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Schools are a critical setting for improving child nutrition and food security and preventing obesity in the United States. The U.S. Department of Agriculture mandates that the Supplemental Nutrition Assistance Program–Education, known as CalFresh Healthy Living (CFHL) in California, implements obesity prevention efforts that utilize multicomponent policy, systems, and environmental change interventions supplemented with direct and indirect education. However, evaluation of these complex interventions has proven challenging due to a lack of established evaluation methods, particularly for comprehensively measuring the dose of multicomponent interventions. This article proposes and demonstrates a method to score the dose of multicomponent California Department of Public Health–funded CFHL school interventions received by children attending public schools, using administrative data collected by CFHL in California.

This cross-sectional study was part of a larger evaluation of a fruit and vegetable (FV) incentive program for Supplemental Nutrition Assistance Program (SNAP) participants in California. We examined the price differences in FV to explore whether these could help explain a previously observed lack of effect of the incentive program on FV consumption. Differences by type (organic/no-spray or conventional), among a convenience sample of farmers’ markets (n = 11) and nearby supermarkets (n = 7), were assessed using Wilcoxon rank-sum tests adjusting for clustering by market. We calculated the cost of market baskets comprising recommended FV servings for a household using median prices to consider the implications of FV price differences for SNAP shoppers who use financial incentives for FV. We found that farmers’ markets primarily offered organic FV while supermarkets primarily offered conventionally grown FV. Farmers’ market prices tended to be lower than supermarkets for organic FV but higher for conventional FV. Compared to supermarkets, the market basket composed only of organic FV cost USD 16.34 less at farmers’ markets, whereas a basket comprised of a mix of conventionally and organically grown FV cost USD 3.68 more. These differences warrant further exploration; FV price and type should be considered in studies aimed at understanding the impact of SNAP financial incentive programs.

Introduction This manuscript describes the prevalence and attributes of community programmes and policies (CPPs) to address childhood obesity documented as occurring in 130 diverse US communities. Methods Key informant interviews (N = 1420) and document abstraction were used to identify and characterize CPPs to promote physical activity and healthy nutrition occurring during a 10-year retrospective study period. Data were collected in 2013-2015 and analysed in 2016. Results Across all 130 communities, 9681 distinct CPPs were reported as occurring by key informants. Of these, 5574 (58%) focused on increasing physical activity, 2596 (27%) on improving nutrition and 1511 (16%) on both behaviours. The mean number of CPPs per community was 74.0, with a range of 25 to 295 across all communities. Most CPPs occurred more than once (63%) and on average lasted 6.1 years. The greatest number of reported CPPs occurred in school settings (44%). Conclusions Communities showed a wide range of investment in the amount of CPPs occurring in settings that affect opportunities for children to engage in physical activity and healthy nutrition. The pattern of implementation of CPPs showed variation over time, with an increase in more recent years. This observational study provides new and valuable information about what US communities are doing to prevent childhood obesity.

BACKGROUND Our objective was to examine the association between school wellness committees and implementation of nutrition wellness policies and children's weight status and obesity-related dietary outcomes. METHODS A cross-sectional study was conducted of 4790 children aged 4-15 years recruited from 130 communities in the Healthy Communities Study. Multilevel statistical models assessed associations between school wellness policies and anthropometric (body mass index z-score [BMIz]) and nutrition measures, adjusting for child and community-level covariates. RESULTS Children had lower BMI z-scores (-0.11, 95% confidence interval [CI]: -0.19, -0.03) and ate breakfast more frequently (0.14 days/week, 95% CI: 0.02-0.25) if attending a school with a wellness committee that met once or more in the past year compared to attending a school with a wellness committee that did not meet/did not exist. Children had lower added sugar (p < .0001), lower energy-dense foods (p = .0004), lower sugar intake from sugar-sweetened beverages (p = .0002), and lower dairy consumption (p = .001) if attending a school with similar or stronger implementation of the nutrition components of the school wellness policies compared to other schools in the district. CONCLUSIONS A more active wellness committee was associated with lower BMI z-scores in US schoolchildren. Active school engagement in wellness policy implementation appears to play a positive role in efforts to reduce childhood obesity.

Background The influence of community characteristics on the effectiveness of childhood obesity prevention efforts is not well understood. Objective Examine the interaction of community characteristics with the relationship between community programmes and policies (CPPs) and dietary intake. Methods An observational study of 5138 children in grades K-8 in 130 US communities was conducted in 2013-2015. Key informant interviews identified and characterized CPPs. CPP scores were generated for the number of target behaviours (CPP-Behav) and the number of behaviour change strategies (CPP-Strat) addressed by all CPPs and CPPs with nutrition goals over the prior 6 years in each community. Dietary intake was assessed by dietary screener and included intake of sugar from sugar-sweetened beverages; energy-dense foods; fruits and vegetables; whole grains; and fibre. Multivariate statistical models assessed the interactions between US region, urbanicity, community-level income, and community-level race/ethnicity and CPP scores in relation to dietary intake. Results CPP-Strat was positively associated with healthier dietary intakes in the Northeast and West, and in high Hispanic communities; the reverse was true in the South, and in high African-American and low-income communities. The CPP-Behav was positively associated with healthier dietary intakes in the South and rural areas, and the reverse was true in the West. Conclusion The relationships between CPP index scores and dietary intake were most strongly influenced by region and urbanicity and to a lesser extent by community-level race/ethnicity and income. Findings suggest that different considerations may be needed for childhood obesity prevention efforts in communities with different characteristics.

BACKGROUND Rational planning of community policies and programs (CPPs) to prevent obesity requires an understanding of CPP objectives associated with dietary behaviours. OBJECTIVE The objective of the study is to identify objectives of CPPs associated with healthful dietary behaviours. METHODS An observational study identified 4026 nutrition CPPs occurring in 130 communities in the prior 6 years. Dietary intakes of fruits and vegetables, added sugar and sugar-sweetened beverages, among others, were reported among 5138 children 4-15 years of age from the communities, using a Dietary Screener Questionnaire with children age 9 years and older (parent assisted) or parent proxies for younger children. CPPs were documented through key informant interviews and characterized by their intensity, count, and objectives including target dietary behaviour and food environment change strategy. Associations between dietary intakes and CPP objectives were assessed using hierarchical statistical models. RESULTS CPPs with the highest intensity scores that targeted fast food or fat intake or provided smaller portions were associated with greater fruit and vegetable intake (0.21, 0.19, 0.23 cup equivalents/day respectively with p values

BACKGROUND Although a national epidemic of childhood obesity is apparent, how community-based programmes and policies (CPPs) affect this outcome is not well understood. OBJECTIVES This study examined the longitudinal relationship between the intensity of CPPs in 130 communities over 10 years and body mass index (BMI) of resident children. We also examined whether these relationships differ by key family or community characteristics. METHODS Five thousand one hundred thirty-eight children in grades K-8 were recruited through 436 schools located within 130 diverse US communities. Measures of height, weight, nutrition, physical activity and behavioural and demographic family characteristics were obtained during in-home visits. A subsample of families consented to medical record review; these weight and height measures were used to calculate BMI over time for 3227 children. A total of 9681 CPPs were reported during structured interviews of 1421 community key informants, and used to calculate a time series of CPP intensity scores within each community over the previous decade. Linear mixed effect models were used to assess longitudinal relationships between childhood BMI and CPP intensity. RESULTS An average BMI difference of 1.4 kg/m2 (p-value

Food insecurity among college students has become a public health concern, yet few studies have examined the sample prevalence in a statewide public university system. We determined the sample prev...

Background Within the context of high childhood obesity prevalence, there is a concern that community efforts intended to reduce childhood obesity may lead to unintended adverse outcomes. Objective This analysis examined relationships between community programs, policies, and environmental changes (CPPs) for obesity prevention with unhealthy dieting behaviours and body weight satisfaction in children. Methods Using the Healthy Communities Study 2013 to 2015 survey sample of 5138 US children aged 4 to 15 years old, multilevel models examined associations between standardized CPP intensity scores and child dieting behaviours and weight satisfaction, adjusting for community and child-level covariates and clustered study design. Results In fully adjusted models, higher total, physical activity, and nutrition CPP intensity scores were associated with lower odds of dissatisfaction with weight (1 year total CPP odds ratio [OR]: 0.41, 95% confidence interval [CI], 0.22-0.73; 6 year total CPP OR: 0.48, 0.29-0.80). Higher physical activity CPP intensity over the past year was associated with greater odds of weight satisfaction (OR: 1.77, 95% CI, 1.10-2.84). No associations were observed with dieting behaviours. Conclusions Results suggest that community efforts focusing on nutrition and physical activity to prevent childhood obesity may be associated with weight satisfaction and not with unhealthy dieting behaviours.

Background A dietary screener questionnaire (DSQ) was used to assess dietary outcomes among children in the Healthy Communities Study (HCS), a study of the relationships between programs and policies to prevent child obesity and child diet, physical activity and weight outcomes. Methods To compare dietary intake estimates derived from the DSQ against those from the Automated Self-Administered 24-Hour Recalls for Children (ASA24-Kids) among children, a measurement error model, using structural equation modelling, was utilized to estimate slopes, deattenuated correlation coefficients, and attenuation factors by age and sex, ethnicity, and BMI status. Participants/setting A randomly selected sub-sample of HCS participants aged 4–15 years in 130 communities throughout the U.S. who completed the DSQ and up to two ASA24-Kids recalls (n = 656;13% of HCS participants). Results For most nutrient/foods examined, the DSQ yielded larger mean intake estimates than the ASA24-Kids, and agreement between the two measures varied by food/nutrient, age and sex, ethnicity, and BMI category. Deattenuated correlation coefficients of 0.4 or greater were observed for added sugars from SSBs (0.54), fruits and vegetables (0.40), and dairy foods (0.50). Lower deattenuated correlation coefficients were seen for total added sugars (0.37), whole grains (0.34), and fiber (0.34). Attenuation factors were most severe for total added sugars intake among overweight children, and for several other dietary outcomes among children aged 9–11 years. Conclusions The DSQ was found to be a tool with acceptable agreement with the ASA24-Kids for measuring multiple dietary outcomes of interest in the HCS, although there may be potential due to measurement error to underestimate results (bias towards the null). In future studies, measurement error modelling and regression calibration may be possible solutions to correct for bias due to measurement error in most food/nutrient intake estimates from the DSQ when used among children. Electronic supplementary material The online version of this article (10.1186/s12937-018-0415-1) contains supplementary material, which is available to authorized users.

Objective To explore California local health department leaders’ experiences planning, implementing, and evaluating nutrition promotion and obesity prevention programs for low-income families. Design Qualitative, cross-sectional study using semi-structured in-depth interviews and panel interviews conducted in 2015–2016. Setting California local health departments (LHDs) funded by the California Department of Public Health to implement Supplemental Nutrition Assistance Program–Education (SNAP-Ed). Participants The authors recruited SNAP-Ed leaders from all 58 California LHDs implementing SNAP-Ed. Leaders from 49 LHDs participated: 36 in hour-long, in-depth interviews and 13 in 1 of 3 90-minute group panel interviews. Phenomenon of Interest Processes, facilitators, and barriers connected to delivering SNAP-Ed reported by leaders in planning, implementing, and evaluating local programs. Analysis Interviews were transcribed, coded, and analyzed using Dedoose software. Results Leaders grappled with introducing, implementing, and integrating policy, systems, and environmental change interventions (PSEs). Information used to make planning decisions varied widely across LHDs. Partnership with nontraditional organizations was described as a resource- intensive, nonlinear process with recognized potential for benefit. Rural programs reported specific and different experiences compared with their urban counterparts. Conclusions and Implications Implementing new, complex interventions to improve diet and activity environments and behaviors is both exciting and challenging for local leaders. They expressed a desire for additional resources and capacity building to facilitate success, particularly related to policy, systems, and environmental change programs. Attention to the specific needs of rural counties is needed.

Food policy councils (FPCs) are collaboratives that work to strengthen food systems. Over 300 FPCs exist in the United States, Canada, and Tribal Nations. In 2015, we surveyed the types of initia­tives FPCs undertook and identified food sector targets and domains of potential impact in an effort to inform comprehensive FPC impact assessments. FPCs (N=66) reported 317 policy, systems, and environmental initiatives. At least half of these were focused on food production, and many were focused on institutional food service and the food assistance sectors. Commercial food service, food processing, and food waste were less often the focus. Potential impacts of their initia­tives were classified into six domains: supporting resilient food systems (235, 74%); increasing access to healthy foods (171, 54%); supporting economic development (115, 36%); promoting equity in the food system (94, 30%); promoting environmental sustainability (82, 26%); and increasing knowledge of or demand for healthy foods (27, 9%). Many initiatives were likely to impact multiple domains.

Multifaceted community interventions directed at improving food environments are emerging, but their impact on dietary change and obesity prevalence has not been adequately documented. The Healthy Communities Study (HCS) is seeking to identify characteristics and combinations of programs and policies that are associated with children's diets and obesity-related outcomes in various types of communities across the U.S. The purpose of this paper is to describe the methods used in 2013-2015 in the HCS to assess dietary intake, school nutrition environments, and other nutrition-related behaviors. The conceptual framework of the HCS is based on the socioecological model and behaviors shown in previous studies to be related to obesity in children guided selection of domains. Nine domains were identified as essential measures of nutrition in the HCS: (1) intake of selected foods and beverages; (2) food patterns and behaviors; (3) social support; (4) home environment; (5) school environment; (6) community environment; (7) breastfeeding history; (8) household food insecurity; and (9) dieting behaviors and body image. Children's dietary intake was assessed using a dietary screener and up to two automated 24-hour recalls. Dietary-related behaviors were assessed by a survey administered to the parent, child, or both, depending on child age. School nutrition measures were obtained from a combination of school staff surveys and researcher observations. Information from these measures is expected to contribute to a better understanding of "what is working" to improve the dietary behaviors that are likely to prevent obesity and improve health in children.

Background Studies of potential adverse effects of traffic related air pollution (TRAP) on allergic disease have had mixed findings. Nutritional studies to examine whether fish oil supplementation may protect against development of allergic disease through their anti-inflammatory actions have also had mixed findings. Extremely few studies to date have considered whether air pollution and dietary factors such as fish oil intake may interact, which was the rationale for this study. Methods We conducted a secondary analysis of the Childhood Asthma Prevention Study (CAPS) birth cohort, where children were randomised to fish oil supplementation or placebo from early life to age 5 years. We examined interactions between supplementation and TRAP (using weighted road density at place of residence as our measure of traffic related air pollution exposure) with allergic disease and lung function outcomes at age 5 and 8 years. Results Outcome information was available on approximately 400 children (~ 70% of the original birth cohort). Statistically significant interactions between fish oil supplementation and TRAP were seen for house dust mite (HDM), inhalant and all-allergen skin prick tests (SPTs) and for HDM-specific interleukin-5 response at age 5. Adjusting for relevant confounders, relative risks (RRs) for positive HDM SPT were RR 1.74 (95% CI 1.22–2.48) per 100 m local road or 33.3 m of motorway within 50 m of the home for those randomised to the control group and 1.03 (0.76–1.41) for those randomised to receive the fish oil supplement. The risk differential was highest in an analysis restricted to those who did not change address between ages 5 and 8 years. In this sub-group, supplementation also protected against the effect of traffic exposure on pre-bronchodilator FEV1/FVC ratio. Conclusions Results suggest that fish oil supplementation may protect against pro-allergic sensitisation effects of TRAP exposure. Strengths of this analysis are that supplementation was randomised and independent of TRAP exposure, however, findings need to be confirmed in a larger experimental study with the interaction investigated as a primary hypothesis, potentially also exploring epigenetic mechanisms. More generally, studies of adverse health effects of air pollution may benefit from considering potential effect modification by diet and other factors. Trial registration Australia New Zealand Clinical Trial Registry. www.anzctr.org.au Registration: ACTRN12605000042640, Date: 26th July 2005. Retrospectively registered, trial commenced prior to registry availability. Electronic supplementary material The online version of this article (10.1186/s12940-018-0370-5) contains supplementary material, which is available to authorized users.

BackgroundThe impact of community-based obesity prevention efforts on child nutrition has not been adequately studied.ObjectiveExamine relationships between number, type and intensity of community programs and policies (CPPs) and child nutrition.MethodsAn observational study of 5138 children (grades K-8) in 130 U.S. communities was conducted in 2013-2015. CPPs were identified by 10-14 key informant interviews per community. CPPs were characterized based on: count, intensity, number of different strategies used and number of different behaviours targeted. Scores for the prior 6years were calculated separately for CPPs that addressed primarily nutrition, primarily physical activity (PA) or total combined. Child intakes were calculated from a dietary screener and dietary behaviours were based on survey responses. Multi-level statistical models assessed associations between CPP indices and nutrition measures, adjusting for child and community-level covariates.ResultsImplementing more types of strategies across all CPPs was related to lower intakes of total added sugar (when CPPs addressed primarily PA), sugar-sweetened beverages (for nutrition and PA CPPs) and energy-dense foods of minimal nutritional value (for total CPPs). Addressing more behaviours was related to higher intakes of fruit and vegetables (for nutrition and total CPPs) and fibre (total CPPs). Higher count and intensity (PA and total CPPs) were related to more consumption of lower fat compared with higher fat milk. A higher count (PA CPPs) was related to fewer energy-dense foods and whole grains. No other relationships were significant at P&nbsp

Consumption of oily fish more than once per week has been shown to improve cognitive outcomes in children. However, it is unknown whether similar benefits can be achieved by long-term omega-3 fatty acid supplementation. The objective was to investigate the effect of omega-3 fatty acid supplementation during the first 5 years of life on subsequent academic performance in children by conducting a secondary analysis of the CAPS (Childhood Asthma Prevention Study).A total of 616 infants with a family history of asthma were randomised to receive tuna fish oil (high in long-chain omega-3 fatty acids, active) or Sunola oil (low in omega-3 fatty acids, control) from the time breastfeeding ceased or at the age of 6 months until the age of 5 years. Academic performance was measured by a nationally standardised assessment of literacy and numeracy (National Assessment Program Literacy and Numeracy (NAPLAN)) in school years 3, 5, 7 and 9. Plasma omega-3 fatty acid levels were measured at regular intervals until 8 years of age. Between-group differences in test scores, adjusted for maternal age, birth weight and maternal education, were estimated using mixed-model regression.Among 239 children, there were no significant differences in NAPLAN scores between active and control groups. However, at 8 years, the proportion of omega-3 fatty acid in plasma was positively associated with the NAPLAN score (0.13 s.d. unit increase in score per 1% absolute increase in plasma omega-3 fatty acid (95% CI 0.03, 0.23)).Our findings do not support the practice of supplementing omega-3 fatty acids in the diet of young children to improve academic outcomes. Further exploration is needed to understand the association between plasma omega-3 fatty acid levels at 8 years and academic performance.

Objective Early life is an important period for determining future risk of cardiovascular disease. Carotid extra-medial thickness is a novel noninvasive measure that estimates arterial adventitial thickness, information concerning vascular health not captured by assessment of arterial intima-media thickness alone. We sought to determine whether fetal growth and early postnatal growth are associated with carotid extra-medial thickness in 8 year old children. Methods Carotid extra-medial thickness was assessed by high-resolution ultrasound in 379 non-diabetic children aged 8-years, with complete data for birth weight, gestational age, early postnatal weight gain and carotid extra-medial thickness. Results Weight gain during infancy, from birth to 18 months of age, was significantly and positively associated with carotid EMT (11 μm per kg length-adjusted weight gain [95% CI 3, 18], P = 0.007). This association was significantly stronger in boys than girls ( P heterogeneity = 0.005). By contrast, there was no significant association between birth weight and carotid EMT (6 μm/kg birth weight [95% CI −12, 24], P = 0.51). Conclusion Excessive weight gain during infancy is associated with increased carotid extra-medial thickness, indicating that the alterations to the vasculature associated with excessive early postnatal growth likely include arterial adventitial thickening.

Four decades ago, the nation was shocked to learn of the extent of hunger in a land and time of prosperity and opportunity.1 Concern arising from this national inquiry led to an expansion of federa...

The study objective was to examine trends in the nutritional quality of emergency foods. Inventory data were obtained from 6 California food banks for 2007 to 2010. We found a substantial increase over this period in fresh fruit and vegetable donations, which, by 2010, comprised over half of the weight of total inventory. Opportunities for further improvements in the nutritional quality of food bank inventory were identified. Over half of the vegetables obtained by food banks were less nutrient-dense varieties. Though snack foods and sugar-sweetened beverages contributed a small percentage of the total inventory weight, they contributed substantial calories. Improvements needed in inventory monitoring are discussed in light of recent interest in nutrition policies among food banks.

A nonprofit policy advocacy organization and an academic research center convened a one-day meeting of 20 key stakeholders from the emergency food network (EFN) to develop policy and practice recommendations that were vltimately crafted by the advocate-researcher team and aimed at improving the nutritional quality of emergency food. The convening was informed by recent studies of food bank inventory trends and aspects of food bank culture, capacity, and practices relating to nutrition. Recommendations were developed to establish nutrition standards for government-sourced emergency food and to review tax benefits for commercial food donations. Recommendations were also developed for EFN agencies to establish organizational nutrition guidelines, adopt metrics that incorporate the nutritional quality of distributed food, and advocate improvements to federal safety net programs.

A national online survey of 137 US food banks was conducted along with in-depth interviews with staff at 6 California food banks to assess the characteristics of their organizational culture, including the extent to which they focused on nutritional quality of emergency food. The majority of US food banks reported a substantial level of commitment to nutrition. Only a minority has written formal nutrition policies, but several California food bankers were in the process of developing policies. US food banks most often reported seeking to increase fresh produce; fewer reported deliberate efforts to increase low-fat dairy, lean meats, or whole grains or to reduce unhealthful foods. California food banks revealed that they have significantly expanded their capacity to respond to increased produce donations, yet there are still substantial limitations to be addressed in procuring, handling, and monitoring the quantity of more nutritious foods. Organizational practices commensurate with a nutrition policy are ...

OBJECTIVE: We hypothesized that early weight gain would be associated with incident obesity, higher blood pressure, systemic inflammation, and arterial wall thickening in later childhood. METHODS: A longitudinal birth cohort was recruited antenatally from 2 maternity hospitals in Sydney, Australia, between September 1997 and December 1999. Three hundred ninety-five nondiabetic children who were followed to age 8 years had complete data for early weight gain and arterial wall thickness. RESULTS: Independent predictors of excess early weight gain (age 0–18 months; adjusted for height gain) included male gender (0.411 kg [SE: 0.103], P < .001), fewer weeks’ gestation (−0.121 kg [SE: 0.044] per week, P = .006), birth length (0.156 kg [SE: 0.024] per cm, P < .001), and failure to breastfeed to 6 months of age (0.498 kg [SE: 0.108], P < .001). Early height-adjusted weight gain was significantly associated with later childhood overweight (odds ratio [OR]: 1.67 [95% confidence interval (CI): 1.26 to 2.20] per kg) and obesity (OR: 2.07 [95% CI: 1.53 to 2.79] per kg), excess central adiposity (OR: 1.54 [95% CI: 1.20 to 1.98] per kg), higher systolic blood pressure (1.24 mm Hg [SE: 0.33] per kg, P < .001), higher C-reactive protein (0.17 mg/dL [SE: 0.06] per 100% increase in weight gain, P = .006), and greater carotid intima-media thickness (0.012 mm [SE: 0.004] per kg, P = .002). CONCLUSIONS: Early postnatal weight gain from birth to age 18 months is significantly associated with later childhood overweight and obesity, excess central adiposity, and greater arterial wall thickness.

Less than 11% of young school-aged children eat the recommended amounts of fruits and vegetables, despite abundant evidence that these foods protect against many types of cancer, heart disease and diabetes, and when combined with other dietary changes can help protect against obesity. In 2005, California became the first state to address the availability of fresh and local produce in the federal School Breakfast Program through state funding. The California Fresh Start Program doubled the number of different fresh fruits offered to students. With the greater variety, the number of fresh fruit servings taken by students in the Fresh Start pilot program more than doubled. Evaluation of the program revealed many lessons, which are especially important now, as schools across the country prepare to increase the number of fruits and vegetables offered in the School Breakfast Program by or before July 2014 as mandated by the Healthy, Hunger-Free Kids Act.

Objective Structural modification of the arterial adventitia may be an early event in atherosclerosis. Carotid extra-medial thickness is a new measure of arterial adventitial thickness. We examined the association of cardiovascular risk factors with extra-medial thickness, in childhood. Methods Carotid extra-medial thickness was assessed by high-resolution ultrasound in 389 non-diabetic children aged 8-years. A non-fasting blood sample was collected from 314 participants. Associations of gender, age, lipoproteins, blood pressure, BMI z -score, waist:height ratio and parental history of early vascular disease, with extra-medial thickness were examined. Results Carotid extra-medial thickness was lower in girls ( r =−.163, P =.001) and directly associated with systolic ( r =.128, P =.009), diastolic blood pressure ( r =.130, P =.009), and height ( r =.170, P =.0006). These associations remained after adjustment for carotid intima-media thickness. In multivariable analysis including carotid intima-media thickness, only gender and height were significantly associated with carotid extra-medial thickness. In gender-stratified analysis, the strongest associations with extra-medial thickness were BMI z -score ( r =.181, P =.01), height ( r =.210, P =.003) and diastolic blood pressure ( r =.167, P =.02) for boys; and systolic blood pressure ( r =.153, P =.03) and parental history of premature cardiovascular disease ( r =.139, P =.05) for girls. The association of BMI z -score with extra-medial thickness differed by gender ( P -interaction=.04). Conclusions Carotid extra-medial thickness is independently associated with gender and height in childhood. Extra-medial thickness may provide important information concerning early arterial health, particularly related to the arterial adventitia.

Background: The effect of breastfeeding duration on subsequent asthma and allergy remains the subject of much controversy. Objective: To investigate whether differences in study design or disease-related exposure modification were the cause of the differences in study findings. Method: The data from two cohorts, the Childhood Asthma Prevention Study (CAPS) from Australia and the Barn Allergi Miljo Stockholm cohort from Sweden, which had reported different findings on the association between breastfeeding and asthma, were combined. For this analysis, the definitions for breastfeeding, asthma, and allergy were harmonized. Subjects were included if they had at least one parent with wheeze or asthma and had a gestational age of more than 36 wks (combined n = 882). The risk of disease-related exposure modification was assessed using survival analysis. Results: Breastfeeding reduced the risk of asthma at 4/5 and 8 yrs of age in children with a family history of asthma. The effect was stronger in the Swedish cohort. Breastfeeding had no effect on the prevalence of sensitization to inhaled allergens in this cohort with a family history of asthma but was a risk factor for sensitization to cow’s milk, peanuts, and eggs in the CAPS cohort at 4/5 yrs and in the combined cohort at 8 yrs. There was no evidence to support the existence of disease-related exposure modification in either cohort. Conclusion: These findings point to the importance of harmonization of features of study design, including subject selection criteria and variable definitions, in resolving epidemiological controversies such as those surrounding the impact of breastfeeding on asthma and allergic sensitization.

This study evaluated a calorie labeling intervention in Kaiser Permanente Hospital cafeterias. Three cafeteria conditions were no labeling; calorie and nutrient labeling on posters only; posters plus point-of-purchase menu board calorie labeling. More respondents noticed calorie information at poster plus menu board sites than at poster-only sites (P < 0.05). Over 80% of patrons supported provision of calorie information. There was a significant increase in purchases of lower calorie side dishes (P < 0.0001) and snacks (P = 0.006) at the menu board site, compared with the no-labeling site. These findings support the premise that menu labeling can be useful in worksite wellness initiatives.

This study examined food and beverage preferences of emergency food program (EFP) clients of the Food Bank of Central New York (Food Bank). Findings suggest that food pantry clients prefer to receive meat/poultry/fish, vegetables, and fruit over soda, candy, and snack foods. This new information supports the effort being made by the Food Bank to limit foods of minimal nutritional value while focusing on increasing distribution of donated and purchased fruits and vegetables. Limitations on the distribution of fresh fruits and vegetables in the emergency food program should be made on the basis of cost, availability, and infrastructure, rather than on the basis of perceived client or staff preferences to the contrary.

Programs to address obesity are a high priority for public policy especially for young children. Research into dietary determinants of obesity is challenging but important for rational planning of interventions to prevent obesity, given that both diet and energy expenditure influence weight status. We investigated whether early life dietary factors were predictive of weight status at 8 years in a cohort of Australian children.We used data from the Childhood Asthma Prevention Study-a birth cohort at high risk of asthma. Dietary data (3-day weighed food records) were collected at 18 months and height, weight and waist circumference were collected at 8 years. We assessed the relationship between dietary predictor variables and measures of adiposity using linear regression.Intakes of protein, meat and fruit at age 18 months were positively associated with measures of adiposity at age 8 years, namely, body mass index and/or waist circumference. We also showed a significant negative relationship between these measures of adiposity at 8 years and intake at 18 months of dairy foods as a percent of total energy, and intake of energy dense cereal-based foods such as cookies and crackers.This birth cohort study with rigorous design, measures and analyses, has shown a number of associations between early dietary intake and subsequent adiposity that contribute to the growing evidence base in this important field.

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.

Few longitudinal population-based cohort studies of older people have described dietary intakes over time. The objective of this study was to assess changes in the food and nutrient intake in a cohort of older Australians, using longitudinal data collected over 10 years. Population-based cohort of people aged 49 years and over at baseline (82% of those eligible) living in two postcode areas, west of Sydney. In 1992–1994, 3654 people were examined; 2334 were reexamined after 5 years and 1952 after 10 years (75% survivors at both examinations). A 145-item food frequency questionnaire was used to assess food and nutrient intake on each occasion, and 1166 participants provided usable dietary data at all three examinations. Energy and sugar intake significantly increased among women over the 10-year period (P-value for trend

Aim: To compare two systems which classify energy-dense, nutrient-poor ‘extra’ foods which can be used to monitor the contribution of these foods in the diets of Australian children. The aim is to develop consistent criteria that may be used to monitor trends in the consumption of ‘extra’ foods in dietary surveys and, for research purposes, to examine associations between ‘extra’ food consumption and weight gain. Methods: The intake of ‘extra’ foods was investigated among 2- to 18-year-old children (n = 3007) who participated in the 1995 National Nutrition Survey. Two classification systems were used, both based on the Australian Guide to Healthy Eating: a simple food grouping system, and a more complex system based on specific fat and sugar cut-points applied to food subgroups. Results: Both classification systems resulted in similar lists of commonly consumed ‘extra’ foods, and showed similar estimates for energy contribution from ‘extra’ foods, 41–42%, and similar, relatively low, contributions of micronutrients, 20–25%. Conclusion: A relatively simple food grouping classification system may be useful to estimate total energy and nutrient intake from ‘extra’ foods. However, for more detailed food-specific analyses, a food criteria system based on cut-points may be preferred. Nationally consistent criteria are needed for classifying ‘extra’ foods for both monitoring and research purposes, to enable comparisons of dietary data from surveys over time, and to investigate associations between ‘extra’ food consumption and nutrition outcomes such as weight gain and body mass index.

Objective To investigate the relationship between breastfeeding and snoring in childhood. Methods In a cohort of children with a family history of asthma who were recruited antenatally we prospectively recorded data on infant feeding practices throughout the first year of life. Snoring status and witnessed sleep apnea were measured at age 8 years by parent-completed questionnaire. Associations were estimated by logistic regression with, and without, adjustment for sets of confounders designed to exclude biasing effects. Results Habitual snoring was reported in 18.8% of the sample, and witnessed apnea in 2.7%. Any breastfeeding for longer than one month was associated with a reduced risk of habitual snoring at age 8 (adjusted OR 0.48, 95% CI 0.29 to 0.81) and duration of breastfeeding was inversely associated with the prevalence of habitual snoring (adjusted OR 0.79, 95% CI 0.62 to 1.00). Any breastfeeding for longer than 1 month was associated with a lower risk of witnessed sleep apnea (adjusted OR 0.17, 95% CI 0.04 to 0.71). The protective associations were not mediated by BMI, current asthma, atopy or rhinitis at age 8 years. Conclusions Breastfeeding for longer than one month decreases the risk of habitual snoring and witnessed apneas in this cohort of children with a family history of asthma. The underlying mechanism remains unclear but the finding would be consistent with a beneficial effect of the breast in the mouth on oropharyngeal development with consequent protection against upper airway dysfunction causing sleep-disordered breathing.

To examine the association between intake of dairy products and indicators of diet quality among a sample of Australian children.Three 24-hour recalls were collected from 222 children aged 8-10 years living in western Sydney. Analysis of covariance was used to examine differences in mean intakes of foods and nutrients among 3 dairy consumption groups (1 serve, 1-2 serves, ≥2 serves per day). The percentage of children meeting healthy eating guidelines for foods and estimated average requirements (EAR) for nutrients was also assessed.Higher dairy consumption was associated with higher intakes of energy, protein, calcium, phosphorus, magnesium, potassium, zinc, vitamin A, riboflavin, and niacin as well as foods from the bread and cereal group but lower intakes of mono- and polyunsaturated fats, foods from the meat and alternatives group, and energy-dense, nutrient-poor foods. Children who consumed ≥2 serves of dairy products per day (38%) were more likely to meet food and nutrient recommendations. Body mass index z-score and waist circumference were not associated with dairy consumption. Milk intake was inversely associated with the intake of sugar-sweetened beverages, and children who did not meet their minimum dairy serve recommendations consumed higher quantities of sugar-sweetened beverages than milk.Adequate dairy consumption was associated with diets of higher nutritional quality but also higher intakes of energy, suggesting a potential benefit from shifting consumption from regular-fat to reduced-fat dairy products in line with current national recommendations.

OBJECTIVES: Impaired fetal growth is an independent cardiovascular risk factor and is associated with arterial wall thickening in children. No preventive strategy has been identified. We sought to determine whether dietary omega-3 fatty acid supplementation during early childhood prevents the association between impaired fetal growth and carotid arterial wall thickening. METHODS: The Childhood Asthma Prevention Study was a randomized, controlled single-blind trial in 616 children born at term, recruited antenatally from maternity hospitals in Sydney. Participants were randomized to either a 500-mg-daily fish oil supplement and canola-based margarines and cooking oil (omega-3 group), or a 500-mg-daily sunflower oil supplement and omega-6 fatty acid–rich margarines and cooking oil (control group), from the start of bottle-feeding or 6 months of age until 5 years of age. Carotid intima-media thickness (IMT), a noninvasive measure of subclinical atherosclerosis, was the primary endpoint of a cardiovascular substudy (CardioCAPS) at age 8 years. We examined the association of fetal growth with carotid IMT in children with birth weight RESULTS: In the control group, fetal growth was inversely associated with carotid IMT, but this was prevented in the omega-3 group (difference between groups of 0.041 mm [95% confidence interval 0.006, 0.075] per kg birth weight, adjusted for gestational age and gender, Pheterogeneity = .02). CONCLUSIONS: The inverse association of fetal growth with arterial wall thickness in childhood can be prevented by dietary omega-3 fatty acid supplementation over the first 5 years of life.

It has been postulated that a higher dairy consumption may affect blood pressure regulation. The aim of this study was to examine the association between dairy consumption and blood pressure in mid-childhood.Subjects (n = 335) were participants of a birth cohort at high risk of asthma with information on diet at 18 months and blood pressure at 8 years. Multivariate analyses were used to assess the association of dairy consumption (serves) and micronutrient intakes (mg). In a subgroup of children (n = 201), dietary intake was also measured at approximately 9 years.Children in the highest quintile of dairy consumption at 18 months had lower systolic blood pressure (SBP) and diastolic blood pressure (DBP) at 8 years (2.5 mm Hg, P=0.046 and 1.9 mm Hg, P = 0.047, respectively) than those in the lowest quintiles. SBP was lowest among children in the highest quintiles of calcium, magnesium and potassium intakes. Significant negative linear trends were observed between SBP and intakes of dairy serves, calcium, magnesium and potassium. Furthermore, SBP and DBP were lowest in the group of children that consumed at least two dairy serves at both 18 months and the follow-up dietary data collection at 9 years, compared with all other children (SBP 98.7 vs 101.0 mm Hg, P = 0.07; and DBP 56.5 vs 59.3 mm Hg, P = 0.006, respectively).These results are consistent with a protective effect of dairy consumption in childhood on blood pressure at age 8 years.

The optimal method for conducting omega (n-)3 polyunsaturated fatty acid (PUFA) supplementation trials in children is unknown.To assess the impact of n-3 and n-6 PUFA intake from the background diet on plasma levels of n-3 and n-6 PUFA in children aged 0-3 years, with and without n-3 supplementation.Subjects were randomised antenatally to receive either n-3 PUFA supplements and low n-6 PUFA cooking oils and spreads or a control intervention, designed to maintain usual fatty acid intake. Dietary intake was assessed at 18 months by 3-day weighed food record and at 3 years by food frequency questionnaire. Plasma phospholipids were measured at both time points. Associations were tested by regression.N-3 PUFA intake from background diet did not significantly affect plasma n-3 levels. In contrast, n-6 PUFA intake in background diet was positively related to plasma n-6 levels in both study groups. In addition, n-6 PUFA intake from diet was negatively associated with plasma n-3 levels at 18 months and 3 years (-0.16%/g n-6 intake, 95%CI -0.29 to -0.03 and -0.05%/g n-6 intake, 95%CI -0.09 to -0.01, respectively) in the active group, but not in the control group.Interventions intending to increase plasma n-3 PUFA in children by n-3 supplementation should also minimise n-6 PUFA intake in the background diet.

To identify the types and quantities of ‘extra’ foods, or energy-dense, nutrient-poor foods, consumed by Australian adults, and assess their contribution to total energy and nutrient intakes. We used 24-h recall data from 10 851 adults, aged 19 years and over, who participated in the nationally representative 1995 National Nutrition Survey. ‘Extra’ foods were defined using principles outlined in the Australian Guide to Healthy Eating and by applying cut points for maximum amounts of fat and sugar within each food category. ‘Extra’ foods contributed to 36% of daily energy intake with the highest contributors being fried potatoes (2.8%), margarine (2.6%), cakes and muffins (2.5%), beer (2.4%), sugar-sweetened soft drinks (2.4%), and meat pies (2.2%). Both age and sex were important determinants of ‘extra’ foods intake; younger adults were more likely to consume sugar-sweetened soft drinks, fried potatoes, meat pies and savoury pastries, pizza, crisps, lollies and chocolate; whereas older adults were more likely to consume sweet and savoury biscuits, cakes and muffins, margarine and butter. In all age groups, ‘extra’ foods contributed more to energy intake for men than women. Overall, ‘extra’ foods contributed 16% protein, 41% total fat, 41% saturated fat, 47% sugar and approximately 20% of selected micronutrients to the diet. ‘Extra’ foods contribute excessively to the energy, fat and sugar intakes of Australian adults, while providing relatively few micronutrients. This is of concern for the increasing risk of overweight and chronic disease and poor micronutrient status.

Pediatric overweight has become the foremost public health issue for American youth. Rates of overweight (body mass index 95th percentile) for children and adolescents have increased more than for any other age group. Since the early 1970s, the prevalence of overweight has more than quadrupled among 6- to 11year-old children and more than tripled among 12- to 19-year-olds (1,2). A recent analysis of data on obesity prevalence in children from 1999 to 2006 shows that the rates appear to have peaked with nearly one in six of our nation’s children now overweight (body mass index 95th percentile) (3). Obesity crosses all ethnic and socioeconomic lines in the United States. No group—young or old, rich or poor— has escaped this epidemic. However, African Americans, Hispanics, and Native Americans are disproportionately more affected (2). Although many talk about the potential health consequences of obesity and the need for action, fewer are talking directly about the seriousness of behaviors that are at the heart of the problem. The issue of child overweight may serve as the canary in the coal mine, bringing attention to the state of our children’s diets. An examination of the diets of a nationally representative sample of children found that only 1% of children meet the dietary recommendations for the healthful core food groups (4,5) as set forth in the 1995 Dietary Guidelines for Americans (http://www.health.gov/dietaryguidelines/dga95/ default.htm). Yet with obesity on the rise, if children were simply eating too much of everything, including the healthful core food groups, many more would be meeting the dietary guideline recommendations for these foods. In that case, dietary change to prevent obesity would require a straightforward overall decrease in food intake. Instead, obesity is the outcome of poor food choices, not just generalized overconsumption of all foods. S o... wherein lies the problem? Which are the poor food choices that children and their parents (and the institutions that care for children) are making that contribute to the obesity epidemic? To answer this question, we need to examine the evidence linking dietary factors to adiposity.

To document dietary intakes and food sources of fatty acids among older Australians.Population-based survivor cohort.Two postcode areas in the Blue Mountains, West of Sydney, Australia.In 1997-9, 2334 people aged 55 years and over, participated in a 5-year follow-up of the cohort attending the Blue Mountains Eye Study (BMES). Dietary data were collected using a semi-quantitative food frequency questionnaire by 2005 persons (86% of those examined). Types of fats were classified as saturated fatty acids (SFA), monounsaturated (MUFA), polyunsaturated (PUFA) and trans unsaturated fatty acids.Mean total fat intake contributed 31.3% of daily energy intake (12.2% SFA, 11.2% MUFA, 5.0% PUFA). Mean omega 3 (n-3) PUFA intake comprised 0.5% of energy intake (long chain n-3 PUFA provided mean intake of 260mg, consisting of eicosapentaenoic (EPA), docosapentaenoic (DPA) and docosahexaenoic (DHA) fatty acids) and the n-6: n-3 PUFA ratio was 9:1. The main fatty acids contributing to the diet were palmitic acid, oleic acid and linoleic acid. Meat products were the highest contributors to total fat and MUFA intakes; milk products were the highest contributor to SFA intakes; and fat spreads and oils, and breads and cereals were the main food groups contributing to PUFA intakes. Fish was the main source of long chain n-3 fatty acids.This population-based descriptive study documents fatty acid intakes in a population of older Australians. It will serve as a basis for investigations of associations between dietary fatty acid intakes and a number of eye diseases.

Objective: To measure the types and quantities of energy-dense, nutrient-poor ‘extra’ foods consumed by Australian children and adolescents and their contribution to total energy and nutrient intakes. Design, setting and subjects: We used data from 3007 children, aged 2–18 years, who participated in the nationally representative 1995 National Nutrition Survey. Intake was determined by 24-h recall and ‘extra’ foods were defined using principles outlined in the Australian Guide to Healthy Eating (AGHE) and by applying cut points for maximum amounts of fat and sugar within each food category. Results: All children (99.8%) consumed at least one ‘extra’ food and the most commonly consumed were margarine, sugarsweetened soft drinks, cordials and sugar. ‘Extra’ foods contributed 41% of daily energy intake. Those foods contributing most to energy intake were fried potatoes (4.2%), sugar-sweetened soft drinks (3.3%), ice cream/ice confection (3.1%) and cordials (2.7%). Age and sex were important determinants of ‘extra’ food intake, with males and older children generally consuming more and different types of, ‘extra’ foods than females and younger children. ‘Extra’ foods contributed 19% protein, 47% total fat, 47% saturated fat, 54% sugar, and approximately 20–25% of selected micronutrients to the diet. Calcium and zinc intakes from core foods were below 70% of the recommended dietary intakes for adolescent girls. Conclusions: ‘Extra’ foods are over-consumed at two to four times the recommended limits and contribute excessively to the energy, fat and sugar intakes of Australian children, while providing relatively few micronutrients. This is of concern in terms of children’s weight and nutrient status. Sponsorship: DR was on placement at NSW Centre for Public Health Nutrition as part of the NSW Health Biostatistical Officer Trainee Program. European Journal of Clinical Nutrition advance online publication, 14 March 2007; doi:10.1038/sj.ejcn.1602720

This study evaluates the contribution of energy-dense, nutrient-poor 'extra' foods to the diets of 16-24-month-old children from western Sydney, Australia.An analysis of cross-sectional data collected on participants in the Childhood Asthma Prevention Study (CAPS), a randomised trial investigating the primary prevention of asthma from birth to 5 years. We collected 3-day weighed food records, calculated nutrient intakes, classified recorded foods into major food groups, and further classified foods as either 'core' or 'extras' according to the Australian Guide to Healthy Eating.Pregnant women, whose unborn child was at risk of developing asthma because of a family history, were recruited from all six hospitals in western Sydney, Australia. Data for this study were collected in clinic visits and at participants' homes at the 18-month assessment.Four hundred and twenty-nine children participating in the CAPS study; 80% of the total cohort.The mean consumption of 'extra' foods was approximately 150 g day(-1) and contributed 25-30% of the total energy, fat, carbohydrate and sodium to the diets of the study children. 'Extra' foods also contributed around 20% of fibre, 10% of protein and zinc, and about 5% of calcium. Children in the highest quintile of 'extra' foods intake had a slightly higher but not significantly different intake of energy from those in the lowest quintile. However, significant differences were evident for the percentage of energy provided by carbohydrate and sugars (higher) and protein and saturated fat (lower). The intake of most micronutrients was also significantly lower among children in the highest quintile of consumption. The intake of 'extra' foods was inversely associated with the intake of core foods.The high percentage of energy contributed by 'extra' foods and their negative association with nutrient density emphasise the need for dietary guidance for parents of children aged 1-2 years. These preliminary data on commonly consumed 'extra' foods and portion sizes may inform age-specific dietary assessment methods.

ith the New Year come those grand statements of good intent — to eat less and live longer. But resolving to eat less is a luxury reserved for affluent people. This New Year, most of the world’s population will still be seeking to increase their food supply. This is not a matter irrelevant to Australia: Harrison and colleagues (page 9) remind us that not all Australians have an abundant, affordable and continuous supply of food. 1 In their article, they report on a series of surveys — the Healthy Food Access Basket (HFAB) surveys — of selected food stores in Queensland. The surveys showed that, to meet their families’ basic food needs, Australian residents in very remote areas paid an average of about 30% ($114) more each fortnight than people living in cities. The price disparity was greater for basic, healthy food items than for “unhealthy” items such as takeaway food, soft drinks and tobacco. Moreover, at the time of the surveys, fewer of the basic healthy foods were available in remote stores than in city stores. Of particular concern were the higher increases in food prices over time in very remote areas — for example, between 2001 and 2004, the cost of the HFAB in very remote areas increased by 18% ($77.00), which was greater than the rise in the Consumer Price Index. Remote Australia is home to many Indigenous Australians. They are doubly disadvantaged, paying more for food and other essential goods, and having the lowest incomes of any population group. A detailed study of costs and incomes in a remote Indigenous community in South Australia found that basic living costs consumed up to 85% of family incomes, with food accounting for 35% of the total. 2 In contrast, Australians in general spend less than 20% of the family income on food. 3