interval between consumption and report increased, the likelihood 1) increased that reported items were intrusions, that reported items were confabulations, and that intrusions were confabulations; and 2) was constant that reported items were stretches. Results concerning reporting-order prompts were inconclusive. Liking ratings were higher for matches (reports of items observed eaten) than stretches, for confabulations than stretches, and for matches than omissions (unreported items observed eaten), but did not vary by retention interval or reporting-order prompts.

Validation-study data and foodservice production records were analyzed to test hypotheses concerning sources of intrusions (reports of uneaten items) in the school-meal parts of children's dietary recalls. Each child was observed eating school meals on two days, and interviewed the morning after each observation day; one interview used forward-order (morning-to-evening) and one used reverse-order (evening-to-morning) prompts. Lunch intrusions were likelier to have been available in the foodservice environment at lunch as day before the interview came closer, and on days before than after the interview. Temporal dating errors are contributing sources of intrusions in the school-lunch parts of children's recalls.

For school breakfast each day, many elementary schools offer a choice between a cold option that includes ready-to-eat (RTE) cereal and a hot option that includes a non-RTE-cereal entrée such as waffles. For breakfast reports, intrusions (reports of uneaten items) in correctly reported and misreported breakfast options were examined using data from five dietary-reporting validation studies. In each study, fourth-grade children were observed eating school breakfast and school lunch and then interviewed to obtain a dietary recall. A breakfast option was correctly reported in 240 breakfast reports for 203 intrusions total, and misreported in 97 breakfast reports for 189 intrusions total. Asymmetry was evident in misreported options; specifically, children observed eating a cold option almost never misreported a hot option, but children observed eating a hot option often misreported a cold option. Proportionately more breakfast reports were intrusion-free when a breakfast option was correctly reported than misreported. Linking of intrusions (i.e., multiple intrusions from the same option in a breakfast report) was especially evident with misreported breakfast options. Methodological aspects of dietary recalls such as target period (prior 24h; previous day), interview time (morning; afternoon; evening), and interview format (meal; open) had implications for intrusions and misreported breakfast options.

In dietary recall for a specified target period, an intrusion denotes an item reported eaten that was not consumed during that period. Intrusions may denote items available during the specified period, items consumed during other periods, or items from general knowledge of dietary intake. To investigate a cognitive basis of intrusions, we analyzed data from a dietary-reporting validation study in which 69 fourth-grade children were observed eating 2 school meals (breakfast and lunch) and interviewed that evening about that day's intake in person or by telephone. Of 450 items reported eaten for school meals, 82 were intrusions. Observations and school food service production records were used to determine whether items denoted by intrusions were available in school food service environments on the interview day, as many as 3 school days prior to the interview day, and the day following the interview. Availability of items denoted by intrusions decreased backward over days from the interview day, and decreased from the interview day to the following day. Among 40 children who reported at least 1 intrusion, mean number of intrusions (controlling for number of items reported) increased as interviews occurred later in the week. These results are consistent with the idea that some intrusions are based on specific memories of items encountered but not eaten during the target period, or encountered before the target period. Other intrusions are likely based on general dietary knowledge. It may be possible to design interview techniques to reduce the occurrence of intrusions that are incorrectly based on specific memories.

Background: Intrusions in dietary recalls may originate in confusion of episodic memories manifested as temporal dating errors., Objective: Data from a validation study (concerning reporting accuracy over multiple recalls) and school foodservice production records were used to investigate origins of intrusions in school meals in children's 24-hour recalls. DESIGN/SUBJECTS/SETTING: During the 1999-2000 school year, 104 fourth-grade children were observed eating school meals on 1 to 3 nonconsecutive days separated by >or=25 days, and interviewed about the previous day's intake in the morning on the day after each observation day., Statistical Analyses Performed: For breakfast and lunch separately, logistic regression was used to investigate the effect of time (ie, days) before the interview day on the probability that intrusions referred to items available in the school foodservice environment. Exploratory analyses were conducted for breakfast options observed and/or reported eaten., Results: For interviews in which reported meals met criteria to be considered school meals and that contained intrusions, of 634 and 699 items reported eaten at breakfast and lunch, respectively, 394 and 331 were intrusions. Availability in the school foodservice environment of items referred to by intrusions in reports of lunch, but not breakfast, decreased as days increased before the interview day (P=0.031 and P=0.285, respectively). Concerning breakfast, children observed eating a cold option (ie, ready-to-eat cereal, milk, juice, crackers [graham or animal]) almost always reported a cold option, whereas children observed eating a hot option (ie, non-ready-to-eat cereal entrée [eg, sausage biscuit], milk, and fruit or juice) reported a cold option in approximately 50% of interviews., Conclusions: In children's 24-hour recalls, confusion of episodic memories contributes to intrusions in school lunch, and generic dietary information (eg, cold option items available daily) or confusion of episodic memories may contribute to intrusions in school breakfast. Understanding the origins of intrusions may help in developing interview methods to decrease the occurrence of intrusions.

Background: Research suggests significant health differences between rural dwelling youth and their urban counterparts with relation to cardiovascular risk factors. This study was conducted to (1) determine relationships between physical activity and markers of metabolic syndrome, and (2) to explore factors relating to physical activity in a diverse sample of rural youth., Methods: Data were collected from 4th, 6th, 8th, and 11th grade public school students in the rural Southeastern United States in the spring of 2002. Physiological data included anthropometrics, fasting glucose, lipids, hemodynamics, and skinfold measurements. Psychosocial data included parental support for physical activity, accessibility of physical activity facilities, and safety concerns for physical activity. Behavioral data included self-reported physical activity and sedentary behaviors., Results: After adjusting for sex, race, and age, subjects with low level of physical activity were 3 times more likely to be positive for metabolic syndrome compared to those reporting a high level of physical activity. Subjects reporting a low level of physical activity were 2.4 times more likely to be overweight compared to subjects reporting a high level of physical activity. Students with high levels of physical activity were more likely to have parents who provided money for physical activity lessons and sports teams., Conclusions: Rural youth with low levels of physical activity participation were at increased risks for metabolic syndrome and overweight. Effective physical activity promotions addressing supports for physical activity are urgently needed in rural America.

Objective: To investigate the effect of observing school meals on children's dietary reports., Subjects and Setting: One hundred and twenty children randomly selected, but with half girls, from usual school-meal eaters among 312 volunteers (from all 443 fourth-grade children in six schools in one district)., Design: Children were assigned randomly to one of 12 conditions yielded by crossing observation status (observed; not observed), target period (previous day; prior 24 hours), and interview time (morning; afternoon; evening)., Results: Response variables included interview length, number of meals and snacks reported for the target period, and, for two school meals, number of meal components reported, importance-weighted number of items reported and kilocalories reported. These variables were transformed to principal components; two were retained (1, the school meal variables; 2, interview length and number of meals and snacks). Analyses of variance on principal component scores tested effects of observation status, target period, interview time and all interactions. Observation status did not affect scores on either retained principal component. Scores on Component 2 showed that more intake was reported in prior-24-hours interviews than in previous-day interviews., Conclusions: The effect of target period on reported intake indicates that the response variables were sufficiently reliable to detect manipulations. This, together with the finding that response variables did not depend on observation status, suggests that observation of school meals does not affect fourth-grade children's dietary reports, and that conclusions about dietary reports by fourth-grade children observed eating school meals in validation studies may be generalised to dietary reports by comparable children not observed.

Objective: To compare reporting accuracy for breakfast and lunch in 2 studies., Design: Children were observed eating school meals and interviewed the following morning about the previous day. In Study 1, 104 children were each interviewed 1 to 3 times with >or=25 days separating any 2 interviews. In Study 2, 121 children were each interviewed once in forward (morning-to-evening) and once in reverse (evening-to-morning) order, with these interviews separated by >or=29 days., Setting: 12 schools., Participants: Fourth-grade children., Main Outcome Measures: For each meal, food-item variables (observed number, reported number, omission rate, intrusion rate, total inaccuracy) and kcal variables (observed, reported, correspondence rate, inflation ratio)., Analysis: General linear mixed models., Results: For each study, observed and reported numbers of items and kcal, and correspondence rate (reporting accuracy), were greater for lunch than for breakfast; omission rate, intrusion rate, and inflation ratio (measures of reporting error) were greater for breakfast than for lunch. In Study 1, for each meal over interviews, total inaccuracy decreased and correspondence rate increased. In Study 2, for each meal for boys for reverse and for girls for forward order, omission rate was lower and correspondence rate was higher., Conclusions and Implications: Breakfast was reported less accurately than lunch. Despite improvement over interviews (Study 1) and differences for order x sex (Study 2), reporting accuracy was low for breakfast and lunch.

Objective: Validation study data are used to illustrate that conclusions about children's reporting accuracy for energy and macronutrients over multiple interviews (ie, time) depend on the analytic approach for comparing reported and reference information-conventional, which disregards accuracy of reported items and amounts, or reporting-error-sensitive, which classifies reported items as matches (eaten) or intrusions (not eaten), and amounts as corresponding or overreported., Subjects and Design: Children were observed eating school meals on 1 day (n=12), or 2 (n=13) or 3 (n=79) nonconsecutive days separated by >or=25 days, and interviewed in the morning after each observation day about intake the previous day. Reference (observed) and reported information were transformed to energy and macronutrients (ie, protein, carbohydrate, and fat), and compared., Main Outcome Measures: For energy and each macronutrient: report rates (reported/reference), correspondence rates (genuine accuracy measures), and inflation ratios (error measures)., Statistical Analyses: Mixed-model analyses., Results: Using the conventional approach for analyzing energy and macronutrients, report rates did not vary systematically over interviews (all four P values >0.61). Using the reporting-error-sensitive approach for analyzing energy and macronutrients, correspondence rates increased over interviews (all four P values <0.04), indicating that reporting accuracy improved over time; inflation ratios decreased, although not significantly, over interviews, also suggesting that reporting accuracy improved over time. Correspondence rates were lower than report rates, indicating that reporting accuracy was worse than implied by conventional measures., Conclusions: When analyzed using the reporting-error-sensitive approach, children's dietary reporting accuracy for energy and macronutrients improved over time, but the conventional approach masked improvements and overestimated accuracy. The reporting-error-sensitive approach is recommended when analyzing data from validation studies of dietary reporting accuracy for energy and macronutrients.

PURPOSE/OBJECTIVES: This article discusses differences by ethnicity (Black, White), gender, and time (season/year) in body mass index (BMI)-for-age percentiles, and prevalence of overweight and at risk of overweight, in fourth-grade children across five studies conducted during four school years. These five studies concerned either the accuracy of children's dietary recalls or children's social desirability, so weight and height measurements were secondary rather than primary aims. METHODS: Across five studies, 1,696 fourth-grade children (54% Black, 46% White; 51% girls) from a total of 14 public elementary schools in one school district were measured. Each child's BMI-for-age percentile was determined using the Centers for Disease Control and Prevention's gender-specific BMI-for-age growth charts. RESULTS: Across all five studies, 20 children (1.2%) were underweight (<5(th) percentile), 989 children (58.3%) were at a healthy weight (≥5(th) and <85(th) percentiles), 281 children (16.6%) were at risk of overweight (≥85(th) and <95(th) percentiles), and 406 children (23.9%) were overweight (≥95(th) percentile). The mean gender-specific BMI-for-age percentile across all children was high (70.1%) and greater for Black children (72.0%) than White children (67.8%) (p=0.02; analysis of covariance). A higher percentage of Black children (26.5%) compared to White children (21.0%) were overweight (p=0.01; chi-square). No differences were found by gender or time in the prevalence of children who were overweight; likewise, no differences were found by ethnicity, gender, or time in the prevalence of children who were at risk of overweight. APPLICATIONS TO CHILD NUTRITION PROFESSIONALS: Schools provide an excellent venue for measuring children's weight and height annually to determine BMI-for-age percentiles. This information can be used to track changes over time, and linked to computerized administrative records of children's daily participation in school meals from one school year to the next to increase knowledge of a relationship between childhood obesity and daily participation in school meals.

Objective: Validation-study data are used to illustrate that conventional energy and macronutrient (protein, carbohydrate, fat) variables, which disregard accuracy of reported items and amounts, misrepresent reporting accuracy. Reporting-error-sensitive variables are proposed which classify reported items as matches or intrusions, and reported amounts as corresponding or overreported., Methods: 58 girls and 63 boys were each observed eating school meals on 2 days separated by > or =4 weeks, and interviewed the morning after each observation day. One interview per child had forward-order (morning-to-evening) prompts; one had reverse-order prompts. Original food-item-level analyses found a sex-x-order prompt interaction for omission rates. Current analyses compared reference (observed) and reported information transformed to energy and macronutrients., Results: Using conventional variables, reported amounts were less than reference amounts (ps<0.001; paired t-tests); report rates were higher for the first than second interview for energy, protein, and carbohydrate (ps< or =0.049; mixed models). Using reporting-error-sensitive variables, correspondence rates were higher for girls with forward- but boys with reverse-order prompts (ps< or =0.041; mixed models); inflation ratios were lower with reverse- than forward-order prompts for energy, carbohydrate, and fat (ps< or =0.045; mixed models)., Conclusions: Conventional variables overestimated reporting accuracy and masked order prompt and sex effects. Reporting-error-sensitive variables are recommended when assessing accuracy for energy and macronutrients in validation studies.

This pilot study investigated body mass index (BMI; calculated as kg/m(2)), sex, interview protocol, and children's accuracy for reporting kilocalories. Forty 4th-grade children (20 low-BMI: >or=5th and <50th percentiles, 10 boys, 15 African American; 20 high-BMI: >or=85th percentile, 10 boys, 15 African American) were observed eating school meals (breakfast, lunch) and interviewed either that evening about the prior 24 hours or the next morning about the previous day, with 10 low-BMI (5 boys) and 10 high-BMI (5 boys) children per interview protocol. Five kilocalorie variables were analyzed using separate four-factor (BMI group, sex, race, interview protocol) analyses of variance. No effects were found for reported or matched kilocalories. More kilocalories were observed (P<0.02) and omitted (P<0.05) by high-BMI than low-BMI children. For intruded kilocalories, means were smaller (better) for high-BMI girls than high-BMI boys, but larger for low-BMI girls than low-BMI boys (interaction P<0.04); low-BMI girls intruded the most while high-BMI girls intruded the least. For interview protocol, omitted and intruded kilocalories were higher (worse), although not significantly so (P values <0.11), for interviews about the previous day than the prior 24 hours. These results illuminate relations of BMI, sex, interview protocol, and children's reporting accuracy, and are consistent with results concerning BMI and sex from studies with adults.

This secondary analysis investigated the influence of body mass index (BMI) category and sex on reporting accuracy during multiple 24-hour dietary recalls. On three occasions, each of 79 children (40 girls) was observed eating school meals and interviewed the next morning about the previous day's intake, with ≥ 25 days between any two consecutive occasions for a child. Using age/sex BMI percentiles, we categorized 48 children as healthy weight (≥ 5(th) percentile <85(th)), 14 as at risk of overweight (≥ 85(th) percentile <95(th)), and 17 as overweight (≥95(th) percentile). A repeated-measures analysis was conducted for each of five outcomes (number of items observed eaten, number of items reported eaten, omission rate, intrusion rate, total inaccuracy). For items observed, BMI category x trial was marginally significant (P=0.079); over trials, this outcome was stable for healthy-weight children, decreased and stabilized for at-risk-of-overweight children, and was stable and decreased for overweight children. This outcome was greatest for overweight children and least for healthy-weight children (P=0.015). For items reported, no significant effects were found. For omission rate (P=0.028) and intrusion rate (P=0.083), BMI category x trial was significant and marginally significant; over trials, both decreased for healthy-weight children, decreased and stabilized for at-risk-of-overweight children, and increased and stabilized for overweight children. Total inaccuracy decreased slightly over trials (P=0.076); this outcome was greater for boys than for girls (P=0.049). Results suggest that children's dietary reporting accuracy over multiple recalls varies by BMI category. Validation studies with adequate samples for each BMI category, sex, and race are needed.

Quality control is an important aspect of a study because the quality of data collected provides a foundation for the conclusions drawn from the study. For studies that include interviews, establishing quality control for interviews is critical in ascertaining whether interviews are conducted according to protocol. Despite the importance of quality control for interviews, few studies adequately document the quality control procedures used during data collection. This article reviews quality control for interviews and describes methods and results of quality control for interviews from two of our studies regarding the accuracy of children's dietary recalls; the focus is on quality control regarding interviewer performance during the interview, and examples are provided from studies with children. For our two studies, every interview was audio recorded and transcribed. The audio recording and typed transcript from one interview conducted by each research dietitian either weekly or daily were randomly selected and reviewed by another research dietitian, who completed a standardized quality control for interviews checklist.Major strengths of the methods of quality control for interviews in our two studies include: (a) interviews obtained for data collection were randomly selected for quality control for interviews, and (b) quality control for interviews was assessed on a regular basis throughout data collection. The methods of quality control for interviews described may help researchers design appropriate methods of quality control for interviews for future studies.

This article (a) provides a general review of interobserver reliability (IOR) and (b) describes our method for assessing IOR for items and amounts consumed during school meals for a series of studies regarding the accuracy of fourth-grade children's dietary recalls validated with direct observation of school meals. A widely used validation method for dietary assessment is direct observation of meals. Although many studies utilize several people to conduct direct observations, few published studies indicate whether IOR was assessed. Assessment of IOR is necessary to determine that the information collected does not depend on who conducted the observation. Two strengths of our method for assessing IOR are that IOR was assessed regularly throughout the data collection period and that IOR was assessed for foods at the item and amount level instead of at the nutrient level. Adequate agreement among observers is essential to the reasoning behind using observation as a validation tool. Readers are encouraged to question the results of studies that fail to mention and/or to include the results for assessment of IOR when multiple people have conducted observations.

Purpose: This study evaluated the effect of recency on accuracy of fourth-graders' dietary reports., Methods: Each of 60 randomly selected children was observed eating school meals (breakfast, lunch) and interviewed to obtain a 24-hour dietary recall using one of six conditions generated by crossing two target periods (previous day, prior 24 hours) with three interview times (morning, afternoon, evening), with 10 children (5 males) per condition. Accuracy of the school meal portions of each recall was assessed by comparing reports to observations. Rates for omissions (items observed but not reported) and intrusions (items reported but not observed) were calculated to determine accuracy for reporting items. A measure of total inaccuracy combined errors for reporting items and amounts., Results: Using the prior 24 hours as the target period yielded better performance than did using the previous day: Omission rates were lower by about one-third, intrusion rates by about one-half, and total inaccuracy by about one-third (all p's<0.01). A marginally significant interaction of target period by interview time was found for omission rate (p=0.08), but not for intrusion rate (p=0.15) or for total inaccuracy (p=0.47)., Conclusions: This provides evidence that recency influences children's recall accuracy and demonstrates the importance of an awareness of principles of memory when designing what are essentially memory tests for epidemiologic studies.

We investigated telephone administration of the Children's Social Desirability (CSD) scale and our adaptation for children of the Social Desirability for Food scale (C-SDF). Each of 100 4th-graders completed 2 telephone interviews 28 days apart. CSD scores had adequate internal consistency and test-retest reliability, and a 14-item subset was identified that sufficiently measures the same construct. Our C-SDF scale performed less well in terms of internal consistency and test-retest reliability; factor analysis revealed 2 factors, 1 of which was moderately related to the CSD. The 14-item subset of the CSD scale may help researchers understand error in children's dietary reports.

Background: Do children recall school breakfast and school lunch intake during 24-h recalls more accurately when prompted to report meals and snacks in reverse versus forward order?, Methods: One hundred twenty-one fourth-graders stratified by race (Black, White) and gender were each observed and interviewed twice (once per order) regarding the previous day's intake. Omission and intrusion rates determined accuracy for reporting items. Total inaccuracy determined accuracy for reporting items and amounts., Results: Results failed to indicate significant effects of interviewer, weekday, sequence (first or second recall), or race on omission rates, intrusion rates, or total inaccuracy. A significant order by gender interaction was found for omission rates, which were lower (i.e., better) for males for reverse (53%) versus forward recalls (62%), but not females (61 versus 53%) (P < 0.008). Intrusion rates were acceptable for males for 54% of reverse recalls and 40% of forward recalls (P = 0.095). Means were 57 and 32%, and 6.4 servings for omission rate, intrusion rate, and total inaccuracy for reverse recalls, and 56 and 39%, and 6.9 servings for forward recalls., Conclusions: Prompting children to report in reverse versus forward order improved omission and intrusion rates for males more so than females. Regardless of reverse or forward order, children reported <50% of items observed; furthermore, >30% of items reported were not observed. Research is needed to enhance accuracy of children's dietary recalls.

Objective: To investigate the accuracy of children's dietary recalls of school breakfast and school lunch validated with observations and obtained during in-person versus telephone interviews., Design: Each child was observed eating school breakfast and school lunch and was interviewed that evening about that day's intake., Setting: Ten elementary schools., Participants: A sample of fourth-graders was randomly selected within race (black, white) and gender strata, observed, and interviewed in person (n = 33) or by telephone (n = 36)., Main Outcomes Measured: Rates for omissions (items observed but not reported) and intrusions (items reported but not observed) were calculated to determine accuracy for reporting items. A measure of total inaccuracy was calculated to determine inaccuracy for reporting items and amounts combined., Analysis: Analysis of variance; chi-square., Results: Interview type (in person, telephone) did not significantly affect recall accuracy. For omission rate, intrusion rate, and total inaccuracy, means were 34%, 19%, and 4.6 servings for in-person recalls and 32%, 16%, and 4.3 servings for telephone recalls of school breakfast and school lunch., Conclusions and Implications: The accuracy of children's recalls of school breakfast and school lunch is not significantly different whether obtained in person or by telephone. Whether interviewed in person or by telephone, children reported only 67% of items observed; furthermore, 17% of items reported were not observed.

Federal policy has encouraged researchers to include children in research studies; thus, it is important to report experiences recruiting children to participate in studies. This article compares fourth-graders' participation rates across four school-based nutrition studies conducted in one school district in a southeastern state. For each study, children were observed eating school meals (breakfast and lunch); interviewed regarding dietary intake; and weighed and measured. For Study 1, children from 11 schools received $10 per interview for up to two interviews conducted in the morning at school. For Study 2, children from 10 schools received $25 if interviewed once in the evening, either by telephone or in a van parked outside the child's home. For Study 3, children from three schools received $10 per interview for up to three interviews held in the evening by telephone. For Study 4, children from six schools received $15 per interview for up to two interviews conducted either in the morning or afternoon at school, or in the evening by telephone. Recruitment procedures were similar for all studies.Participation rates were 73% (n=635) for Study 1, 57% (n=432) for Study 2, 66% (n=158) for Study 3, and 71% (n=296) for Study 4. Logistic regression was used to determine whether study (1, 2, 3, 4), race (black, white), or gender (male, female) were significant predictors of participation (agreed, denied). The results indicated that study (p<0.0001), race (p=0.0198), and gender (p=0.0188) were significant predictors, however, no two-factor interactions among these effects were significant. Post hoc pairwise comparisons with Bonferroni adjustment indicated that agreement to participate for Study 2 was lower (p<0.0001) than that for Studies 1, 3, and 4, which did not differ. Agreement to participate across all four studies was higher for black (69%) than white (63%; p=0.0054) children and for females (69%) than males (64%; p=0.0209). Schools provide a natural environment for nutrition research because school foodservice programs feed millions of children one or two meals (breakfast and/or lunch) each school day. Observations of children eating school meals provide a convenient and relatively unobtrusive means of validating children's dietary recalls. Thus, at some point, most child nutrition professionals are likely to be involved in research either directly (i.e. by conducting studies themselves) or indirectly (i.e. by allowing others access to their school cafeterias to collect data).This paper references the following data:Table 1. Similarities and Differences in the Designs for Each of the Four Studies.Table 2. Number and Percent of Fourth-Grade Children Who Agreed or Denied to Participate by Race and Gender Across all Four Studies Combined.Table 3. Number and Percent of Fourth-Grade Children Who Agreed or Denied to Participate by Gender and Race for Each of the Four Studies Separately.

Objective: To use data from observations and interviews to document fourth-graders' preferences for, and consumption of, fruits compared to vegetables available as part of school lunches., Design: Observations and interviews were conducted for studies regarding the impact of time interval between eating and reporting on the accuracy of children's school lunch recalls., Subjects/settings: Children were recruited from up to 4 schools in one district during 3 school years; 63% agreed to participate. Randomly selected children (n = 237) were each observed eating school lunch once and were interviewed (regarding items eaten and preferences for items eaten) within 11/2 hours or the next morning., Main Outcome Measures: Observed consumption of servings of items available as part of school lunch was recorded as none, taste, little bit, half, most, and all. Response options for preferences for items available as part of school lunch were liked not at all, a little, and a lot., Statistical Analyses Performed: Mixed-model analysis of variance., Results: Preferences were higher for fruits than vegetables. As preferences increased, consumption increased (P <.0001). Consumption of fruits compared to vegetables was similar after adjusting for preferences., Implications: Research is needed to understand how to increase children's preferences for vegetables as a means of increasing consumption.

Objective: To explore fourth-graders' school breakfast participation by gender and race (black, white) and examine the extent to which parents' responses to "Does this child usually eat school breakfast?" reflected their children's participation., Design: Parents answered "yes" or "no" to the questions printed on consent forms. Observers documented which children participated in school breakfast on 26 to 51 randomly selected days per school during 24 weeks in the 1999-2000 school year., Subjects: 357 children recruited from all 22 fourth-grade classes from 6 schools in 1 public school district., Variables Measured: Participation rate, participation rate grouping [usually participated (>or=50% of days observed), did not usually participate (< 50% of days observed)]., Statistical Analyses Performed: Komolgorov-Smirnov tests, McNemar's test., Results: Median participation rate was 37.5% overall. Distribution of participation rates differed significantly by race (K-S test, P <.001) but not gender. There was a significant difference in the percentage of parents who said "yes" or "no" compared to children's usual participation grouping (McNemar test, P <.001). Of parents who said "yes," 66% of children usually participated; of parents who said "no," 92% of children did not usually participate., Implications: Children, not parents, must be the source for learning about what children eat at school.

Objective: To determine the accuracy and consistency of fourth-graders' school breakfast and school lunch recalls obtained during 24-hour recalls and compared with observed intake., Design: Children were interviewed using a multiple-pass protocol at school the morning after being observed eating school breakfast and school lunch., Subjects: 104 children stratified by ethnicity (African-American, white) and gender were randomly selected and interviewed up to 3 times each with 4 to 14 weeks between each interview., Statistical Analysis: Match, omission, and intrusion rates to determine accuracy of reporting items; arithmetic and/or absolute differences to determine accuracy for reporting amounts; total inaccuracy to determine inaccuracy for reporting items and amounts combined; intraclass correlation coefficients (ICC) to determine consistency., Results: Means were 51% for omission rate, 39% for intrusion rate, and 7.1 servings for total inaccuracy. Total inaccuracy decreased significantly from the first to the third recall (P=0.006). The ICC was 0.29 for total inaccuracy and 0.15 for omission rate. For all meal components except bread/grain and beverage, there were more omissions than intrusions. Mean arithmetic and absolute differences per serving in amount reported for matches were -0.08 and 0.24, respectively. Mean amounts per serving of omissions and intrusions were 0.86 and 0.80, respectively., Applications/conclusions: The low accuracy and low consistency of children's recalls from this study raise concerns regarding the current uses of dietary recalls obtained from children. To improve the accuracy and consistency of children's dietary recalls, validation studies are needed to determine the best way(s) to interview children.

This article describes the methods used to recruit fourth-grade children for a school-based study concerning the accuracy of their school breakfast and lunch recalls, and it reports the impact of school, class, ethnicity, and gender on agreement to participate. A total of 522 children (27% White Males [WM], 30% White Females [WF], 21% Black Males [BM], 22% Black Females [BF]) was available to recruit from 22 classes at six public schools in one district in a southeastern state during the 1999-2000 school year. Across classes, 45% to 95% of children agreed to participate (n = 376, 25% WM, 30% WF, 22% BM, 23% BF) with 72% overall. Logistic regression indicated class as a marginally significant predictor of participation (p < 0.04), but failed to indicate school, ethnicity, or gender as significant predictors. Other specific factors that may influence children's participation need to be investigated and results shared to help improve recruitment efforts for future school-based studies.