Foods Served in Child Care Facilities Participating in the Child and Adult Care Food Program: Menu Match and Agreement with the New Meal Patterns and Best Practices.

OBJECTIVE: To assess the agreement of posted menus with foods served to 3- to 5-year-old children attending federal Child and Adult Care Food Program (CACFP)-enrolled facilities, and the degree to which the facilities met the new meal patterns and best practices. DESIGN: On-site observations and menu coding. PARTICIPANTS/SETTING: Nine early care and education centers. MAIN OUTCOME MEASURES: Agreement of posted menus with foods served, and comparison of foods served and consumed with the new CACFP meal guidelines and best practices. ANALYSIS: Data were compiled for each meal (breakfast, lunch, and snacks). Frequencies and percentages of agreement with the posted menu (coded matches, substitutions, additions, and omissions) were calculated for each food component in the CACFP menu guidelines. Menu total match was created by summing the menu match plus acceptable substitutions. Menus were compared with the new CACFP meal guidelines and best practices. RESULTS: The match between the posted menus and foods actually served to children at breakfast, lunch, and snack was high when the acceptable menu substitutions were considered (approximately 94% to 100% total match). Comparing the menus with the new meal guidelines and best practices, the 1 guideline that was fully implemented was serving only unflavored, low-fat, or 1% milk; fruit and vegetable guidelines were partially met; fruit juice was not served often, nor were legumes; the guideline for 1 whole grain-rich serving/d was not met; and regular beef and full-fat cheese products were commonly served. CONCLUSIONS AND IMPLICATIONS: Early care and education centers enrolled in CACFP provided meals that met the current CACFP guidelines. Some menu improvements are needed for the centers to meet the new guidelines and best practices.

Randomized Controlled Trial to Prevent Infant Overweight in a High-Risk Population.

OBJECTIVES: Infants are at risk of overweight. Infant overweight predisposes child, adolescent, and adult to obesity. We hypothesized that parent education, initiated prenatally and provided in the home, would reduce the incidence of infant overweight at age 12 months. METHODS: Pregnant obese Latina women were recruited at Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and randomized to intervention versus control. Intervention subjects received home visits by trained Spanish-fluent community health workers who provided counseling on infant growth, breastfeeding, nutrition, child development, sleep, physical activity, and safety. Promotoras did not visit the control subjects. A research assistant collected outcome data on all subjects. RESULTS: Compared to controls, parent education did not reduce infant overweight. Infant overweight developed rapidly and was present in 46% of infants by age 6 months. Infants overweight at 6 months were likely to be overweight at age 12 months (r = 0.60, P < .0001). Overweight was more common in formula-fed infants at ages 6 months (P < .06) and 12 months (P = .005). Breastfeeding was less common in families with employed mothers (P = .02) and unemployed fathers (P < .01), but the father living with the mother at the time of the prenatal visit predicted successful breastfeeding at infant age 2 months (P < .003). Compared to formula feeding, overweight at age 12 months was 2.7 times less likely for infants breastfed for ≥2 months (P = .01). CONCLUSIONS: The lack of success of the intervention may be explained in part by a high cesarean section rate in the intervention group, food and employment insecurity, and confounding by WIC breastfeeding promotion, which was available to all mothers. Breastfeeding was the most important mediator of infant overweight. The study supports efforts by WIC to vigorously promote breastfeeding.

Texting to Increase Adolescent Physical Activity: Feasibility Assessment.

OBJECTIVE: Feasibility trials assess whether a behavior change program warrants a definite trial evaluation. This paper reports the feasibility of an intervention consisting of Self Determination Theory-informed text messages, pedometers, and goal prompts to increase adolescent physical activity. METHODS: A 4-group randomized design with baseline and immediate post-study assessments was used. Groups (pedometer; pedometer + goal prompt; pedometer + goal prompt + theory-informed texts; no-treatment control) were systematically varied to assess the additive effect of intervention components on objectively measured physical activity (ie, ActiGraph). The primary outcome of the 12-week intervention was program feasibility. Changes in average daily step counts and minutes of moderate-to-vigorous physical activity also were examined. Post-intervention research with a subset of participants examined program reactions. RESULTS: Participants (N = 160) were evenly split by sex, mostly 14-15 years old, and of diverse race/ethnicity. Feasibility criteria were met. The attrition rate was less than 2%. Modest increases in average daily step counts and moderate-to-vigorous physical activity were observed in all groups except the control group. Participants reported positive reactions to the intervention. CONCLUSIONS: An intervention consisting of pedometers, theory-informed texts, and goal prompts, is a feasible and acceptable method for promoting physical activity to adolescents.

Creating action plans in a serious video game increases and maintains child fruit-vegetable intake: a randomized controlled trial.

BACKGROUND: Child fruit and vegetable intake is below recommended levels, increasing risk for chronic disease. Interventions to influence fruit and vegetable intake among youth have had mixed effects. Innovative, theory-driven interventions are needed. Goal setting, enhanced by implementation intentions (i.e., plans tightly connected to a behavioral goal), may offer a solution. Action plans state "how" a goal will be achieved, while coping plans identify a potential barrier and corresponding solution. The research reported here evaluated the short- and long-term effects of goal setting enhanced with implementation intentions on child fruit and vegetable intake in a 10-episode, theoretically-grounded serious videogame promoting fruit and vegetables. This is one of the first studies to test the efficacy of implementation intentions on the dietary intake of healthy children. METHODS: A four-group randomized design with three data collection periods (baseline, immediate post-intervention, 3 months post-intervention) was employed. Groups varied on whether children created an implementation intention (none, action, coping, both) as part of goal setting. Participants were 4th and 5th grade children (~9-11 years old) and one parent. An a priori power analysis indicated this would provide >80% power to detect a small effect (Cohen's d = 0.17). Children played a 10-episode online videogame; parents received 10 electronic newsletters and access to a parent-only website. The primary outcome was child fruit and vegetable intake, assessed via three, dietitian-assisted telephone recalls at each data collection period. The primary analysis was conducted using a repeated measures analysis of covariance with a mixed model procedure. Secondary analyses examined intervention effects on fruit and vegetables separately. RESULTS: Four hundred parent/child dyads were recruited. A significant group-by-time interaction for fruit and vegetable intake (p < 0.001) was found in only the Action group, which had significant increases in fruit and vegetable intake at post 1 (p < 0.0001) and post 2 (p < 0.0001). No other significant interactions were observed; however, there were significant time effects for fruit (p < 0.0001). CONCLUSIONS: Action intentions may be an important component of successful interventions to increase and maintain fruit and vegetable intake in pre-adolescent children. Videogames promoting healthy diets offer an effective vehicle for delivering behavior change interventions to children. TRIAL REGISTRATION: ClinicalTrials.gov NCT01004094 .

Differential Improvements in Student Fruit and Vegetable Selection and Consumption in Response to the New National School Lunch Program Regulations: A Pilot Study.

OBJECTIVE: To investigate changes in student food selection and consumption in response to the new National School Lunch Program meal patterns during fall 2011. DESIGN: Eight elementary and four intermediate schools in one Houston area school district were matched on free/reduced-price meal eligibility and randomized into control or intervention conditions. INTERVENTION: Both intervention and control school cafeterias served the same menu. The intervention school cafeterias posted the new meal pattern daily; students could select one fruit and two vegetable servings per reimbursable meal. Control school students could only select the previous meal pattern: a total of two fruit and vegetable servings per meal. MAIN OUTCOME MEASURES: Students were observed during lunch: student sex and foods selected/consumed were recorded. Diet analysis software was used to calculate energy/food groups selected/consumed. STATISTICAL ANALYSES PERFORMED: Cochran-Mantel-Haenszel χ² tests examined differences in the percent of students selecting each meal component by condition, controlling for sex, grade, and school free/reduced-price meal eligibility. Analysis of covariance assessed differences in amount of energy/food groups selected and consumed, and differences in percent of food groups consumed. RESULTS: Observations were conducted for 1,149 elementary and 427 intermediate students. Compared with students in the control schools, significantly more intervention elementary and intermediate school students selected total (P<0.001, P<0.05) and starchy vegetables (P<0.001, P<0.01); more intervention intermediate school students selected fruit (P<0.001), legumes (P<0.05), and protein foods (P<0.01). There were significantly greater amounts of these foods selected and consumed, but no differences in the proportion of the foods consumed by condition. Fewer calories were consumed by elementary and intermediate school intervention students. CONCLUSIONS: More intervention students selected fruit and vegetables at lunch and consumed them compared with control condition students. Future studies with larger and more diverse student populations are warranted.

Quality and cost of student lunches brought from home.

IMPORTANCE: The nutritional quality and cost of lunches brought from home are overlooked and understudied aspects of the school food environment. OBJECTIVES: To examine the quality and cost of lunches brought from home by elementary and intermediate school students. DESIGN, SETTING, AND PARTICIPANTS: An observational study was conducted in 12 schools (8 elementary and 4 intermediate) in one Houston, Texas, area school district from October 6, 2011, to December 5, 2011. Participants included 242 elementary and 95 intermediate school students who brought lunches from home. EXPOSURES: Lunches brought from home. MAIN OUTCOMES AND MEASURES: Foods brought and amounts eaten were recorded along with student grade level and sex. Nutrient and food group content were calculated and compared with current National School Lunch Program (NSLP) guidelines. Per-serving prices for each item were collected from 3 grocery stores in the study area and averaged. RESULTS: Compared with the NSLP guidelines, lunches brought from home contained more sodium (1110 vs ≤640 mg for elementary and 1003 vs ≤710 mg for intermediate students) and fewer servings of fruits (0.33 cup for elementary and 0.29 cup for intermediate students vs 0.50 cup per the NSLP guidelines), vegetables (0.07 cup for elementary and 0.11 cup for intermediate students vs 0.75 cup per the NSLP guidelines), whole grains (0.22-oz equivalent for elementary and 0.31-oz equivalent for intermediate students vs 0.50-oz minimum per the NLSP guidelines), and fluid milk (0.08 cup for elementary and 0.02 cup for intermediate students vs 1 cup per the NSLP guidelines). About 90% of lunches from home contained desserts, snack chips, and sweetened beverages, which are not permitted in reimbursable school meals. The cost of lunches from home averaged $1.93 for elementary and $1.76 for intermediate students. Students from lower-income intermediate schools brought significantly higher-priced ($1.94) lunches than did students from middle-income schools ($1.63). CONCLUSIONS AND RELEVANCE: Lunches brought from home compared unfavorably with current NSLP guidelines. Strategies are needed to improve the nutritional quality of lunches brought from home.

Household food insecurity and dietary intake among Mexican-American women participating in federal food assistance programs.

PURPOSE: To explore the association between food insecurity and dietary intake among Mexican-American women after controlling for sociocultural and economic factors including participation in federal food assistance programs. DESIGN: Cross-sectional. SETTING: Three cities in Texas. SUBJECTS: Seven hundred seven Mexican-American women (26-44 years). MEASURES: Demographics, anthropometrics, acculturation, and food security status were obtained using validated measures. Dietary intake was assessed by a 24-hour dietary food record. ANALYSIS: Logistic regression was used to examine the association between individual and household characteristics on food security status. One-way analysis of covariance tested the association between food security status and dietary intake after adjusting for socio-demographic variables, acculturation, body mass index, participation in federal food assistance programs, and energy intake. RESULTS: About 77% of food-insecure women participated in at least one federal food assistance program. Each additional child in the household increased the odds of being food insecure by 25%. A higher proportion of obese women was found in the food-insecure group. No significant differences in dietary intake were found by food security status. CONCLUSION: Food insecurity did not negatively influence dietary intake independently of women's participation in federal food assistance programs. Food security did not ensure consumption of nutritionally adequate foods. Educational and food assistance programs need to be optimized to facilitate enrollment and improve the nutritional status of this ethnic group, food secure or not.

Comparison of a Web-based versus traditional diet recall among children.

Self-administered instruments offer a low-cost diet assessment method for use in adult and pediatric populations. This study tested whether 8- to 13-year-old children could complete an early version of the Automated Self Administered 24-hour diet recall (ASA24) and how this compared to an interviewer-administered 24-hour diet recall. One-hundred twenty 8- to 13-year-old children were recruited in Houston from June through August 2009 and randomly assigned to complete either the ASA24 or an interviewer-administered 24-hour diet recall, followed by the other recall mode covering the same time interval. Multivariate analysis of variance, testing for differences by age, sex, and ethnic/racial group, were applied to percentages of food matches, intrusions, and omissions between reports on the ASA24 and the interviewer-administered 24-hour diet recall. For the ASA24, qualitative findings were reported regarding ease of use. Overall matches between interviewer-administered and ASA24 self-administered 24-hour diet recall was 47.8%. Matches were significantly lower among younger (8- to 9-year-old) compared with older (10- to 13-year-old) children. Omissions on ASA24 (18.9% overall) were most common among 8-year-olds and intermediate among 9-year-olds. Eight- and 9-year-olds had substantial difficulties and often required aid in completing ASA24. Findings from this study suggest that a simpler version of an Internet-based diet recall program would be easier for children to use.

The impact of the Texas public school nutrition policy on student food selection and sales in Texas.

OBJECTIVES: We assessed the statewide impact of the 2004 Texas Public School Nutrition Policy on foods and beverages served or sold in schools. METHODS: We collected lunch food production records from 47 schools in 11 Texas school districts for the school years before (2003-2004) and after (2004-2005) policy implementation. Cafeteria servings of fruit, vegetables (regular and fried), and milk served each day were calculated. Twenty-three schools from 5 districts provided records of à la carte sales of candy, chips, desserts, drinks, ice cream, and water. We examined aggregated school-level differences in total items served or sold per day per student between study years. RESULTS: School demographics were similar to state data. Regardless of district and school size, cafeterias served significantly fewer high-fat vegetable items per student postpolicy (P < .001). Postpolicy snack bar sales of large bags of chips were significantly reduced (P = .006), and baked chips sales significantly increased (P = .048). CONCLUSIONS: School food policy changes have improved foods served or sold to students. It is not known whether improved lunch choices influence consumption for the whole day.

Social desirability is associated with some physical activity, psychosocial variables and sedentary behavior but not self-reported physical activity among adolescent males.

This study examined whether controlling for social desirability improved the association between self-reported and objectively measured physical activity among adolescent males and the extent that psychosocial variables predict physical activity after controlling for social desirability. Participants (n=447) were 10- to 14-year old Houston Boy Scouts. Participants completed self-reports of physical activity, sedentary behavior, preferences, self-efficacy and social desirability and wore an MTI accelerometer for 3 days. Correlations were conducted among variables. Regression models were performed to examine the relationships between objectively measured (accelerometer) and self-reported physical activity, objectively measured physical activity and psychosocial variables and self-reports of physical activity and psychosocial variables. All models controlled for social desirability. There were weak associations between self-reported and objectively measured physical activity measures that were slightly improved after controlling for social desirability. Psychosocial variables were strongly associated with self-reports of physical activity, but weakly associated with accelerometer physical activity. Social desirability was positively associated with physical activity preferences (r=0.169) and self-efficacy (r=0.118) and negatively associated (r=-0.158) with self-reported sedentary behavior. Differences in the strength of relationships between self-reported and objectively measured physical activity and psychosocial variables were not a function of social desirability.

Fit for Life Boy Scout badge: outcome evaluation of a troop and Internet intervention.

BACKGROUND: This study reports the results of a 9-week intervention on the physical activity levels of adolescent males. METHODS: Participants were 473 10- to 14-year-old Houston Boy Scouts (42 troops) with troops randomly assigned to intervention or control conditions. Data were collected in spring (16 troops) and fall (26 troop) waves during 2003. Intervention participants received a 9-week troop and Internet program to increase physical activity skills, self-efficacy and goal-setting. Physical activity was assessed at baseline, end of the intervention (Post#1) and post-6 months (Post#2) by accelerometer. Minutes of sedentary, light and moderate to vigorous physical activity were calculated. Repeated measure analyses were performed to test differences in physical activity over time between groups with participants nested in troops. RESULTS: A three-way interaction (group * time * wave) that approached significance (P = 0.051) indicated a 12-min reduction in sedentary behavior among spring intervention participants. A significant three-way interaction (P = 0.011) (group * time * wave) indicated a 12-min increase in light intensity activity among the spring intervention group. CONCLUSION: Participation in the Fit for Life badge program resulted in a trend towards a small decrease in sedentary behavior and increased light intensity physical activity among spring participants only. There was no effect on moderate to vigorous physical activity.

Anthropometric, parental, and psychosocial correlates of dietary intake of African-American girls.

OBJECTIVE: This paper identifies the anthropometric, parental, and psychosocial characteristics and meal practices (e.g., breakfast skipping and number of meals and snacks consumed) associated with consumption of total energy, percent energy from fat, fruit, 100% fruit juice, vegetables, sweetened beverages, and water among 8- to 10-year-old African-American girls. RESEARCH METHODS AND PROCEDURES: This study included 114 8- to 10-year-old African-American girls and a parent or primary caregiver. Girls and a parent or primary caregiver completed several dietary questionnaires. Two 24-hour dietary recalls were conducted with each girl. Height and weight were measured. Separate hierarchical regression analyses were conducted for each dependent dietary variable; potential field center differences were examined. RESULTS: The number of meals and snacks consumed was correlated with energy intake. Lower BMI was related to higher vegetable consumption, and the number of snacks consumed was positively related to sweetened beverage consumption. Greater low-fat food preparation practices reported by parents were related to lower consumption of fat as a percentage of total energy. DISCUSSION: Dietary behavior differed across geographic areas. Low-fat food preparation practices in the home seemed to be an important influence on the percentage of energy consumed from fat. Greater vegetable consumption was associated with lower BMI. Interventions to prevent excessive weight gain in African-American girls should encourage low-fat food preparation in the home and greater consumption of vegetables.

Misclassification associated with measurement error in the assessment of dietary intake.

OBJECTIVE: Dietary assessment has been used for certification to receive food supplements or other nutrition services and to provide feedback for educational purposes. The proportion of individuals correctly certified as eligible is a function of the amount of error that exists in the dietary measures and the level of dietary intake used to establish eligibility. Whether individuals are correctly counselled to increase or decrease the consumption of selected foods or nutrients is a function of the same factors. It is not clear, however, what percentage of individuals would be correctly classified under what circumstances. The objective of this study is to demonstrate the extent to which measurement error and eligibility criteria affect the accuracy of classification. DESIGN: Hypothetical distributions of dietary intake were generated with varying degrees of measurement error. Different eligibility criteria were applied and the expected classification rates were determined using numerical methods. SETTING AND SUBJECTS: Simulation study. RESULTS: Cut points of dietary intake at decreasing levels below the 50th percentile of true intake were associated with lower sensitivity and predictive value positive rates, but higher specificity and predictive value negative rates. The correct classification rates were lower when two cut points of dietary intake were used. Using a single cut point that was higher than the targeted true consumption resulted in higher sensitivity but lower predictive value positive, and lower specificity but higher predictive value negative. CONCLUSIONS: Current methods of dietary assessment may not be reliable enough to attain acceptable levels of correct classification. Policy-makers and educators must consider how much misclassification error they are willing to accept and determine whether more intensive methods are necessary.

Collaborative planning for formative assessment and cultural appropriateness in the Girls health Enrichment Multi-site Studies (GEMS): a retrospection.

OBJECTIVE: The Girls health Enrichment Multi-site Studies (GEMS), Phase 1, developed and pilot-tested interventions to prevent obesity in African-American preadolescent girls. This article describes the collaborative planning process undertaken to take full advantage of formative assessment activities for improving contextual relevance and cultural appropriateness. DESIGN: Working group activities were designed to stimulate awareness and reflection among group members and, through them, among other field center investigators and staff about developmental, cultural, and contextual issues for formative assessment. SETTING: Telephone, Internet, and face-to-face interactions across GEMS field centers in Houston, Texas; Memphis, Tennessee; Minneapolis, Minnesota; and Palo Alto, California. PARTICIPANTS: Investigators and staff involved in intervention development. MAIN OUTCOME MEASURES: The utility of the process was judged from feedback by participants and field center principal investigators about the contribution of the collaborative effort to improving the perceived relevance and cultural appropriateness of formative assessment data collection and interpretation. RESULTS: A working bibliography was compiled. A detailed matrix of programmatic, child, family, and contextual issues related to ethnicity, socioeconomic status, general health and lifestyle, food, physical activity, and body image/weight control was completed. Additional guidance was derived from a workshop that involved scholars with expertise in aspects of African-American culture, child development, and family processes. CONCLUSIONS: This process improved the breadth and depth of GEMS formative assessment activities by increasing the appreciation of the complex structural, contextual, and personal forces at play. A similar process may be useful to other investigators when attempting to develop culturally appropriate interventions.