The relationship between community food environment around schools and student meal participation: the role of school CEP participation status.

BACKGROUND: Despite the many benefits of school meals, not all students participate. One reason students may not participate in school meals is because they instead purchase breakfast or lunch from food outlets located around schools that mostly carry unhealthy items. This study examined whether school participation in the Community Eligibility Provision (CEP), which allows qualifying schools to serve free meals to all students, moderated the association between the community food environment around schools and student meal participation. METHODS: This study employed a longitudinal repeated-measures design using school-level data collected between 2014 and 2020 within four low-income school districts (n = 126 schools) in the US. We obtained meal participation data from state records and created a measure characterizing the community food environment within 0.25 miles of schools (characterized as low-density of unhealthy food outlets vs. high-density of unhealthy food outlets) through a latent class analysis. Regression analysis estimated associations between community food environments, CEP participation, and participation rates in school breakfast and school lunch, assessed in separate models. RESULTS: While no moderating effect of school CEP status was observed for breakfast or lunch participation, school breakfast participation was predicted to be 4% lower in high-density food environments than in low-density environments (P-value = .049) among non-CEP schools, and there was no difference in participation by the community food environment among CEP-participating schools. Differences in breakfast participation by the community food environment among non-CEP schools were mostly attributable to middle/high schools, with participation predicted to be 10% lower in high-density environments than in low-density environments among non-CEP middle/high schools (P-value < .001), whereas such a difference in participation was not observed among non-CEP elementary schools. CONCLUSIONS: Negative associations between food environment around schools and school breakfast participation were observed only among middle and high schools not participating in CEP, suggesting that policy actions to increase access to free school meals may benefit students, particularly older children and adolescents.

The association between unhealthy dietary behaviors and participation in the Supplemental Nutrition Assistance Program (SNAP): No evidence in support of the self-selection hypothesis.

Supplemental Nutrition Assistance Program (SNAP) participants tend to have unhealthier dietary consumption compared to eligible non-participants. It has been suggested, though never empirically tested, that individuals who enroll in SNAP may have unhealthy diets prior to program participation. Using a longitudinal cohort study design, we examined the association between low-income adults' SNAP participation status and prior dietary behaviors to test the argument that individuals with unhealthier dietary consumption self-select into SNAP. A sample of households from predominantly lower-income cities were surveyed at baseline (T1) and 2-4 years later (T2). The main analyses were restricted to adults who did not participate in SNAP at T1 and with household income <200% of the federal poverty line (n = 170) at both T1 and T2. Participants were grouped into two categories, based on their SNAP participation at T2; (a) Non-participants (n = 132): no SNAP participation at T1 or T2, and (b) T2 SNAP participants (n = 38): SNAP participation at T2 but not T1. Daily consumption frequency of whole fruits, fruit juice, vegetables, sugar-sweetened beverages (SSBs), and energy dense snacks were measured through self-reports. To observe dietary differences between the two groups prior to SNAP participation, T1 behaviors were compared. There were no significant differences in dietary behaviors at T1 (prior to SNAP participation) between non-participants and T2 participants, providing no evidence of self-selection of individuals with unhealthier dietary consumption into SNAP among our study sample. Improvements in SNAP participants' diets may benefit from focusing on policy changes that encourage healthy dietary habits during participation in the program.

Food Environments Within and Outside of Schools Play a Critical Role in Curtailing the Rise in Obesity among School-Aged Children over Time.

BACKGROUND: Sound evidence for effective community-based strategies is needed to curtail upward trends in childhood obesity in the United States (US). OBJECTIVES: The aim of the study was to assess the association between school and community food environments and the prevalence of obesity over time. METHODS: Data were collected from K-12 schools in 4 low-income New Jersey cities in the US. School-level obesity prevalence, calculated from nurse-measured heights and weights at 4 time points, was used as the outcome variable. Data on the school food environment (SFE) measured the healthfulness of school lunch and competitive food offerings annually. The community food environment (CFE), i.e., the number of different types of food outlets within 400 m of schools, was also captured annually. The count and presence of food outlets likely to be frequented by students were calculated. Exposure to composite environment profiles both within schools and in communities around schools was assessed using latent class analysis. Data from 106 schools were analyzed using multilevel linear regression. RESULTS: The prevalence of obesity increased from 25% to 29% over the course of the study. Obesity rates were higher in schools that had nearby access to a greater number of limited-service restaurants and lower in schools with access to small grocery stores and upgraded convenience stores participating in initiatives to improve healthful offerings. Interaction analysis showed that schools that offered unhealthier, competitive foods experienced a faster increase in obesity rates over time. Examining composite food environment exposures, schools with unhealthy SFEs and high-density CFEs experienced a steeper time trend (ß = 0.018, P < 0.001) in obesity prevalence compared to schools exposed to healthy SFE and low-density CFEs. CONCLUSIONS: Food environments within and outside of schools are associated with differential obesity trajectories over time and can play an important role in curtailing the rising trends in childhood obesity.

The relationship between changes in neighborhood physical environment and changes in physical activity among children: a prospective cohort study.

BACKGROUND: Physical activity (PA) is associated with positive health outcomes over the entire life course. Many community-based interventions that promote PA focus on implementing incremental changes to existing facilities and infrastructure. The objective of this study was to determine if such upgrades were associated with increases in children's PA. METHODS: Two cohorts of 3- to 15-year-old children (n = 599) living in 4 low-income New Jersey cities were followed during 2- to 5-year periods from 2009 to 2017. Data on children's PA were collected at 2 time points (T1 and T2) from each cohort using telephone survey of parents; data on changes to existing PA facilities were collected yearly from 2009 to 2017 using Open Public Records Act requests, publicly available data sources, and interviews with key stakeholders. PA changes were categorized into six domains (PA facility, park, trail, complete street, sidewalk, or bike lane) and coded as new opportunity, renovated opportunity, or amenity. A scale variable capturing all street-related upgrades (complete street, sidewalk, and bike lane) was constructed. PA was measured as the number of days per week the child engaged in at least 60 min of PA. The association between change in PA between T1 and T2, ranging from - 7 to + 7, and changes to the PA environment was modeled using weighted linear regression controlling for PA at T1, child age, sex, race, as well as household and neighborhood demographic and socioeconomic characteristics. RESULTS: While most measures of the changes to the PA environment were not associated with change in PA between T1 and T2, the street-related upgrades were positively associated with the change in PA; specifically, for each additional standard deviation in street upgrades within a 1-mile radius of their homes, the change in PA was 0.42 (95% CI: 0.02, 0.82; p = 0.039) additional days. This corresponds to an 11% increase over the mean baseline value (3.8 days). CONCLUSIONS: The current study supports funding of projects aimed at improving streets and sidewalks in cities, as it was shown that incremental improvements to the PA environment near children's homes will likely result in increased PA among children.

Differential Associations Between Changes in Food Environment and Changes in BMI Among Adults Living in Urban, Low-Income Communities.

BACKGROUND: Food environments can contribute to excess weight gain among adults, but the evidence is mixed. OBJECTIVES: This longitudinal study investigated the associations between changes in the food environment and changes in BMI in adults and whether changes in the food environment differentially impact various subgroups. METHODS: At 2 time points, BMI was calculated using self-reported height and weight data from 517 adults (mean age, 41 years) living in 4 New Jersey cities. The counts of different types of food outlets within 0.4, 0.8, and 1.6 km of respondents' residences were collected at baseline and tracked until follow-up. A binary measure of social standing (social-advantage group, n = 219; social-disadvantage group, n = 298) was created through a latent class analysis using social, economic, and demographic variables. Multivariable linear regression modeled the associations between changes in BMI with measures of the food environment; additionally, interaction terms between the measures of food environment and social standing were examined. RESULTS: Overall, over 18 months, an increase in the number of small grocery stores within 0.4 km of a respondent's residence was associated with a decrease in BMI (ß = -1.0; 95% CI: -1.9, -0.1; P = 0.024), while an increase in the number of fast-food restaurants within 1.6 km was associated with an increase in BMI (ß = 0.1; 95% CI: 0.01, 0.2; P = 0.027). These overall findings, however, masked some group-specific associations. Interaction analyses suggested that associations between changes in the food environment and changes in BMI varied by social standing. For instance, the association between changes in fast-food restaurants and changes in BMI was only observed in the social-disadvantage group (ß = 0.1; 95% CI: 0.02, 0.2; P = 0.021). CONCLUSIONS: In a sample of adults living in New Jersey, changes in the food environment had differential effects on individuals' BMIs, based on their social standing.

Impact of the 2010 US Healthy, Hunger-Free Kids Act on School Breakfast and Lunch Participation Rates Between 2008 and 2015.

OBJECTIVES: To evaluate National School Lunch Program (NSLP) and School Breakfast Program (SBP) participation over a 7-year period before and after the implementation of the 2010 Healthy, Hunger-Free Kids Act (HHFKA), which required healthier school lunch options beginning in school year (SY) 2012-2013 and healthier school breakfast options beginning in SY2013-2014. METHODS: Data were gathered from low-income, high-minority public schools in 4 New Jersey cities. We conducted longitudinal analyses of annual average daily participation (ADP) in school meals among enrolled students overall and among those eligible for free or reduced-price meals. We used linear mixed models to compare NSLP and SBP participation rates from SY2008-2009 to SY2014-2015. RESULTS: NSLP participation rates among students overall differed little across years (from 70% to 72%). SBP rates among enrolled students were stable from the beginning of the study period to SY2013-2014 and then increased from 52% to 59%. Among students eligible for free or reduced-price meals, the ADP was lowest in SY2012-2013 (when the HHFKA was implemented) before rebounding. CONCLUSIONS: The HHFKA did not have a negative impact on school meal participation over time. Public Health Implications. The HHFKA-strengthened nutrition standards have not affected school meal participation rates. With time, students are likely to accept healthier options.

Predicted Impact of the Food and Drug Administration's Menu-Labeling Regulations on Restaurants in 4 New Jersey Cities.

OBJECTIVES: To determine the proportion of restaurants that will be required to post calorie information under the Food and Drug Administration's menu-labeling regulations in 4 New Jersey cities. METHODS: We classified geocoded 2014 data on 1753 restaurant outlets in accordance with the Food and Drug Administration's guidelines, which will require restaurants with 20 or more locations nationwide to post calorie information. We used multivariate logistic regression analyses to assess the association between menu-labeling requirements and census tract characteristics. RESULTS: Only 17.6% of restaurants will be affected by menu labeling; restaurants in higher-income tracts have higher odds than do restaurants in lower-income tracts (odds ratio [OR] = 1.55; P = .02). Restaurants in non-Hispanic Black (OR = 1.62; P = .02) and mixed race/ethnicity (OR = 1.44; P = .05) tracts have higher odds than do restaurants in non-Hispanic White tracts of being affected. CONCLUSIONS: Additional strategies are needed to help consumers make healthy choices at restaurants not affected by the menu-labeling law. These findings have implications for designing implementation strategies for the law and for evaluating its impact.

The relative contribution of layers of the Social Ecological Model to childhood obesity.

OBJECTIVE: The Social Ecological Model (SEM) has been used to describe the aetiology of childhood obesity and to develop a framework for prevention. The current paper applies the SEM to data collected at multiple levels, representing different layers of the SEM, and examines the unique and relative contribution of each layer to children's weight status. DESIGN: Cross-sectional survey of randomly selected households with children living in low-income diverse communities. SETTING: A telephone survey conducted in 2009-2010 collected information on parental perceptions of their neighbourhoods, and household, parent and child demographic characteristics. Parents provided measured height and weight data for their children. Geocoded data were used to calculate proximity of a child's residence to food and physical activity outlets. SUBJECTS: Analysis based on 560 children whose parents participated in the survey and provided measured heights and weights. RESULTS: Multiple logistic regression models were estimated to determine the joint contribution of elements within each layer of the SEM as well as the relative contribution of each layer. Layers of the SEM representing parental perceptions of their neighbourhoods, parent demographics and neighbourhood characteristics made the strongest contributions to predicting whether a child was overweight or obese. Layers of the SEM representing food and physical activity environments made smaller, but still significant, contributions to predicting children's weight status. CONCLUSIONS: The approach used herein supports using the SEM for predicting child weight status and uncovers some of the most promising domains and strategies for childhood obesity prevention that can be used for designing interventions.

The New Jersey Medicaid ACO Demonstration Project: seeking opportunities for better care and lower costs among complex low-income patients.

A small but growing number of states are turning to accountable care concepts to improve their Medicaid programs. In 2011 New Jersey enacted the Medicaid Accountable Care Organization (ACO) Demonstration Project to offer local provider coalitions the opportunity to share any savings they generate. Impetus came from initiatives in Camden that aim to reduce costs through improved care coordination among hospital high users and that have received considerable media attention and substantial federal and private grant support. Though broadly similar to Medicare and commercial ACOs, the New Jersey demonstration addresses the unique concerns faced by Medicaid populations. Using hospital all-payer billing data, we estimate savings from care improvement efforts among inpatient and emergency department high users in thirteen communities that are candidates for participation in the New Jersey demonstration. We also examine their characteristics to inform Medicaid accountable care strategies. We find substantial variation in the share of high-user hospital patients across the study communities and high rates of avoidable use and costs among these patients. The potential savings among Medicaid enrollees are considerable, particularly if Medicaid ACOs can develop ways to successfully address the high burden of chronic illness and behavioral health conditions prevalent in the prospective demonstration communities.

Emergency Free School Meal Distribution During the COVID-19 Pandemic in High-Poverty Urban Settings.

BACKGROUND: The coronavirus disease 2019 pandemic triggered nationwide school closures in March 2020, putting millions of children in the United States who were reliant on subsidized school meals at risk of experiencing hunger. In response, the US Department of Agriculture mobilized the Summer Food Service Program and Seamless Summer Option program to provide emergency free school meals. There is a need to investigate the effectiveness of these programs in covering underresourced communities during the pandemic. OBJECTIVE: This study assessed associations between meal distribution and census tract demographics (ie, poverty level, race/ethnicity, and deprivation level based on social deprivation index score). DESIGN: An observational study using longitudinal meal distribution data collected over an 18-month period following school closures (March 2020 to August 2021). PARTICIPANTS AND SETTING: Monthly meal distribution data were collected for community sites serving 142 census tracts within 4 urban New Jersey cities predominantly populated by people with low incomes and from racial and ethnic minority groups. MAIN OUTCOME MEASURES: Main outcome measures were the number of meals served monthly by Summer Food Service Program and Seamless Summer Option meal sites. STATISTICAL ANALYSES PERFORMED: A 2-part multivariable regression approach was used to analyze the data. RESULTS: In the first step, logistic regression models showed that high-deprivation tracts were more likely to serve meals during the observed period (odds ratio 3.43, 95% CI 1.001 to 11.77; P = 0.0499). In the second step, among tracts that served any meals during the observed period, mixed effects negative binomial regression models showed that high-poverty and high-deprivation tracts served comparatively more meals (incidence rate ratio [IRR] 2.83, 95% CI 2.29 to 3.51; P < 0.001 and IRR 1.94, 95% CI 1.65 to 2.28; P < 0.001, respectively). CONCLUSIONS: Findings show that meal distribution during the pandemic was higher within census tracts with higher poverty and deprivation levels, indicating that underresourced communities with higher need had more free meals available during this unprecedented public health emergency.

A closer examination of the relationship between children's weight status and the food and physical activity environment.

OBJECTIVES: Conflicting findings on associations between food and physical activity (PA) environments and children's weight status demand attention in order to inform effective interventions. We assess relationships between the food and PA environments in inner-city neighborhoods and children's weight status and address sources of conflicting results of prior research. METHODS: Weight status of children ages 3-18 was assessed using parent-measured heights and weights. Data were collected from 702 children living in four low-income cities in New Jersey between 2009 and 2010. Proximity of a child's residence to a variety of food and PA outlets was measured in multiple ways using geo-coded data. Multivariate analyses assessed the association between measures of proximity and weight status. RESULTS: Significant associations were observed between children's weight status and proximity to convenience stores in the 1/4 mile radius (OR = 1.9) and with presence of a large park in the 1/2 mile radius (OR = 0.41). No associations were observed for other types of food and PA outlets. CONCLUSIONS: Specific aspects of the food and PA environments are predictors of overweight and obese status among children, but the relationships and their detection are dependent upon aspects of the geospatial landscape of each community.

Improvements in School Food Offerings over Time: Variation by School Characteristics.

The 2010 Healthy, Hunger-Free Kids Act (HHFKA) improved the nutritional quality of food served in schools. This longitudinal study examined school food offerings over time from school year 2010-11 to 2017-18 in public schools (n = 148) in four New Jersey cities. Six food indices were used to assess the number of healthy and unhealthy items offered as part of the National School Lunch Program (NSLP), in vending machines, and à la carte (i.e., competitive foods). Multilevel, multivariable linear regression with quadratic terms was used to model the trends over time. Interaction terms were added to examine whether the time trends varied by school-level factors, such as proportion of students eligible for free or reduced-price meals (FRPMs), race/ethnicity of enrolled students, and school level. Over the study period, healthy items offered in the NSLP increased (p < 0.001), while unhealthy items in the NSLP decreased (p < 0.001). Significantly different rates of declines in NSLP unhealthy offering were observed among schools at the two extremes of FRPM eligibility (p < 0.05). The trends for healthy and unhealthy foods offered in competitive foods showed significant non-linear trends, and differences were observed for school-level race/ethnicity, with worse outcomes for schools with majority Black student enrollment.

Schools' Participation in the Community Eligibility Provision Affects Students' Receipt of Emergency Benefits during the COVID-19 Pandemic.

Pandemic Electronic Benefits Transfer (P-EBT) benefits were intended for families of school children who lost access to free or reduced-price school meals (FRPMs) during the COVID-19 pandemic-related school closures. In high-poverty communities, all students from schools participating in the Community Eligibility Provision (CEP) were automatically eligible for P-EBT benefits; in non-CEP schools, only students already participating in FRPMs-for which their parents submitted an individual application-were eligible for P-EBT benefits. Using publicly available data from 105 K-12 public schools located in 4 sizeable low-income New Jersey (NJ) cities, this study investigated the association between school CEP participation status and the reach of P-EBT benefits for eligible students. A generalized linear model with a logit link, a binomial family, and robust standard errors was used. Across all levels of FRPM eligibility based on students' household income, as expected, almost all students from CEP schools received P-EBT benefits; significantly fewer received P-EBT benefits if they attended non-CEP schools, even when they were eligible for FRPMs. Our findings show that without changes to the qualification process for CEP, large numbers of eligible children will not receive the intended health benefits of federal meals programs or similar emergency relief initiatives. Expanding CEP eligibility and simplifying the process through which schools qualify would likely improve the uptake of federal meals programs and emergency interventions, and more effectively achieve their intent.

Active commuting to school: A longitudinal analysis examining persistence of behavior over time in four New Jersey cities.

Evidence suggests that healthy behaviors initiated during childhood may continue over time. The objective of this study was to determine whether active commuting to/from school (ACS) at baseline predicted continued ACS at follow-up two to five years later. Two cohorts of households with 3-15 year-olds in four low-income New Jersey cities were randomly sampled and followed for two to five year periods between 2009 and 2017. Children who walked, bicycled, or skateboarded to/from school at least one day/week were classified as active commuters. Children with complete data at both time points were included in this analysis (n = 383). Multivariate logistic regression was used to examine the association between ACS at T1 and T2. Models adjusted for child age, sex, and race/ethnicity; parent's education and nativity status (native-born vs foreign-born); household poverty level; car availability; neighborhood level characteristics; and distance from home to school. Children who engaged in ACS at T1 had over seven times the odds of ACS at T2 compared to children who did not actively commute at T1 (p < 0.001), after adjusting for distance to school and other relevant covariates. Distance, regardless of active commuting status at T1 was inversely associated with active commuting at T2. Policies and interventions encouraging ACS, and those that decrease the distance between a child's home and school, may result in increased, habitual active commuting and physical activity behavior throughout childhood and possibly into adulthood.

Impact Of The New Jersey COVID-19 Temporary Emergency Reciprocity Licensure Program On Health Care Workforce Supply.

New Jersey's COVID-19 Temporary Emergency Reciprocity Licensure program provided temporary licenses to more than 31,000 out-of-state health care practitioners. As one of the first COVID-19 hot spots in the US, New Jersey is uniquely positioned to provide insights on enabling an out-of-state health care workforce through temporary licensure to address critical, ongoing concerns about health care workforce supply. In January 2021 we surveyed New Jersey temporary licensees. We analyzed more than 10,000 survey responses and found that practitioners who used the temporary license originated from every state in the US, provided both COVID-19- and non-COVID-19-related care, served a combination of new and existing patients, conversed with patients in at least thirty-six languages, and primarily used telehealth. Findings suggest that temporary licensure of out-of-state practitioners, along with telehealth waivers, may be a valuable, short-term solution to mitigating health care workforce shortages during public health emergencies.

Do Parental Perceptions of the Nutritional Quality of School Meals Reflect the Food Environment in Public Schools?

(1) Background: It is unknown whether parents' perception of school meals, a determinant of student meal participation, align with the nutritional quality of meals served in schools. This study compares the healthfulness of foods offered in schools with parental perception of school meals at those same schools. (2) Method: Parents were asked to rate the healthfulness of school meals at their child's school. Data on the types of foods offered were collected from public schools in four cities in New Jersey and matched with parent-reported data. Measures were developed to capture the presence of healthy and unhealthy items in the National School Lunch Program and the presence of a la carte offerings as well as vending machines. Multivariable analysis examined the association between parental perceptions of school meals and the school food measures after adjusting for covariates. (3) Results: Measures of the school food environment and parental perceptions were available for 890 pre-K to 12th grade students. No significant associations were observed between parental perceptions and food environment measures when examined one by one or in a comprehensive model. (4) Conclusions: Parents' perception of the healthfulness of meals served do not align with the nutritional quality of foods offered at schools.

Evidence That Changes in Community Food Environments Lead to Changes in Children's Weight: Results from a Longitudinal Prospective Cohort Study.

BACKGROUND: Strategies to improve the community food environment have been recommended for addressing childhood obesity, but evidence substantiating their effectiveness is limited. OBJECTIVE: Our aim was to examine the impact of changes in availability of key features of the community food environment, such as supermarkets, small grocery stores, convenience stores, upgraded convenience stores, pharmacies, and limited service restaurants, on changes in children's body mass index z scores (zBMIs). DESIGN: We conducted a longitudinal cohort study. PARTICIPANTS/SETTING: Two cohorts of 3- to 15-year-old children living in 4 low-income New Jersey cities were followed during 2- to 5-year periods from 2009 through 2017. Data on weight status were collected at 2 time points (T1 and T2) from each cohort; data on food outlets in the 4 cities and within a 1-mile buffer around each city were collected multiple times between T1 and T2. MAIN OUTCOME MEASURES: We measured change in children's zBMIs between T1 and T2. STATISTICAL ANALYSIS: Changes in the food environment were conceptualized as exposure to changes in counts of food outlets across varying proximities (0.25 mile, 0.5 mile, and 1.0 mile) around a child's home, over different lengths of time a child was exposed to these changes before T2 (12 months, 18 months, and 24 months). Multivariate models examined patterns in relationships between changes in zBMI and changes in the food environment. RESULTS: Increased zBMIs were observed in children with greater exposure to convenience stores over time, with a consistent pattern of significant associations across varying proximities and lengths of exposure. For example, exposure to an additional convenience store over 24 months within 1 mile of a child's home resulted in 11.7% higher odds (P = 0.007) of a child being in a higher zBMI change category at T2. Lower zBMIs were observed in children with increased exposure to small grocery stores selling an array of healthy items, with exposure to an additional small grocery store within 1 mile over 24 months, resulting in 37.3% lower odds (P < 0.05) of being in a higher zBMI change category at T2. No consistent patterns were observed for changes in exposure to supermarkets, limited service restaurants, or pharmacies. CONCLUSIONS: Increased availability of small grocery stores near children's homes may improve children's weight status, whereas increased availability of convenience stores is likely to be detrimental.

The Policy and Practice Legacy of the New Jersey Medicaid ACO Demonstration Project.

The New Jersey Medicaid Accountable Care Organization (ACO) Demonstration was created with a unique combination of features regarding ACO geography, involvement of managed care organizations (MCOs), and shared savings parameters. Ultimately, the Demonstration did not lead to a sustainable accountable care financing model and shared savings were deemphasized. Instead, the ACOs evolved into community health coalitions focused on coordinating and enhancing a wide range of activities in partnership with state government, private health systems, community leaders, and MCOs. Currently, the state is developing policy parameters to reposition the ACOs as regional partners to implement state-directed population health initiatives.

Healthier school food and physical activity environments are associated with lower student body mass index.

School food and physical activity (PA) environments can influence children's dietary and physical activity behaviors. However, evidence on whether school environment is associated with students' weight status is less definitive. In this study, we examined the association between students' body mass index (BMI) and measures of school food and PA environments. We calculated BMI from nurse-measured data collected on 19,188 6-19-year-old students from 90 public schools in four low-income cities in New Jersey in 2015-2016. Based on a questionnaire administered to school nurses, we constructed 6 food and 3 PA indices capturing the healthfulness of key dimensions in the school food and PA environment domains. Multilevel linear models, stratified by school level (elementary and secondary), examined the association between BMI z-scores and indices of the school environment. The food and PA domains were modeled separately and then combined. Joint significance of indices within each domain was tested. Analyses were conducted in 2019-2020. In the combined model for elementary schools, indices in both the food and PA domains were jointly significant (p = 0.005 and p < 0.001, respectively). With regard to specific indices in the model, students' BMI z-score was 0.03 units lower for each additional outdoor PA facility (95% CI [-0.06, -0.00]; p = 0.036). Similarly, for secondary schools, both the food and PA domains were jointly significant (p = 0.004 and p = 0.020, respectively). Each additional unhealthy item in vending machines was associated with a 0.12 unit increase in BMI z-score (95% CI [+0.00, 0.23]; p = 0.042). Overall, healthier food and PA environments were associated with lower student BMI.

Parental Perceptions of the Nutritional Quality of School Meals and Student Meal Participation: Before and After the Healthy Hunger-Free Kids Act.

OBJECTIVES: To examine (1) parental perceptions of school meals and (2) student meal participation before and after the implementation of the Healthy Hunger-Free Kids Act (HHFKA). DESIGN: Data were collected from telephone surveys of 2 independent cross-sectional panels in New Jersey (2009-2010 and 2016-2017). PARTICIPANTS: Households with children aged 7-18 years (pre-HHFKA: n = 1,027; post-HHFKA: n = 324). MAIN OUTCOME MEASURES: Parental perception of school meals and parental reports of student participation in school meals. ANALYSIS: Multivariable logistic regression models were developed to examine outcome variables. For school meal participation, nested models were analyzed first controlling for sociodemographic variables, followed by parental perception, and then the interaction between perception and time. RESULTS: Parental perceptions of school meals did not change significantly after the HHFKA. At both time points, school meal participation rates were significantly higher for children of parents who perceived school meals as healthy compared with children whose parents perceived meals to be unhealthy (pre-HHFKA: 89.9% vs 75.1%, P < 0.001; post-HHFKA: 87.3% vs 64.9%, P = 0.02). CONCLUSION AND IMPLICATIONS: Because higher perception of school meal quality is associated with higher participation, it is important for school food programs to inform parents about the improved nutritional quality of school meals.