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.

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).

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.

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.

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.

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.

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.

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.

Effect of Removing Chocolate Milk on Milk and Nutrient Intake Among Urban Secondary School Students.

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

Impact of Physical Education Litigation on Fifth Graders' Cardio-Respiratory Fitness, California, 2007-2018.

Objectives. To examine the impact of physical education (PE) litigation on changes in cardio-respiratory fitness among racially/ethnically and socioeconomically diverse students.Methods. We used annual school-level data for all California schools with measures of fifth graders' cardio-respiratory fitness spanning 2007-2008 through 2017-2018. A difference-in-difference design assessed changes before and after lawsuits in the proportion of students meeting fitness standards in schools in districts that were parties to PE lawsuits (n = 2715) versus in schools in districts not involved (n = 3152). We ran separate models with the proportion of students meeting fitness standards by sex, race/ethnicity, and low-income status as outcomes.Results. PE litigation led to a 1-percentage-point increase in the proportion of fifth-grade students meeting cardio-respiratory fitness standards (95% confidence interval [CI] = 0.03%, 2.0%). Effects were especially pronounced for female (1.3-percentage-point increase; 95% CI = 0.1%, 2.5%), African American (3.4-percentage-point increase; 95% CI = 0.5%, 6.2%), and low-income (2.8-percentage-point increase; 95% CI = 0.5%, 6.0%) students.Conclusions. Schools in districts subject to PE litigation showed greater improvements in student fitness, particularly among students typically at higher risk for inactivity and low fitness. Litigation may be an impactful tool for enforcing PE provision in accordance with the law.

Access to credentialed elementary physical education teachers in California and students' cardiorespiratory fitness.

Physical education (PE) can improve student health. Schools with credentialed PE teachers receive more PE. However, many schools have reduced PE funding, resulting in fewer teachers and potentially poorer student health. We examined if PE teachers are equally available across school districts, and if availability is associated with higher student cardiorespiratory fitness. We contacted California districts educating students in grades K-6 (n = 894) to determine the number of credentialed elementary PE teachers per district in 2016-17. Public datasets provided demographics and student fitness. Generalized linear models examined associations between district-level demographic characteristics and PE teacher-to-student ratio. Linear regression assessed the relationship between PE teacher-to-student ratio and student fitness. Seventy-five percent of districts (n = 669) responded. On average, there were 0.6 PE teachers for every 500 students, including the half (51%) of districts without elementary PE teachers. Each additional100 students of all racial/ethnic backgrounds in the district was associated with a 0.1% (95% CI -0.2%, -0.1%) decrease in the ratio. Each 10% increase in African American and Latino students was associated with 29% (95% CI -47%, -5%) and 18% (95% CI -31%, -3%) decreases in the ratio, respectively. Each additional PE teacher per 500 students was associated with a 3% increase in aerobically fit students (95% CI 1%, 4%). Elementary PE teachers are lacking in California, particularly in districts with a high proportion of African American and Latino students, which may be contributing to health disparities. Creative action to fund PE should be explored to ensure all students benefit from quality PE.

Potentially addictive properties of sugar-sweetened beverages among adolescents.

Sugar-sweetened beverages (SSBs) increase risk of cardiometabolic disease. Young people consume the largest amounts of SSBs and have experienced the greatest relative gains in obesity in the past several decades. There is evidence of addictive properties of both caffeine and sugar, the primary ingredients in SSBs, but little research into such properties of SSBs in naturally occurring consumption patterns. Thus, in this exploratory study, we sought to examine potentially addictive properties of SSBs during a 3-day SSB cessation intervention in overweight and obese adolescents who typically consume ≥3 SSBs daily. Participants (n = 25) were aged 13-18 years, mostly female (72%), and African American (56%) or Hispanic (16%) with a BMI≥95th percenttile (76%). Withdrawal symptoms and SSB craving were assessed approximately 1-week apart, during both regular SSB consumption and a 3-day period of SSB cessation in which participants were instructed to drink only plain milk and water. During SSB cessation, adolescents reported increased SSB cravings and headache and decreased motivation, contentment, ability to concentrate, and overall well-being (uncorrected Ps < 0.05). After controlling the false discovery rate, changes in motivation, craving, and well-being remained significant (corrected Ps < 0.05). Using 24-hr recalls and drink journals, participants reported lower total daily consumption of sugar (-80 g) and added sugar (-16 g) (Ps < 0.001) during cessation. This study provides preliminary evidence of withdrawal symptoms and increased SSB cravings during cessation in a diverse population of overweight or obese adolescents.

Impact of the Berkeley Excise Tax on Sugar-Sweetened Beverage Consumption.

OBJECTIVES: To evaluate the impact of the excise tax on sugar-sweetened beverage (SSB) consumption in Berkeley, California, which became the first US jurisdiction to implement such a tax ($0.01/oz) in March 2015. METHODS: We used a repeated cross-sectional design to examine changes in pre- to posttax beverage consumption in low-income neighborhoods in Berkeley versus in the comparison cities of Oakland and San Francisco, California. A beverage frequency questionnaire was interviewer administered to 990 participants before the tax and 1689 after the tax (approximately 8 months after the vote and 4 months after implementation) to examine relative changes in consumption. RESULTS: Consumption of SSBs decreased 21% in Berkeley and increased 4% in comparison cities (P = .046). Water consumption increased more in Berkeley (+63%) than in comparison cities (+19%; P < .01). CONCLUSIONS: Berkeley's excise tax reduced SSB consumption in low-income neighborhoods. Evaluating SSB taxes in other cities will improve understanding of their public health benefit and their generalizability.

Isolation of CeLu2 N@Ih -C80 through a Non-Chromatographic, Two-Step Chemical Process and Crystallographic Characterization of the Pyramidalized CeLu2 N within the Icosahedral Cage.

By combining two chemical methods of purification, 4 mg of purified CeLu2 N@C80 was readily isolated from 500 mg of carbon soot extract without the use of recycling HPLC, a method which has previously been necessary to obtain pure samples of endohedral fullerenes. In stage 1, CeLu2 N@C80 was selectively precipitated by virtue of its low first oxidation potential (+0.01 V) and the judicious choice of MgCl2 as the Lewis acid precipitant. For stage 2, we used a stir and filter approach (SAFA), which employed the electron-rich NH2 groups immobilized on silica gel to selectively bind residual endohedrals and higher cage fullerenes that were contaminants from stage 1. Crystallographic analysis of CeLu2 N@C80 in the co-crystal CeLu2 N@Ih -C80 ⋅Ni(octaethylporphyrin)⋅2(toluene) reveals that the Ih -C80 cage is present with a pyramidalized CeLu2 N unit inside.

Critical Elements of a School Report to Parents on Body Mass Index.

School-based body mass index (BMI) screening and reporting could have a positive impact on student health, but best practices for writing a report are unknown. Building on previous qualitative work, 8 focus groups were conducted with a diverse group of California parents (n = 79) to elicit feedback on report content and design. Results indicate that parents want a visually appealing, picture-heavy report that clearly defines BMI, avoids stigmatizing language, and includes recommendations for appropriate actions whole families can take. Next steps involve using the final report in a statewide, randomized trial to determine the effectiveness of school-based BMI screening and reporting in reducing childhood obesity.

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.

Are physical education policies working? A snapshot from San Francisco, 2011.

INTRODUCTION: School physical education (PE) has been identified as a critical public health tool to increase physical activity among youths. We sought to objectively assess compliance with PE quantity mandates and quality recommendations in a large urban California school district. METHODS: We collected PE schedules and systematically observed PE lessons (n=154) in 20 elementary, 4 middle, and 4 high schools from February through May 2011. RESULTS: On the basis of schools' master schedules, 83% of elementary schools met the California state mandate of 100 PE minutes per week. Teachers' actual schedules indicated that 20% of schools met the mandate, and observation showed that only 5% were in compliance. All middle and high schools met the mandated 200 minutes per week. On average, classes at all school levels met the recommended 50% of PE lesson time in moderate-to-vigorous physical activity. No teacher- or school-level factors significantly predicted PE quantity, but credentialed elementary PE teachers spent more time building students' motor skills. CONCLUSIONS: Our results suggest that current national estimates of PE, which are based on schools' self-report, overestimate the amount of PE provided in elementary schools. Although more than half of PE class time was spent in moderate-to-vigorous physical activity, total physical activity in elementary schools from PE is minimal and may do little to contribute to students' overall health.

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.

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.

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.