Effects of a Behavioral Economics Intervention on Food Choice and Food Consumption in Middle-School and High-School Cafeterias.

INTRODUCTION: Changing food choice architecture in school cafeterias through behavioral economics may increase student selection and consumption of healthy foods. However, most research assesses the effects of short-term interventions. We evaluated a year-long choice architecture intervention implemented by school food service staff. METHODS: Food service staff from 6 secondary schools in one school district received training and support to implement behavioral economics strategies in their cafeterias to promote student selection of fruit, vegetables, and low-fat white milk. We compared student selection and consumption of these foods in the intervention schools to 5 comparison schools in the same district on the basis of visual assessment of plate waste. We applied a difference-in-differences approach to estimate intervention effect. RESULTS: Data for 902 students were assessed at baseline, and data for 1,407 were assessed at follow-up. In fully adjusted analyses for all students, there were significantly greater absolute increases in the proportions of intervention school students selecting any fruit, including (0.09) and excluding (0.16) juice, and students selected more fruit items including (0.21) and excluding (0.17) juice. The absolute increase in proportion of intervention students consuming fruit excluding juice (0.14) was significantly greater. However, in some analyses, fewer intervention students who selected fruits or vegetables ate them, or they ate fewer of them. There were no intervention effects for vegetables or low-fat white milk. CONCLUSION: Our results indicate that behavioral economics-based choice architecture can promote student selection of healthy foods, but they raise questions about whether it increases their consumption.

Examining the Washington State Breastfeeding-Friendly Policy Development Process Using the Advocacy Coalition Framework.

Objectives Breastfeeding promotion is increasingly recognized as a key public health strategy. Policies can promote breastfeeding by creating supportive environments and addressing challenges. In 2014, the Washington State legislature considered bills to create a voluntary recognition system for breastfeeding-friendly hospitals, clinics, worksites and childcare settings. These Breastfeeding-Friendly Washington (BFW) bills (SB 6298 and HB 2329) did not pass. Methods The purpose of this case study was to analyze the policy development process for the BFW bills using the Advocacy Coalition Framework. Data were collected through semi-structured interviews with key stakeholders in the state policy process, and document review. We used thematic analysis to identify deductive and inductive themes. Results Though all policy actors indicated general support for breastfeeding, two main coalitions (proponents and opponents) diverged in their support of the BFW bills as policy solutions to address barriers to breastfeeding. We conducted 29 interviews with mainly bill proponents, and 54 documents confirmed data about bill opponents. Proponents supported the bills given increasingly strong evidence of breastfeeding's benefits and that public policy could address environmental challenges to breastfeeding. Opponents saw the bills as government overreach into the private matter of choosing to breastfeed. Opposition to the bills came late in the session, and proponents felt opponents' messaging misconstrued the intent of the legislation. Conclusions for Practice Key learnings for developing breastfeeding-friendly state policies include analyzing differences between proponents' and opponents' beliefs, framing advocacy messages beyond individuals and health, expanding the coalition outside of traditional health entities, and anticipating the opposition.

Physical Activity Practices, Policies and Environments in Washington State Child Care Settings: Results of a Statewide Survey.

Objectives Child care is an important setting for the promotion of physical activity (PA) in early childhood. The purpose of this study was to examine the associations between specific PA environments and recommended practices in child care settings as well as the degree to which child care settings met recommended standards for total PA time. Methods In 2013, all programs licensed to care for children ages 2-5 in WA state were surveyed about their PA related practices. Logistic regression was used to determine odds of meeting best-practice standards for outdoor time and PA. Results The response rate was 45.8 % from centers (692/1511) and 32.1 % from homes (1281/3991). Few programs reported meeting best-practice standards for the amount of time children spend being physically active (centers: 12.1 %, homes: 20.1 %) and outdoor time (centers: 21.8 %, homes: 21.7 %). Programs where children go outside regardless of weather and those reporting more adult-led PA had higher odds of meeting best-practice standards for both PA and outdoor time. Meeting best-practice standards for outdoor time was the strongest predictor of meeting best-practice standards for total PA time [centers: OR 15.9 (9.3-27.2), homes: OR 5.2 (3.8-7.1)]. Conclusions for Practice There is considerable room for improvement in licensed child care settings in WA to meet best-practice standards for young children's outdoor and PA time. Initiatives that create policies and environments encouraging outdoor play and adult-led PA in child care have the potential to increase physical activity in substantial numbers of young children.

Creating Environments to Support Breastfeeding: The Challenges and Facilitators of Policy Development in Hospitals, Clinics, Early Care and Education, and Worksites.

Objectives Supportive organizational breastfeeding policies can establish enabling environments for breastfeeding. In this qualitative study we identify facilitators and barriers to the development, adoption, and implementation of supportive breastfeeding policies and practices in four influential sectors for breastfeeding women: hospitals, clinics, early care and education settings, and worksites. Methods We interviewed 125 individuals representing 110 organizations in Washington State about their breastfeeding policy development and implementation process between August 2014 and February 2015. Greenhalgh's diffusion of innovations framework guided the interviews and qualitative analysis. Results Breastfeeding policy facilitators across the sectors include national and state laws and regulations, performance tracking requirements, and an increasingly supportive sociopolitical climate; barriers include limited resources and appreciation about the need for breastfeeding policies, and certain organizational characteristics such as workforce age. Despite broad support for breastfeeding, organizations differed on perceptions about the usefulness of written breastfeeding policies. Personal breastfeeding experiences of policy makers and staff affect organizational breastfeeding policies and practices. Conclusions for Practice Supportive organizational systems and environments are built through effective policy development processes; public health can support breastfeeding policy development and assure a coordinated continuum of care by leveraging federal health care policy requirements, building networks to support training and collaboration, and disseminating strategies that reflect the personal nature of breastfeeding.

Developing local board of health guidelines to promote healthy food access - King County, Washington, 2010-2012.

Policies that change environments are important tools for preventing chronic diseases, including obesity. Boards of health often have authority to adopt such policies, but few do so. This study assesses 1) how one local board of health developed a policy approach for healthy food access through vending machine guidelines (rather than regulations) and 2) the impact of the approach. Using a case study design guided by "three streams" policy theory and RE-AIM, we analyzed data from a focus group, interviews, and policy documents. The guidelines effectively supported institutional policy development in several settings. Recognition of the problem of chronic disease and the policy solution of vending machine guidelines created an opening for the board to influence nutrition environments. Institutions identified a need for support in adopting vending machine policies. Communities could benefit from the study board's approach to using nonregulatory evidence-based guidelines as a policy tool.

Developing an agenda for research about policies to improve access to healthy foods in rural communities: a concept mapping study.

BACKGROUND: Policies that improve access to healthy, affordable foods may improve population health and reduce health disparities. In the United States most food access policy research focuses on urban communities even though residents of rural communities face disproportionately higher risk for nutrition-related chronic diseases compared to residents of urban communities. The purpose of this study was to (1) identify the factors associated with access to healthy, affordable food in rural communities in the United States; and (2) prioritize a meaningful and feasible rural food policy research agenda. METHODS: This study was conducted by the Rural Food Access Workgroup (RFAWG), a workgroup facilitated by the Nutrition and Obesity Policy Research and Evaluation Network. A national sample of academic and non-academic researchers, public health and cooperative extension practitioners, and other experts who focus on rural food access and economic development was invited to complete a concept mapping process that included brainstorming the factors that are associated with rural food access, sorting and organizing the factors into similar domains, and rating the importance of policies and research to address these factors. As a last step, RFAWG members convened to interpret the data and establish research recommendations. RESULTS: Seventy-five participants in the brainstorming exercise represented the following sectors: non-extension research (n = 27), non-extension program administration (n = 18), "other" (n = 14), policy advocacy (n = 10), and cooperative extension service (n = 6). The brainstorming exercise generated 90 distinct statements about factors associated with rural food access in the United States; these were sorted into 5 clusters. Go Zones were established for the factors that were rated highly as both a priority policy target and a priority for research. The highest ranked policy and research priorities include strategies designed to build economic viability in rural communities, improve access to federal food and nutrition assistance programs, improve food retail systems, and increase the personal food production capacity of rural residents. Respondents also prioritized the development of valid and reliable research methodologies to measure variables associated with rural food access. CONCLUSIONS: This collaborative, trans-disciplinary, participatory process, created a map to guide and prioritize research about polices to improve healthy, affordable food access in rural communities.

Life Course Perspective: evidence for the role of nutrition.

The "Life Course Perspective" proposes that environmental exposures, including biological, physical, social, and behavioral factors, as well as life experiences, throughout the entire life span, influence health outcomes in current and future generations. Nutrition, from preconception to adulthood, encompasses all of these factors and has the potential to positively or negatively shape the individual or population health trajectories and their intergenerational differences. This paper applies the T2E2 model (timing, timeline, equity and environment), developed by Fine and Kotelchuck, as an overlay to examine advances in nutritional science, as well as the complex associations between life stages, nutrients, nutrigenomics, and access to healthy foods, that support the life course perspective. Examples of the application of nutrition to each of the four constructs are provided, as well as a strong recommendation for inclusion of nutrition as a key focal point for all health professionals as they address solutions to optimize health outcomes, both domestically and internationally. The science of nutrition provides strong evidence to support the concepts of the life course perspective. These findings lend urgency to the need to improve population health across the life span and over generations by ensuring ready access to micronutrient-dense foods, opportunities to balance energy intake with adequate physical activity and the need for biological, social, physical, and macro-level environments that support critical phases of human development. Recommendations for the application of the life course perspective, with a focus on the emerging knowledge of nutritional science, are offered in an effort to improve current maternal and child health programs, policies, and service delivery.

Perceived impact and feasibility of strategies to improve access to healthy foods in Washington State, USA.

OBJECTIVE: The present study measured the perceived impact and political and implementation feasibility of state-level policy strategies related to increasing access to healthy foods and limiting unhealthy foods. DESIGN: Potential state-level policy strategies to improve access to healthy foods were identified through a review of evidence-based literature and policy recommendations. Respondents rated the perceived impact and political and implementation feasibility of each policy on a five-point scale using online surveys. SETTING: Washington State policy process. SUBJECTS: Forty-nine content experts (national researchers and subject experts), forty policy experts (state elected officials or their staff, gubernatorial or legislative policy analysts) and forty-five other stakeholders (state-level advocates, programme administrators, food producers). RESULTS: In aggregate, respondents rated policy impact and implementation feasibility higher than political feasibility. Policy experts rated policy strategies as less politically feasible compared with content experts (P < 0·02) or other stakeholders (P < 0·001). Eight policy strategies were rated above the median for impact and political and implementation feasibility. These included policies related to nutrition standards in schools and child-care facilities, food distribution systems, urban planning projects, water availability, joint use agreements and breast-feeding supports. CONCLUSIONS: Although they may be perceived as potentially impactful, some policies will be more difficult to enact than others. Information about the potential feasibility of policies to improve access to healthy foods can be used to focus limited policy process resources on strategies with the highest potential for enactment, implementation and impact.

Zinc protoporphyrin-to-heme ratios in high-risk and preterm infants.

OBJECTIVES: To refine the reference range for the zinc protoporphyrin-to-heme ratio (ZnPP/H) of preterm infants, we assessed the impact of maternal risk factors on ZnPP/H and evaluated the impact of changes in iron supplementation on iron status. STUDY DESIGN: The reference range for neonatal ZnPP/H was refined using prospective data from 31 reference infants ≤ 35 weeks' postmenstrual age (PMA) plus retrospective data from 51 infants <30 weeks' PMA, and 59 infants 30-40 weeks' PMA. Cord blood and first week of life values were compared when both were available. The impact of maternal risk factors was assessed by examining prospectively collected ZnPP/H from 48 high-risk infants. The effect of changing iron supplementation guidelines was evaluated by retrospective chart review of serial ZnPP/H from 194 infants. RESULTS: Cord ZnPP/H was lower at 30-35 weeks' gestation than at 24-26 weeks' gestation (P = .01). Cord ZnPP/H values from insulin-dependent diabetic mothers were elevated compared with reference values. Changing the iron supplementation protocol was not associated with improved ZnPP/H measurements. CONCLUSIONS: Cord blood and postnatal reference ranges for ZnPP/H are defined. Iron balance depends on a complex interaction of prenatal and postnatal factors.

Improving nutrition in home child care: are food costs a barrier?

OBJECTIVE: Child-care providers have a key role to play in promoting child nutrition, but the higher cost of nutritious foods may pose a barrier. The present study tested the hypothesis that higher nutritional quality of foods served was associated with higher food expenditures in child care homes participating in the Child and Adult Care Food Program (CACFP). DESIGN: In this cross-sectional study, nutritional quality of foods served to children and food expenditures were analysed based on 5 d menus and food shopping receipts. Nutritional quality was based on servings of whole grains, fresh whole fruits and vegetables, energy density (kJ/g) and mean nutrient adequacy (mean percentage of dietary reference intake) for seven nutrients of concern for child health. Food expenditures were calculated by linking receipt and menu data. Associations between food expenditures and menu quality were examined using bivariate statistics and multiple linear regression models. SETTING: USA in 2008-2009. SUBJECTS: Sixty child-care providers participating in CACFP in King County, Washington State. RESULTS: In bivariate analyses, higher daily food expenditures were associated with higher total food energy and higher nutritional quality of menus. Controlling for energy and other covariates, higher food expenditures were strongly and positively associated with number of portions of whole grains and fresh produce served (P = 0·001 and 0·005, respectively), with lower energy density and with higher mean nutrient adequacy of menus overall (P = 0·003 and 0·032, respectively). CONCLUSIONS: The results indicate that improving the nutritional quality of foods in child care may require higher food spending.

Changes in local school policies and practices in Washington State after an unfunded physical activity and nutrition mandate.

INTRODUCTION: Policies and practices in schools may create environments that encourage and reinforce healthy behaviors and are thus a means for stemming the rising rates of childhood obesity. We assessed the effect of a 2005 statewide school physical activity and nutrition mandate on policies and practices in middle and high schools in Washington State. METHODS: We used 2002, 2004, and 2006 statewide School Health Profiles survey data from Washington, with Oregon as a comparison group, to create longitudinal linear regression models to describe changes in relevant school policies after the Washington statewide mandate. Policy area composite measures were generated by principal component factor analysis from survey questions about multiple binary measure policy and practice. RESULTS: Relative to expected trends without the mandate, we found significant percentage-point increases in various policies, including restricted access to competitive foods in middle and high schools (increased by 18.8-20.0 percentage points); school food practices (increased by 10.4 percentage points in middle schools); and eliminating exemptions from physical education (PE) for sports (16.6 percentage-point increase for middle schools), exemptions from PE for community activities (12.8 and 14.4 percentage-point increases for middle and high schools, respectively) and exemptions from PE for academics (18.1 percentage-point increase for middle schools). CONCLUSION: Our results suggest that a statewide mandate had a modest effect on increasing physical activity and nutrition policies and practices in schools. Government policy is potentially an effective tool for addressing the childhood obesity epidemic through improvements in school physical activity and nutrition environments.

Understanding infant feeding beliefs, practices and preferred nutrition education and health provider approaches: an exploratory study with Somali mothers in the USA.

The objective of this study was to explore Somali mothers' beliefs and practices around infant feeding and education, towards developing a culturally informed infant nutrition curriculum for health providers. Four focus groups were conducted to explore: (1) beliefs about infant feeding, hunger and ideal weight; (2) feeding practices; (3) nutrition education approaches; and (4) provider/mother interactions. Thirty-seven Somali mother participants identified the following themes within these topics: (1) strategies for assessing hunger, satiety and when to feed; shared beliefs that plump babies are healthy, leading to worry about infant weight; (2) context of breast milk adequacy, difficulties breastfeeding and environmental and cultural barriers to breastfeeding, leading to nearly universal early supplementation with formula; (3) preferred education approaches include provider visits with interpreters, Somali language educational materials and advice from older, experienced family members; and (4) desired health provider skills include: listening, explaining, empathy, addressing specific concerns, repeating important information, offering preventive advice and sufficient visit time. This study presents knowledge about Somali beliefs and practices that can directly guide discussions with these families. Given that these infants appear on a trajectory towards obesity, influencing infant feeding practices in the Somali community is a good upstream approach to preventing obesity. These findings will underpin a new infant nutrition curriculum for health providers.

School Lunch Entrées Before and After Implementation of the Healthy, Hunger-Free Kids Act of 2010.

BACKGROUND: The Healthy, Hunger-Free Kids Act (HHFKA) 2010 updated standards to increase the nutritional quality of school meals. Studies of HHFKA outcomes have focused primarily on fruit and vegetables, nutrient quality of whole meals, and plate waste. OBJECTIVE: To examine changes in school lunch entrée nutrient quality and student selections after HHFKA implementation. DESIGN: Descriptive, longitudinal study analyzing 1.7 million student-selected lunch entrées in eight entrée categories. PARTICIPANTS/SETTING: Three middle schools and three high schools in an urban school district in Washington State, from January 2011 to January 2014 (16 months before and 15 months after HHFKA implementation). MAIN OUTCOME MEASURES: Nutritional quality of each entrée category was assessed by analyzing mean adequacy ratio, energy density, and energy per serving. Selection was determined by analyzing number of entrées in each category selected by students. STATISTICAL ANALYSES PERFORMED: Comparison of indices of pre- and postimplementation nutritional quality using a combination of Wilcoxon two-sample test with t approximation and a two-sided alternative t test assuming equal variances and t test assuming unequal variances using Satterthwaite approximation. Quantity of entrée categories selected was also determined by Satterthwaite approximation. RESULTS: After implementation, there was significant improvement in mean adequacy ratio and energy per serving overall for all entrées combined. There were significant improvements in both mean adequacy ratio and energy per serving for salads, burritos, and pizza in middle schools and for hot sandwiches and burritos in high schools. For energy density, middle schools also had significant decreases for casseroles and salads, with no significant changes found in high schools. The variety of entrées decreased by 44%, and there were significant changes in the proportions of entrées selected from specific food categories. CONCLUSION: Nutritional quality of lunch entrées, variety of entrées available, and student entrée selections changed after implementation of HHFKA policy in one urban school district in Washington State.

An Assessment of Perceived Barriers to Farmers' Market Access.

OBJECTIVE: To explore whether Supplemental Nutrition Assistance Program-Education (SNAP-Ed) stakeholders (individuals involved in work to increase access to farmers' markets [FMs] for low-income populations) perceive the same barriers to shopping at FMs as those reported by SNAP participants in Washington State. DESIGN: Descriptive study; data included a stratified clustered random sample of SNAP participants and stakeholder interviews. SETTING: Washington State. PARTICIPANTS: A total of 400 SNAP participants and 51 SNAP-Ed stakeholders. MAIN OUTCOME MEASURES: The SNAP participants' reported barriers to accessing FMs and the SNAP-Ed stakeholders' perceptions of FM access barriers. ANALYSIS: Thematic content analysis, descriptive statistics, 2-sample tests of proportion, and Pearson chi-square tests (P < .025). RESULTS: A majority of SNAP participants reported they did not shop at an FM because it is inconvenient (n = 193; 51%) and not financially viable (n = 84; 22%). Moreover, 9% of SNAP participants (n = 34) stated that they experienced no barriers. The SNAP-Ed stakeholders placed increased emphasis on transportation and cost barriers compared with the SNAP participants. CONCLUSIONS AND IMPLICATIONS: Comprehensive, multilevel strategies that reflect the perspectives of SNAP participants could increase SNAP use at FMs. Opening FMs in diverse locations at variable operating times may address convenience barriers while engaging the targeted populations' communities to promote FMs, and FM incentive programs may address financial and awareness barriers.

An Evaluation of Washington State SNAP-Ed Farmers' Market Initiatives and SNAP Participant Behaviors.

OBJECTIVE: To describe Supplemental Nutrition Assistance Program-Education (SNAP-Ed)-supported farmers' market (FM) access activities in Washington State communities and identify associations between participation in these activities and SNAP participants' FM shopping and fruit and vegetable consumption. DESIGN: Descriptive study; data included stakeholder interviews and surveys with FM managers and a stratified clustered random sample of SNAP participants. SETTING: Washington State. PARTICIPANTS: A total of 51 SNAP-Ed stakeholders, 400 SNAP participants, and 94 FM managers participated. MAIN OUTCOME MEASURE(S): Partnership measures and SNAP-Ed FM access activities; SNAP participants' participation in FM access activities, FM shopping frequency, and fruit and vegetable consumption. ANALYSIS: Thematic content analysis, descriptive statistics, and 0-inflated Poisson and ordinary least-squares regression models. RESULTS: A total of 343 FM access activities and strong multi-sector partnerships were identified. Fifty percent of SNAP participants shopped at an FM in the past year, and 30% at least monthly. The SNAP participants participating in FM access activities shopped at FMs more frequently (P=.005). The SNAP participants shopping at FMs ate fruit and vegetables more frequently than did non-FM shoppers (P<.001). CONCLUSIONS AND IMPLICATIONS: Through nutrition education and systems and environmental changes, Washington SNAP-Ed developed effective programming and multi-sector partnerships. These efforts are associated with SNAP participants' FM shopping and fruit and vegetable consumption.

Validation of a Two-Item Food Security Screening Tool in a Dental Setting.

Purpose: The United States is typically viewed as a wealthy country, yet not all households have access to enough food for an active, healthy life. The purpose of this study was to validate a two-item written food security screen that health providers may use to identify food insecurity in their patient populations.Methods: Data were obtained from 150 parents or guardians who brought a child to a dental appointment at The Center for Pediatric Dentistry, University of Washington, Seattle, Wash., USA. The sensitivity and specificity of two written questions were determined by comparing with the United States Department of Agriculture Six-item Short Form of the Food Security Survey Module.Results: The sample consisted of 141 surveys after those with critical questions left blank were removed. The prevalence of food insecurity was found to be 31 percent at the Center for Pediatric Dentistry. The six-item screen identified 44 foodinsecure families with an affirmative response to two or more questions. Compared with the six-item screen, the two-item screen was found to have 95.4 percent sensitivity and 83.5 percent specificity.Conclusions: The two-item food security screen was found to be sensitive and reasonably specific, providing a quick and accurate method to identify food-insecure families.

Small-grants programs: lessons from community-based approaches to changing nutrition environments.

Providing small grants to community organizations can be an effective way to encourage changes in the environment that support better nutrition. This is effective because these organizations can provide insights into their communities, ready-made relationships with community members, and the trust of the community. Small-grants programs are more likely to be successful when they are tailored to the needs of individual communities, led by organizations that have established reputations with the community, fully supported by the lead community organization, and engage local partners that complement the skills and resources of the lead organization. An evaluation of a small-grants program, Grants for Healthy Youth, found that grantees developed unique approaches to improving their community nutrition environments, gained experience and skills in program development, built partnerships, and received recognition for their project work. Grantees faced some common barriers, especially with program evaluation. Small-grants programs can be an effective way to improve community nutrition environments, but granting agencies need to provide effective technical assistance to communities throughout the process.

Exploring the Use of Seattle's Farmers' Market Incentive Program ("Fresh Bucks") by Household Food Security Levels.

The objective of this study was to explore Seattle's farmers' market incentive program, known as Fresh Bucks, and associated shopping behaviors based on participants' food security status. Researchers surveyed a convenience sample of Fresh Bucks users and classified subjects as high/marginal, low, or very low food security. Investigators analyzed for differences in demographics and farmers' market shopping behaviors by food security levels. Study findings suggest that once present at the farmers' market, Fresh Bucks users across all food security levels experience the market and the Fresh Bucks program in similar ways. These relationships should be explored in a larger and more diverse population.

Validity and Interrater Reliability of the Visual Quarter-Waste Method for Assessing Food Waste in Middle School and High School Cafeteria Settings.

BACKGROUND: Measuring food waste (ie, plate waste) in school cafeterias is an important tool to evaluate the effectiveness of school nutrition policies and interventions aimed at increasing consumption of healthier meals. Visual assessment methods are frequently applied in plate waste studies because they are more convenient than weighing. The visual quarter-waste method has become a common tool in studies of school meal waste and consumption, but previous studies of its validity and reliability have used correlation coefficients, which measure association but not necessarily agreement. OBJECTIVE: The aims of this study were to determine, using a statistic measuring interrater agreement, whether the visual quarter-waste method is valid and reliable for assessing food waste in a school cafeteria setting when compared with the gold standard of weighed plate waste. METHODS: To evaluate validity, researchers used the visual quarter-waste method and weighed food waste from 748 trays at four middle schools and five high schools in one school district in Washington State during May 2014. To assess interrater reliability, researcher pairs independently assessed 59 of the same trays using the visual quarter-waste method. Both validity and reliability were assessed using a weighted κ coefficient. RESULTS: For validity, as compared with the measured weight, 45% of foods assessed using the visual quarter-waste method were in almost perfect agreement, 42% of foods were in substantial agreement, 10% were in moderate agreement, and 3% were in slight agreement. For interrater reliability between pairs of visual assessors, 46% of foods were in perfect agreement, 31% were in almost perfect agreement, 15% were in substantial agreement, and 8% were in moderate agreement. CONCLUSIONS: These results suggest that the visual quarter-waste method is a valid and reliable tool for measuring plate waste in school cafeteria settings.

Preventing obesity: a life cycle perspective.

Traditional approaches to treating overweight and obese adults by focusing on individual weight loss have not been effective in stemming the tide of obesity in the population. Recent research has identified critical factors that, as they accumulate and interact over an individual's life span, may put a person at risk for obesity. These factors include rapid weight gain in infancy and childhood, early puberty, and excessive weight gain in pregnancy. Based on this research, a life cycle perspective can be used to develop comprehensive interventions that address the multiple determinants of obesity. Because obesity tracks across generations, it is essential to adopt effective obesity prevention measures now to prevent even higher rates of obesity in future generations. Dietetics professionals can reduce individual risks by providing nutritional services that support appropriate weight gain in childhood and pregnancy. We can also advocate for policies in communities, schools, and worksites that support breastfeeding, ensure access to health-promoting foods, and provide opportunities to be physically active.