Impact of a multi-level, multi-component intervention to improve elementary school physical education on student cardiorespiratory fitness: an application of the parametric g-formula.

Background: School physical education is an important population-level health intervention for improving youth fitness. The purpose of this study is to determine the causal impact of New York City's PE Works program on student cardiorespiratory fitness. Methods: This longitudinal study (2014-2019) includes 581 elementary schools (n=315,999 4th/5th-grade students; 84% non-white; 74% who qualify for free or reduced-price meals). We apply the parametric g-formula to address schools' time-varying exposure to intervention components and time-varying confounding. Results: After four years of staggered PE Works implementation, 49.7% of students per school (95% CI: 42.6%, 54.2%) met age/sex-specific cardiorespiratory fitness standards. Had PE Works not been implemented, we estimate 45.7% (95% CI: 36.9%, 52.1%) would have met fitness standards. Had PE Works been fully implemented in all schools from the program's inception, we estimate 57.4% (95% CI: 49.1%, 63.3%) would have met fitness standards. Adding a PE teacher, alone, had the largest impact (6.4% (95% CI: 1.0, 12.0) increase). Conclusion: PE Works, which included providing PE teachers, training for classroom teachers, and administrative/teacher support for PE, positively impacted student cardiorespiratory health. Mandating and funding multilevel, multicomponent PE programs is an important public health intervention to increase children's cardiorespiratory fitness.

Associations between Changes in Food Acquisition Behaviors, Dietary Intake, and Bodyweight during the COVID-19 Pandemic among Low-Income Parents in California.

COVID-19 disrupted food access, potentially increasing nutritional risk and health inequities. This study aimed to describe and assess associations between changes in food/meal acquisition behaviors and relative changes in dietary intake and bodyweight from before to during the pandemic. Low-income parents (n = 1090) reported these changes by online survey in April-August 2021. Associations were assessed by multinomial logistic regression. Compared to those with no change, those who decreased supermarket shopping had greater odds of decreased fruit and vegetable (FV; OR[95%CI] = 2.4[1.4-4.1]) and increased salty snack intakes (OR[95%CI] = 1.7[1.0-2.8]). Those who decreased farmer's market shopping had greater odds of decreased FV intake (OR[95%CI] = 1.8[1.0-3.1]), increased bodyweight (OR[95%CI] = 1.7[1.1-2.6]), and increased SSB (OR[95%CI] = 1.9[1.1-3.2]) and sweets intakes (OR[95%CI] = 1.8[1.1-2.9]). Those who increased online food ordering had greater odds of increased sweets (OR[95%CI] = 1.7[1.1-2.8]), salty snacks (OR[95%CI] = 1.9[1.2-3.2]), and fast food (OR[95%CI] = 2.0[1.2-3.5]) intakes and bodyweight (OR[95%CI] = 1.8[1.1-2.9]). Those who increased healthy meal preparation had greater odds of increased FV intake (OR[95%CI] = 4.0[2.5-6.5]), decreased SSB (OR[95%CI] = 3.7[2.3-6.0]), sweets (OR[95%CI] = 2.7[1.6-4.4]), salty snacks (OR[95%CI] = 3.0[1.8-5]) and fast food intakes (OR[95%CI] = 2.8[1.7-4.6]) and bodyweight (OR[95%CI] = 2.2[1.2-4.0]). Interventions to address the potentially negative impacts of online food/meal shopping and support healthy home cooking may be needed to improve nutrition-related outcomes and reduce health disparities in the aftermath of the current pandemic and during future emergencies requiring similar restrictions.

Parent perceptions of changes in eating behavior during COVID-19 of school-aged children from Supplemental Assistance Program Education (SNAP-Ed) eligible households in California.

This cross-sectional study examined the associations between parent-reported, perceptions of changes in school-aged children's (ages 5-18) school meal participation, household cooking, fast food consumption, dietary intake, and weight during the COVID-19 pandemic. Respondents with low-income and school-aged children (n = 1040) were enrolled using quota sampling to approximate the distribution of low-income households and race/ethnicity among California residents who completed an on-line questionnaire developed by the authors. Adjusted multinomial models examined associations between parent-reported changes in school meal participation and time spent cooking, with parent-reported changes in child diet and body weight during COVID-19 (from before March 2020 to January-March 2021). During the pandemic, decreased school meal participation was associated with decreased child's fast food intake (OR[95 %CI] = 1.47[1.04-2.07]); conversely, increased school meal participation was associated with increased child's fast food intake (OR[95 %CI] = 1.71[1.09-2.68]). Decreased cooking at home was associated with decreased fruit and vegetable intake (OR[95 %CI] = 2.71[1.62-4.53]), increased sugar-sweetened beverage intake (OR[95 %CI] = 3.83[2.16-6.81]), and increased fast food intake (OR[95 %CI] = 4.09[2.45-6.84]); while increased cooking at home was associated with increased fruit and vegetable (OR[95 %CI] = 2.26[1.59-3.20]), sugar-sweetened beverage (OR[95 %CI] = 1.88[1.20-2.94]), sweets (OR[95 %CI] = 1.46[1.02-2.10]), and salty snack food intake (OR[95 %CI] = 1.87[1.29-2.71]). These parent-reported perceived changes in meal sources during the pandemic for children from low-income California households, and the mixed results in their associations with changes in parent-reported child dietary intake, suggest the need for strengthening policies and programs to support both access to, and healthfulness of, meals from school and home during prolonged school closures.

Latent class analysis identifies a promising combination of Supplemental Nutrition Assistance Program-Education interventions for improving student cardiorespiratory fitness.

OBJECTIVE: To inform Supplemental Nutrition Assistance Program Education (SNAP-Ed) and other school-based interventions aiming to improve youth cardiorespiratory fitness, this study aimed to identify which SNAP-Ed school-based physical activity intervention combinations were associated with better student cardiorespiratory fitness. METHODS: This study, utilizing cross-sectional secondary data, included 5th and 7th grade students who attended SNAP-Ed-eligible public schools in California (n = 442,743 students; 4271 schools) and had complete 2016-17 state-mandated fitness test results. Latent class analysis was used to identify underlying school-based intervention combinations. Propensity score methods were used to ensure comparability of intervention and comparison schools, by calculating inverse probability weights. Multilevel models, using those inverse probability weights, assessed the associations between the identified intervention combinations and student cardiorespiratory fitness, as measured by VO2max. The models were adjusted for school-level variables (urbanicity, percent of students eligible for free- or reduced-price meals, total enrollment, and school type), child-level variables (age, gender, and race/ethnicity), and for clustering of students within schools. RESULTS: We found that students attending schools with interventions focusing on comprehensive policy changes along with improving opportunities for physical activity had, on average, 1.17 mL/kg/min (95% CI: 0.72, 1.62) greater VO2max than students attending schools without any intervention. They also had statistically significantly greater VO2max compared to students attending schools with any other type of intervention combination. CONCLUSION: Our results suggest that comprehensive school-based physical activity interventions that include policy changes along with improving physical activity opportunities may be the most effective approach for improving fitness and may warrant prioritization in SNAP-Ed efforts.

School-level self-reported versus objective measurements of body mass index in public high school students.

Population-level surveillance of student weight status (particularly monitoring students with a body mass index (BMI) ≥95th percentile) remains of public health interest. However, there is mounting concern about objectively measuring student BMI in schools. Using data from the nation's largest school district, we determined how closely students' self-reported BMI approximates objectively-measured BMI, aggregated at the school level, to inform decision-making related to school BMI measurement practices. Using non-matched data from n = 82,543 students with objective height/weight data and n = 7676 with self-reported height/weight from 84 New York City high schools (88% non-white and 75% free or reduced-price meal-eligible enrollment), we compared school-level mean differences in height, weight, BMI, and proportion of students by weight status, between objective and self-reported measures. At the school-level, the self-reported measurement significantly underestimated weight (-1.38 kg; 95% CI: -1.999, -0.758) and BMI (-0.38 kg/m2; 95% CI: -0.574, -0.183) compared to the objective measurement. Based on the objective measurement, 12.1% of students were classified as having obesity and 6.3% as having severe obesity (per CDC definition); the self-report data yielded 2.5 (95% CI: -1.964, -0.174) and 1.4 (95% CI: -2.176, -0.595) percentage point underestimates in students with obesity and severe obesity, respectively. This translates to 13% of students with obesity and 21% of students with severe obesity being misclassified if using self-reported BMI. School-level high school students' self-reported data underestimate the prevalence of students with obesity and severe obesity and is particularly poor at identifying highest-risk students based on BMI percentile.

Not all fun and games: Disparities in school recess persist, and must be addressed.

School recess is an evidence-backed approach to increase school-based opportunities for students to play, accrue necessary physical activity, and socialize with peers, to the benefit of their physical, academic, and socioemotional health. As such, the Centers for Disease Control recommend at least 20 min of daily recess in elementary schools. However, unequal provision of recess contributes to persistent health and academic disparities for students, which remain to be addressed. We analyzed data from the 2021-22 school year from a sample of low-income (Supplemental Nutrition Assistance Program Education-eligible) elementary schools (n = 153) across California. Just 56 % of schools reported providing more than 20 min of recess daily. Differences in daily recess provision were apparent, with students in larger and lower-income schools receiving less daily recess than students in smaller and higher income schools. These findings support the enactment of legislation mandating health-sufficient daily recess in California elementary schools. They also highlight the importance of, and need for, annually-collected data sources to enable monitoring of recess provision, and potential disparities, over time, in order to assist in identifying additional interventions to address this public health problem.

Implementation of elementary school physical education quantity and quality law through school district audit, feedback, and coaching.

BACKGROUND: To address low state physical education (PE) quantity and quality law implementation in elementary schools, the New York City Department of Education (NYCDOE) delivered a multilevel intervention (PE Works; 2015-2019), which included a district-led audit of school PE-law implementation, feedback, and coaching with principals. Using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) implementation science framework, we assessed the primary multilevel drivers of success for this approach in increasing adherence to PE quantity and quality law. METHODS: We conducted in-depth, semi-structured interviews with district-level personnel (n=17), elementary school administrators (n=18), and PE teachers (n=6) in 2020-21. RESULTS: Interview results suggested several key RE-AIM drivers of successful PE law implementation. Reach: Ensure higher-need schools receive the necessary initial support to improve PE and later focus on lower-need schools. EFFECTIVENESS: Provide support tailored to school needs, not penalties, to improve PE. Adoption: Increase the priority of PE at both district and school levels (e.g., audit and feedback, themselves, appear to elevate PE's priority). Streamline data collection and feedback reports; collecting/reporting too much information is burdensome and leads to lack of focus. Involve qualified (i.e., skilled in both school administration and PE programming/pedagogy) district-level personnel to work collaboratively with schools. IMPLEMENTATION: Build strong, trusting district-school relationships. Maintenance: Provide ongoing district-level support to schools and involve parents to advocate for quality PE. CONCLUSIONS: PE audits, feedback, and coaching (PEAFC) can guide schools in establishing long-term plans for successfully implementing PE-related law. Future research should examine the impact of PEAFC elsewhere (e.g., secondary schools, other districts).

Feasibility and Response to the San Diego County, California, Supplemental Nutrition Assistance Program (SNAP) Agency Sending Food and Nutrition Text Messages to All Participants: Quasi-Experimental Web-Based Survey Pilot Study.

BACKGROUND: The Supplemental Nutrition Assistance Program (SNAP) provides over 40 million Americans with money for food without typically providing participants with food or nutrition information. Educational SMS text messages can reach large numbers of people, and studies suggest SNAP participants appreciate nutrition education and have access to mobile phones. OBJECTIVE: Using a pre-post intervention design, we assessed the feasibility of, and program satisfaction and outcomes resulting from, the San Diego County, California SNAP agency sending monthly food and nutrition education SMS text messages to all SNAP participants to increase fruit and vegetable purchasing and consumption. METHODS: We developed and sent 5 behavioral science-informed SMS text messages with links to a project website in English and Spanish with information about selecting, storing, and preparing seasonal fruits and vegetables. The San Diego County SNAP agency sent monthly texts to ~170,000 SNAP households from October 2020 to February 2021. SNAP participants completed web-based surveys in response to a text invitation from the SNAP agency in September 2020 (baseline, n=12,036) and April 2021 (follow-up, n=4927). Descriptive frequencies were generated, and adjusted multiple linear mixed models were run on a matched data set of participants that completed both baseline and follow-up surveys (n=875) assessing pre- or postattitudes, behaviors, knowledge, and self-efficacy. We used adjusted logistic regression models to assess differences between the matched (n=875) and nonmatched (n=4052) participants related to experiences with the intervention (questions asked only at follow-up). RESULTS: After the intervention, matched participants reported significant increase in knowing where to get information about selecting, storing, and preparing fruits and vegetables (3.76 vs 4.02 on a 5-point Likert scale with 5=strongly agree, P<.001); feeling good about participating in SNAP (4.35 vs 4.43, P=.03); and thinking the CalFresh program helps them eat healthy (4.38 vs 4.48, P=.006). No significant pre- or postdifferences were found in fruit or vegetable consumption, though most participants at follow-up (n=1556, 64%) reported their consumption had increased. Among the sample that completed the follow-up survey only (n=4052, not including 875 participants who completed follow-up and baseline), 1583 (65%) and 1556 (64%) reported purchasing and eating more California-grown fruits and vegetables, respectively. Nearly all respondents appreciated the intervention (n=2203, 90%) and wanted it to continue (n=2037, 83%). CONCLUSIONS: SNAP can feasibly provide food and nutrition messages via text to participants. A monthly text campaign was well received by responding participants and improved some measures of their self-reported knowledge, self-efficacy, produce consumption, and perceptions of SNAP participation. Participants expressed interest in continuing to receive texts. While educational messages will not solve the complex food and nutrition challenges confronting SNAP participants, further work should employ rigorous methods to expand and test this intervention in other SNAP programs before considering to implement it at scale.

NYC FITNESSGRAM: Population-Level Physical Fitness Surveillance for New York City Youth.

NYC FITNESSGRAM, monitored by the New York City (NYC) Department of Education and the NYC Department of Health and Mental Hygiene, functions as the NYC Department of Education's citywide youth fitness surveillance program. Here we present the methods, characteristics, and data used in this surveillance system to monitor physical fitness in public school students (grades kindergarten through 12; initiated in 2006; n = 6,748,265 observations; mean sample of 519,097 observations per year to date) in New York, New York. Youth physical fitness prevalence estimates, longitudinal trends, and spatial analyses may be investigated using continuous fitness composite percentile scores and Cooper Institute for Aerobic Research-defined sex- and age-specific Healthy Fitness Zones. Healthy Fitness Zones are based on individual-child fitness test performance, with standard errors clustered at the school and student levels and adjusted for sociodemographic characteristics. Results may be used to show trends in youth fitness attainment over time and highlight disparities in the fitness prevalence of NYC students. In sum, continuous fitness composite percentile scores offer the opportunity for prospective tracking of shifts in youth physical fitness on a population scale and across subpopulations. NYC FITNESSGRAM can accompany a growing body of surveillance tools demonstrating the potential for population-level surveillance tools to promote global public health.

BMI Reporting and Accuracy of Child's Weight Perception.

OBJECTIVES: To estimate whether school-based body mass index (BMI) reports impacted the accuracy of children's self-reported weight category, for children overall and within subgroups. METHODS: We analyzed existing data from the Fit Study, a randomized controlled trial of a BMI screening and reporting intervention conducted in California from 2014 to 2017. The sample included 4690 children in 27 schools randomized to receive BMI reports and 4975 children in 27 controls schools that received BMI screening only. To estimate how BMI reporting affected accuracy, we fit multinomial logistic regression models to our data. We calculated average marginal effects, which capture the change in probability that children more accurately reported their weight category because of BMI reporting. RESULTS: We detected no impact of BMI reporting on children's self-reported weight accuracy. Exploratory subgroup analyses show that for Black children, exposure to 1 round of BMI reporting was associated with a 10.0 percentage point increase in the probability of accurately reporting their weight category (95% confidence interval [CI]: 2.6 to 17.4). Two rounds of reporting were associated with an increase in the probability of accuracy for Asian children (6.6 percentage points; 95% CI: 0.4 to 12.8), 5th graders (11.1 percentage points; 95% CI: 1.6 to 20.5), and those with BMI <5th percentile (17.1 percentage points; 95% CI: 2.7 to 31.6). CONCLUSIONS: BMI reporting has limited efficacy in increasing children's weight perception accuracy. Although exploratory analyses show that specific subpopulations became more accurate, future prospective studies should be designed to confirm these results.

Impact of an Arts-based Public Health Literacy Program Delivered Online to High School Students during the COVID-19 Pandemic.

The COVID-19 pandemic, coupled with the domestic socio-political unrest of 2020, provides a critical opportunity to reframe how we engage with youth around health and disease risk. The Bigger Picture (TBP), a spoken word, arts-based public health literacy campaign, uses a social justice and racial equity frame to activate youth around social determinants of health, including salient topics such as type 2 diabetes, COVID-19, climate change, and police violence. This quasi-experimental study determined the impact of providing an online adaptation of TBP during the COVID-19 pandemic to urban, low-income, diverse high school students (3 intervention schools assigned to receive TBP-based spoken word program; 3 comparison schools received a non-health focused spoken word program). We used outcomes derived from the Culture of Health framework, including: (1) health-related mind-sets and expectations; (2) sense of belonging; and (3) civic engagement. Students completed pre/post surveys; a subset of adults and youth from all 6 schools completed semi-structured interviews. TBP participation resulted in measurable shifts in students' mind-sets around structural drivers of health and health inequity and increases in plans for future civic engagement. Arts-based programming with an intentional focus on the social ecological model and health equity appears to impact young people, even when delivered online.

Impact of a Teacher Intervention to Encourage Students to Eat School Lunch.

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.

Evaluating Food Packaging Waste in Schools: A Systematic Literature Review.

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.

The Relationship between Breastfeeding and Initial Vegetable Introduction with Vegetable Consumption in a National Cohort of Children Ages 1-5 Years from Low-Income Households.

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.

Weight Measurements in School: Setting and Student Comfort.

OBJECTIVE: To examine how body mass index assessments are conducted in schools and whether student comfort with assessments varies by students' perceived weight status, weight satisfaction, or privacy during measurements. METHODS: In-person cross-sectional surveys with diverse fourth- to eighth-grade students (n = 11,510) in 54 California schools in 2014-2015 about their experience being weighed in the prior school year. RESULTS: Half of the students (49%) reported being weighed by a physical education teacher and 28% by a school nurse. Students were more comfortable being weighed by nurses than physical education teachers (P = 0.01). Only 30% of students reported privacy during measurements. Students who were unhappy with their weight (P <0.001) and those who perceived themselves as overweight (P <0.001) were less comfortable being weighed than their peers. CONCLUSIONS AND IMPLICATIONS: Student weight dissatisfaction, higher perceived weight status, and being female were associated with discomfort with school-based weight measurements. Prioritizing school nurses to conduct weight measurements could mitigate student discomfort, and particular attention should be paid to students who are unhappy with their weight to avoid weight stigmatization.

Context, importance, and process for creating a body mass index surveillance system to monitor childhood obesity within the New York City public school setting.

The Office of School Health, a joint program of the Departments of Health and Education, administers New York City's (NYC) body mass index (BMI) surveillance system to monitor childhood obesity. We describe the context, importance, and process for creating a multi-agency, school-based BMI surveillance system using BMI collected from annual FITNESSGRAM® physical fitness assessments conducted as part of a larger physical activity and wellness curriculum in NYC public schools. We also summarize our current system and methodology, highlighting the types of data and data sources that comprise the system and partnership between the Departments of Health and Education that enable data sharing. Strategies for addressing threats to data quality, including missing data, biologically implausible values, and imprecise/subjective weight or height equipment are discussed. We also review current and future surveillance data products, and provide recommendations for collecting, analyzing, interpreting, and reporting BMI data for childhood obesity surveillance. Collaboration between Departments of Health and Education as well as attention to safeguards of BMI reporting and data quality threats have enabled NYC to collect high quality BMI data to accurately monitor childhood obesity trends. These findings have implications for youth BMI surveillance systems in the United States and globally.

Limited implementation of California's Healthy Default Beverage law for children's meals sold online.

OBJECTIVE: To reduce children's sugar-sweetened beverage intake, California's Healthy-By-Default Beverage law (SB1192) mandates only unflavoured dairy/non-dairy milk or water be the default drinks with restaurant children's meals. The objective of this study is to examine consistency with this law for meals sold through online platforms from restaurants in low-income California neighbourhoods. DESIGN: This observational, cross-sectional study examines beverage availability, upcharges (additional cost) and presentation of beverage options consistent with SB1192 (using four increasingly restrictive criteria) within a random sample of quick-service restaurants (QSR) in Supplemental Nutrition Assistance Program Education eligible census tracts selling children's meals online from November 2020 to April 2021. SETTING: Low-income California neighbourhoods (n 226 census tracts). PARTICIPANTS: QSR that sold children's meals online via a restaurant-specific platform, DoorDash, GrubHub and/or UberEats (n 631 observations from 254 QSR). RESULTS: Seventy percent of observations offered water; 63 % offered unflavoured milk. Among all beverages, water was most likely to have an upcharge; among observations offering water (n 445), 41 % had an upcharge (average $0·51). Among observations offering unflavoured milk (n 396), 11 % had an upcharge (average $0·38). No observations upcharged for soda (regular or diet). Implementation consistency with SB1192 ranged from 40·5 % (using the least restrictive criteria) to 5·6 % (most restrictive) of observations. CONCLUSIONS: Based on observations from restaurant websites and three of the most popular online ordering platforms, most California QSR located in low-income neighbourhoods are not offering children's meal beverages consistent with the state's Healthy-By-Default Beverage law. As the popularity of online ordering increases, further work to ensure restaurants offering healthy default beverages with children's meals sold online is necessary.

Physical Education Teachers' Perceived Effectiveness in Association with Student Attendance, Teacher Adaptability, External Educational Supports, and Teaching Format During the COVID-19 Pandemic.

Spring 2020 pandemic-control policies included an abrupt shift to remote teaching, which may have affected physical education (PE) teachers' perceived effectiveness. This study examined K-12 PE teachers' perceived effectiveness in association with student attendance, teacher adaptability, PE supports, teaching format (in-person, remote synchronous, remote asynchronous, etc.), and teacher- and school-level demographics at three time points (pre-pandemic 2019-early 2020, Spring 2020, 2020-2021 school year). An electronic survey was developed by an expert panel and distributed to U.S. public school PE teachers (convenience sampling via school health-related organizations). For analyses, teacher perceived effectiveness was dichotomized (very/extremely effective= "1"; not at all/slightly/moderately effective= "0"). Logistic regression models assessed associations between perceived effectiveness and independent variables (student attendance, teacher adaptability, PE supports, teaching format, and demographic variables) at each time point. Respondents (n=134; M age=46) were mostly female (62%), general PE teachers (82%, versus adapted), had a graduate degree (66%), had >11 years of teaching experience (63%), and from 26 states. Perception of being very/extremely effective was highest pre-pandemic 2019-early 2020 (93%), lowest in Spring 2020 (12%), and recovered somewhat in 2020-2021 (45%). During the 2020-2021 school year, teachers had greater odds of perceiving they were more effective if they reported having higher student attendance (OR 1.06 [CI:1.02-1.09], p>.001) and higher adaptability (OR 1.22 [CI: 1.09-1.37], p>.001), adjusting for gender, education level, years of experience, grade level taught, and Title I status. Professional development opportunities are needed for remote teaching of PE to enhance teachers' adaptability and perceived effectiveness during potential future school closures.

The association between student body mass index and tests of flexibility assessed by the FITNESSGRAM®: New York City public school students, 2017-18.

FITNESSGRAM® is the most widely used criterion-referenced tool to assess/report on student health-related fitness across the US. Potential weight-related biases with the two most common tests of musculoskeletal fitness-the trunk extension and Back-Saver Sit-and-Reach (sit-and-reach)-have been hypothesized, though have not been studied. To determine the association between musculoskeletal fitness test performance and weight status, we use data from 571,133 New York City public school 4th-12th grade students (85% non-White; 75% qualified for free or reduced-price meals) with valid/complete 2017-18 FITNESSGRAM® data. Adjusted logistic mixed effects models with a random effect for school examined the association between weight status and whether a student was in the Healthy Fitness Zone (HFZ; met sex- and age-specific criterion-referenced standards) for the trunk extension and sit-and-reach. Compared to students with normal weight, the odds of being in the HFZ for trunk extension were lower for students with underweight (OR = 0.77; 95% CI: 0.741, 0.795) and higher for students with overweight (OR = 1.10; 95% CI: 1.081, 1.122) and obesity (OR = 1.11; 95% CI: 1.090, 1.13). The odds of being in the HFZ for sit-and-reach were lower for students with underweight OR = 0.85; 95% CI: 0.826, 0.878), overweight (OR = 0.83; 95% CI: 0.819, 0.844) and obesity (OR = 0.65; 95% CI: 0.641, 0.661). Students with overweight and obesity perform better on the trunk extension, yet worse on the sit-and-reach, compared to students with normal weight. Teachers, administrators, and researchers should be aware of the relationship of BMI with student performance in these assessments.

Seeing "The Bigger Picture:" Impact of an Arts-Focused Type 2 Diabetes Education Program in High Schools.

Traditional health education efforts rarely align with youth social justice values. The Bigger Picture (TBP), a spoken word arts campaign, leverages a social justice approach to activate youth around the social determinants of type 2 diabetes (T2D). This quasi-experimental study examines the impact of embedding TBP in urban, low-income high schools (3 intervention schools received TBP; 3 comparison schools received a non-health related spoken word program) with respect to (1) health-related mind-sets and expectations; (2) sense of belonging; and (3) civic engagement among youth. Adults and youth who participated in programming at all 6 schools were interviewed, and a content analysis of students' poems was performed. TBP was well-received by adults and students. While students in both TBP and comparison programs described multiple social determinants of T2D, intervention students more frequently articulated the connections between race/ethnicity and T2D as a social justice issue. Further, all comparison students explicitly mentioned individual dietary behavior as a T2D determinant while most, yet not all, intervention students did. Students in both programs reported a high sense of belonging at school and confidence in civic engagement. Content analysis of TBP students' poems revealed youth's detailed understanding of T2D determinants. Future studies might explore program scalability, and how the integration of civic engagement opportunities into TBP curriculum might impact students' capacity to create positive social change.