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Early life exposures have been associated with obesity later in life. We aim to assess the association between early life exposure to food insecurity and change in BMI throughout childhood and adolescents. Food security status and growth variables from 243 Mother–child dyads from the Center for the Health Assessment of Mothers and Children of Salinas study were assessed 7 times over a 12-year period. Generalized log linear models with Poisson distributions and linear regression models were implemented to assess the associations between early life food insecurity and obesity and growth. Early life food insecurity was associated with a 0.43 (0.01, 0.82) kg/m2 decrease in BMI from age 2 to 3.5, and a 0.92 kg/m2 (0.38, 1.46) increase in BMI among boys from ages 3.5 to 5, after adjusting for covariates. Sex and age modify the association between early life exposure to food insecurity and BMI.

Objectives. To identify lessons learned from implementation of the nation’s first sugar-sweetened beverage (SSB) excise tax in 2015 in Berkeley, California. Methods. We interviewed city stakeholders and SSB distributors and retailers (n = 48) from June 2015 to April 2017 and analyzed records through January 2019. Results. Lessons included the importance of thorough and timely communications with distributors and retailers, adequate lead time for implementation, advisory commissions for revenue allocations, and funding of staff, communications, and evaluation before tax collection begins. Early and robust outreach about the tax and programs funded can promote and sustain public support, reduce friction, and facilitate beverage price increases on SSBs only. No retailer reported raising food prices, indicating that Berkeley’s SSB tax did not function as a “grocery tax,” as industry claimed. Revenue allocations totaled more than $9 million for public health, nutrition, and health equity through 2021. Conclusions. The policy package, context, and implementation process facilitated translating policy into public health outcomes. Further research is needed to understand long-term facilitators and barriers to sustaining public health benefits of Berkeley’s tax and how those differ from facilitators and barriers in jurisdictions facing significant industry-funded repeal efforts.

BACKGROUND The National School Lunch and Breakfast Programs help to reduce food insecurity and improve nutrition. The Community Eligibility Provision (CEP) enables high-poverty schools to offer breakfast and lunch at no cost to all students. This study examines associations between CEP and participation among students eligible for free or reduced-price meals ("FRPM"), possibly eligible ("near-cutoff"), or ineligible ("full-price"). METHODS Using data from the 2013-2015 Healthy Communities Study, we compared school breakfast and lunch participation between 842 students in K-8 at 80 CEP schools and 1463 students at 118 schools without CEP. Cross-sectional difference-in-difference (DID) models compared meal participation among near-cutoff and full-price groups to that in the FRPM group. RESULTS Overall, FRPM students had high participation in school lunch and breakfast at both types of schools. In adjusted DID models, lunch participation among near-cutoff students was 12 points higher in CEP versus comparison schools (p

Public schools in the U.S. generate about 14,500 tons of municipal solid waste daily, and approximately 42% of that is food packaging generated by school foodservice, contributing significantly to the global packaging waste crisis. This literature review summarizes methods used to evaluate food packaging waste in school foodservice. This review has two objectives: first, to understand which methodologies currently exist to evaluate food packaging waste generation and disposal in school foodservice; and second, to describe the creation of and share a practical standardized instrument to evaluate food packaging waste generation and disposal in school foodservice. A systematic review was conducted using the following search terms: solid waste, school, cafeteria and food packaging, waste, and school. The final review included 24 studies conducted in school environments (kindergarten through twelfth grade or college/university), 16 of which took place in the U.S. Food packaging waste evaluations included objective methods of waste audits, models, and secondary data as well as subjective methods of qualitative observations, questionnaires, interviews, and focus groups. Large variation exists in the settings, participants, designs, and methodologies for evaluating school foodservice packaging waste. Lack of standardization was observed even within each methodology (e.g., waste audit). A new instrument is proposed to support comprehensive and replicable data collection, to further the understanding of school foodservice food packaging waste in the U.S., and to reduce environmental harms.

Highlights • 7 U.S. cities have a sugar-sweetened-beverage tax, raising $134 million annually. • Early childhood programs received the largest investment of tax revenues ($58M). • Community improvements (e.g., rec centers & libraries) were second largest ($21M). • Increasing healthy food and beverage access (e.g., produce subsidies) received $17M. • 85% of revenues supported projects and programs in impacted communities., We sought to describe how revenues from sugar-sweetened beverage (SSB) excise taxes in 7 U.S. cities are being allocated, who is benefiting from these investments, and whether allocations are consistent with the original intent of tax legislation. We collected information from public documents and key informants about allocations in the most recent fiscal year available (ranging from 2018 to 2021). Across the 7 U.S. cities with taxes, the average annual revenue from SSB taxes totaled $133.9 M. In the fiscal year studied, cities allocated a total of $133.2 M in SSB tax revenues. Human and community capital investments totaled $89.6 M (67% of all allocations) funding early childhood development, community infrastructure improvements, and youth and workforce development. Health-related investments totaled $36.9 M (28% of total allocations), funding access to healthy foods and beverages; support for physical activity opportunities; promotion of overall physical, mental or social health and wellbeing; health and nutrition education; chronic-disease prevention and management; and reducing SSB consumption. In the 3 cities that specified how tax revenues would be spent, allocations were consistent with promised uses of revenues. In addition, 85% of aggregated revenues ($112.9 M) were targeted to support work and programs in impacted communities (communities that experience health inequities, discrimination and exclusion). SSB tax revenues are supporting initiatives to improve community health, develop human and community capital, and advance equity. These investments may yield additional health benefits beyond those resulting from lower SSB consumption. Consistent tracking and public reporting on revenue allocations would increase transparency and accountability.

Advertising exerts a powerful influence over consumer decision-making, and disproportionate marketing for unhealthy products may contribute to health inequities. The objective of this study was to examine socioeconomic and racial and ethnic disparities in outdoor branded advertising for products harmful to health in San Francisco and Oakland, CA. We collected cross-sectional data on outdoor advertising from 372 blocks with≥1 residential or mixed-residential parcel in SF and Oakland in 2018-2019. Blocks were randomly sampled by city, land use, majority vs. non-majority Black and/or Hispanic composition, and upper and lower tertiles of household income. Advertisements were coded by product, healthfulness, and branding. Exposure variables were neighborhood household median income and percent of residents who were Hispanic of any race, non-Hispanic Asian, non-Hispanic Black, and non-Hispanic White. The primary outcome variable was block-level dichotomous presence of any unhealthy branded advertisement for food, beverage, alcohol, or tobacco. Analyses were unadjusted and adjusted for land use and number of total advertisements on each block. Each additional $10,000 in neighborhood household median income was associated with an 11% lower adjusted odds of having any unhealthy branded advertisements on the block (95%CI: 0.80-0.99; P=0.03). There were no significant associations between neighborhood racial and ethnic composition and presence of unhealthy branded advertisements, but with each 10% higher neighborhood composition of Hispanic residents, there was a borderline significant higher presence of unhealthy branded advertisements (OR=1.23; 95%CI: 1.00-1.51; P=0.05). Results indicate that low-income neighborhoods were disproportionately exposed to outdoor branded advertisements for unhealthy products.

While school meals are often the healthiest option for students, lunch participation remains relatively low. Few approaches for increasing participation have leveraged teachers’ potential social influence. We determined if a teacher intervention about the benefits of school lunch could improve teachers’ perceptions of, and participation in, school lunch, and encouragement of students to eat school lunch. This repeated cross-sectional study included teacher/student survey administration in spring of 2016 and 2018 in 19 public secondary schools (9 intervention, 10 comparison) educating students of ages ≈ 11–18. Intervention teachers received monthly newsletters; lunch taste tests; and a promotional video and website. Mixed effects models with a random effect for school showed the proportion of teachers that reported eating with students increased in intervention schools relative to control schools (difference-in-change: 7.6%; 95% CI: 3.578%, 14.861%), as did student agreement that adults at their schools encouraged them to eat school lunch (difference-in-change: 0.15 on a 5-point scale; 95% CI: 0.061, 0.244). There were no between-group differences in teachers’ perceptions of school meals or teachers’ lunch participation. These findings suggest that teachers’ perceptions of school meals do not necessarily need to improve to promote the school lunch program to students. However, to see meaningful change in teacher lunch participation, the taste of school meals likely needs improving.

Despite a growing body of evidence showing that sugar-sweetened beverage (SSB) taxes nudge consumers away from SSBs, we lack an understanding of people’s awareness and perceptions of SSB taxes and whether tax awareness and perceptions differ based on sociodemographic characteristics. We used serial cross-sectional study intercept surveys (n = 2715) in demographically diverse neighborhoods of Berkeley and Oakland in 2015 and 2017, and San Francisco and Richmond in 2017. In the year following successful SSB tax ballot measures, 45% of respondents correctly recalled that an SSB tax had passed in their city. In untaxed cities, 14% of respondents incorrectly thought that a tax had passed. Perceived benefits of SSB taxes to the community and to children’s health were moderate and, like correct recall of an SSB tax, were higher among respondents with higher education levels. Awareness of SSB taxes was low overall, and perceptions about taxes’ benefits varied by educational attainment, reflecting a missed opportunity to educate citizens about how SSB taxes work and their importance. Public health efforts should invest in campaigns that explain the benefits of SSB taxes and provide information about how tax revenues will be invested, both before and after a tax proposal has passed.

Consumption of sugar-sweetened beverages (SSBs) contributes to adverse health outcomes and excess health care spending. To provide context for ongoing work assessing the impact of public health strategies, including SSB excise taxes, we used data from the California Health Interview Survey from 2011-2018 to estimate trends in beverage consumption among adults, teens, and children overall and by education, race/ethnicity, and family income. We found reductions in the annual prevalence and frequency of soda consumption across all age groups and heterogeneous increases in the consumption of fruit drinks among adults and children. Surveillance of beverage consumption trends will continue to strengthen and improve the ability of researchers and policy makers to effectively improve population health.

Background Persistent household food insecurity may have a greater adverse effect on children's health outcomes than experiencing household food insecurity for a shorter duration. Objectives Examine how changing household food security status and prolonged exposure to household marginal food security or food insecurity are associated with changes in children's growth from age 5 to 12. Methods We analyzed 204 mother-child dyads from the Center for Health Assessment of Mothers and Children of Salinas (CHAMACOS), a longitudinal birth cohort study of Latino households. Generalized estimating equations assessed how changing household food security status and persistent exposure to marginal food security or food insecurity were associated with growth throughout childhood. Results Living in a marginally food secure of food insecure household compared to highly food secure household was associated with a decrease in BMI z-score of 0.18 (0.09, 0.26) between age 9 and 10.5. Changing from a highly food secure household to a marginally food secure or food insecure household was associated with a 0.10 (0.01, 0.20) decrease in body mass index z-score compared to those who persistently lived in highly food secure households. Conclusions Changes in food security status and duration of food insecurity were associated with changes in children's growth.

The sugar-sweetened beverage (SSB) industry has claimed that food and beverage retailers are opposed to SSB taxes. In 2018 and 2019, we formally evaluated retailers' perceptions of SSB taxes using semi-structured interviews (including open- and closed-ended questions) with 103 randomly selected retailers (50 corner and liquor stores; 28 chain convenience, drug, and mass-merchandise stores; 18 chain supermarkets and discount supermarkets; and 7 independent supermarkets) across 3 cities with SSB taxes (Berkeley, Oakland, and San Francisco); interviews occurred in 2018 and 2019 (approximately 3years, 1year and 6months post tax-implementation, respectively). A majority of both small and large retailers reported the tax had only a minimal effect on their business (70%). About half of retailers believed that other cities should adopt SSB taxes (53%), and were supportive of a statewide SSB tax (53%), noting it would level the playing field and better support health in their communities. Retailers' responses did not differ based on neighborhood income, and only 2 responses differed significantly between large and small retailers. Only 2 of 103 retailers reported raising the price of a non-beverage product in response to the tax, specifically raising the price of snack foods of low nutritional quality and alcoholic beverages. A majority of retailers in 3 California cities with SSB taxes have no concerns regarding the tax, endorse the health goals of SSB taxes and support statewide expansion of SSB tax policies.

Author(s): Thompson, Hannah R; Ritchie, Lorrene; Park, Esther; Madsen, Kristine A; Gosliner, Wendi | Abstract: IntroductionSchools across the United States have removed sweetened, flavored milk from cafeterias to reduce students' sugar consumption and improve their health. However, evidence on the impact of the removal is limited. We examined the effect of a policy that removed chocolate milk from secondary schools on students' milk consumption and estimated milk-related nutrient intake.MethodsWe collected data on milk selection and consumption during 1 lunch period in 24 California public secondary schools pre-policy (N = 3,158 students in 2016) and post-policy (N = 2,966 students in 2018). Schools had a student population that was 38% Asian and 29% Latino, with 63% qualifying for free or reduced-price meals. We used linear mixed effects models to assess changes in milk selection and waste, and we estimated related changes in added sugars, calcium, protein, and vitamin D consumed from milk.ResultsThe proportion of students selecting milk declined 13.6%, from 89.5% pre-policy to 75.9% post-policy (95% CI for difference, 10.8% tο 16.4%), but the proportion of milk wasted remained stable (37.1% vs 39.3%; 95% CI for difference, -0.2% to 4.6%). Although average per-student milk consumption declined by less than 1 ounce per student (from 4.8 oz to 3.8 oz; 95% CI for difference, -1.1 oz to -0.7 oz), we observed no significant reductions in average per-student intake of calcium, protein, or vitamin D from milk. Estimated added sugars from milk declined significantly, by 3.1 grams per student (95% CI, -3.2 g to -2.9 g).ConclusionRemoving chocolate milk modestly reduced student milk consumption without compromising average intake of key milk-related nutrients, and consumption of added sugars from milk declined significantly. Secondary schools should consider removing chocolate milk to support healthy beverage consumption.

Objectives. To examine how much sugar-sweetened beverage (SSB) excise taxes increased SSB retail prices in Oakland and San Francisco, California. Methods. We collected pretax (April–May 2017) and posttax (April–May 2018) retail prices of SSBs and non-SSBs from 155 stores in Oakland, San Francisco, and comparison cities. We analyzed data using difference-in-differences high-dimensional fixed-effects regressions, weighted by regional beverage sales. Results. Across all beverage sizes, the weighted average price of SSBs increased by 0.92 cents per ounce (95% confidence interval [CI] = 0.28, 1.56) in Oakland and 1.00 cents per ounce (95% CI = 0.35, 1.65) in San Francisco, compared with prices in untaxed cities. The tax did not significantly alter prices of water, 100% juice, or milk of any size examined. Diet soda only, among non-SSBs, exhibited a higher price increase for some sizes in taxed cities. Conclusions. Within 4 to 10 months of implementation, Oakland’s and San Francisco’s SSB excise taxes significantly increased SSB retail prices by approximately the amount of the taxes, a key mechanism for reducing consumption.

Child obesity is understudied in Asian Americans, which include a growing population of recent immigrants. We examined the relationship between maternal nativity and time in the US, and obesity and obesogenic behaviors among Asian American children. We analyzed public-use data from the 2013&ndash, 2016 California Health Interview Survey for Asian American children ages 2 to 11 years. We used logistic regression to determine the odds of obesity and obesogenic behaviors associated with maternal nativity and time in the US. This study included n = 609 children. Children of US-born mothers had lower odds of obesity (adjusted odds ratio, AOR, 0.12, 95% CI 0.02 to 0.91) and lower fruit intake (AOR 0.15, 95% CI 0.03 to 0.81) than children of recent immigrants (&lt, 5 years in the US). Asian American children with recent immigrant mothers are more likely to be obese and eat less fruit than children with US-born mothers. Efforts to prevent obesity and increase fruit consumption are particularly important for this vulnerable population of children of recent immigrants.

Background Community initiatives to promote physical activity in children are common, but evidence supporting their effectiveness is limited. Objectives The objective of this study is to examine the relationships between community programmes and policies and children's physical activity in a large and diverse sample of US communities. Methods Programmes and policies to promote children's physical activity were assessed in 130 communities by key informant interviews, and physical activity behaviours were measured by self-report and parental report in samples of children in each community (total n = 5138). Associations between composite indices of community programmes and policies and indicators of total and moderate-to-vigorous physical activity were examined without and with adjustment for demographic factors. Results An index reflecting the 6-year history of the number of behaviour change strategies used in community programmes and policies was positively associated with children's moderate-to-vigorous physical activity. This association was attenuated with adjustment for demographic factors. Effect modification analyses found that the association was positive among non-Hispanic children but was negative for Hispanic children. Conclusions Community initiatives to promote physical activity in children were positively associated with children's physical activity in non-Hispanic children. Such initiatives were negatively associated with physical activity in Hispanic children, suggesting that future research should consider unique cultural factors when designing community initiatives to promote activity in this population sub-group.

Objectives. To evaluate a mass media campaign to reduce the consumption of sugar-sweetened beverages (SSBs). Methods. We disseminated messages emphasizing the health risks of SSBs through television, digital channels, and local organizations over 15 weeks in 2015–2016 in the Tri-Cities region of northeast Tennessee, southwest Virginia, and southeast Kentucky. We evaluated the campaign with pre- and post-telephone surveys of adults aged 18 to 45 years in the intervention area and by examining changes in beverage sales in the intervention and a matched comparison area in western Virginia. Results. Fifty-four percent of postcampaign respondents recalled seeing a campaign advertisement. After the campaign, 53% of respondents believed SSBs were a cause of heart disease, and respondents were more likely postcampaign to consider SSBs a “big cause of diabetes” (75% vs 60%; P

[ ]public health may be able to engage a broader coalition in fighting other preventable but deadly diseases, perhaps even obesity and diabetes [ ]sales taxes on soft drinks in Maine and Ohio, where 5 5% and 5 0% taxes, respectively, were added at the register, had no effect on sales 4 By contrast, a similarly sized excise tax in Washington State, which led to a 6% increase in shelf prices, was associated with a 5% decline in soft drink sales 5 Although Chriqui et al explain that Cook County used a sales tax because of existing restrictions, the tax size (equivalent to a 26% price increase) was five times larger than those in Maine and Ohio and led to a 21% net decline in sales while it was in place 2 FOCUS ON HEALTH Although excise taxes increase the cost of doing business for SSB manufacturers, and thereby lead to higher SSB prices and reduced consumption,1 it remains important to frame SSB taxes as a remedy to SSB-related disease and the tax revenues as a source of funding for health promotion By contrast, highlighting taxes as a means of reducing SSB consumption plays into the beverage industry's faulty but repeated claims that excise taxes restrict personal choice 3 Further, focusing on individual behaviors aligns with industry's talking points about personal responsibility;such talking points minimize the role inequitable environments across economic strata, including SSB advertising, play in shaping individual behaviors 1 NEXT STEPS Although Cook County's tax failed, it does pose an elegant natural experiment that could augment the science on SSB taxes, if the repeal's effect is consistent with evidence from Washington State and Denmark

Objectives. To examine the impact of physical education (PE) litigation on changes in cardio–respiratory fitness among racially/ethnically and socioeconomically diverse students. Methods. We used annual school-level data for all California schools with measures of fifth graders’ cardio–respiratory fitness spanning 2007–2008 through 2017–2018. A difference-in-difference design assessed changes before and after lawsuits in the proportion of students meeting fitness standards in schools in districts that were parties to PE lawsuits (n = 2715) versus in schools in districts not involved (n = 3152). We ran separate models with the proportion of students meeting fitness standards by sex, race/ethnicity, and low-income status as outcomes. Results. PE litigation led to a 1-percentage-point increase in the proportion of fifth-grade students meeting cardio–respiratory fitness standards (95% confidence interval [CI] = 0.03%, 2.0%). Effects were especially pronounced for female (1.3-percentage-point increase; 95% CI = 0.1%, 2.5%), African American (3.4-percentage-point increase; 95% CI = 0.5%, 6.2%), and low-income (2.8-percentage-point increase; 95% CI = 0.5%, 6.0%) students. Conclusions. Schools in districts subject to PE litigation showed greater improvements in student fitness, particularly among students typically at higher risk for inactivity and low fitness. Litigation may be an impactful tool for enforcing PE provision in accordance with the law.

Author(s): Thompson, Hannah R; Linchey, Jennifer K; King, Benjamin; Himes, John H; Madsen, Kristine A | Abstract: BackgroundThe accuracy of students' heights and weights measured by school staff for body mass index (BMI) screening/reporting has not been established. This study examined school staffs' measurement accuracy, comparing accuracy by staff- and student-level characteristics.MethodsSchool staff and researchers measured the height and weight of 1008 4th-8th grade students, within 1 month of each other. Bland-Altman plots, mean differences, and intraclass correlation coefficients (ICCs) were calculated to examine measurement accuracy. Linear mixed effects models assessed accuracy by staff- and student-level characteristics.ResultsBland-Altman plots revealed no appreciable bias in differences between researcher and staff measurements. The mean absolute difference between researcher and school staff measurements were 1.0 ± 1.6ncm (height), 0.7 ± 1.8nkg (weight), and 0.4 ± 0.8nkg/m2 (BMI). Inter-rater ICC values were ≥0.97, demonstrating "excellent" reliability. Categorical weight status was correctly classified for 94% of students (kappa 0.90), and for 96% with a BMI ≥95th% (kappa 0.94). Physical education (PE) teachers were slightly less accurate than school nurses in measuring height (0.4ncm less accurate; pn=n.045) and weight (0.4nkg; pn=n.015).ConclusionsSchool staff conducted height/weight measurements on 4th-8th grade students with high accuracy. Resultant school-based BMI reports using similar protocols should validly reflect weight status for almost all students.

ObjectiveThe present study aimed to determine the store types from which people in low-income neighbourhoods purchase most sugar-sweetened beverages (SSB) and to identify associations between purchasing location and demographic characteristics.DesignStreet-intercept surveys of passers-by near high foot-traffic intersections in 2016. Participants completed a beverage frequency questionnaire and identified the type of store (e.g. corner store, chain grocery) from which they purchased most SSB.SettingEight low-income neighbourhoods in four Bay Area cities, California, USA.ParticipantsSample of 1132 individuals who reported consuming SSB, aged 18–88 years, who identified as African-American (41 %), Latino (29 %), White (17 %) and Asian (6 %).ResultsBased on surveys in low-income neighbourhoods, corner stores were the primary source from which most SSB were purchased (28 %), followed by discount stores (18 %) and chain groceries (16 %). In fully adjusted models, those with lower education were more likely to purchase from corner stores or discount groceries than all other store types. Compared with White participants, African-Americans purchased more frequently from corner stores, discount groceries and chain groceries while Latinos purchased more frequently from discount groceries.ConclusionsThe wide range of store types from which SSB were purchased and demographic differences in purchasing patterns suggest that broader methodological approaches are needed to adequately capture the impact of SSB taxes and other interventions aimed at reducing SSB consumption, particularly in low-income neighbourhoods.

Consumption of sugar-sweetened carbonated beverages (including soda) has declined nationally, but trends by state are unknown. We used data from the California Health Interview Survey to assess overall changes in soda consumption among adults aged 18 or older from 2011 through 2016 and identified differences by education and income level. Frequency of soda consumption (times per week) declined from 2011 through 2014 by 16.5% but returned to 2011 levels in 2015 and 2016; trends did not differ by education or income. The proportion of the population that consumed soda did not change among adults with less than a high school diploma or equivalent, but declined significantly among those with at least a high school diploma. Our findings suggest that soda consumption remains a pressing public health problem in California.

OBJECTIVES:To estimate changes in sugar-sweetened beverage (SSB) and water consumption 3 years after an SSB tax in Berkeley, California, relative to unexposed comparison neighborhoods. METHODS:Data came from repeated annual cross-sectional beverage frequency questionnaires from 2014 to 2017 in demographically diverse Berkeley (n = 1513) and comparison (San Francisco and Oakland; n = 3712) neighborhoods. Pretax consumption (2014) was compared with a weighted average of 3 years of posttax consumption. RESULTS:At baseline, SSBs were consumed 1.25 times per day (95% confidence interval [CI] = 1.00, 1.50) in Berkeley and 1.27 times per day (95% CI = 1.13, 1.42) in comparison city neighborhoods. When we adjusted for covariates, consumption in Berkeley declined by 0.55 times per day (95% CI = -0.75, -0.35) for SSBs and increased by 1.02 times per day (95% CI = 0.54, 1.50) for water. Changes in consumption in Berkeley were significantly different from those in the comparison group, which saw no significant changes. CONCLUSIONS:Reductions in SSB consumption were sustained in demographically diverse Berkeley neighborhoods over the first 3 years of an SSB tax, relative to comparison cities. These persistent, longer-term reductions in SSB consumption suggest that SSB taxes are an effective policy option for jurisdictions focused on improving public health. (Am J Public Health. Published online ahead of print February 21, 2019: e1-e3. doi:10.2105/AJPH.2019.304971).

School lunch programs provide an opportunity to improve students&rsquo, diets. We sought to determine the impact of a multifaceted intervention (cafeteria redesigns, increased points-of-sale and teacher education) on secondary students&rsquo, perceptions of school-lunch quality and convenience and fruit and vegetable intake. Surveys (n = 12,827) from middle and high school students in 12 intervention and 11 control schools were analyzed. We investigated change in school-lunch perceptions and lunchtime and daily fruit and vegetable consumption from 2016 to 2018. Among 8th graders, perceptions that school lunch tastes good and that school lunch was enough to make students feel full increased 0.2 points (on a 5-point scale, p &lt, 0.01) in intervention schools relative to control schools. Among 10th graders, lunchtime fruit and vegetable consumption increased 6% in intervention relative to control schools (p &lt, 0.05 and p &lt, 0.01 respectively). Daily fruit intake increased 0.1 cups/day in intervention relative to control schools among 9th graders (p &lt, 0.01). This study provides important evidence on the limited effect of design approaches in the absence of meal changes. We observed only modest changes in school lunch perceptions and fruit and vegetable consumption that were not consistent across grades, suggesting that additional efforts are needed to improve school-lunch uptake.

Physical education (PE) can improve student health. Schools with credentialed PE teachers receive more PE. However, many schools have reduced PE funding, resulting in fewer teachers and potentially poorer student health. We examined if PE teachers are equally available across school districts, and if availability is associated with higher student cardiorespiratory fitness. We contacted California districts educating students in grades K-6 (n = 894) to determine the number of credentialed elementary PE teachers per district in 2016–17. Public datasets provided demographics and student fitness. Generalized linear models examined associations between district-level demographic characteristics and PE teacher-to-student ratio. Linear regression assessed the relationship between PE teacher-to-student ratio and student fitness. Seventy-five percent of districts (n = 669) responded. On average, there were 0.6 PE teachers for every 500 students, including the half (51%) of districts without elementary PE teachers. Each additional100 students of all racial/ethnic backgrounds in the district was associated with a 0.1% (95% CI −0.2%, −0.1%) decrease in the ratio. Each 10% increase in African American and Latino students was associated with 29% (95% CI −47%, −5%) and 18% (95% CI −31%, −3%) decreases in the ratio, respectively. Each additional PE teacher per 500 students was associated with a 3% increase in aerobically fit students (95% CI 1%, 4%). Elementary PE teachers are lacking in California, particularly in districts with a high proportion of African American and Latino students, which may be contributing to health disparities. Creative action to fund PE should be explored to ensure all students benefit from quality PE.

BackgroundMany elementary schools have policies requiring a minimum amount of physical education (PE). However, few schools comply with local/state PE policy and little is known about how to improve adherence. We evaluated changes in PE among fifth-grade classes, following participatory action research efforts to improve PE quantity and policy compliance that focused on publically disclosing PE data.MethodsData were collected in 20 San Francisco public elementary schools in spring 2011 and 2013. PE schedules were collected and PE classes were directly observed (2011, N = 30 teachers; 2013, N = 33 teachers). Data on the proportion of schools meeting state PE mandates in 2011 were shared within the school district and disclosed to the general public in 2012.ResultsFrom 2011 to 2013, PE increased by 11 minutes/week based on teachers' schedules (95% CI: 3.0, 19.6) and by 14 minutes/week (95% CI: 1.9, 26.0) based on observations. The proportion of schools meeting the state PE mandate increased from 20% to 30% (p = .27).ConclusionsPositive changes in PE were seen over a 2-year period following the public disclosure of data that highlighted poor PE policy compliance. Public disclosure could be a method for ensuring greater PE policy adherence.

Promoting active commuting by walking or biking to and from school could increase physical activity and reduce obesity among youth. However, exposure to the retail food environment while commuting may lead to greater dietary intake among active commuters.To examine the relationship between commute patterns and dietary intake and quality in elementary students.Fourth and fifth grade students (N=3,316) in 44 California schools reported commute modes to and from school and dietary intake for the same 24-hour period in 2012. Differences between active and passive commuters in total energy intake (kcal), energy from purchased foods, and energy from sweets and snack-type foods were compared, stratified by after-school program (ASP) participation (analysis conducted in 2013).Twenty-three percent of youth actively commuted to school; 27% actively commuted from school. Passive commuters, 87% of whom traveled by car, consumed 78 more kcal from purchased foods (p0.01) than active commuters in the 24-hour period, though total energy intake did not differ by commute mode overall or by ASP participation. Among the 72% of students who did not attend an ASP, passive commuters consumed 56 more kcal from purchased foods (p0.01) and 25 more kcal from sweets and snack-type foods (p=0.02) than active commuters.Passive commuters consumed more sweets and snack-type foods and more purchased foods than active commuters. These results, which suggest that parents are providing unhealthy foods for their children during the school commute, reinforce the need for multilevel strategies to promote energy balance in youth.

Childhood obesity is a public health threat that disproportionally affects Latino youth in the United States. Active and Healthy Families (AHF) is a culturally tailored, family-based program for addressing obesity disparities in a predominantly immigrant Latino population. AHF was the first primary care, culturally tailored intervention for Latino children to significantly reduce BMI in a randomized controlled trial. The 10-week AHF intervention reduced BMI (kg/m2) among overweight or obese children by 0.5, compared with an increase of 0.3 in the control group, yielding a -0.8 difference ( p < .01). A unique aspect of the program is its provider team: a physician, dietitian, and promotora. Because early feedback from families highlighted the importance of promotoras specifically, we sought to understand the unique mechanisms of promotora effectiveness in AHF. We conducted in-depth, semistructured interviews with the AHF providers ( n = 5) and parent participants ( n = 23) by phone between November 2012 and May 2013. In a grounded theory analysis, three main categories encompassing five themes emerged: (a) bridging communication by promotoras; (b) promotoras' personal qualities, including themes of kindness and caring and shared experiences with patients; and (c) impactful task performance, including themes of motivation, positive environment, and self-efficacy. Together, the themes serve as the basis of a conceptual model illustrating the process through which promotoras may enhance the impact of team-based obesity programs for the Latino community. Because this study identifies the specific ways through which promotoras can bridge cultural, linguistic, and other divides, it may inform development and dissemination of evidence-based approaches for obesity prevention in the Latino community.

Objectives. To evaluate the impact of the excise tax on sugar-sweetened beverage (SSB) consumption in Berkeley, California, which became the first US jurisdiction to implement such a tax ($0.01/oz) in March 2015. Methods. We used a repeated cross-sectional design to examine changes in pre- to posttax beverage consumption in low-income neighborhoods in Berkeley versus in the comparison cities of Oakland and San Francisco, California. A beverage frequency questionnaire was interviewer administered to 990 participants before the tax and 1689 after the tax (approximately 8 months after the vote and 4 months after implementation) to examine relative changes in consumption. Results. Consumption of SSBs decreased 21% in Berkeley and increased 4% in comparison cities (P = .046). Water consumption increased more in Berkeley (+63%) than in comparison cities (+19%; P Conclusions. Berkeley’s excise tax reduced SSB consumption in low-income neighborhoods. Evaluating SSB taxes in other cities will improve understanding of their public health benefit and their generalizability.

ObjectiveTo examine the association between added sugar intake and metabolic syndrome among adolescents.DesignDietary, serum biomarker, anthropometric and physical activity data from the US National Health and Nutrition Examination Survey cycles between 2005 and 2012 were analysed using multivariate logistic regression models. Added sugar intake in grams per day was estimated from two 24 h standardized dietary recalls and then separated into quintiles from lowest to highest consumption. Multivariate logistic regression analyses were adjusted for physical activity, age, BMI Z-score and energy intake, and their interactions with race were included.SettingNationally representative sample, USA.SubjectsUS adolescents aged 12–19 years (n 1623).ResultsAdded sugar was significantly associated with metabolic syndrome. The adjusted prevalence odds ratios for having metabolic syndrome comparing adolescents in the third, fourth and fifth quintiles v. those in the lowest quintile of added sugar were 5·3 (95 % CI 1·4, 20·6), 9·9 (95 % CI 1·9, 50·9) and 8·7 (95 % CI 1·4, 54·9), respectively.ConclusionsOur findings suggest that higher added sugar intake, independent of total energy intake, physical activity or BMI Z-score, is associated with increased prevalence of metabolic syndrome in US adolescents. Further studies are needed to determine if reducing intake of added sugar may help US adolescents prevent or reverse metabolic syndrome.

IntroductionBecause California is home to one in eight U.S. children and accounts for the highest Medicaid and Children's Health Insurance Program spending, childhood obesity trends in California have important implications for the entire nation. California's racial/ethnic diversity and large school-based data set provide a unique opportunity to examine trends by race/ethnicity, including understudied Asian and American Indian youth, which has not been possible using national data sets. This study examined racial/ethnic disparities in prevalence of high BMI from 2003 to 2012.MethodsThis observational study included 11,624,865 BMI records from repeated cross-sections of fifth-, seventh-, and ninth-graders who underwent California's school-based fitness testing. Analyses conducted in 2015 used logistic regression to identify trends in prevalence of high BMI (BMI ≥85th, 95th, and 97th percentiles) and differences in trends by race/ethnicity from 2003 to 2012.ResultsAfrican American and Hispanic girls and American Indian boys increased in prevalence of high BMI, whereas non-Hispanic white and Asian youth and Hispanic boys decreased in prevalence of high BMI (p-values

Increasing physical activity is one of the cornerstones for combating obesity and reducing the risk of weight-related morbidity among America’s youth.1, 2 Despite the known importance of physical activity, only 18% of adolescents report achieving the recommended 60 minutes of daily physical activity.3 This is particularly concerning as disparities in physical activity3 parallel increasing disparities in pediatric obesity.4 Schools are a natural venue in which to increase physical activity among diverse youth and the after-school period poses fewer time constraints than the school day.5 Results of intervention studies to increase after-school physical activity have been mixed,6 making it difficult to identify best practices for promoting physical activity after school. Strategies that have been proven effective during the school day may be equally effective after school. Sports Play and Active Recreation for Kids (SPARK) is one program that was demonstrated to increase students’ moderate to vigorous physical activity (MVPA) during the school day.7 The SPARK program consists of 3 primary features: an active curriculum, staff-development, and follow-up support.7 However, no studies to date have examined the use of SPARK after school as a tool to help staff increase children’s physical activity. During the 2008–2009 school year, a large urban school district set a new policy of achieving 30 minutes of MVPA in the after-school setting per day. To assist schools in reaching this goal, the district purchased the SPARK program. The school district planned to introduce SPARK to 13 schools over a one-year period, and was willing to stagger implementation in order to evaluate SPARK’s impact on physical activity. We took advantage of this opportunity to examine the potential of SPARK to increase MVPA in the after-school setting and improve cardiorespiratory fitness and weight status.

Pediatric obesity in the United States remains a major public health concern.1, 2 An Institute of Medicine (IOM) report recommended school-based body mass index (BMI) screening to address childhood obesity, asserting that “schools should measure yearly each student’s [BMI] and make this information available to parents and to the student (when age appropriate).”3 As of 2010, 20 states require BMI or body composition screening and 6 states recommend screening, either alone or as part of a comprehensive fitness assessment.4 Among states requiring BMI or body composition screening, fewer than half require parent notification of test results,4 and prevalence of notification is unknown in these states. Yet, notification serves as the major mechanism by which BMI screening is expected to impact obesity: it is theorized that increasing parents’ awareness of their child’s risk will compel them to take steps towards improving their child’s health.5, 6 In addition to uncertainty about notification rates, little is known about methods used when school districts elect to notify parents. The FITNESSGRAM®,7 a battery of 6 fitness assessments that evaluate body composition (BMI, skinfolds, or bioelectrical impedance), aerobic capacity, flexibility, and strength and endurance, is required or recommended in at least 16 states4 and may be the vehicle for BMI or body composition screening and notification in many school districts (in California, 95% of schools use BMI to assess body composition for the FITNESSGRAM, personal communication from the California Department of Education [CDE]). A recent study of BMI screening and notification via FITNESSGRAM assessments did not demonstrate improvements in pediatric obesity at the population level;8 therefore, a better understanding of current notification methods will be critical in informing school-based efforts to reduce obesity. In California, annual FITNESSGRAM assessments have been required for 5th, 7th, and 9th grade students since 2001;9 however, parent notification has been optional. California’s policy affords the opportunity to collect meaningful data on the practice of BMI and body composition notification in the most populous state. Therefore, this study sought to examine the prevalence of and reasons for notification among school districts when notification is optional, the methods by which notification occurs, and the content and quality of notification messages.

BACKGROUND: Protective factors associated with positive youth development predict health and education outcomes. This study explored trends in these protective factors and in physical activity among low-income students, and determined the impact of a school-based youth development program on these trends. METHODS: This study used a quasi-experimental time series design including data from 158 low-income schools from 2001 to 2007. Ninety-four schools had exposure to a school-based program promoting physical activity and youth development through structured play; 64 schools served as controls. Primary outcomes were 5th-grade student scores (n = 13,109) on a California statewide survey for physical activity (1–6 scale) and measures of protective factors including problem solving skills, meaningful participation in school, and caring adults (1–4 scales). Predictors were time (year) and school's number of years of exposure to the program. RESULTS: Overall, significant annual declines were seen in protective factors, including students' report of feeling safe (−0.03, 95% CI [−0.03, −0.01]), caring adults at school (−0.03 [−0.05, −0.02]), and problem solving skills (−0.03 [−0.04, −0.02]). Cumulative declines over 6 years were equivalent to a drop of 1 school-level SD. Each additional year of exposure to the program predicted greater meaningful participation (0.02 [0.001, 0.5]), problem-solving skills (0.03 [0.0001, 0.06]), and increased physical activity (0.06 [0.01, 0.10]); exposure throughout elementary school (6 years) increased scores by 1 school-level SD. CONCLUSIONS: Low-income students reported a significant decline in protective factors since 2001. School partnerships with youth development programs promoting physical activity may ameliorate declines in emotional well-being and increase physical activity.

School-based body mass index (BMI) screening and reporting could have a positive impact on student health, but best practices for writing a report are unknown. Building on previous qualitative work, 8 focus groups were conducted with a diverse group of California parents (n = 79) to elicit feedback on report content and design. Results indicate that parents want a visually appealing, picture-heavy report that clearly defines BMI, avoids stigmatizing language, and includes recommendations for appropriate actions whole families can take. Next steps involve using the final report in a statewide, randomized trial to determine the effectiveness of school-based BMI screening and reporting in reducing childhood obesity.

Introduction The Alliance for a Healthier Generation’s Healthy Schools Program (HSP) is a national evidence-based obesity-prevention initiative aimed at providing the schools in greatest need with onsite training and technical assistance (TTA) and consultation with national experts (HSP national advisors) to create sustainable healthy change in schools’ nutrition and physical activity environments. The objective of this study was to evaluate the impact of HSP on the prevalence of overweight and obesity in California schools, from HSP’s inception in 2006 through 2012. Methods We used statewide body mass index (BMI) data collected annually from 5th-, 7th-, and 9th-grade students to determine whether enrolling in the HSP’s onsite intervention reduced the prevalence of overweight and obesity in intervention schools (n = 281) versus propensity-score matched control schools (n = 709) and whether increasing exposure to the program (TTA and contact with HSP national advisors) was associated with reductions in the prevalence of overweight and obesity. Results Analyses showed no difference between HSP schools and control schools in overweight or obesity prevalence. However, program exposure varied widely among participating schools, and each additional contact with TTA or HSP national advisors was associated with a 0.3% decline in overweight and obesity prevalence (P < .05). Conclusion HSP appears to be an important means of supporting schools in reducing obesity. Although participation in HSP alone was not sufficient to improve weight status in California schools, there was a clear dose–response relationship to the program. HSP serves as an effective model for addressing childhood obesity among engaged schools.

Since 2011 we have taught a public health innovations course at the University of California, Berkeley. Students gain skills in systematic innovation, or human-centered design, while working in small interdisciplinary teams on domestic and global health projects with client organizations. To support acquisition of meaningful problem-solving skills, we structured the course so that the majority of learning happens in scenarios that do not involve faculty. Taken by students representing 26 graduate programs (as diverse as epidemiology, city planning, and mechanical engineering), it is one of the 10 highest-rated courses offered by the School of Public Health. We present the blueprints for our course with the hope that other institutions whose students could benefit will borrow from our model.

Objectives. We assessed the short-term ability to increase retail prices of the first US 1-cent-per-ounce excise tax on the distribution of sugar-sweetened beverages (SSBs), which was implemented in March 2015 by Berkeley, California. Methods. In 2014 and 2015, we examined pre- to posttax price changes of SSBs and non-SSBs in a variety of retailers in Berkeley and in the comparison cities Oakland and San Francisco, California. We examined price changes by beverage, brand, size, and retailer type. Results. For smaller beverages (≤ 33.8 oz), price increases (cents/oz) in Berkeley relative to those in comparison cities were 0.69 (95% confidence interval [CI] = 0.36, 1.03) for soda, 0.47 (95% CI = 0.08, 0.87) for fruit-flavored beverages, and 0.47 (95% CI = 0.25, 0.69) for SSBs overall. For 2-liter bottles and multipacks of soda, relative price increases were 0.46 (95% CI = 0.03, 0.89) and 0.49 (95% CI = 0.21, 0.77). We observed no relative price increases for nontaxed beverages overall. Conclusions. Approximately 3 months after the tax was implemented, SSB retail prices increased more in Berkeley than in nearby cities, marking a step in the causal pathway between the tax and reduced SSB consumption.

Author(s): Thompson, Hannah R; Linchey, Jennifer; Madsen, Kristine A | Abstract: IntroductionSchool physical education (PE) has been identified as a critical public health tool to increase physical activity among youths. We sought to objectively assess compliance with PE quantity mandates and quality recommendations in a large urban California school district.MethodsWe collected PE schedules and systematically observed PE lessons (n=154) in 20 elementary, 4 middle, and 4 high schools from February through May 2011.ResultsOn the basis of schools' master schedules, 83% of elementary schools met the California state mandate of 100 PE minutes per week. Teachers' actual schedules indicated that 20% of schools met the mandate, and observation showed that only 5% were in compliance. All middle and high schools met the mandated 200 minutes per week. On average, classes at all school levels met the recommended 50% of PE lesson time in moderate-to-vigorous physical activity. No teacher- or school-level factors significantly predicted PE quantity, but credentialed elementary PE teachers spent more time building students' motor skills.ConclusionsOur results suggest that current national estimates of PE, which are based on schools' self-report, overestimate the amount of PE provided in elementary schools. Although more than half of PE class time was spent in moderate-to-vigorous physical activity, total physical activity in elementary schools from PE is minimal and may do little to contribute to students' overall health.

BACKGROUND: This study sought to elucidate students' perceptions of school food environments and to assess correlations between perceptions and purchasing and consumption behaviors at school. METHODS: Seventh and ninth graders (n = 5365) at 19 schools in multiethnic, low-income California communities participating in the Healthy Eating Active Communities program completed questionnaires assessing their attitudes and behaviors regarding school food environments during spring 2006. RESULTS: Most students (69%) reported that fresh fruit was important to be able to buy at school; more than chips (21%), candy (28%), or soda (31%). Reported importance of food offerings was correlated with the consumption of those items. Most students did not perceive foods/beverages offered at school to be healthy; fewer than a quarter reported eating fruits or vegetables (FV) at school. Students eating school lunch were more than twice as likely to consume FV, though if they also purchased from competitive venues, their consumption of candy, chips, and soda was similar to their peers who purchased only competitive foods. CONCLUSION: Students report healthy foods to be important to be able to buy at school, but do not perceive their school food environment to be healthy and consume more unhealthy foods at school. Students served healthy items via school lunch are more likely to consume them; however, they also purchase and consume unhealthy items if available. Findings suggest that modifying school food environments to facilitate consumption of healthy foods and limit unhealthy foods will better match students' preferences and could lead to improved dietary intake.

Purpose: Disordered eating is prevalent among obese adolescents. Little is known about how disordered eating behavior impacts the clinical course of obese adolescents undergoing treatment. We sought to determine if disordered eating behaviors at baseline predicted treatment response among adolescents seeking weight management.