"Competitive" Food and Beverage Laws and Obesity Among Diverse Youth in California High Schools.

PURPOSE: To investigate associations between the California "competitive" food and beverage (CF&B) laws and overweight/obesity (OV/OB) among high school youth by gender, school-neighborhood income, and race/ethnicity, and to examine racial/ethnic OV/OB disparities before and after CF&B policies. METHODS: Using an interrupted time series design paired with retrospective cross-sectional Fitnessgram data from 3,565,260 youth-level records on ninth-grade students in California public schools, we estimated gender, school-neighborhood income, and racial/ethnic OV/OB prevalence trends before (2002-2007) and after the CF&B policies were in effect (2008-2012). RESULTS: In the period before the CF&B policies, OV/OB prevalence increased annually among the majority of subgroups regardless of gender, school-neighborhood income and race/ethnicity. In the period after the policies took place, OV/OB increased at a slower rate, plateaued or declined. Changes in log odds of OV/OB trends ranged from -0.03 to -0.07. In the period before the CF&B policies, OV/OB disparities widened between African American and Latino versus White males within each school-neighborhood income tertile; afterwards, disparities ceased to increase or slightly narrowed. DISCUSSION: The California CF&B laws for high schools are associated with favorable trends in youth OV/OB. This is the first study to examine these associations among multiple socio-demographically diverse high school youth simultaneously considering gender, school-neighborhood income and race/ethnicity. The degree to which observed changes in OV/OB trends are attributable to CF&B policies is unclear. Nevertheless, the results suggest that strengthening CF&B policies may help further reduce OV/OB among youth of different genders and ethnicities in schools across neighborhoods of varying income levels.

Effect of diet on the management of hypertension and type 2 diabetes mellitus in adults from low-income and middle-income countries: protocol for a systematic review of randomised controlled trials.

INTRODUCTION: Hypertension and type 2 diabetes mellitus (T2DM) are two highly prevalent non-communicable diseases worldwide, both leading to disability and premature mortality in low-and-middle-income countries (LMICs). Nutritional interventions towards a healthier dietary pattern or food and nutrients intake have an important role on the management of this disease. This systematic review aims to evaluate the effect of nutritional interventions on the management of blood pressure and glycaemia in adults with hypertension and T2DM from LMICs. METHODS AND ANALYSIS: We will conduct a systematic review of randomised controlled trials (RCTs) on the effect of nutritional interventions on blood pressure and glycaemia in adult patients with hypertension and T2DM. Literature search will be conducted in MEDLINE, EMBASE, Scopus, Cochrane and Web of Science databases from anytime until April 2024. Nutritional interventions would have been applied in addition to regular or standard treatment, which is prescribed and/or provided by the healthcare system. Studies in English and Spanish will be selected and reviewed by two independent reviewers. Risk of bias will be assessed using the Cochrane tool for RCTs. Heterogeneity and publication bias will be estimated using the I2 and Egger's test, respectively. ETHICS AND DISSEMINATION: Ethics approval was not required for this systematic review, considering there was no direct data collection or participation of patients. The investigators will write a manuscript of the final detailed report with the study development and main findings to be published in a peer- reviewed journal. The main findings may be shared with academia partners and groups working on similar topics in LMICs, in addition to policymakers and authorities in these countries. PROSPERO REGISTRATION NUMBER: CRD42023483847.

The Quality of Menu Offerings in Independently Owned Restaurants in Baltimore, Maryland: Results from Mixed-Methods Formative Research for the FRESH Trial.

(1) Background: Independently owned restaurants (IORs) are prevalent in under-resourced racial and ethnic minority communities in the US and present a unique setting for public health nutrition interventions. (2) Methods: We conducted 14 in-depth interviews with IOR owners in Baltimore about their perceptions of healthy food, and customers' acceptance of healthier menus and cooking methods and concurrent observations of the availability of healthy options on their menus. Qualitative data were coded and analyzed using ATLAS.ti. Observations were analyzed with statistical analysis performed in R. (3) Results: Owners perceived non-fried options, lean proteins, and plant-based meals as healthy. While open to using healthier cooking fats, they had mixed feelings about reducing salt, adopting non-frying methods for cooking, and adding vegetables and whole grains to the menu, and were reluctant to reduce sugar in recipes and beverages. Only 17.5% of 1019 foods and 27.6% of 174 beverages in these IORs were healthy, with no significant differences in the healthfulness of restaurant offerings within low-healthy-food-access/low-income neighborhoods and those outside. (4) Conclusion: Healthy options are generally scarce in Baltimore's IORs. Insights from owners inform future interventions to tailor healthy menu offerings that are well-received by customers and feasible for implementation.

Temporal Patterns in Fruit and Vegetable Intake Among Racially and Ethnically Diverse Children and Adolescents in California.

Introduction: Childhood dietary behaviors, including fruit and vegetable intake, are associated with adult health. Most children do not meet daily recommended servings of fruits and vegetables. Less is known about temporal patterns in fruit and vegetable consumption or if they vary by race and ethnicity. We investigated temporal patterns in fruit and vegetable intake among California school-age children and adolescents overall and by race and ethnicity. Methods: We used 2-year cross-sectional datasets from the child and adolescent samples in the California Health Interview Surveys from 2011-2012 through 2019-2020 and modified Poisson regression models to estimate the likelihood of consuming 5 or more servings of fruits and vegetables in 2013-2016 and 2017-2020 compared with 2011-2012. Models controlled for age, race and ethnicity, gender, citizenship status, family income, and adult education and tested for differences by race and ethnicity. The samples included 16,125 children aged 5 to 11 years and 9,672 adolescents aged 12 to 17 years. Results: Overall, 29.3% of children and 25.9% of adolescents reported intake of 5 or more fruits and vegetables per day. Among children, adjusted prevalence ratios (PR) of fruit and vegetable intake were higher in 2013-2016 (PR,1.25; 95% CI, 1.11-1.42) and 2017-2020 (PR,1.13; 95% CI, 0.99-1.30) compared with 2011-2012. Among adolescents, the adjusted prevalence did not differ significantly over time. We found no evidence of differential associations by race and ethnicity for children and adolescents. Conclusion: We found favorable temporal changes in fruit and vegetable consumption among children, but not among adolescents. Monitoring temporal patterns in fruit and vegetable intake remains critical for planning population-level interventions to increase consumption.

"Competitive" food and beverage policies and weight status: A systematic review of the evidence among sociodemographic subgroups.

Prior studies identified variable associations between competitive food and beverage policies (CF&B) and youth obesity, potentially due to differences across population subgroups. This review summarizes the evidence on associations between CF&B policies and childhood obesity within gender, grade level/ age, race/ethnicity, and/or socioeconomic levels. PubMed, EMBASE, CINAHL, and ERIC database searches identified studies published in English in Canada and the United States between January 1, 2000, and February 28, 2022. Of the 18 selected studies, six were cross-sectional, two correlational, nine were before/after designs, and one study utilized both a cross-sectional and pre-post design. Twelve studies reported findings stratified by a single sociodemographic factor, with grade level/age as the most frequently reported. Although the evidence varied, greater consistency in direction of associations and strengths of evidence were seen among middle school students. Six studies reported findings jointly by multiple sociodemographic subgroups with evidence suggesting CF&B associations with slower rate of increase or plateaus or declines in obesity among multiple subgroups, though the strengths of evidence varied. Over the past two decades, there have been relatively limited subgroup analyses on studies about CF&B policies and childhood obesity. Studies are needed with stronger designs and analyses disaggregated, particularly by race/ethnicities and socioeconomic factors, across places and time.

CML Outcomes and Care Delivery During the COVID-19 Pandemic in Low- and Middle-Income Countries.

PURPOSE OF REVIEW: The study aims to evaluate the impact of COVID-19 on the delivery of health care and services to patients with chronic myeloid leukemia in low- and middle-income countries (LMICs) accessing treatment through The Max Foundation. RECENT FINDINGS: An online survey was developed and sent via email to 527 partner physicians who had active patients under their care in July 2020, asking about the disruption of health services with multiple-choice answers or a five-point ordinal scale. Data from The Max Foundation's Patient Access Tracking System (PATS®) was analyzed to evaluate program performance in 2020 compared with 2019. PATS® is used to track key patient information and supply chain data to ensure robust reporting, quality assurance, and safety. Among the 111 physicians who responded (20% response rate), 48% reported that someone on their team had contracted COVID-19. A total of 95 (85%) physicians reported at least some disruption of services to patients due to COVID-19, with 29 (26%) reporting frequent or complete disruption. Almost all physicians in the South Asia and Asia Pacific regions reported disruption (96% and 95%, respectively), compared with three quarters of physicians in Latin America. Institutions overcame challenges using a variety of solutions including telemedicine (60%), electronic prescriptions (45%), home delivery via courier services (31%), government workers (9%), and dispensation coordination with regional hospitals (14%). The COVID-19 pandemic has disrupted services for CML physicians and patients worldwide. Overall, these disruptions did not appear to significantly affect The Max Foundation's ability to provide patients with access to treatment, as novel approaches in telemedicine, supply chain, and dispensing, as well as provision of guidance and support for physicians were utilized to overcame disruption of services.

Trends in school-neighbourhood inequalities and youth obesity: Repeated cross-sectional analyses of the public schools in the state of California.

BACKGROUND: It is currently unknown whether the relationship between affluence of school neighbourhoods and prevalence of youth overweight/obesity is uniform across demographic subgroups and areal context in the United States. METHODS: We examined association between school-neighbourhood income tertiles and school-level overweight/obesity (OVOB) prevalence, using data on body mass index of fifth, seventh, and nineth graders who attended public schools in California in 2001 and 2010 (n = 1 584 768), using multiple logistic regression models. RESULTS: Overall, OVOB prevalence was higher in lower-income school neighbourhoods, with a steeper income-OVOB gradient for girls. Among boys, the gradient became steeper in 2010 than 2000. Among Asian and White girls, the negative gradients were steepest in rural areas. For African-American students in all areas and Latino boys in rural areas, there was less clear evidence of inverse income-OVOB gradients. Addition of fast-food restaurant availability to the models did not change the observed inverse school-neighbourhood income-obesity gradients. CONCLUSIONS: The findings suggest the needs to investigate reasons for this variability with consideration to combinations of sociodemographic, economic, and environmental risk factors that may contribute to disparities in childhood obesity.

Characterizing food environments near schools in California: A latent class approach simultaneously using multiple food outlet types and two spatial scales.

It is challenging to evaluate associations between the food environment near schools with either prevalence of childhood obesity or with socioeconomic characteristics of schools. This is because the food environment has many dimensions, including its spatial distribution. We used latent class analysis to classify public schools in urban, suburban, and rural areas in California into food environment classes based on the availability and spatial distribution of multiple types of unhealthy food outlets nearby. All urban schools had at least one unhealthy food outlet nearby, compared to seventy-two percent of schools in rural areas did. Food environment classes varied in the quantity of available food outlets, the relative mix of food outlet types, and the outlets' spatial distribution near schools. Regardless of urbanicity, schools in low-income neighborhoods had greater exposure to unhealthy food outlets. The direction of associations between food environment classes and school size, type, and race/ethnic composition depends on the level of urbanicity of the school locations. Urban schools attended primarily by African American and Asian children are more likely to have greater exposures to unhealthy food outlets. In urban and rural but not suburban areas, schools attended primarily by Latino students had more outlets offering unhealthy foods or beverages nearby. In suburban areas, differences in the spatial distribution of food outlets indicates that food outlets are more likely to cluster near K-12 schools and high schools compared to elementary schools. Intervention design and future research need to consider that the associations between food environment exposures and school characteristics differ by urbanicity.

Racial/ethnic disparities in childhood obesity: The role of school segregation.

OBJECTIVE: Recent studies have observed that racial or ethnic adult health disparities revealed in national data dissipate in racially integrated communities, supporting the theory that "place, not race" shapes the nature and magnitude of racial/ethnic health disparities. This study tested this theory among children. METHODS: In 2020, the racial/ethnic childhood obesity disparities within integrated schools and between segregated schools were estimated using statewide cross-sectional data collected in 2019 on fifth, seventh, and ninth grade students from California public schools. RESULTS: School segregation accounted for a large part of the obesity disparities between White children and children of color (Latino, Black, and Filipino children). In racially integrated schools, obesity disparities were much smaller than those in statewide data, whereas racial or ethnic childhood obesity disparities were larger when comparing children in majority-White schools with those attending schools with a majority enrollment of children of color, except for Asian children, who generally had lower obesity rates than their White peers. CONCLUSIONS: School-level racial segregation is a salient contributor to racial/ethnic childhood obesity disparities. Reducing obesity disparities may be particularly effective if place-level interventions target socioeconomically disadvantaged integrated schools and segregated schools attended primarily by children of color.

Competitive Food and Beverage Policies and Obesity among Middle School Students: Variability by Urbanicity in California.

Introduction: This study examined the association between California school nutrition policies and population-level trends in childhood overweight/obesity by levels of urbanicity. Methods: We used interrupted time series with Fitnessgram data on overweight/obesity from the period 2002 to 2010 pertaining to African American, Latino, Asian, and White students in seventh grades who attended California public schools. We used multilevel logistic regression models to examine the impact of the introduction of successive California school nutrition policies on overweight/obesity prevalence, stratified by gender and adjusted for school district-, school-, and student-level characteristics. Results: At the start of the study period, rural areas and second cities (i.e., population centers with lower population densities than urban areas) had relatively low prevalence, but experienced sharp increases in 2002-2004, leading to higher prevalence of overweight/obesity than suburban areas. There was evidence of beneficial policy influences on overweight/obesity in most areas, except for girls in urban areas and boys in second cities. The evidence of beneficial changes was strongest among children attending schools located in rural areas, and boys in suburban and urban areas. These results persisted even after we accounted for differences in racial/ethnic compositions, socioeconomic characteristics of the schools and school neighborhoods, and school sizes, as well as child-level race/ethnicity, age, and student fitness levels. Conclusion: Despite evidence of beneficial policy impact, childhood obesity prevalence remains high, especially in urban areas in California. Additional policies and environmental interventions are recommended to address obesogenic risk factors unique to each area.

Low Healthy Diet Self-Efficacy and Intentions Associated with High Sweet Snacks and Sugar Sweetened Beverages Consumption among African American Adolescents Recruited from Low-Income Neighborhoods in Baltimore.

Psychosocial factors may influence consumption patterns of sweet snacks and sugar sweetened beverages (SSB), which are potential risk factors for obesity among African American (AA) adolescents. We used multivariable linear and logistic regression models to examine cross-sectional associations among psychosocial factors, sweet snacks and SSB consumption, and BMI z-scores in 437 AA adolescents aged 9-14 years living in low-income neighborhoods in Baltimore City, U.S.A. Mean caloric intake from sugar was 130.64 ± 88.37 kcal. Higher sweet snacks consumption was significantly associated with lower self-efficacy (adjusted Odds Ratio (aOR) = 0.81; 95% CI = 0.71 to 0.93) and lower food intentions scores (0.43; 0.30 to 0.61). Higher SSB consumption was associated with lower outcome expectancies (aOR = 0.98; 95% CI = 0.96-0.99), lower self-efficacy (0.98; 0.96 to 0.99), and lower food intentions (0.91; 0.87 to 0.95). No significant association was found between SSB and sweet snacks consumption and weight status. Psychosocial factors may play a role in sugar consumption behaviors among AA adolescents in low-income neighborhoods. Further studies are needed to improve our understanding of causal mechanisms of this association.

Sleep apnea, coronary artery calcium density, and cardiovascular events: results from the Multi-Ethnic Study of Atherosclerosis.

STUDY OBJECTIVES: Evaluate the association between obstructive sleep apnea (OSA), coronary artery calcium (CAC) density, and cardiovascular events in the Multi-Ethnic Study of Atherosclerosis (MESA). METHODS: We analyzed 1,041 participants with nonzero CAC scores who had polysomnography and CAC density data from the fifth examination of the Multi-Ethnic Study of Atherosclerosis. OSA was defined as apnea-hypopnea index ≥ 15 events/h. Multivariable linear regression models were used to evaluate the independent association between OSA and CAC density. Additionally, we evaluated the impact of OSA on associations of CAC measures with incident cardiovascular disease events by testing for interaction in Cox proportional hazard regression models. RESULTS: Our analytical sample was 45% female with a mean age of 70.6 +/- 9 years. Of this sample, 36.7% (n = 383/1041) had OSA (apnea-hypopnea index ≥ 15 events/h). OSA was inversely and weakly associated with CAC density (ß = -0.09; 95% CI, -0.17 to -0.02; P = .014) and remained significantly associated after controlling for traditional cardiovascular risk factors (ß = -0.08; 95% CI, -0.16 to 0; P = .043). However, this inverse association was attenuated after controlling for body mass index (ß = -0.05; 95% CI, -0.13 to 0.02; P = .174). The mean follow-up period for cardiovascular disease events was 13.3 +/- 2.8 years. Additionally, exploratory analysis demonstrated that CAC density was independently and inversely associated with cardiovascular disease events only in the non-OSA subgroup (apnea-hypopnea index ≤ 15 events/h) (hazard ratio, 0.509; 95% CI, 0.323-0.801); P = .0035). CONCLUSIONS: OSA was associated with lower CAC density, but this association was attenuated by body mass index. Further, increased CAC density was associated with a reduced risk of cardiovascular disease events only in individuals within the non-OSA group in exploratory analysis. CITATION: Newman SB, Kundel V, Matsuzaki M, et al. Sleep apnea, coronary artery calcium density, and cardiovascular events: results from the Multi-Ethnic Study of Atherosclerosis. J Clin Sleep Med. 2021;17(10):2075-2083.

Exploration of Machine Learning and Statistical Techniques in Development of a Low-Cost Screening Method Featuring the Global Diet Quality Score for Detecting Prediabetes in Rural India.

BACKGROUND: The prevalence of type 2 diabetes has increased substantially in India over the past 3 decades. Undiagnosed diabetes presents a public health challenge, especially in rural areas, where access to laboratory testing for diagnosis may not be readily available. OBJECTIVES: The present work explores the use of several machine learning and statistical methods in the development of a predictive tool to screen for prediabetes using survey data from an FFQ to compute the Global Diet Quality Score (GDQS). METHODS: The outcome variable prediabetes status (yes/no) used throughout this study was determined based upon a fasting blood glucose measurement ≥100 mg/dL. The algorithms utilized included the generalized linear model (GLM), random forest, least absolute shrinkage and selection operator (LASSO), elastic net (EN), and generalized linear mixed model (GLMM) with family unit as a (cluster) random (intercept) effect to account for intrafamily correlation. Model performance was assessed on held-out test data, and comparisons made with respect to area under the receiver operating characteristic curve (AUC), sensitivity, and specificity. RESULTS: The GLMM, GLM, LASSO, and random forest modeling techniques each performed quite well (AUCs >0.70) and included the GDQS food groups and age, among other predictors. The fully adjusted GLMM, which included a random intercept for family unit, achieved slightly superior results (AUC of 0.72) in classifying the prediabetes outcome in these cluster-correlated data. CONCLUSIONS: The models presented in the current work show promise in identifying individuals at risk of developing diabetes, although further studies are necessary to assess other potentially impactful predictors, as well as the consistency and generalizability of model performance. In addition, future studies to examine the utility of the GDQS in screening for other noncommunicable diseases are recommended.

Validation of Global Diet Quality Score Among Nonpregnant Women of Reproductive Age in India: Findings from the Andhra Pradesh Children and Parents Study (APCAPS) and the Indian Migration Study (IMS).

BACKGROUND: In India, there is a need to monitor population-level trends in changes in diet quality in relation to both undernutrition and noncommunicable diseases. OBJECTIVES: We conducted a study to validate a novel diet quality score in southern India. METHODS: We included data from 3041 nonpregnant women of reproductive age (15-49 years) from 2 studies in India. Diet was assessed using a validated food frequency questionnaire (FFQ). The Global Diet Quality Score (GDQS) was calculated from 25 food groups (16 healthy; 9 unhealthy), with points for each group based on the frequency and quantity of items consumed in each group. We used Spearman correlations to examine correlations between the GDQS and several nutrient intakes of concern. We examined associations between the GDQS [overall, healthy (GDQS+), and unhealthy (GDQS-) submetrics] and overall nutrient adequacy, micro- and macronutrients, body mass index (BMI), midupper arm circumference, hemoglobin, blood pressure, high density lipoprotein (HDL), and total cholesterol (TC). RESULTS: The mean GDQS was 23 points (SD, 3.6; maximum, 46.5). In energy-adjusted models, positive associations were found between the overall GDQS and GDQS+ and intakes of calcium, fiber, folate, iron, monounsaturated fatty acid (MUFA), protein, polyunsaturated fatty acid (PUFA), saturated fatty acid (SFA), total fat, and zinc (ρ = 0.12-0.39; P < 0.001). Quintile analyses showed that the GDQS was associated with better nutrient adequacy. At the same time, the GDQS was associated with higher TC, lower HDL, and higher BMI. We found no associations between the GDQS and hypertension. CONCLUSIONS: The GDQS was a useful tool for reflecting overall nutrient adequacy and some lipid measures. Future studies are needed to refine the GDQS for populations who consume large amounts of unhealthy foods, like refined grains, along with healthy foods included in the GDQS.

There's an App for That: Development of an Application to Operationalize the Global Diet Quality Score.

BACKGROUND: The global diet quality score (GDQS) is a simple, standardized metric appropriate for population-based measurement of diet quality globally. OBJECTIVES: We aimed to operationalize data collection by modifying the quantity of consumption cutoffs originally developed for the GDQS food groups and to statistically evaluate the performance of the operationalized GDQS relative to the original GDQS against nutrient adequacy and noncommunicable disease (NCD)-related outcomes. METHODS: The GDQS application uses a 24-h open-recall to collect a full list of all foods consumed during the previous day or night, and automatically classifies them into corresponding GDQS food group. Respondents use a set of 10 cubes in a range of predetermined sizes to determine if the quantity consumed per GDQS food group was below, or equal to or above food group-specific cutoffs established in grams. Because there is only a total of 10 cubes but as many as 54 cutoffs for the GDQS food groups, the operationalized cutoffs differ slightly from the original GDQS cutoffs. RESULTS: A secondary analysis using 5 cross-sectional datasets comparing the GDQS with the original and operationalized cutoffs showed that the operationalized GDQS remained strongly correlated with nutrient adequacy and was equally sensitive to anthropometric and other clinical measures of NCD risk. In a secondary analysis of a longitudinal cohort study of Mexican teachers, there were no differences between the 2 modalities with the beta coefficients per 1 SD change in the original and operationalized GDQS scores being nearly identical for weight gain (-0.37 and -0.36, respectively, P < 0.001 for linear trend for both models) and of the same clinical order of magnitude for waist circumference (-0.52 and -0.44, respectively, P < 0.001 for linear trend for both models). CONCLUSION: The operationalized GDQS cutoffs did not change the performance of the GDQS and therefore are recommended for use to collect GDQS data in the future.

Development and Validation of a Novel Food-Based Global Diet Quality Score (GDQS).

BACKGROUND: Poor diet quality is a major driver of both classical malnutrition and noncommunicable disease (NCD) and was responsible for 22% of adult deaths in 2017. Most countries face dual burdens of undernutrition and NCDs, yet no simple global standard metric exists for monitoring diet quality in populations and population subgroups. OBJECTIVES: We aimed to develop an easy-to-use metric for nutrient adequacy and diet related NCD risk in diverse settings. METHODS: Using cross-sectional and cohort data from nonpregnant, nonlactating women of reproductive age in 10 African countries as well as China, India, Mexico, and the United States, we undertook secondary analyses to develop novel metrics of diet quality and to evaluate associations between metrics and nutrient intakes and adequacy, anthropometry, biomarkers, type 2 diabetes, and iteratively modified metric design to improve performance and to compare novel metric performance to that of existing metrics. RESULTS: We developed the Global Diet Quality Score (GDQS), a food-based metric incorporating a more comprehensive list of food groups than most existing diet metrics, and a simple means of scoring consumed amounts. In secondary analyses, the GDQS performed comparably with the Minimum Dietary Diversity - Women indicator in predicting an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B12 adequacy and with anthropometric and biochemical indicators of undernutrition (including underweight, anemia, and serum folate deficiency), and the GDQS also performed comparably or better than the Alternative Healthy Eating Index - 2010 in capturing NCD-related outcomes (including metabolic syndrome, change in weight and waist circumference, and incident type 2 diabetes). CONCLUSIONS: The simplicity of the GDQS and its ability to capture both nutrient adequacy and diet-related NCD risk render it a promising candidate for global monitoring platforms. Research is warranted to validate methods to operationalize GDQS assessment in population surveys, including a novel application-based 24-h recall system developed as part of this project.

School nutrition laws in the US: do they influence obesity among youth in a racially/ethnically diverse state?

BACKGROUND/OBJECTIVES: Little is known about the separate or combined effects of state and national nutrition policies regulating food and beverages in schools on child overweight/obesity (OV/OB) and related racial/ethnic disparities. We investigated the influence of school nutrition policies enacted in California, independently and in combination with the United States' national policy "Healthy Hunger Free Kids Act" (HHFKA) on childhood OV/OB and racial/ethnic disparities. SUBJECTS/METHODS: An interrupted time series design was used with data from 12,363,089 child-level records on 5th- and 7th-graders in California public schools to estimate sex- and racial/ethnic-specific time trends in OV/OB prevalence during three periods: before the California nutrition policies (2002-2004); when only California policies were in effect (2005-2012); and when they were in effect simultaneously with HHFKA (2013-2016). RESULTS: Before the state's policies, OV/OB prevalence increased annually among children in most subgroups. Improvements in OV/OB trends were observed for almost all groups after the California policies were in effect, with further improvements after the addition of HFFKA. The total change in annual log-odds of OV/OB, comparing the periods with both state and federal policies versus no policies, ranged from -0.08 to -0.01 and varied by grade, sex, and race/ethnicity. Within each sex and grade, the greatest changes were among African-American (-0.08 to -0.02, all p < 0.05) followed by Latino children (-0.06 to -0.01, all p < 0.05). Although disparities narrowed among these groups versus White children after the dual policy period, disparities remained large. CONCLUSIONS: State and national nutrition policies for schools may have contributed to containing the upward trend in childhood OV/OB and racial/ethnic OV/OB disparities within California. However, sizable OV/OB prevalence and disparities persist. To end the epidemic, promote healthy weight and increase health equity, future efforts should strengthen state and national policies to improve food quality in schools, particularly those serving populations with the highest OV/OB prevalence.

Physical activity strategies in low-resource elementary schools: Why and how are they prioritized?

Most US children do not achieve the recommended daily 60 minutes of moderate to vigorous physical activity (PA). Schools are ideal settings to promote PA given their reach to large child populations, including students with less resources and limited access to PA opportunities. Although limited in numbers, schools that offer enough PA strategies can provide insights to increase PA in these settings. However, few studies have examined why and how these schools successfully prioritize PA strategies, particularly schools serving socioeconomically disadvantaged student populations. This qualitative study of low-resource, PA-supportive schools was conducted during 2017-2018 to obtain in-depth information about why and how schools make decisions to prioritize and implement PA strategies. Forty-two study participants in 17 states plus Washington DC were recruited. Content analysis revealed the following themes: (1) Schools prioritize PA because it helps advance learning and health goals; (2) Policies and standards for PA/PE reinforce the importance of PA; (3) A culture of learning and health advances decisions to offer PA; (4) Advocates play a key role in generating support to integrate PA; (5) Stakeholder buy-in enables decisions to offer PA opportunities; (6) Collaboration focused on PA specifically can facilitate decisions to increase PA strategies; and (7) Funding and resources drive decisions to put PA strategies into practice. The study findings offer insights that may be useful in efforts to increase access to PA opportunities in low-resource elementary schools.

California and federal school nutrition policies and obesity among children of Pacific Islander, American Indian/Alaska Native, and Filipino origins: Interrupted time series analysis.

BACKGROUND: Obesity prevalence remains high among children of Pacific Islander (PI) origin, Filipino (FI), and American Indian/Alaska Native (AIAN) origins in the United States. While school nutrition policies may help prevent and reduce childhood obesity, their influences specifically among PI, FI, and AIAN children remain understudied. We evaluated the association of the California (CA) state school nutrition policies for competitive food and beverages and the federal policy for school meals (Healthy, Hunger-Free Kids Act of 2010 (HHFKA 2010)) with overweight/obesity among PI, FI, and AIAN students. METHODS AND FINDINGS: We used an interrupted time series (ITS) design with FitnessGram data from 2002 to 2016 for PI (78,841), FI (328,667), AIAN (97,129), and White (3,309,982) students in fifth and seventh grades who attended CA public schools. Multilevel logistic regression models estimated the associations of the CA school nutrition policies (in effect beginning in academic year 2004 to 2005) and HHFKA 2010 (from academic year 2012 to 2013) with overweight/obesity prevalence (above the 85 percentile of the age- and sex-specific body mass index (BMI) distribution). The models were constructed separately for each grade and sex combination and adjusted for school district-, school-, and student-level characteristics such as percentage of students eligible for free and reduced price meals, neighborhood income and education levels, and age. Across the study period, the crude prevalence of overweight/obesity was higher among PI (39.5% to 52.5%), FI (32.9% to 36.7%), and AIAN (37.7% to 45.6%) children, compared to White (26.8% to 30.2%) students. The results generally showed favorable association of the CA nutrition policies with overweight/obesity prevalence trends, although the magnitudes of associations and strengths of evidence varied among racial/ethnic subgroups. Before the CA policies went into effect (2002 to 2004), overweight/obesity prevalence increased for White, PI, and AIAN students in both grades and sex groups as well as FI girls in seventh grade. After the CA policies took place (2005 to 2012), the overweight/obesity rates decreased for almost all subgroups who experienced increasing trends before the policies, with the largest decrease seen among PI girls in fifth grade (before: log odds ratio = 0.149 (95% CI 0.108 to 0.189; p < 0.001); after: 0.010 (-0.005 to 0.025; 0.178)). When both the CA nutrition policies and HHFKA 2010 were in effect (2013 to 2016), declines in the overweight/obesity prevalence were seen among White girls and FI boys in fifth grade. Despite the evidence of the favorable association of the school nutrition policies with overweight/obesity prevalence trends, disparities between PI and AIAN students and their White peers remained large after the policies took place. As these policies went into effect for all public schools in CA, without a clear comparison group, we cannot conclude that the changes in prevalence trends were solely attributable to these policies. CONCLUSIONS: The current study found evidence of favorable associations of the state and federal school nutrition policies with overweight/obesity prevalence trends. However, the prevalence of overweight/obesity continued to be high among PI and AIAN students and FI boys. There remain wide racial/ethnic disparities between these racial/ethnic minority subgroups and their White peers. Additional strategies are needed to reduce childhood obesity and related disparities among these understudied racial/ethnic populations.