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Introduction: The U.S. Child and Adult Care Food Program (CACFP) provides tiered reimbursements for healthy foods for children at participating family childcare homes (FCCH). Higher tier 1 reimbursements are for providers who operate in low-income communities or who are themselves living on a low income. All FCCHs received a higher rate to address food insecurity during the COVID-19 pandemic. Methods: A survey was administered in the spring of 2023 to a randomly selected sample of licensed California FCCHs to assess the perceived impacts of the increased reimbursement on CACFP participation and anticipated challenges with reinstated tiered rates. A total of 518 surveys (261 tier 1, 257 tier 2) were analyzed using linear or logistic regression, adjusting for confounders. Results: Among tier 1 and tier 2 providers combined, over half reported lowering out-of-pocket spending for food (59%) and serving greater variety (55%) and quality (54%) of foods. Tier 2 providers reported experiencing more benefits (p < 0.05) and tended to be more likely to implement optional CACFP best practices (although not significantly different between tiers). Most FCCH providers found reimbursement rates were inadequate before (83%) the pandemic; this amount decreased to 54% post-pandemic for tier 1 and tier 2 providers combined. Conclusions: The temporary CACFP reimbursement positively impacted the perceived quality and variety of foods served to children, especially among tier 2 providers. Increased reimbursements for all FCCHs may ensure children have access to the healthy meals and snacks provided by the CACFP.

BACKGROUND: Fruits and vegetables (FV) are a critical source of nutrients, yet children in the United States are not meeting the Dietary Guidelines for Americans (DGA). The monthly FV cash value benefit (CVB) included in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)s food package to support child FV intake (FVI) received a substantial increase for economic relief during the COVID-19 pandemic. OBJECTIVES: To evaluate how an expansion of the monthly WIC CVB to purchase FV for WIC children ages 1-4 y is associated with diversity in FV redeemed, and how changes in redeemed FV are related to FVI. METHODS: Caregivers representing 1463 WIC-participating children recruited from Los Angeles County, California, completed surveys during the CVB augmentation (T1: CVB = $9/mo; T2 = $35/mo; T3 = $24/mo). Redeemed price look-up codes (PLUs), corresponding to a food item, were assigned to its corresponding MyPlate FV group. Multivariable generalized estimating equation regression models assessed changes in amount and diversity of FV redemption across MyPlate groups and associations between changes in FV diversity and changes in FVI. RESULTS: Slightly over half of all households were food insecure (55%), half of the children were female (52%), and most were Hispanic (78%). Compared with T1, significant increases in the number of PLUs and dollars redeemed were observed in most MyPlate FV groups. From T1 to T2, significant increases in diversity scores were observed for total fruit (β: 1.6 pts; 95% confidence interval [CI]: 1.4, 1.7), total vegetable (β: 3.6 pts; 95%CI: 3.4, 3.9), and total FV (β:7.8 pts; 95%CI: 7.4, 8.2). Similarly, increases in diversity score were observed at T3 compared with T1. Changes in FV diversity redeemed were not associated with changes in FVI. CONCLUSIONS: During the CVB augmentation, WIC participants redeemed a greater amount and variety of FV according to DGA MyPlate recommendations, supporting its permanent increase.

INTRODUCTION: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition support for racially and ethnically diverse populations. In 2021, the monthly cash value benefit (CVB) for the purchase of fruits and vegetables increased from $9 to $35 and was later adjusted to $24. This study investigated, by racial and ethnic groups, whether CVB increases were associated with increases in CVB redemption, household food security, child fruit and vegetable intake, satisfaction with CVB amount, and likelihood of continued participation in WIC if the CVB returned to $9 per month. METHODS: We conducted a longitudinal study of WIC participants (N = 1,770) in southern California at 3 time points, from April 2021 through May 2022; the CVB amount was $9 at baseline, $35 at Survey 2, and $24 at Survey 3. Racial and ethnic groups were Hispanic English-speakers, Hispanic Spanish-speakers, non-Hispanic Asian, non-Hispanic Black, non-Hispanic Other, and non-Hispanic White. We used mixed-effect and modified Poisson regressions to evaluate outcomes by group. RESULTS: At baseline, groups differed significantly in dollars of CVB redeemed, percentage of CVB redeemed, household food security, and satisfaction with CVB amount. After the increase in CVB, we found increases in all groups in CVB redemption, household food security, and satisfaction. Non-Hispanic Black and Hispanic English-speaking groups, who had low levels of satisfaction at baseline, had larger increases in satisfaction than other groups. Reported likelihood of continued WIC participation if the monthly CVB returned to $9 also differed significantly by group, ranging from 62.5% to 90.0%. CONCLUSION: The increase in CVB for children receiving WIC benefited all racial and ethnic groups. Continued investment in an augmented CVB could improve health outcomes for a racially and ethnically diverse WIC population.

Parental perceptions of school meals can affect student participation and overall support for school meal policies. Little is known about parental school meal perceptions under universal free school meals (UFSM) policies. We assessed California parents perceptions of school meals during the COVID-19 emergency response with federally funded UFSM and whether perceptions differed by race/ethnicity. Among 1110 California parents of K-12 students, most reported school meals benefit their families, saving them money (81.6%), time (79.2%), and stress (75.0%). Few reported that their child would be embarrassed to eat school meals (11.7%), but more parents of White students than Hispanic students reported this. Many parents reported that their child likes to eat lunch to be with friends (64.7%); about half felt their child has enough time to eat (54.2%). Fewer parents perceived school lunches to be of good quality (36.9%), tasty (39.6%), or healthy (44.0%). Parents of Hispanic and Asian students had less favorable perceptions of school meal quality, taste, and healthfulness than parents of White students. Parents report that school meals benefit their families, but policy efforts are needed to ensure schools have the resources needed to address cultural appropriateness. Schools should address parental perceptions of meals to optimize participation, nutrition security, and health.

PurposeThe National Heart, Lung and Blood Institute Growth and Health Study (NGHS) prospectively collected anthropometric, biospecimens, clinical, health behaviour and psychosocial measures associated with cardiovascular disease from childhood to young adulthood. The aim of the current study was to assess the impact of stress, dysregulated eating and social genomic biomarkers on cardiometabolic risk factors among the original participants now in midlife and their children.ParticipantsBeginning in 1987-1988, NGHS recruited black and white girls (age 9-10 years) from socioeconomically diverse backgrounds from from three sites: Cincinnati, Ohio; Washington, DC; and Western Contra Costa County, California (N=2379) and followed them for 10 years. The study maintained an 89% retention rate. The current study is 30 years after the start of the original study and focused on the participants of California (n=887) and their children aged 2-17 years. We re-enrolled 624 of 852 eligible participants (73%): 49.2% black and 50.8% white. The mean age was 39.5 years. Among the 645 eligible biological children, 553 were enrolled; 49% black and 51% white, with 51.5% girls and 48.5% boys. The mean age was 9.3 years.Findings to dateLongitudinal analysis of adolescent drive for thinness predicted higher scores for drive for thinness during midlife, which was indirectly associated with greater adult body mass index through adult drive for thinness. Latent trajectory modelling of adolescent growth over 10 years found that women with persistently high weight trajectory had twice the odds of having children who met the definition for obesity compared with the persistently normal group, adjusting for adult weight.Future plansNew studies on neighbourhood socioeconomic status, food insecurity and additional biomarkers of chronic stress, microbiome and accelerated ageing (ie, telomere length and epigenetic clock) are underway. We are developing a 10-year follow-up to understand changes in ageing biomarkers of the participants and their children.Trial registration numberNCT00005132.

BACKGROUND: Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages for children ages 1 to 4 y include a cash value benefit (CVB) redeemable for fruits and vegetables (FVs) with participating vendors. The CVB value was increased beginning in June 2021. OBJECTIVES: This study evaluated associations of the augmented CVB with the amount and diversity of redeemed FVs. METHODS: Price look-up codes (PLUs) in redemption data determined outcomes including any redemption (any, none), amount redeemed (United States dollars [USD]/mo), and percent of total CVB redemption (percent) in 54 FV commodity groups among a cohort of 1770 WIC-participating children in Southern California. Outcomes across all commodity groups for fresh fruits, fresh vegetables, and all FVs were evaluated including dollar amount redeemed, percentage of redemption, and diversity of produce redeemed (variety and balance among items redeemed). Comparisons were made between augmented CVB periods (35 USD/mo in June-September 2021, 24 USD/mo October 2021-June 2022) and the preaugment period (9 USD/mo in June 2020-May 2021). Associations were tested in multivariable generalized estimating equation Poisson (any redemption) and linear (amount, percent, diversity) regression models. RESULTS: The augmented CVB was associated with higher any redemption prevalence and amount redeemed for 53 of 54 commodity groups at both 35 USD/mo and 24 USD/mo compared with 9 USD/mo. Redemption diversity increased for both fruits, vegetables, and all produce during both augment periods, and modestly greater increases in redeemed fruits relative to vegetables were observed at 35 USD/mo. The most commonly redeemed vegetables were tomatoes, onions, cucumbers, peppers, and avocados and the most commonly redeemed fruits were bananas, apples, grapes, limes, and melons. CONCLUSIONS: The augmented CVB was associated with greater redeemed FV amount and greater redeemed FV diversity. Data on FV intake diversity among WIC-participating children are needed to understand dietary impacts of the CVB increase.

BACKGROUND AND OBJECTIVE: Drinking water promotion and access shows promise for preventing weight gain. This study evaluated the impact of Water First, a school-based water promotion and access intervention on changes in overweight. METHODS: Low-income, ethnically diverse elementary schools in Californias Bay Area were cluster-randomized to intervention and control groups. Water First includes classroom lessons, water stations, and schoolwide water promotion over 1 school year. The primary outcome was overweight prevalence (BMI-for-age-and-sex ≥85th percentile). Students (n = 1249) in 56 fourth-grade classes in 18 schools (9 intervention, 9 control) from 2016 to 2019 participated in evaluation at baseline, 7, and 15 months. Data collection was interrupted in 8 additional recruited schools because of coronavirus disease 2019. RESULTS: Of 1262 students from 18 schools, 1249 (47.4% girls; mean [SD] age, 9.6 [0.4] years; 63.4% Hispanic) were recruited. From baseline to 7 months, there was no significant difference in changes in overweight prevalence in intervention schools (-0.2%) compared to control schools (-0.4%) (adjusted ratio of odds ratios [ORs]: 0.7 [confidence interval (CI): 0.2-2.9] P = 0.68). From baseline to 15-months, increases in overweight prevalence were significantly greater in control schools (3.7%) compared to intervention schools (0.5%). At 15 months, intervention students had a significantly lower change in overweight prevalence (adjusted ratio of ORs: 0.1 [CI: 0.03-0.7] P = .017) compared to control students. There were no intervention effects for obesity prevalence. CONCLUSIONS: Water First prevented increases in the prevalence of overweight, but not obesity, in elementary school students.

BackgroundHealthy nutrition during the first year of life is critical for optimal growth and development. Limited techniques are available to assess diet quality in infancy, and few have been shown to be predictive of dietary and adiposity outcomes in low-income children.ObjectiveThe objectives of this study were to construct an Infant Diet Quality Index (IDQI) to assess the diet quality from birth to 12 mo and to determine whether the IDQI exhibits predictive validity by estimating the longitudinal associations of IDQI scores with diet quality and weight status at 2 to 4 y.DesignData were analyzed from the longitudinal Women, Infants, and Children Infant and Toddler Feeding Practices Study-2 (unweighted, n = 2858; weighted. N = 392,439) using one 24-h dietary recall and survey responses during infancy. The newly constructed IDQI consists of 16 equally-weighted components: 1) breastfeeding duration; 2) exclusive breastfeeding; age of first introduction of: 3) solids, 4) iron-rich cereals, 5) cow milk, 6) sugar-sweetened beverages, 7) salty/sweet snacks, 8) other drinks/liquids, and 9) textured foods; frequency of consuming 10) fruit or 11) vegetables; frequency of consuming different 12) fruit or 13) vegetables; 14) nonrecommended bottle-feeding practices; 15) use of commercial baby foods; and 16) number of meals and snacks. Regression analysis was used to estimate associations between the total IDQI score (range, 0-1) and Healthy Eating Index-2015 (HEI-2015) scores and body mass index z-scores (BMIz) at 2 to 4 y of age, adjusted for covariates (e.g., child age, sex and race/ethnicity; maternal education level, etc.) RESULTS: The total IDQI score was positively associated with HEI-2015 at the age of 2 y (β = 16.7; 95% CI: 12.6, 20.9; P < 0.001), 3 y (β = 14.5; 95% CI: 8.1, 21.0; P < 0.001), and 4 y (β = 15.4; 95% CI: 8.4, 22.4; P < 0.001); and negatively associated with BMIz at the age of 2 y (β = -1.24; 95% CI: -2.01, -0.47; P = 0.002) and 4 y (β = -0.92; 95% CI: -1.53, -0.30; P = 0.003).ConclusionsThe IDQI has predictive validity for diet quality and weight status in low-income US children.

In this special issue, California Agriculture features articles on lessons learned during the COVID-19 “natural experiment” to inform Cooperative Extension programming and local, state and federal policy to improve population health, food security, economic resilience, equity and sustainability throughout the state and food system.

Understanding satisfaction of nutrition education and other services provided in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is needed to ensure the program is responsive to the needs of diverse populations. This study examined the variation of WIC participants’ perceptions and satisfaction with WIC nutrition education and services by race, ethnicity, and language preference. Phone surveys were conducted in 2019 with California WIC families with children aged 1−4 years. While most participants (86%) preferred one-on-one nutrition education, online/mobile apps were also favored (69%). The majority (89%) found nutrition education equally important to receiving the WIC food package. Racial/ethnic groups differed in which WIC service they primarily valued as 20% of non-Hispanic White people rated the food package as more important than nutrition education compared to 5% of Spanish- and 6% of English-speaking Hispanic people, respectively. More Spanish (91%) and English-speaking Hispanic people (87%) than non-Hispanic white (79%) or Black people (74%) changed a behavior because of something they learned at WIC (p < 0.001). Spanish-speaking Hispanic people (90%) had the highest satisfaction with WIC nutrition education. Preferential differences among participants suggest that providing flexible options may improve program satisfaction and emphasizes the need for future studies to examine WIC services by race and ethnicity.

ObjectiveTo examine students' experiences of water security at school and how experiences relate to intake of water from different sources of water at school.Design/methodsIn this cross-sectional study, 651 students in grades 3 to 5 in 12 low-income public elementary schools in the San Francisco area completed surveys about their daily intake of water from different sources of water at school, experiences of water security including safety, cleanliness, and taste of water at school, and their demographics. Multivariable linear regressions examined associations between students' water security experiences at school and reported intake from different sources of water at school.ResultsApproximately half of students were Latino (56.1%) and had overweight/obesity (50.4%). Most (74.5%) had some negative water security experience at school. Students drank from the school fountain or water bottle filling station a mean of 1.2 times/day (standard deviation [SD] = 1.4), sinks 0.2 times/day (SD = 0.7), tap water dispensers 0.2 times/day (SD = 0.6), and bottled water 0.5 times/day (SD = 1.0). In multivariable linear regression, students with more negative experiences of school water security drank less frequently from fountains (-0.5 times/day, P value < .001), but more frequently from tap water dispensers (0.1 times/day, P value = .040) and sinks (0.1 times/day, P value = .043), compared to students with no negative perceptions.ConclusionsOn average, students had negative school water security experiences, which decreased their consumption of water from tap water sources. However, relationships between negative water security experiences and reported water intake appeared to be mitigated by water source. Schools should consider installing more appealing water sources to promote water intake.

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 March 2021.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.

School meals play a major role in supporting children's diets and food security, and policies for universal school meals (USM) have the potential to contribute to positive child health outcomes. During the COVID-19 pandemic, schools provided free school meals to all students in the United States, but this national USM policy ended in school year (SY) 2022-2023; however, a few states have adopted policies to continue USM statewide for SY 2022-2023. Research examining the challenges and strategies for successful continuation of USM is essential, along with studying pandemic-related challenges that are likely to persist in schools. Therefore, we conducted a study in Maine (with a USM policy) to evaluate the impact of COVID-19 and the concurrent implementation of USM, as well as examine differences in implementation by school characteristics, throughout the state. A total of n = 43 school food authorities (SFAs) throughout Maine completed surveys. SFAs reported multiple benefits of USM including increased school meal participation; reductions in the perceived stigma for students from lower-income households and their families; and no longer experiencing unpaid meal charges and debt. SFAs also experienced challenges due to the COVID-19 pandemic, particularly regarding costs. When considering future challenges, most respondents were concerned with obtaining income information from families, product and ingredient availability, and the costs/financial sustainability of the school meal programs. Overall, USM may have multiple important benefits for students and schools, and other states should consider implementation of a USM policy.

Universal school meals (USM) have the potential to increase access to healthy food for millions of U.S. students. This study evaluated school food authorities’ (SFA) perspectives of federal USM in response to COVID-19 (school year (SY) 2021−22) and California’s upcoming USM policy in the SY 2022−23. In February 2022, all SFAs in California (n = 1116) were invited to complete an online survey. Descriptive statistics and logistic regression examining differences by school demographic characteristics were used. Five hundred and eighty-one SFAs completed the survey; 63% of them first implemented USM during the COVID-19 pandemic. Reported benefits included increased student meal participation (79.2%) and reduced stigma (39.7%). Top challenges included staffing (76.9%) and meal packaging/solid waste (67.4%). Nearly all SFAs reported pandemic-related challenges procuring the necessary types (88.9%) and amounts of foods (85.9%), and non-food supplies/equipment (82.6%). Over 40% reported that federal reimbursements were insufficient to cover costs. SFAs with

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

The United States Department of Agriculture approved an increase to the Cash Value Benefit (CVB) for the purchase of fruits and vegetables issued to participants receiving an eligible Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package. In order to understand satisfaction, perceptions, and the overall impact of additional benefits for fruits and vegetables at the household level, a qualitative study consisting of structured phone interviews was conducted with families served by WIC in Southern California from November to December 2021 (n = 30). Families were selected from a large longitudinal study sample (N = 2784); the sample was restricted by benefit redemption and stratified by language and race. WIC participants were highly satisfied with the CVB increase, reporting increased purchasing and consumption of a variety of fruits and vegetables. Respondents noted the improved quality and variety of fruits and vegetables purchased due to the increased amount. Findings are expected to inform policy makers to adjust the CVB offered in the WIC food package with the potential to improve participant satisfaction and increase participation and retention of eligible families with benefits from healthy diets supported by WIC.

Compared to other food groups, vegetable intakes are lowest relative to recommendations. Breastfeeding and initial introduction to vegetables may help infants establish long-lasting taste preferences. We examined the relationship between breastfeeding and initial vegetable introduction and vegetable intake in early childhood (ages 13-60 months). This repeated cross-sectional study used data from the national WIC Infant and Toddler Feeding Practices Study-2 collected from low-income mother/caregivers about infants from around birth through age 5 (60 months; n = 3773). Survey-weighted adjusted regression models assessed associations between breastfeeding and vegetable introduction measures with vegetable consumption at child ages 13, 24, 36, 48, and 60 months. Longer breastfeeding duration was associated with a slightly, but significantly, greater variety of vegetables consumed/day in early childhood. There was also a small but positive statistically significant association between the number of different types of vegetables consumed on a given day at 9 months and the amount and variety of vegetables consumed/day in early childhood. Age of initial vegetables introduction and whether vegetables were the first/second food introduced were not consistently related to the amount or variety of vegetables consumed later in childhood. Longer breastfeeding and introduction to a greater variety of vegetables at 9 months may be behaviors to target to increase consumption of a greater variety of vegetables by young children.

ObjectiveIn 2019, California and Wilmington, Delaware' implemented policies requiring healthier default beverages with restaurant kids' meals. The current study assessed restaurant beverage offerings and manager perceptions.DesignPre-post menu observations were conducted in California and Wilmington. Observations of cashiers/servers during orders were conducted pre-post implementation in California and post-implementation in Wilmington. Changes in California were compared using multilevel logistic regression and paired t tests. Post-implementation, managers were interviewed.SettingInside and drive-through ordering venues in a sample of quick-service restaurants in low-income California communities and all restaurants in Wilmington subject to the policy, the month before and 7-12 months after policy implementation.ParticipantsRestaurant observations (California n 110; Wilmington n 14); managers (California n 75; Wilmington n 15).ResultsPre-implementation, the most common kids' meal beverages on California menus were unflavoured milk and water (78·8 %, 52·0 %); in Wilmington, juice, milk and sugar-sweetened beverages were most common (81·8 %, 66·7 % and 46·2 %). Post-implementation, menus including only policy-consistent beverages significantly increased in California (9·7 % to 66·1 %, P < 0·0001), but remained constant in Wilmington (30·8 %). During orders, cashiers/servers offering only policy-consistent beverages significantly decreased post-implementation in California (5·0 % to 1·0 %, P = 0·002). Few managers (California 29·3 %; Wilmington 0 %) reported policy knowledge, although most expressed support. Most managers wanted additional information for customers and staff.ConclusionsWhile the proportion of menus offering only policy-consistent kids' meal default beverages increased in California, offerings did not change in Wilmington. In both jurisdictions, managers lacked policy knowledge, and few cashiers/servers offered only policy-consistent beverages. Additional efforts are needed to strengthen implementation of kids' meal beverage policies.

This study assessed relationships of duration of family Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participation with racial/ethnic disparities in child sugar-sweetened beverage (SSB) and water intake. Child beverage intake and family duration on WIC were collected during three cross-sectional surveys of WIC-participating families in Los Angeles County, California (2014, 2017 and 2020; n = 11,482). The associations of family duration of WIC participation, a proxy for the amount of WIC services received, with daily intake of total SSBs, fruit-flavored SSBs and water were assessed in race/ethnicity strata with multivariable negative binomial and Poisson regression models. Among English-speaking Hispanic children, those of families reporting 10 years of WIC participation consumed 33% and 27% fewer servings of total and fruit-flavored SSBs compared to those of families reporting 1 year on WIC. Among Black children, those from families reporting 5 and 10 years of participation in WIC consumed 33% and 45% more daily servings of fruit-flavored SSBs than those from families reporting 1 year on WIC. Disparities in daily total and fruit-flavored SSB intake between Black and White children increased with longer family duration on WIC. Duration of family WIC participation is associated with healthier beverage choices for infants and children, but does not appear to be equally beneficial across racial/ethnic groups in Los Angeles County.

ObjectiveTo examine associations between household food insecurity and children's physical activity and sedentary behaviours.DesignSecondary 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.SettingA total of 130 communities in the USA.ParticipantsIn sum, 5138 US children aged 4-15 years.ResultsNo 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).ConclusionsAdditional 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.

The Child and Adult Care Food Program (CACFP) provides reimbursements for nutritious foods for children with low-income at participating child care sites in the United States. The CACFP is associated with improved child diet quality, health outcomes, and food security. However CACFP participation rates are declining. Independent child care centers make up a substantial portion of CACFP sites, yet little is known about their barriers to participation. Researcher-led focus groups and interviews were conducted in 2021-2022 with 16 CACFP-participating independent centers and 5 CACFP sponsors across California CACFP administrative regions to identify participation benefits, barriers, and facilitators. Transcripts were coded for themes using the grounded theory method. CACFP benefits include reimbursement for food, supporting communities with low incomes, and healthy food guidelines. Barriers include paperwork, administrative reviews, communication, inadequate reimbursement, staffing, nutrition standards, training needs, eligibility determination, technological challenges, and COVID-19-related staffing and supply-chain issues. Facilitators included improved communication, additional and improved training, nutrition standards and administrative review support, online forms, reduced and streamlined paperwork. Sponsored centers cited fewer barriers than un-sponsored centers, suggesting sponsors facilitate independent centers' CACFP participation. CACFP participation barriers should be reduced to better support centers and improve nutrition and food security for families with low-income.

Poor nutrition among young children is a national health crisis which contributes to obesity and chronic disease later in life. Since children spend so much time in child care, child care providers can help improve the quality of young children's nutrition and foster lifelong healthy eating habits. However, California's family child care home (FCCH) providersreceive little training on what and how to feed young children. To address this problem, we developed a self-paced online training on child nutrition in English and Spanish for FCCH providers. Our feasibility study evaluated providers’ satisfaction with the training and ease of use, using an online survey and a 45-minute interview upon completing the training. Providers rated their training experience as excellent, easy to enroll in, and complete. Most providers reported they were somewhat likely to make changes to what and how they feed infants and toddlers. Many recommended adding printed resources and culturally relevant material for future trainings.

ObjectiveThis paper identifies implementation leadership characteristics in the school nutrition setting and places findings in the context of implementation leadership literature.MethodsFourteen interviews were conducted with school district leadership/staff in an urban school district. Modified grounded theory was employed.ResultsFour themes emerged: (1) understanding of technical/operational intervention details; (2) ability to proactively develop and communicate plans; (3) supervisory oversight; and (4) intervention framing. Themes were consistent with 4 of the 5 dimensions comprising the Implementation Leadership Scale: knowledgeable, proactive, perseverant, and distributed leadership. The supportive domain was not a major finding. An additional domain, how leaders message the intervention to staff, was identified.Conclusions and implicationsImplementation leadership in school nutrition appears similar, but not identical, to leader behaviors present in the Implementation Leadership Scale. School nutrition leaders might consider involving staff early in implementation planning, incorporating technical expertise, and clearly communicating the intervention purpose to support successful implementation. Future research might explore the interplay between leadership and implementation outcomes.

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

BackgroundChildren's consumption of sugar-sweetened beverages is associated with obesity, diabetes, and dental decay. California's Healthy Beverages in Child Care Act (AB 2084) requires all licensed child care centers and family child care homes to comply with healthy beverages standards, however many licensed providers in California are unaware of the law and few are fully compliant with the law's requirements. The aim of the current project is to describe the development of a self-paced online training on best practices and implementation of AB 2084 in English and Spanish for family child care home and child care center providers; and to evaluate the feasibility, defined as being accessible, acceptable, and satisfactory to providers, of this new online course.MethodsThe project was broken into two main stages: (1) development of the online course; and (2) evaluation of the final online course. The first stage was completed in five phases: (1) identify relevant course content and develop narration script; (2) conduct in-person focus groups with child care providers to review and edit the content; (3) adapt course content and translate for Spanish-speaking providers; (4) build the online course and resources; and (5) pilot online course and evaluate accessibility. The second stage, evaluation of the acceptability and satisfaction of the final course was rated on a Likert scale from 1 to 4; the evaluation was completed as part of a larger randomized control trial with 43 child care providers. The course features four key requirements of AB 2084 as the main sections of the course (milk, sweetened beverages, juice, and water), plus background information about beverages and children's health, special topics including caring for children with special needs, family engagement, written policies, and child engagement.ResultsThe child care providers who completed the evaluation found the online training was easily understandable (median(Q1,Q3,IQR) = 4 (4,4,0)), included new information (3 (1, 3, 4)), provided useful resources (4(4,4,0)), and was rated with high overall satisfaction (3 (1, 3, 4)).ConclusionOnline training in English and Spanish designed for child care providers is a feasible medium to deliver important health messages to child care providers in an accessible, acceptable, and satisfactory manner.

Early in the COVID-19 pandemic, the U.S. Department of Agriculture (USDA), State governments, and school districts took unprecedented steps to mitigate the pandemic's impact on students' nutrition. To examine the effect of emergency responses on 6-year-old children's nutritional outcomes, this study analyzed longitudinal data from a national study of children's feeding practices, the Special Supplemental Nutrition Program for Women, Infants, and Children-Infant and Toddler Feeding Practices Study-2 (WIC ITFPS-2). Findings include no differences in food insecurity prevalence; however, there were shifts in sources of food, with children in the post-COVID-emergency-declaration (post-ED) group consuming more dietary energy from stores and community food programs and less from restaurants and schools than children in the pre-COVID-emergency-declaration (pre-ED) group (p < 0.01 for all comparisons). Examination of within-person mean differences in 2015 Healthy Eating Index scores and nutrient intakes between ages 5 and 6 years revealed few statistically significant differences between the two groups: children in the post-ED group consumed slightly fewer vegetables (p = 0.02) and less sodium (p = 0.01) than their pre-ED peers. Findings suggest emergency efforts to maintain children's nutrition were largely successful in the early months of the pandemic. Research is needed to understand the mechanisms by which emergency efforts contributed to these findings.

BackgroundAlthough 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.ObjectiveThis 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.MethodsThis 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.ResultsSix 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

ImportanceAnnually, US schools screen millions of students' body mass index (BMI) and report the results to parents, with little experimental evidence on potential benefits and harms.ObjectiveTo determine the impact of school-based BMI reporting on weight status and adverse outcomes (weight stigmatization and weight-related perceptions and behaviors) among a diverse student population.Design, setting, and participantsCluster randomized clinical trial. The Fit Study (2014-2017) randomized 79 California schools to BMI screening and reporting (group 1), BMI screening only (group 2), or control (no BMI screening or reporting [group 3]) in grades 3 to 8. The setting was California elementary and middle schools. Students in grades 3 to 7 at baseline participated for up to 3 years. A modified intent-to-treat protocol was used. Data analysis was conducted from April 13, 2017, to March 26, 2020.InterventionsSchool staff assessed BMI each spring among students in groups 1 and 2. Parents of students in group 1 were sent a BMI report each fall for up to 2 years.Main outcomes and measuresChanges in BMI z score and in adverse outcomes (based on surveys conducted each fall among students in grades 4 to 8) from baseline to 1 and 2 years of follow-up.ResultsA total of 28 641 students (14 645 [51.1%] male) in grades 3 to 7 at baseline participated in the study for up to 3 years. Among 6534 of 16 622 students with a baseline BMI in the 85th percentile or higher (39.3%), BMI reporting had no effect on BMI z score change (-0.003; 95% CI, -0.02 to 0.01 at 1 year and 0.01; 95% CI, -0.02 to 0.03 at 2 years). Weight dissatisfaction increased more among students having BMI screened at school (8694 students in groups 1 and 2) than among control participants (5674 students in group 3). Results of the effect of BMI reporting on other adverse outcomes were mixed: compared with the control (group 3), among students weighed at school (groups 1 and 2), weight satisfaction declined more after 2 years (-0.11; 95% CI, -0.18 to -0.05), and peer weight talk increased more after 1 year (0.05; 95% CI, 0.01-0.09); however, concerning weight control behaviors declined more after 1 year (-0.06; 95% CI, -0.10 to -0.02).Conclusions and relevanceBody mass index reports alone do not improve children's weight status and may decrease weight satisfaction. To improve student health, schools should consider investing resources in evidence-based interventions.Trial registrationClinicalTrials.gov Identifier: NCT02088086.

IntroductionPromoting water consumption among children in schools is a promising intervention to reduce sugar-sweetened beverage (SSB) intake and achieve healthful weight. To date, no studies in the United States have examined how a school-based water access and promotion intervention affects students' beverage and food intake both in and out of school and weight gain over time. The Water First trial is intended to evaluate these interventions.MethodsInformed by the PRECEDE-PROCEED model and Social Cognitive Theory, the Water First intervention includes: 1) installation of lead-free water stations in cafeterias, physical activity spaces, and high-traffic common areas in lower-income public elementary schools, 2) provision of cups/reusable water bottles for students, and 3) a 6-month healthy beverage education campaign. A five year-long cluster randomized controlled trial of 26 low-income public elementary schools in the San Francisco Bay Area is examining how Water First impacts students' consumption of water, caloric intake from foods and beverages, and BMI z-score and overweight/obesity prevalence, from baseline to 7 months and 15 months after the start of the study. Intervention impact on outcomes will be examined using a difference-in-differences approach with mixed-effects regression accounting for the clustering of students in schools and classrooms.DiscussionThis paper describes the rationale, study design, and protocol for the Water First study. If the intervention is effective, findings will inform best practices for implementing school water policies, as well as the development of more expansive policies and programs to promote and improve access to drinking water in schools.

OBJECTIVES: Childcare is an important setting for nutrition; nearly half of young children in the United States participate in licensed childcare, where they consume up to two-thirds of their daily dietary intake. We compared state regulations for childcare with best practices to support breastfeeding and healthy beverage provision. METHODS: We reviewed regulations for childcare centers (centers) and family childcare homes (homes) in effect May-July 2016 and rated all 50 states for inclusion (1 = not included, 2 = partially included, 3 = fully included) of 12 breastfeeding and beverage best practices. We calculated average ratings for 6 practices specific to infants aged 0-11 months, 6 practices specific to children aged 1-6 years, and all 12 practices, by state and across all states. We assessed significant differences between centers and homes for each best practice by using McNemar-Bowker tests for symmetry, and we assessed differences across states by using paired student t tests. RESULTS: States included best practices in regulations for centers more often than for homes. Average ratings (standard deviations) in regulations across all states were significantly higher in centers than in homes for infant best practices (2.1 [0.5] vs 1.8 [0.5], P < .001), child best practices (2.1 [0.6] vs 1.8 [0.6], P = .002), and all 12 best practices combined (2.1 [0.5] vs 1.8 [0.6], P < .001). CONCLUSIONS: Although best practices were more consistently included in regulations for centers than for homes, many state childcare regulations did not include best practices to support breastfeeding and the provision of healthy beverages. Findings can be used to inform efforts to improve regulations and to reduce differences between centers and homes.

The study evaluated an educational intervention with family child care home (FCCH) providers to implement nutrition standards. A convenience sample of licensed California FCCH providers (n = 30) attended a 2-hour, in-person group training in English or Spanish on nutrition standards for infants and children aged 1 to 5 years. Provider surveys and researcher observations during meals/snacks were conducted pre- and 3 months post-intervention. Providers rated the training as excellent (average score of 4.9 on a scale of 1-5). Adherence, assessed by survey and observation and compared over time using paired t-tests, increased from an average of 36% pre-intervention to 44% post-intervention (P = .06) of providers (n = 12) for infant standards and from 59% to 68% (P

Children eat more fruits and vegetables when more are available at home, but less is known about how the neighborhood food environment relates to children's diet and weight outcomes. The goal of this study was to determine whether parental perception of the food environment (neighborhood and home) is associated with children's fruit and vegetable (F&V) intake and weight outcomes, and to assess differences by household food security status and household income. Cross-sectional data from the 2013-2015 U.S. Healthy Communities Study included 5138 children, aged 4 to 15 years old, from 130 U.S. communities. Neighborhood and home food environments were assessed with parent-reported, perceived F&V availability scores. Associations were tested with multi-level linear regression models. Parents' perception of produce availability was associated with household F&V availability ratings (β = 0.09 points, p < 0.001). Household F&V availability was associated with child F&V intake (β = 0.32 cups/day or 25.6 g/day, p < 0.001). A higher child F&V intake was associated with a lower child BMI z-score (β = -0.05, p = 0.002). Weaker relationships were seen for children living in food insecure or low-income households. Optimizing neighborhood and home access to F&V may help children improve diet quality, but may not be as effective for children living in food insecure or low-income households.

The consumption of sugar-sweetened beverages (SSBs) has been linked to obesity, diabetes, and other negative health outcomes among children. In response, many government entities have enacted healthy default beverage policies that require restaurants offering bundled kids meals-food and drink items combined and sold as a single unit-to include only healthier drinks. Despite growing interest in these policies, little is known about their potential reach, restaurant management perceptions, and possible implementation challenges. This study evaluated restaurant managers knowledge and support of a policy in Delaware that had passed, but not yet gone into effect. We conducted structured in-person interviews with managers (n = 50) from full-service and quick-service chain and non-chain restaurants (QSRs) using a stratified random sample. Managers were interviewed about the number of bundled meals sold, beverage sales with those meals, and awareness and perceptions of the policy. On average, QSRs sold significantly more bundled kids meals per week (281) compared to full-service restaurants (111), and managers from chain restaurants reported selling significantly more bundled kids meals per week (233) compared to non-chain restaurants (91). Managers reported 72.5% of those meals were sold with a healthier beverage (water, milk, or 100% juice), consistent with the forthcoming policy, while 28% were sold with SSBs. Furthermore, although only three managers (6%) reported knowing about the policy, the majority supported it when it was explained. Our findings indicate general support for the intent of the policy, but suggest the need for tailored implementation approaches and additional education for restaurant managers and staff.

Little is known about how the neighborhood social environment (e.g., safety, crime, traffic) impacts child physical activity. We examine the mechanism by which the neighborhood social environment is associated with child physical activity, moderated by individual-level cultural factors (e.g., language at home, immigrant generation) and mediated by neighborhood physical activity-related social norms (e.g., seeing walkers in the neighborhood). Data included 2749 non-Hispanic White and Hispanic children from the Healthy Communities Study. Multilevel regression was performed. The neighborhood social environment was not associated with physical activity in the full sample. However, Hispanic children speaking both English and Spanish and first- or second-generation Hispanic children engaged in more physical activity when the quality of the neighborhood social environment was higher (b = 1.60, p < 0.001 for Hispanic children speaking English and Spanish; b = 2.03, p < 0.01 for first-generation Hispanic children; b = 1.29, p < 0.01 for second-generation Hispanic children). Neighborhood physical activity-related social norms mediated the association between the neighborhood social environment and physical activity among Hispanic children speaking English and Spanish (b = 0.33, p < 0.001) and second-generation Hispanic children (b = 0.40, p < 0.001). Findings suggest heterogeneity in how neighborhood social environments impact physical activity by cultural factors. Health promotion programs may need to enhance neighborhood social environments to increase Hispanic children's physical activity.

Meta-analysis has been used to examine the effectiveness of childhood obesity prevention efforts, yet traditional conventional meta-analytic methods restrict the kinds of studies included, and either narrowly define mechanisms and agents of change, or examine the effectiveness of whole interventions as opposed to the specific actions that comprise interventions. Taxonomic meta-analytic methods widen the aperture of what can be included in a meta-analysis data set, allowing for inclusion of many types of interventions and study designs. The National Collaborative on Childhood Obesity Research Childhood Obesity Evidence Base (COEB) project focuses on interventions intended to prevent childhood obesity in children 2-5 years old who have an outcome measure of BMI. The COEB created taxonomies, anchored in the Social Ecological Model, which catalog specific outcomes, intervention components, intended recipients, and contexts of policies, initiatives, and interventions conducted at the individual, interpersonal, organizational, community, and societal level. Taxonomies were created by discovery from the literature itself using grounded theory. This article describes the process used for a novel taxonomic meta-analysis of childhood obesity prevention studies between the years 2010 and 2019. This method can be applied to other areas of research, including obesity prevention in additional populations.

Objective: To evaluate the efficacy of childhood obesity interventions and conduct a taxonomy of intervention components that are most effective in changing obesity-related health outcomes in children 2-5 years of age. Methods: Comprehensive searches located 51 studies from 18,335 unique records. Eligible studies: (1) assessed children aged 2-5, living in the United States; (2) evaluated an intervention to improve weight status; (3) identified a same-aged comparison group; (4) measured BMI; and (5) were available between January 2005 and August 2019. Coders extracted study, sample, and intervention characteristics. Effect sizes [ESs; and 95% confidence intervals (CIs)] were calculated by using random-effects models. Meta-regression was used to determine which intervention components explain variability in ESs. Results: Included were 51 studies evaluating 58 interventions (N = 29,085; mean age = 4 years; 50% girls). Relative to controls, children receiving an intervention had a lower BMI at the end of the intervention (g = 0.10, 95% CI = 0.02-0.18; k = 55) and at the last follow-up (g = 0.17, 95% CI = 0.04-0.30; k = 14; range = 18-143 weeks). Three intervention components moderated efficacy: engage caregivers in praise/encouragement for positive health-related behavior; provide education about the importance of screen time reduction to caregivers; and engage pediatricians/health care providers. Conclusions: Early childhood obesity interventions are effective in reducing BMI in preschool children. Our findings suggest that facilitating caregiver education about the importance of screen time reduction may be an important strategy in reducing early childhood obesity.

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

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

Many quick-service restaurants (QSRs) instituted voluntary kids' meal default beverage standards (standards) between 2013 to 2017. Little is known about impacts of standards on QSR drive-through practices and on customer choices. This study assessed differences in restaurant practices including kids' meal beverages shown on menu boards, offered by cashiers, and selected by customers in QSRs with and without voluntary standards. Observations (n = 111) and customer surveys (n = 84) were conducted in 2018 at QSRs with standards (n = 70) and without (n = 41) in low-income California, U.S. neighborhoods. Kids' meal beverages on menu boards (n = 149) and offered by cashiers (n = 185) at QSRs with and without standards were analyzed using multilevel logistic regression. Significantly more menu boards at QSRs with standards (n = 103) vs. without (n = 46) featured only milk, water or unsweetened juice (65.1% vs. 4.4%; p < 0.001). Most cashiers at QSRs with standards and QSRs without (53.1%, 62.5%) asked what drink the data collector wanted rather than first offering default beverages. A small sample of customer interviews found that customers at QSRs with standards most commonly ordered juice (37.0%); at QSRs without standards, soda (45.5%). Although menu boards showed healthier kids' meal beverages at QSRs with standards than without, cashier behavior was inconsistent. Results suggest additional measures (legislation, implementation support, enforcement) may be needed to ensure optimal implementation.

Introduction: Schools meals offer a critical opportunity for improving youths' diets, particularly for economically disadvantaged students. We examine the impact of a multipronged intervention to increase middle and high school students' lunch participation in an urban school district. Methods: In school years 2015-2016 through 2017-2018, a quasi-experimental study was conducted in 24 secondary schools, half (n = 12) of which received the following intervention: cafeteria redesign, additional school lunch points-of-sale (mobile carts and vending machines), and teacher education. Results: From baseline to follow-up, lunch participation dropped 4.1% in intervention and 5.1% in comparison schools (difference-in-difference 1.0%, 95% CI 0.5-1.4). The overall decline in lunch participation occurred simultaneously with a drop-in free or reduced-price meal eligibility (from 72% to 58%) across all schools, which is likely related to changing local economic conditions, including a county-wide minimum wage increase that began in summer 2015. Among students eligible for free or reduced-price meals, participation decreased 1.8% in intervention and 4.9% in comparison schools (difference-in-difference 3.1%, 95% CI: 2.5-3.7), with a larger difference-in-difference seen in high schools (5.0%, 95% CI: 4.2-5.9) than middle schools (1.8%, 95% CI: 0.8-2.6). Conclusions: While this intervention demonstrated a modest, but significant relative increase in school lunch participation, the effect was not sufficient to halt large district-wide declines in participation during this study period. Given the significant time, money, and political capital required to implement the intervention, districts should carefully consider similar investments. Broader public policies or other changes to economic conditions that affect eligibility for means-tested benefits-in this case, a strengthening local economy coupled with an increased local minimum wage-may influence school lunch participation more than school-level interventions.

INTRODUCTION: Since 2012, licensed California child care centers and homes, per state policy, are required to serve only unflavored low-fat or nonfat milk to children aged 2 years or older, no more than one serving of 100% juice daily, and no beverages with added sweeteners, and they are required to ensure that drinking water is readily accessible throughout the day. We evaluated adherence to the policy after 4 years in comparison to the adherence evaluation conducted shortly after the policy went into effect. METHODS: Licensed California child care sites were randomly selected in 2012 and 2016 and surveyed about beverage practices and provisions to children aged 1-5 years. We used logistic regression to analyze between-year differences for all sites combined and within-year differences by site type and participation in the federal Child and Adult Care Food Program (CACFP) in self-reported policy adherence and beverage provisions. RESULTS: Respondents in 2016 (n = 680), compared with those in 2012 (n = 435), were more adherent to Californias 2010 Healthy Beverages in Child Care Act overall (45.1% vs 27.2%, P < .001) and with individual provisions for milk (65.0% vs 41.4%, P < .001), 100% juice (91.2% vs 81.5%, P < .001), and sugar-sweetened beverages (97.4% vs 93.4%, P = .006). In 2016, centers compared with homes (48.5% vs 28.0%, P = .001) and CACFP sites compared with non-CACFP sites (51.6% vs 27.9%, P < .001) were more adherent to AB2084 overall. DISCUSSION: Beverage policy adherence in California child care has improved since 2012 and is higher in CACFP sites and centers. Additional policy promotion and implementation support is encouraged for non-CACFP sites and homes. Other states should consider adopting such policies.

BackgroundWithin 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.ObjectiveThis analysis examined relationships between community programs, policies, and environmental changes (CPPs) for obesity prevention with unhealthy dieting behaviours and body weight satisfaction in children.MethodsUsing 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.ResultsIn 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.ConclusionsResults 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.