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Objective Examine the association between the timing of sugar-sweetened beverages (SSBs) and 100% juice introduction with subsequent diet quality at age 3 years. Design Secondary analysis of a publicly available, national longitudinal dataset. Participants A total of 2,218 children from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Main Outcome Measure Dietary intakes were assessed using a 24-hour dietary recall completed by caregivers of children aged 3 years. Diet quality was assessed using the Healthy Eating Index Score-2015 (HEI-2015). Analysis Linear regression was used to assess the relationship between the timing of introduction to 100% juice and SSBs with HEI-2015. Adjustments were made for child- and maternal-related factors. Results Delayed introduction of SSBs during the first 2 years of life was associated with an increased HEI-2015 score. In adjusted analyses, for every 1-month delay in the introduction, there was a 0.09-point increase (95% confidence interval, 0.04–0.13) in the HEI-2015 score at 3 years. Conclusions and Implications Earlier introduction to SSBs may be associated with subsequent lower diet quality in WIC participants. This association may be driven by total fruit, whole grains, and added sugars HEI component scores. Further research is needed to support changes to existing WIC nutrition practices regarding SSBs and 100% juice.

BACKGROUND: Although it has been recommended that schools be the hub of efforts to improve child nutrition, research describing school nutrition environments in US public schools and their associations with child health is limited. OBJECTIVE: This study aimed to evaluate the applicability of factor analysis methods to characterize school nutrition environments by identifying underlying factors, or dimensions, in the observed data and to examine the relation between school nutrition environment dimensions and child anthropometric and dietary outcomes. METHODS: This study examined a cross-sectional sample of 4635 US children aged 4–15 y from 386 US elementary and middle schools from the Healthy Communities Study (2013–2015). Data collected from schools were used to create 34 variables that assessed the school nutrition environment. To identify dimensions of school nutrition environments, exploratory factor analysis was conducted with orthogonal rotation, and factor scores were derived using methods to account for sporadic missing data. Mixed-effects regression models adjusted for child- and community-level variables and clustered by community and school examined the associations of school nutrition environment dimensions with child anthropometric and dietary outcomes. RESULTS: Six dimensions of school nutrition environments were derived: nutrition education, food options, wellness policies, dining environment, unhealthy food restriction, and nutrition programs. The unhealthy food restriction dimension was negatively associated with added sugar intake (β = –1.13, P

OBJECTIVES: To examine (1) parental perceptions of school meals and (2) student meal participation before and after the implementation of the Healthy Hunger-Free Kids Act (HHFKA). DESIGN: Data were collected from telephone surveys of 2 independent cross-sectional panels in New Jersey (2009–2010 and 2016–2017). PARTICIPANTS: Households with children aged 7–18 years (pre-HHFKA: n = 1,027; post-HHFKA: n = 324). MAIN OUTCOME MEASURES: Parental perception of school meals and parental reports of student participation in school meals. ANALYSIS: Multivariable logistic regression models were developed to examine outcome variables. For school meal participation, nested models were analyzed first controlling for sociodemographic variables, followed by parental perception, and then the interaction between perception and time. RESULTS: Parental perceptions of school meals did not change significantly after the HHFKA. At both time points, school meal participation rates were significantly higher for children of parents who perceived school meals as healthy compared with children whose parents perceived meals to be unhealthy (pre-HHFKA: 89.9% vs 75.1%, P < 0.001; post-HHFKA: 87.3% vs 64.9%, P = 0.02). CONCLUSION AND IMPLICATIONS: Because higher perception of school meal quality is associated with higher participation, it is important for school food programs to inform parents about the improved nutritional quality of school meals.

ObjectiveTo increase understanding about the healthfulness of school lunch and participation, this study measured 3 school lunch variables, students' perception of healthfulness, objective healthfulness, and participation, and examined associations between each pair of variables (3 associations).MethodsMultilevel models were used for a secondary analysis of data from the Healthy Communities Study, a 2013-2015 observational study of schools (n = 423) and children (n = 5,106) from 130 US communities.ResultsStudents who reported that school lunches were sometimes, often, or very often healthy ate school lunches more frequently per week (β = .71; P < .001) than did students who responded never or rarely. No associations were found with objective school lunch healthfulness.Conclusions and implicationsStudent perception of healthfulness of school lunch is positively associated with participation but not with objective school lunch healthfulness. Understanding how student perception is associated with participation can inform effective communications to students to increase participation in the school lunch program.

Background The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides supplemental foods to assist participants in meeting their dietary needs. Few studies have described the extent to which WIC-eligible foods contribute to the overall diet of children who were enrolled in WIC prenatally or in early infancy. Objective Our aims were to examine commonly consumed foods and estimate the proportion of dietary intake contributed by WIC-eligible foods among 13- and 24-month-old children, and to assess differences by WIC participation status at 24-months. Design This was a national observational study. Participants/setting Children participating in the WIC Infant and Toddler Feeding Practices Study-2 were included (13 months old [n=2,777] and 24 months old [n=2,450]) from 2013 to 2016. Main outcome measures Dietary intakes were assessed using 24-hour dietary recalls at 13 and 24 months. The 10 most commonly consumed foods were described using the What We Eat in America food category classification system. WIC-eligible foods were defined as meeting the WIC nutrient criteria set forth in the Federal regulation. Statistical analyses performed The estimated proportion (mean±standard error) of WIC-eligible foods to total daily intake was calculated for energy, macronutrients, and select micronutrients. Multiple linear regression, adjusted for confounders, was conducted to compare the estimated proportion of nutrient intake from WIC-eligible foods by WIC participation at 24 months. Results At 13 and 24 months, most (60% and 63%, respectively) of the commonly consumed foods were eligible for purchase as part of the child WIC food package. WIC-eligible foods provided >40% of calories and close to 50% or more of other nutrients, and the contribution of WIC-eligible foods to overall micronutrient intake increased between 13 and 24 months. Children still on WIC at 24 months obtained a larger proportion of calories and most other nutrients from WIC-eligible foods than children no longer on WIC. Conclusions WIC-eligible foods could contribute to the overall diet of toddlers who were enrolled in WIC prenatally or in early infancy. Further, there may be additional nutritional benefits of staying on the program through 24 months.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) differs from other federal nutrition programs in that nutrition education is a required component. WIC programs traditionally provide in-person education, but recently some WIC sites have started offering online education. Education focused on reducing salt intake is an important topic for WIC participants because a high-sodium diet has been associated with high blood pressure, and low-income populations are at increased risk.Our aim was to examine the impacts of traditional in-person and online nutrition education on changes in knowledge, self-efficacy, and behaviors related to reducing salt intake in low-income women enrolled in WIC.Although a comparison of groups was not the primary focus, a randomized trial examining the impact of online and in-person nutrition education on participant knowledge, self-efficacy, and behaviors related to salt intake was conducted.Five hundred fourteen WIC participants from three Los Angeles, CA, WIC clinics received either in-person (n=257) or online (n=257) education. Questionnaires assessing salt-related knowledge, self-efficacy, and behaviors were administered at baseline and 2 to 4 months and 9 months later from November 2014 through October 2015.Positive changes in knowledge and self-efficacy were retained 2 to 4 months and 9 months later for both groups (P0.05). Both groups reported significant changes in behaviors related to using less salt in cooking (P0.0001) and eating fewer foods with salt added at the table or during cooking (P0.001) at 2 to 4 months and 9 months.Both online and in-person education resulted in improvements during a 9-month period in knowledge, self-efficacy, and reported behaviors associated with reducing salt intake in a low-income population. Offering an online education option for WIC participants could broaden the reach of nutrition education and lead to long-term positive dietary changes.

Background Few studies have assessed the dietary quality of children who eat meals from home compared with school meals according to the 2010 Dietary Guidelines for Americans. Objective The objective of this study was to examine diet quality for elementary school students in relation to source of breakfast and lunch (whether school meal or from an outside source). Design An observational study was conducted of students in 43 schools in San Diego, CA, during the 2011-2012 school year. Participants/setting Fourth- and fifth-grade students (N=3,944) completed a diary-assisted 24-hour food recall. Main outcome measures The Healthy Eating Index-2010 (HEI-2010) scores of children who ate breakfast and lunch at school were compared with the HEI-2010 scores of children who obtained their meals from home and a combination of both school and home. Statistical analysis Analysis of variance, χ 2 test, and generalized estimating equation models adjusted for age, sex, race/ethnicity, grade, language, and school level clustering were performed. Results School lunch eaters had a higher mean±standard deviation overall diet quality score (HEI-2010=49.0±11.3) compared with students who ate a lunch obtained from home (46.1±12.2; P =0.02). There was no difference in overall diet quality score by breakfast groups. Students who ate school breakfast had higher total fruit ( P =0.01) and whole fruit ( P =0.0008) scores compared with students who only ate breakfast obtained from home. Students who ate school foods had higher scores for dairy ( P =0.007 for breakfast and P P =0.01 for breakfast and P =0.007 for lunch). Conclusions Eating school lunch was associated with higher overall diet quality compared with obtaining lunch from home. Future studies are needed that assess the influence of the Healthy Hunger-Free Kids Act on children's diet quality.

BACKGROUND UVB light from the sun increases serum 25-hydroxyvitamin D [25(OH)D] concentration, but this relation may depend on skin pigmentation among different racial/ethnic groups. OBJECTIVE We used quantitative measures of exposed (facultative) and unexposed (constitutive) skin color to examine relations between serum 25(OH)D concentration, tanning, race/ethnicity, and constitutive skin color over the summer, following winter vitamin D supplementation. METHODS The subjects (n= 426, mean age 11.7 ± 1.4 y, 51% female) were racially/ethnically diverse schoolchildren (57% non-white/Caucasian) enrolled in a 6-mo vitamin D supplementation trial (October-December to April-June). In this secondary analysis, measures of serum 25(OH)D concentration and skin color, with the use of reflectance colorimetry, were taken over a 6-mo period after supplementation, from pre-summer (April-June) to post-summer (September-December). Multiple linear regression was used to evaluate longitudinal relations. RESULTS Following supplementation, mean serum 25(OH)D concentration was 29.3 ± 9.5 ng/mL but fell to 25.6 ± 7.9 ng/mL (P< 0.0001) by the end of summer. The decrease in white/Caucasian children was less than in black/African American children (P< 0.01) and tended to be less than in Hispanic/Latino, Asian, and multiracial/other children (P= 0.19-0.50) despite similar changes in sun-exposed skin color among all groups. Tanning was significantly associated with post-summer serum 25(OH)D concentration (β = -0.15,P< 0.0001), as was race/ethnicity (P= 0.0002), but the later association disappeared after adjusting for constitutive skin color. CONCLUSIONS Tanning significantly contributed to serum 25(OH)D concentration over the summer, independent of race/ethnicity, but was not sufficient to maintain serum 25(OH)D concentration attained with supplementation. Much of the variation in serum 25(OH)D concentration between racial/ethnic groups may be explained by skin color. This trial was registered atclinicaltrials.govasNCT01537809.

Vitamin D supplementation is an important strategy for preventing low levels of serum 25OHD and improving bone health and consequent associated health risks, especially in children at risk of deficiency. Although vitamin D supplements are recommended, there is limited research on the factors that influence adherence to taking them. In a cross-sectional sample of 256 child (aged 9 to 15 years) and parent pairs in the Boston, MA, area during January to March 2012, analysis of covariance was used to determine associations between health beliefs about vitamin D, parental vitamin D−containing supplement use, and the individual responsible for pill administration with supplement adherence measured by pill counts. Mean and median supplement pill count adherence over 3 months were 84% and 89%, respectively. Adherence was positively associated with parents' use of vitamin D−containing supplements (7% higher, P =0.008) and with combined child and parent responsibility for administration of the supplement compared with child only (9% higher, P =0.03). Parents' beliefs about vitamin D neither predicted their children's beliefs nor positively influenced children's adherence. Adherence was higher when parents took vitamin D−containing supplements and when parents and children shared responsibility for administering the supplement. Promoting child supplement use through parent involvement and role modeling may be a practical solution for registered dietitians who are aiming to improve vitamin D adherence in at-risk youth.

Dietary factors vary widely among ethnic groups. However, the effect of specific nutrients on cardiometabolic risk is not well understood, especially in children. Four dietary factors known to influence cardiometabolic risk (ie, carbohydrate, saturated, monounsaturated, and polyunsaturated fat intake) were assessed by the Block Kids 2004 Food Frequency Questionnaire in a cross-sectional sample of racially diverse fourth- through eighth-grade students (n=148) in a Boston-area school district studied between January and April 2010. Fasting total cholesterol, low-density lipoprotein, high-density lipoprotein (HDL) cholesterol, triglyceride, C-reactive protein (CRP), and interleukin-6 (IL-6) levels, and body mass index z scores were measured. Differences in dietary factors and cardiometabolic risk factors were examined among the following racial/ethnic groups: white (39%), Hispanic (32%), black (8%), Asian (10%), and multiracial/other (11%). In bivariate analyses, total, saturated, and polyunsaturated fat intakes differed by race/ethnicity (P

Background: Research on the association between school meal consumption and overall dietary intake post-Healthy Hunger-Free Kids Act implementation is limited. Objective: This study examines the association between frequency of participating in the National School Lunch and School Breakfast Programs and children’s dietary intakes. Design: The Healthy Communities Study was a cross-sectional observational study conducted between 2013-2015. Participants/setting: U.S. children ages 4-15 years (n=5,106). Main outcome measures: Dietary measures were assessed using the National Health and Nutrition Examination Survey Dietary Screener Questionnaire. Dietary intake included fruit/vegetables, fiber, whole grains, dairy, calcium., total added sugar, sugar-sweetened beverages, and energy-dense foods of minimal nutritional value. Statistical analysis: Multivariate statistical models assessed associations between frequency of eating school breakfast or lunch (every day vs. not every day) and dietary intake, adjusting for child and community-level covariates. Results: Children who ate school breakfast every day compared to children who ate 0-4 days/week, reported consuming more fruits/vegetables (0.1 cup/day, 95% CI: 0.01, 0.1), dietary fiber (0.4 g/day, 95% CI: 0.2, 0.7), whole grains (0.1 oz/day, 95% CI: 0.05, 0.1), dairy (0.1 cup/day, 95% CI: 0.05, 0.1), and calcium (34.5 mg/day, 95% CI: 19.1, 49.9). Children who ate school lunch every day compared to those who ate less frequently, consumed more dairy (0.1 cup/day, 95% CI: 0.1, 0.2) and calcium (32.4 mg/day, 95% CI: 18.1, 46.6). No significant associations were observed between school meal consumption and energy-dense nutrient poor foods or added sugars. Conclusions: Eating school breakfast and school lunch every day by U.S. schoolchildren was associated with modestly healthier dietary intakes. These findings suggest potential nutritional benefits of regularly consuming school meals.

To examine satisfaction with in-person group and online nutrition education and compare findings based on language preference by Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants.A total of 1,170 WIC participants were randomly assigned to 2 nutrition education modalities between March, 2014 and October, 2015 in Los Angeles, CA. Logistic regressions compared differences between groups in satisfaction outcomes.Participants in both education groups were highly satisfied regardless of modality of nutrition education (89% and 95%; P = .01). The online group reported a stronger preference for online education than did the in-person group (P .001). In the in-person group, Spanish-speaking participants were less likely than were English-speaking participants to prefer online education (P .001). A training video improved access to online education.Online delivery of education can be an acceptable addition for WIC participants with online access. High-quality online education platforms represent an important avenue to promote continued satisfaction with nutrition education.