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

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

BackgroundHispanics are a heterogeneous population with differences in the prevalence of cardiovascular disease (CVD) and its related risk factors among ethnic sub-groups. This study evaluated the association of genetic admixture and CVD in self-identified Hispanic women from the Women's Health Initiative (WHI).MethodsData came from the WHI Observational Study and the Clinical Trial Components conducted among postmenopausal women. The CVD outcomes included coronary heart disease (CHD) and stroke. The proportions of European (EUR), sub-Saharan African (AFR), and Amerindian (AMI) admixture were estimated using 92 ancestry-informative markers. Cox regression models were used to assess the relationship between genetic admixture and CVD adjusting for age, lifestyle risk factors, known risk factors, and neighborhood socioeconomic status.ResultsAmong 5195 participants EUR ancestry was associated with a lower CHD risk after adjusting for age (HR 0.41, p=0.02), and in the fully adjusted model (HR 0.40, p=0.03). AFR ancestry was associated with a higher CHD risk after adjusting for age (HR 2.91, p=0.03), but it only showed a trend in in the fully adjusted model (HR 2.46, p=0.10). AMI ancestry was not statistically significantly associated with CHD and none of the genetic admixture proportions were statistically significantly associated with stroke (p>0.05).ConclusionEUR ancestry was associated with a lower risk of CHD in Hispanic women. This highlights the need to account for genetic admixture in future CVD studies to consider different heritage groups to understand the role that genetic, neighborhood socioeconomic status, and environmental factors contribute to CVD health disparities in Hispanic women.

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

Objective: To examine associations between household food insecurity and children’s physical activity and sedentary behaviours. Design: Secondary analysis was conducted on the Healthy Communities Study, an observational study from 2013 to 2015. Household food insecurity was assessed by two items from the US Department of Agriculture’s 18-item US Household Food Security Survey Module. Physical activity was measured using the 7-d Physical Activity Behaviour Recall instrument. Data were analysed using multilevel statistical modelling. Setting: A total of 130 communities in the USA. Participants: In sum, 5138 US children aged 4–15 years. Results: No associations were found for the relationship between household food insecurity and child physical activity. A significant interaction between household food insecurity and child sex for sedentary behaviours was observed (P = 0·03). Conclusions: Additional research capturing a more detailed assessment of children’s experiences of food insecurity in relation to physical activity is warranted. Future studies may consider adopting qualitative study designs or utilising food insecurity measures that specifically target child-level food insecurity. Subsequent research may also seek to further explore sub-group analyses by sex.

BackgroundThe US Department of Agriculture granted waivers to allow flexibility in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) operations during the coronavirus disease 2019 (COVID-19) pandemic; however, research examining the associations between waiver introduction and changes in perceptions, practices, and challenges of WIC participants' and agency directors' experiences is limited.ObjectiveThe objective of this study was to assess California WIC participants' and agency directors' perceptions and practices of remote WIC services during the COVID-19 pandemic. A secondary aim was to understand other COVID-19 challenges related to maintaining access to healthy foods by WIC participants.DesignA qualitative study that included semistructured interviews was conducted between June 2020 and March2021.Participants and settingOne hundred eighty-two WIC participants with a child aged 0 to 5 years from three regions of California (Southern, Central, and Northern) and 22 local WIC agency directors across the state were interviewed.Main outcome measuresWIC participants' and agency directors' perceptions, practices, and other challenges during COVID-19.Statistical analyses performedInterviews were recorded, transcribed, and analyzed using a grounded theory approach.ResultsParticipants shared that they valued the information received from WIC and were very satisfied with remote WIC services. Participants reported that enrolling in WIC remotely was easier than coming in person. All waivers and changes to WIC operations, namely the physical presence, remote benefit issuance, and separation of duties waivers, and remote work and remote delivery of nutrition education, were largely viewed by WIC agency directors as options that should be continued postpandemic. Further, a majority (63%) of households reported experiencing food insecurity, and half of respondents received food from a food bank or pantry during the pandemic.ConclusionsFindings suggest WIC will attract and retain the most families by offering a hybrid model of services, incorporating both onsite services and remote options to work more efficiently and effectively.

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

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

OBJECTIVES: While it has been recommended that schools be the hub of efforts to improve child nutrition, research describing dimensions of U.S. school nutrition environments is limited. This study used exploratory factor analysis to estimate dimensions of school nutrition environments and examined their association with child anthropometric and dietary measures. METHODS: Cross-sectional analyses of 386 U.S. elementary and middle schools and 4635 children from the national Healthy Communities Study (2013–2015) was conducted. Three complementary instruments to assess the school nutrition environment were used to create 34 variables. Data were collected by observation and surveys. Factor analysis was done with orthogonal rotation. Mixed-effects regression models examined the multivariate-adjusted associations of dimensions of school nutrition environments with child anthropometric and dietary measures accounting for community and school variation. RESULTS: Six dimensions of school nutrition environments were derived: 1) nutrition education; 2) fruit and vegetable availability; 3) dining environment, including size and crowding; 4) school meal quality, including compliance with competitive food standards, amount of whole grains, and high fat foods; 5) school participation in state and federal nutrition programs; and 6) self-reported implementation of school wellness policies. Higher school meal quality was associated with lower added sugars intake (ß = –0.94, P

Child care has broad reach to young children. Yet, not all child care settings have nutrition standards for what and how foods and beverages should be served to infants as they transition to toddlerhood. The purpose of this paper is to describe the development of nutrition recommendations to guide feeding young children in licensed child care settings in the USA, a process that could be adapted in other countries. Nutrition standards were designed by nutrition and child care experts to address what and how to feed young children, also including the transition from infants to toddlers. Nutrition standards are important for health and can be feasibly implemented in child care settings. Feasibility considerations focused on family child care homes, which typically have fewer resources than child care centers or preschools. Infant standards include recommendations for vegetables, fruits, proteins, grains, and breast milk and other beverages. Also included are recommendations for supporting breastfeeding, introducing complementary foods, and promoting self-regulation in response to hunger and satiety. Toddler standards are expanded to address the frequency as well as types of food groups, and recommendations on beverages, sugar, sodium, and fat. Feeding practice recommendations include meal and snack frequency and style, as well as the promotion of self-regulation among older children.

Objective Assess alignment of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participant preferences with the National Academies of Sciences, Engineering, and Medicine WIC child food package recommendations and compare differences by race/ethnicity. Methods Cross-sectional examination of survey responses collected between January and May 2019 from 2,993 California WIC families with children aged 1–4 years. Results Over half of WIC participants (56.1%) wanted an increase in the amount allocated for fruits and vegetables. Many WIC participants (69.6%) thought the amount of juice offered by WIC was just right. Overall, the majority (91.0%) wanted to substitute more fruits and vegetables for juice. Most were satisfied with the amount of beans (78.4%), peanut butter (78.7%), and milk (88.3%). Preferences differed by race/ethnicity. Conclusions and Implications Preferences of California WIC participants are highly aligned with the proposed National Academies of Sciences, Engineering, and Medicine changes for increasing fruits and vegetables. Notable differences by race/ethnicity suggest the need for more flexibility.

Objective This study determined the extent to which schools adhered to select nutrition and wellness provisions of the 2010 Healthy, Hunger-Free Kids Act and examined differences by US region and school poverty level. Design Comparison of cross-sectional observational data from the Healthy Communities Study (2013–2015) by region and school poverty level. Participants A total of 401 US elementary and middle schools. Main Outcome Measures Adherence with federal nutrition standards for meals and competitive foods; extent of implementation of select aspects of school wellness policies. Analysis Descriptive statistics and multivariate regression were used. Differences were examined by school poverty level and region, adjusting for other school- and community-level covariates. Results Most schools reported meeting reimbursable school meal nutrition standards (74%); more schools in the West met nutrition standards (82%) than in the Midwest (64%). Most grains offered at lunch were whole grain–rich (82%), and most competitive foods complied with standards (78%) before they were required. Most schools had a wellness coordinator (80%). Lowest levels of adherence were reported for guidelines for classroom or school event foods. No differences were observed by school poverty level. Conclusions and Implications Findings suggest that Healthy Hunger-Free Kids Act provisions were feasible across a wide variety of schools, and schools successfully implemented reimbursable school meal nutrition standards regardless of school poverty level.

Child care has broad reach to young children. Yet, not all child care settings have nutrition standards for what and how foods and beverages should be served to infants as they transition to toddlerhood. The purpose of this paper is to describe the development of nutrition recommendations to guide feeding young children in licensed child care settings in the USA, a process that could be adapted in other countries. Nutrition standards were designed by nutrition and child care experts to address what and how to feed young children, also including the transition from infants to toddlers. Nutrition standards are important for health and can be feasibly implemented in child care settings. Feasibility considerations focused on family child care homes, which typically have fewer resources than child care centers or preschools. Infant standards include recommendations for vegetables, fruits, proteins, grains, and breast milk and other beverages. Also included are recommendations for supporting breastfeeding, introducing complementary foods, and promoting self-regulation in response to hunger and satiety. Toddler standards are expanded to address the frequency as well as types of food groups, and recommendations on beverages, sugar, sodium, and fat. Feeding practice recommendations include meal and snack frequency and style, as well as the promotion of self-regulation among older children.

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 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

Introduction Efforts to address the critical public health problem of childhood obesity are occurring across the USA; however, little is known about how to characterize the intensity of these efforts. Objectives The purposes of this study are to describe the intensity of community programs and policies (CPPs) to address childhood obesity in 130 US communities and to examine the extent to which observed CPPs targeted multiple behaviours and employed a comprehensive array of strategies. Methods To document CPPs occurring over a 10-year period, key informants were interviewed using a semi-structured interview protocol. Staff coded CPPs for key characteristics related to intensity, including reach, duration and strategy. Three types of CPP scores were calculated for intensity of CPPs, targeting of CPPs towards multiple behaviours and strategies used. Results Nine thousand six hundred eighty-one CPPs were identified. On average, communities had 74 different CPPs in place (standard deviation 30), with variation in documented CPPs (range 25-295). Most communities experienced a steady, modest increase in intensity scores over 10 years. CPP targeting scores suggested that communities expanded the focus of their efforts over time to include more behaviours and strategies. Conclusions Findings of this large-scale study indicate that great variation exists across communities in the intensity and focus of community interventions being implemented to address childhood obesity.

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

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

Background Limited research exists on the relationship between food insecurity and children's adiposity and diet and how it varies by demographic characteristics in the United States. Objective The aim of this study was to assess the relationship between household food insecurity and child adiposity-related outcomes, measured as BMI (kg/m2) z score (BMI-z), weight status, and waist circumference, and diet outcomes, and examined if the associations differ by age, sex, and race/ethnicity. Methods Data collected in 2013-2015 from 5138 US schoolchildren ages 4-15 y from 130 communities in the cross-sectional Healthy Communities Study were analyzed. Household food insecurity was self-reported using a validated 2-item screener. Dietary intake was assessed using the 26-item National Cancer Institute's Dietary Screener Questionnaire, and dietary behaviors were assessed using a household survey. Data were analyzed using multilevel statistical models, including tests for interaction by age, sex, and race/ethnicity. Results Children from food-insecure households had higher BMI-z (β: 0.14; 95% CI: 0.06, 0.21), waist circumference (β: 0.91 cm; 95% CI: 0.18, 1.63), odds of being overweight or obese (OR: 1.17; 95% CI: 1.02, 1.34), consumed more sugar from sugar-sweetened beverages (β: 1.44 g/d; 95% CI: 0.35, 2.54), and less frequently ate breakfast (β: -0.28 d/wk; 95% CI: -0.39, -0.17) and dinner with family (β: -0.22 d/wk; 95% CI: -0.37, -0.06) compared to children from food-secure households. When examined by age groups (4-9 and 10-15 y), significant relationships were observed only for older children. There were no significant interactions by sex or race/ethnicity. Conclusions Household food insecurity was associated with higher child adiposity-related outcomes and several nutrition behaviors, particularly among older children, 10-15 y old.

OBJECTIVES: This study assesses the relationship between household food insecurity and adiposity, measured as BMI-for-age z-score (BMI-z), overweight/obesity, and waist circumference, as well as dietary intake and diet-related behaviors in US children. METHODS: A total of 5138 US schoolchildren ages 4–15 years from 130 communities in the cross-sectional Healthy Communities Study were included in this analysis. Household food insecurity was self-reported using a validated 2-item screener. Dietary intake was assessed using National Cancer Institute's (NCI) Dietary Screener Questionnaire (DSQ), a 26-item food frequency questionnaire, and dietary behaviors were assessed during a household survey. Data were analyzed using multilevel statistical models, including interaction tests for age, sex, and race/ethnicity. RESULTS: Food insecure children had a BMI z-score of 0.14 higher (95% CI: 0.06, 0.21) and a waist circumference of 0.91 cm higher (95% CI: 0.18, 1.63) than food secure children. Food insecure children have 1.17 times the odds of being overweight/obesity compared with food secure children (95% CI: 1.02, 1.34). There was no significant interaction by sex or race/ethnicity. Food insecure children consumed more sugar from sugar sweetened beverages (0.36 tsp/day; 95% CI: 0.09, 0.63), and ate breakfast (−0.28 days/week; 95% CI: −0.39, −0.17) and together with family (−0.22 days/week; 95% CI: −0.37, −0.06) less frequently compared to food secure children. CONCLUSIONS: The present study found a significant, positive association between household food insecurity and child adiposity for children ages 10–15 years, as well as for several dietary intake and diet-related behaviors. This research helps disentangle the complex picture of food insecurity as a contributor to childhood obesity and poorer dietary outcomes in diverse populations. FUNDING SOURCES: Research was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL131630. The authors would also like to acknowledge the Global Food Initiative at the University of California Office of the President for their support of this project.

OBJECTIVES: This study examined how duration of participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is associated with dietary quality at age 24 months using Healthy Eating Index-2015 (HEI-2015) scores. METHODS: Data from the WIC Infant and Toddler Feeding Practices Study-2 (WIC ITFPS-2), a longitudinal study on WIC caregivers and their children, was used to examine WIC participation and diet quality. A weighted sample of 407,416 caregivers (unweighted = 1,349) from 80 WIC sites nationwide was included. Duration of WIC participation reflects the number of interviews during which caregivers responded that they were receiving WIC benefits (9 interviews occurred between 3 and 24 months). Responses were categorized into low (

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

Background Despite the important implications of childhood dietary intakes on lifelong eating habits and health, data are lacking on the diet quality of low-income infants and toddlers. Objective The objective of this study was to characterize diet quality in low-income US infants and toddlers. Methods A national observational study was conducted of 7- to 12-mo-old (n = 1261), 13-mo-old (n = 2515), and 24-mo-old (n = 2179) children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) prenatally/at birth from 2013 to 2016. The study used a 24-h dietary recall and survey questions. For 7- to 12-mo-olds, an adapted Complementary Feeding Utility Index (CFUI) was used, and for 13- and 24-mo-olds, the Healthy Eating Index-2015 (HEI-2015) was used. Descriptive statistics were calculated for CFUI and HEI-2015 scores. Results For 7- to 12-mo-olds, the CFUI score (mean ± SE) was 0.56 ± 0.003 (range: 0.34-0.90, maximum possible 1.0). Most children met CFUI standards for exposure to iron-rich cereal (86.7%), and low exposure to energy-dense nutrient-poor foods (72.2%) and teas/broths (67.5%). Conversely, at 7-12 mo of age, exposure was low for vegetables (7.0%), fruits (14.4%), any sugary drinks (14.0%), and 12-mo breastfeeding duration (23.8%). At 13 and 24 mo of age, the HEI-2015 total score (maximum possible 100), on average, was 64.0. At both 13 and 24 mo of age, participants achieved, on average, maximal HEI-2015 component scores for total and whole fruits and dairy; however, scores for total vegetables, greens and beans, whole grains, seafood and plant proteins, fatty acids, and saturated fats were relatively low. Scores for refined grains, sodium, and added sugar were lower at 24 than at 13 mo of age, representing higher consumption, on average, over time. Conclusions Although findings demonstrate that young children are doing well on some dietary components, there is room for improvement, especially as children age. Findings may be used to inform the Pregnancy and Birth to 24-mo (P/B-24) Project. This trial was registered at clinicaltrials.gov as NCT02031978.

Background Food insecurity is associated with poor diet and obesity among adult women, but evidence among children is mixed, and few studies have examined differences between boys and girls. Objective This study examined the relationship between self-reported food insecurity and dietary intake among boys and girls. Design Cross-sectional survey data were used from the Children’s PowerPlay! Campaign evaluation. Participants and setting In all, 3,547 fourth- and fifth-grade students (9 to 11 years old) from 44 San Diego-area elementary schools in 2012 completed diary-assisted 24-hour recalls and a questionnaire that included five questions from the Child Food Security Assessment. Main outcome measures Individual dietary components (including total energy, nutrients, and sugar-sweetened beverages), Healthy Eating Index-2010 scores, and meal patterns (such as meal sizes and missed meals) were derived from 24-hour recalls. Statistical analyses Multivariable linear and logistic regression models were used to estimate the relationships between food insecurity and diet characteristics. Results Girls with the highest food insecurity consumed 135 total kilocalories (P Conclusions Food insecurity among girls in grades 4 and 5 was associated with higher energy intake. Findings support the need for further research to better understand the nature of this relationship and its implications for energy balance.

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

INTRODUCTON Studies have identified geographic variation in overweight and obesity rates among children, with higher rates of overweight and obesity often found among children living in rural compared to urban areas. A small number of studies have explored differences in overweight and obesity based on more nuanced gradations along the urban-rural continuum. The purpose of the present study was to identify differences in overweight and obesity based on gradations along the urban-rural continuum among children in 42 Californian counties with populations less than 500 000. METHODS An observational study was conducted using FITNESSGRAM data collected from 5th, 7th and 9th grade students in public schools in California during 2010-2011. The FITNESSGRAM dataset was merged with the 2011 Public Elementary/Secondary School Universe Survey Data from the National Center for Educational Statistics Common Core of Data, which includes an 'urban-centric locale' code for each school, consisting of four broad classifications - city, suburb, town, and rural - each of which is further broken down into three subcategories. Multivariate analyses using a general linear model were conducted to compare differences in body mass index (BMI) between geographic regions of schools (city, suburb, town and rural) as well as 11 urban-centric locale code subcategories; none of the schools were located in large cities. The percentage of students who were overweight and/or obese was compared by grade level, gender, and race/ethnicity across geographic regions using multivariate logistic regression models. Analyses were adjusted for student age, grade, gender, race/ethnicity (African-American, Asian, Hispanic, Indian/Alaskan, White, two or more races or unknown), eligibility for free or reduced price meals, and clustering of students by school. When a stratified analysis was done, the variable of stratification (ie grade, gender, race/ethnicity) was not included among the covariates. When significant differences in BMI or prevalence of overweight or obesity were found between geographic regions, Tukey's method was applied to adjust for multiple comparisons at a 5% procedure-wise error rate. A p-value at or less than 0.05 was used to indicate statistical significance. RESULTS Students in suburban schools had significantly lower mean BMI and lower prevalence of overweight than students in other geographic areas (p

Objective Examine factors associated with retention on the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) after 1 year of age. Setting A large California WIC program. Participants WIC participants 14 months old (9,632) between July and September, 2016. Main Outcome Measure Recertification in WIC by 14 months of age. Analysis Multivariate logistic regression was performed and odds ratios (ORs) and 95% confidence intervals (CIs) were computed to examine factors associated with child retention in WIC at age 14 months. Results Mothers performing any amount of breastfeeding from 6 to 12 months were more likely than mothers not breastfeeding to recertify their children in WIC at age 14 months. The odds of retention for children fully breastfed from 6 to 12 months was about 3 times higher than for fully formula-fed children (95% CI, 2.46–3.59). The odds of retention for mostly breastfed children and children fed some breast milk but mostly formula were 1.95 (95% CI, 1.57–2.43) and 1.72 (95% CI, 1.41–2.10) times higher than fully formula-fed children. Prenatal intention to breastfeed (OR = 1.34; 95% CI, 1.16–1.55), online education (OR = 1.08; 95% CI, 1.03–1.13), missing benefits (OR = 0.19; 95% CI, 0.17–0.21), underredemption of WIC benefits (OR = 0.51, 95% CI, 0.45–0.58), early enrollment in WIC (OR = 1.11; 95% CI, 1.09–1.14), number of family members receiving WIC (OR = 1.29, 95% CI, 1.14–1.46), English language preference (OR, 0.55; 95% CI, 0.47–0.64), and participation in Medicaid (OR = 1.29; 95% CI, 1.14–1.47) were also associated with retention. Conclusions and Implications Results from this study suggested there are a number of areas WIC programs may target to promote ongoing participation in the program. These include support for both breastfeeding and non-breastfeeding women, technology-based strategies, and targeted outreach to pregnant women, participants who have missed benefits, and participants who have not redeemed their benefits. Research that examines the impact of targeted interventions directed at ≥1 of these areas is essential to help WIC programs maintain contact with children into early childhood.

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

School-based body mass index (BMI) notification programs are often used to raise parental awareness of childhood overweight and obesity, but how BMI results are associated with physical fitness and diet is less clear. This study examined the relationship between BMI, fitness, and diet quality in a diverse sample of urban schoolchildren ( n = 122) utilizing a school-based cardiorespiratory fitness test and a food frequency questionnaire. Fifty-two percent of children were overweight/obese. Fit children were more likely to be normal weight than unfit children ( p < .001). Weight status was not associated with adherence to any specific dietary guidelines; however, greater overall adherence to the recommendations was associated with normal weight ( p < .05). These findings suggest a potential benefit may be gained by combining BMI reports with results of in-school fitness testing and basic information on how children’s diets compare to recommendations.

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

High blood pressure is one of the leading causes of preventable morbidity and mortality in the U.S., and low-income populations are at increased risk. The purpose of this randomized controlled tria...

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.

The purpose of this randomized-controlled trial was to compare the impact of online to in-person group nutrition education on changes in knowledge, beliefs, and behaviors related to breakfast eatin...

Breakfast skipping has been associated with obesity. Schools have adopted breakfast policies to increase breakfast participation. Recently, there have been concerns that students in schools where breakfast is served in the classroom may be eating two breakfasts--one at home and one at school--thereby increasing their risk of excessive energy intake and weight gain.The study objective was to compare the prevalence of not eating breakfast, eating breakfast at home or school only, and eating double breakfasts (home and school) by students in schools with distinct breakfast policies and evaluate the relationship of breakfast policy to energy intake and diet quality.Baseline data were collected in 2011-2012 as part of a cluster randomized controlled trial to evaluate the effectiveness of a school-based intervention to promote fruit and vegetable intake and physical activity in low-resource elementary schools in California.Participants were 3,944 fourth and fifth graders from 43 schools, 20 served breakfast in the cafeteria before school, 17 served breakfast in the classroom at the start of school, and 6 served "second chance" breakfast (in the cafeteria before school and again at first recess).As part of a secondary data analysis, differences in school and individual characteristics by school breakfast policy were assessed by χ(2) test of independence or analysis of variance. Associations between school breakfast policy and breakfast eating patterns were assessed. Outcomes included calorie intake at breakfast, total daily calorie intake, and diet quality as measured by the Healthy Eating Index 2010. Control variables included student race/ethnicity, grade, and language spoken at home, and clustering of students by school.Breakfast in the classroom was associated with fewer students not eating breakfast (P0.001), but more eating breakfast at both home and school (P0.001). Students in the breakfast in the classroom group did not have higher mean energy intakes from breakfast or higher daily energy intakes that were higher than other breakfast policy groups. The breakfast in the classroom group had higher overall diet quality (P=0.01).No evidence was found to support discontinuation of breakfast in the classroom policy on the basis of concerns that children will eat excess calories.

The objective of this study was to determine the extent to which constitutive skin color explains racial/ethnic differences in serum 25-hydroxyvitamin D (25OHD) concentrations in urban schoolchildren. Analysis of covariance (ANCOVA) was used to determine associations of 25OHD with parent-reported race/ethnicity and constitutive skin color as measured by reflectance colorimeter [individual typology angle (ITA°; higher value corresponds to lighter skin)] in 307 Greater Boston schoolchildren aged 9–15 during October–December 2011. Nearly 60% of all children were inadequate in 25OHD (

Overweight children and minorities are at risk of vitamin D deficiency. Little information exists on whether overweight children and minorities who do not meet dietary vitamin D recommendations are at risk for low 25-hydroxyvitamin D (25OHD) status. Vitamin D intake from foods and dietary supplements was estimated in 3,310 children/adolescents who were examined as part of the 2005-2006 National Health and Nutrition Examination Survey. Weight status was dichotomized into healthy weight or overweight/obese. Parent-reported race/ethnicity was categorized as non-Hispanic white, non-Hispanic black, Mexican American, or other. Adjusted logistic regression was used to determine whether children who did not achieve the Estimated Average Requirement (EAR) were at increased risk for inadequate 25OHD. Nearly 75% of children failed to meet the EAR. Overall, not meeting the EAR was associated with inadequate 25OHD (odds ratio=2.5; 95% CI 1.4 to 4.5). However, this association differed by weight status (P=0.02) and race/ethnicity (P=0.02). Overweight/obese children who failed to meet the EAR were five times more likely to be at risk for inadequate 25OHD than overweight/obese children who met it (95% CI 2.0 to 12.7; P

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

Throughout life, vitamin D is important for Ca absorption and bone growth(1). Emerging evidence suggests that low vitamin D levels are also associated with obesity, diabetes and CVD, and that ethnic minorities are most affected(2). Recently, vitamin D has received growing attention due to the increased awareness of possible deficiencies among certain racial/ethnic populations at risk of vitamin D deficiency(3,4). Various studies have found that attaining optimal serum 25-hydroxyvitamin D (25(OH)D) concentrations is more challenging for certain racial/ethnic groups(2). Ethnic minorities have significantly higher rates of vitamin D deficiency (25(OH)D