Evaluating the Association of the Increase in the WIC Cash Value Benefit on the Diversity of MyPlate Fruits and Vegetables Redeemed and Consumed By Children in Low-Income Households.

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 (ß: 1.6 pts; 95% confidence interval [CI]: 1.4, 1.7), total vegetable (ß: 3.6 pts; 95%CI: 3.4, 3.9), and total FV (ß: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.

The Benefits and Challenges of Providing School Meals during the First Year of California's Universal School Meal Policy as Reported by School Foodservice Professionals.

States in the U.S. are newly implementing universal school meal (USM) policies, yet little is known about the facilitators of their success and the challenges they confront. This study evaluated the challenges and facilitators faced by school food authorities (SFAs) implementing California's universal school meal (USM) policy during its inaugural year (2022-2023) using an online survey. In March 2023, 430 SFAs reported many benefits, including increased meal participation (64.2% of SFAs) and revenues (65.7%), reduced meal debt (41.8%) and stigma (30.9%), and improved meal quality (44.3%) and staff salaries (36.9%). Reported challenges include product/ingredient availability (80.9%), staffing shortages (77.0%), vendor/distributor logistics issues (75.9%), and administrative burden (74.9%). Top facilitators included state funding (78.2%) and increased federal reimbursement (77.2%). SFAs with fewer students eligible for free or reduced-price meals (as opposed to SFAs with more) reported greater increases in meal participation and reductions in stigma but also more administrative burdens. Larger SFAs reported greater increases in revenues, staff salaries, and improvements in meal quality than smaller SFAs but also more challenges. Overall, California's USM policy has enhanced student access to healthy meals while mitigating social and financial barriers. Understanding California's experience can inform other jurisdictions considering or implementing similar policies.

Students' Perspectives on the Benefits and Challenges of Universal School Meals Related to Food Accessibility, Stigma, Participation, and Waste.

OBJECTIVE: To reveal students' experiences and perspectives related to Universal School Meals (USM) under the federal coronavirus disease 2019 waivers during school years 2021-22. DESIGN: Qualitative; 17 focus groups in June-July 2022. SETTING: Virtual; students from 9 California regions in public and charter schools. PARTICIPANTS: 67 students (n = 31 in high school, n = 36 in middle school) from a racially and economically diverse sample. PHENOMENON OF INTEREST: Students' perceived benefits and drawbacks of USM. ANALYSIS: Thematic analysis using an immersion-crystallization approach. RESULTS: Students appreciated USM for increasing school meals' accessibility, promoting food security by financially supporting families, reducing the stigma associated with school meals, simplifying the payment system, and enhancing school meals convenience. An increase in school meal participation was observed. However, concerns emerged regarding a perceived decline in food quality and quantity and increased food waste. CONCLUSIONS AND IMPLICATIONS: Universal School Meals showed promise in increasing access to meals, reducing food insecurity, stigma, and increasing participation. Addressing food quality, quantity, and waste concerns is critical for its sustained success. Policymakers need to advocate for the expansion and continuous refinement of USM, prioritizing stakeholder feedback. Ensuring adequate funding to balance meal quality and quantity while minimizing waste is essential for an adequate school meal policy.

Universal School Meals During the Pandemic: A Mixed Methods Analysis of Parent Perceptions From California and Maine.

BACKGROUND: In response to the COVID-19 pandemic, the US Congress authorized the US Department of Agriculture to waive a variety of school meal regulations and funded school meals daily for all students at no charge regardless of family income. Because federal Universal Free School Meals (UFSM) ended with the 2021-2022 school year, several states, including California and Maine, adopted state-level UFSM policies. OBJECTIVE: This study aimed to understand parent perceptions of school meals and the federal and new state UFSM policies in California and Maine, including potential challenges and benefits to students and households. DESIGN: A mixed methods study design was used. A quantitative cross-sectional survey was administered, and semi-structured interviews were conducted in English and Spanish during the 2021-2022 school year. PARTICIPANTS/SETTING: The quantitative survey was administered to parents of students in elementary, middle, and high schools in rural, suburban, and urban communities in California (n = 1110) and Maine (n = 80). Qualitative interviews were then conducted with a subset of these parents in California (n = 46) and Maine (n = 20) using Zoom (Zoom Video Communications). Most survey participants (708 of 1190 [59.5%]) and interviewees (40 of 66 [60.6%]) were parents of students who were eligible for free or reduced-price meals. MAIN OUTCOME MEASURES: Parents' perceptions of UFSM, school meal quality, and experiences applying for free or reduced-price meals were examined. ANALYSES PERFORMED: Tests of proportions were used to analyze survey data. Using grounded theory, interview transcripts were analyzed qualitatively by 2 trained research assistants, applying principles of content analysis to identify themes and domains. Inter-rater reliability was conducted. RESULTS: Parents perceived that school meals and UFSM saved families money and time, as parents had fewer meals to purchase and prepare for their children. In addition, UFSM reduced parents' stress and reduced stigma for children and for parents, who described feelings of embarrassment when they previously filled out paperwork for free or reduced-price meals. Although parent perceptions of school meal quality and healthfulness were mixed, most parents reported feeling grateful for school meals. CONCLUSIONS: Parents had mixed opinions on the quality and healthfulness of school meals, but believed UFSM saved them money and time and reduced their stress. Parents also felt UFSM reduced stigma for families.

School Meals for All: A Qualitative Study Exploring Lessons in Successful Advocacy and Policymaking in Maine and California.

BACKGROUND: The COVID-19 pandemic focused national attention on food insecurity, equity, and the role of school meal programs in supporting children, families, and communities. In doing so, the pandemic created a rare policy window-an opportunity to advance a longstanding public health goal of guaranteed access to free school meals for all students. In July 2021, California and Maine became the first states to authorize school meal for all legislation (also known as universal free meals). OBJECTIVE: The aim of this study was to explore perspectives of policymakers, state agency officials, and advocates on the conditions and mechanisms that facilitated passage of school meal for all legislation in California and Maine. DESIGN: A qualitative case study was conducted. PARTICIPANTS: Between December 2021 and June 2022, semistructured interviews were conducted with 30 policymakers, state agency officials, and advocates. STATISTICAL ANALYSIS PERFORMED: Interviews were analyzed using principles of content analysis. Key themes are organized using Kingdon's multiple streams framework for public policy. RESULTS: Eleven key themes were identified. Lessons are drawn from the policy and advocacy strategies used to advance laws in California and Maine. For instance, paving the way with incremental policy change, tailoring messaging to diverse audiences, and organizing at the grassroots and grasstops levels were critical to success of advocacy efforts. CONCLUSIONS: Promising practices can guide efforts to expand access to school meals and advance other child nutrition policies in other states and nationally. Moving forward, lessons learned from implementation of universal free school meal legislation in California, Maine, and other early adopters should be documented and shared.

Parent perceptions of school meals and how perceptions differ by race and ethnicity.

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.

Parent Perceptions of School Meals Influence Student Participation in School Meal Programs.

OBJECTIVE: To evaluate if parent perceptions of school meals influence student participation. DESIGN: In May 2022, an online survey was used to evaluate parents' perceptions of school meals and their children's participation. PARTICIPANTS: A total of 1,110 California parents of kindergarten through 12th-grade students. MAIN OUTCOME MEASURES: Student participation in school lunch and breakfast. ANALYSIS: Principal component analysis and Poisson regression models. RESULTS: Three groups of parental perceptions were identified: (1) positive perceptions (eg, liking school meals and thinking that they are tasty and healthy), (2) perceived benefits to families (eg, school meals save families money, time, and stress), and (3) negative (eg, concerns about the amount of sugar in school meals and stigma). More positive parental perceptions about school meals and their benefits to families were associated with greater student meal participation. In contrast, more negative parental perceptions were associated with reduced student participation in school meals (P < 0.05). CONCLUSION AND IMPLICATIONS: Parent perceptions of school meals may affect student participation in school meal programs. Working to ensure parents are familiar with the healthfulness and quality of school meals and the efforts schools are making to provide high-quality, appealing meals may be critical for increasing school meal participation rates.

Associations of Increased WIC Benefits for Fruits and Vegetables With Food Security and Satisfaction by Race and Ethnicity.

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.

SNAP Student Rules Are Not So Snappy: Lessons Learned From a Qualitative Study of California County Agency Workers.

OBJECTIVE: To examine the college student Supplemental Nutrition Assistance Program (SNAP) application process from the perspective of county agency workers. DESIGN: A qualitative study that included semistructured individual and group interviews (n = 14) between February and December, 2021. SETTING: Nine California counties with a University of California campus. PARTICIPANTS: A total of 24 county agency workers who regularly process or advise on college student SNAP applications. PHENOMENON OF INTEREST: Facilitators and barriers to processing student SNAP applications. ANALYSIS: Interviews were recorded, transcribed, and coded using thematic analysis. RESULTS: Five themes were identified regarding student applications: (1) a need for more consistency in policy dissemination and program administration, (2) student exemptions and the application process are perceived as challenging for students, (3) facilitators of successfully processing student applications, (4) tracking policy changes is burdensome, and (5) eliminate the student rules. CONCLUSION AND IMPLICATIONS: County agency workers perceived that students experience unnecessary barriers to accessing SNAP benefits and that implementing the student rules was taxing. Expanding SNAP access to low-income college students could be an equitable solution to mitigate the risk of student hunger while they pursue their degrees.

Cohort profile: the longitudinal National Growth and Health Study (NGHS) of black and white girls from Northern California tracking how behavioural and psychosocial risk factors predict cardiovascular risk and biological ageing in midlife and in offspring.

PURPOSE: The 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. PARTICIPANTS: Beginning 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 DATE: Longitudinal 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 PLANS: New 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 NUMBER: NCT00005132.

Differences in Infant Diet Quality Index by Race and Ethnicity Predict Differences in Later Diet Quality.

BACKGROUND: Racial and ethnic disparities in infant-feeding practices may negatively influence diet quality and health. OBJECTIVES: This study investigated the racial, ethnic, and language (English or Spanish) differences in infant diet quality, later diet quality, and weight status at 2-5 y, and whether these differences were explained through infant diet quality among participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). METHODS: Using the WIC Infant and Toddler Feeding Practices Study-2 (unweighted n = 2663; weighted n = 362,712), relationships between the Infant Dietary Quality Index (IDQI; range 0-1) and Healthy Eating Index-2020 (HEI-2020; range 0-100) and BMI z-score (BMIz) at 2-5 y were analyzed by race, ethnicity, and language preference [Hispanic Spanish-speaking, Hispanic English-speaking, non-Hispanic (NH) White, and NH Black participants]. Statistical interaction between IDQI and each group was evaluated in multivariable models. The mediation of each group through the IDQI was assessed using causal mediation methods. RESULTS: Differences in IDQI [mean (standard deviation)] were observed between Hispanic Spanish-speaking participants [0.41 (0.10)], Hispanic English-speaking participants [0.37 (0.10)], NH White participants [0.36 (0.10)], and NH Black participants [0.35 (0.09)], P < 0.001. Differences in HEI-2020 occurred at 2-5 y, with the Hispanic Spanish-speaking participants having consistently higher HEI-2020 scores. Differences in BMIz were observed at 5 y, with higher scores among Hispanic Spanish-speaking participants. Interaction between race, ethnicity, and IDQI was observed for all outcomes except for BMIz at 3 y. Through mediation, IDQI explained 13%-20% of the difference in HEI-2020 scores between Hispanic Spanish-speaking and NH White participants at 2-5 y. IDQI explained 22%-25% of the difference in HEI-2020 scores between the Hispanic Spanish-speaking and NH Black participants at 4 y and 5 y. CONCLUSIONS: Higher infant diet quality scores observed in Hispanic Spanish-speaking participants explain some of the racial and ethnic differences observed in later diet quality, suggesting that improving infant diet quality may help reduce diet disparities during early childhood.

Increased WIC Cash Value Benefit is Associated with Greater Amount and Diversity of Redeemed Fruits and Vegetables among Participating Households.

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.

Effectiveness of a School Drinking Water Promotion and Access Program for Overweight Prevention.

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 California's 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.

Increased WIC Benefits for Fruits and Vegetables Increases Food Security and Satisfaction Among California Households with Young Children.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a critical source of nutrition support for young children in low-income families, providing access to healthy foods and a cash value benefit (CVB) for the purchase of fruits and vegetables (FV). In 2021, the WIC CVB increased substantially for women and children aged 1 to 5 years. OBJECTIVE: To investigate whether or not the increased WIC CVB for purchasing FV was associated with greater redemption of the FV benefit, satisfaction, household food security, and child FV intake. DESIGN: Longitudinal study of WIC participants receiving WIC benefits from May 2021 through May 2022. Through May 2021, the WIC CVB for children aged 1 to 4 years was $9/month. The value increased to $35/month from June through September 2021, and changed to $24/month starting October 2021. PARTICIPANTS AND SETTING: WIC participants from seven WIC sites in California with one or more child aged 1 to 4 years during May 2021 and one or more follow-up surveys during September 2021 or May 2022 (N = 1,770). MAIN OUTCOMES AND MEASURES: CVB redemption (in US dollars), satisfaction with the amount (prevalence), household food security (prevalence), and child FV intake (cups per day). STATISTICAL ANALYSES: Associations of increased CVB issuance following the June 2021 CVB augmentation with child FV intake and CVB redemption were assessed using mixed effects regression, and associations with satisfaction and household food security were assessed using modified Poisson regression. RESULTS: The increased CVB was associated with significantly greater redemption and satisfaction. At the second follow-up (May 2022), household food security increased by 10% (95% CI 7% to 12%); total FV intake decreased by 0.03 c/day (95% CI -0.06 to -0.01) in the overall sample, but increased by 0.23 c/day (95% CI 0.17 to 0.29) among children with the lowest baseline FV intake. CONCLUSIONS: This study documented benefits of augmentation to the CVB for children. WIC policy augmenting the value of WIC food packages to increase access to FV had the intended effects, lending support to making the increased FV benefit permanent.

The Infant Diet Quality Index Predicts Dietary and Adiposity Outcomes in US Children 2 to 4 years old.

BACKGROUND: Healthy 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. OBJECTIVE: The 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. DESIGN: Data 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 (ß = 16.7; 95% CI: 12.6, 20.9; P < 0.001), 3 y (ß = 14.5; 95% CI: 8.1, 21.0; P < 0.001), and 4 y (ß = 15.4; 95% CI: 8.4, 22.4; P < 0.001); and negatively associated with BMIz at the age of 2 y (ß = -1.24; 95% CI: -2.01, -0.47; P = 0.002) and 4 y (ß = -0.92; 95% CI: -1.53, -0.30; P = 0.003). CONCLUSIONS: The IDQI has predictive validity for diet quality and weight status in low-income US children.

Adherence to Healthy Default Beverage Laws for Children's Meals in 3 U.S. Cities.

INTRODUCTION: Healthy default beverage laws are relatively new interventions designed to improve the healthfulness of children's meals in restaurants. In this study, researchers assessed adherence to healthy default beverage laws among children's meals ordered online in Los Angeles (California statewide law effective from September 2018), Baltimore (effective from April 2018), and New York City (effective from April 2019) compared with that in Boston, where no law existed. METHODS: Between November and December 2020, researchers ordered children's meals from online ordering platforms (e.g., GrubHub, Uber Eats) from the top-grossing restaurant chains in each location (n=337 meal orders from 106 restaurants), coded these meals using four successively stricter definitions of adherence to the default beverage laws in each respective jurisdiction, and then applied each law to data collected in Boston to simulate different policy scenarios in a city with no such law. The team analyzed these data in late 2021. RESULTS: Differences in adherence existed across jurisdictions, with 15% adherent in Los Angeles, 30% in Baltimore, and 43% in New York City, compared with 7%-30% in Boston, using the most lenient definition of adherence. Fewer than 3% of all meals adhered to laws when applying the strictest definition of adherence. CONCLUSIONS: Overall adherence was low and variable across jurisdictions. Adherence may be lower in jurisdictions with fewer allowable default beverages, although more research is needed to assess this potential causal relation. In addition to increased resources and support for restaurants, additional policy design considerations may be necessary to increase adherence to healthy default beverage laws.

Racial and Ethnic Comparisons in Satisfaction with Services Provided by the Special Supplemental Nutrition Program for Women, Infants, and Children in California.

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.

Water Security Experiences and Water Intake Among Elementary Students at Low-Income Schools: A Cross-Sectional Study.

OBJECTIVE: To examine students' experiences of water security at school and how experiences relate to intake of water from different sources of water at school. DESIGN/METHODS: In 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. RESULTS: Approximately 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. CONCLUSIONS: On 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.

Child and Adult Care Food Program Participation Benefits, Barriers and Facilitators for Independent Child Care Centers in California.

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.