Helping parents provide vegetable snacks: Investigating price and taste as barriers.

Snacks contribute nearly one-quarter of children's daily energy intake in the USA. Snack time therefore represents an opportunity for parents to provide foods with key nutrients. Instead, the most common snack foods are major contributors to children's consumption of added sugars and sodium. Parents face major barriers to providing healthier snacks, including perceptions of high cost and lack of child acceptance. We obtained both economic and qualitative data to inform and optimize interventions for parents to promote vegetable snacks for children. We conducted a survey with parents (n = 368) to estimate how much of a discount would influence vegetable snack purchases by estimating willingness-to-pay using the contingent valuation method, using baby-cut carrots as a sample product. We conducted three focus groups (n = 19) and 1 group interview (n = 2) with children to help understand how to increase the appeal of vegetable snacks. Most (70%) parents accepted the reference price for the vegetable snack. Among those who did not, contingent valuation analysis revealed that a mean discount of approximately 30% would shift consumers to purchasing the snack. Focus group results revealed that the appeal of vegetable snacks to children was influenced by how they were prepared and presented, and the child's familiarity with the vegetables and ability to choose among them. This study lays the groundwork for effective interventions to promote the provision of vegetable snacks by parents.

Processed food consumption is associated with diet quality, but not weight status, in a sample of low-income and ethnically diverse elementary school children.

Excess consumption of highly processed foods may be associated with lower diet quality and obesity prevalence, but few studies have examined these relationships in children from low-income households. Therefore, the objective of this study was to evaluate the relationship between food consumption by processing category, diet quality as measured by the Healthy Eating Index-2015 (HEI-2015) and body mass index (BMI) in a sample of low-income children. Data from a study assessing the impact of Summer Food Service participation on diet quality and weight status (N = 131) was used to conduct a cross-sectional analysis of children aged six to twelve years from low-income communities in the Northeastern U.S. Total HEI-2015 score and percentage of calories consumed by processing level were computed per day from three 24-h diet recalls. Multivariable linear regression was used to assess the relationship between percentage of calories from foods by processing category (unprocessed and minimally, basic, moderately and highly processed), HEI-2015 and BMI-z score. The final sample was 58% male and 33.8% obese. On average, children consumed 39.8 ± 17.2% of calories from highly processed foods. A 10% increase in calories consumed from highly processed foods was associated with a 2.0 point decrease in total HEI-2015 score [95% CI (-2.7, -1.2)], and a 10% increase in calories from minimally processed foods was associated with a 3.0 increase in HEI-2015 score [95% CI (2.1, 3.8)]. Relationships between processing level and BMI-z score were not significant. Among this sample of low-income children, greater intake of highly processed foods was associated with lower dietary quality, but not weight status. Future research should explore prospective associations between food consumption by processing category and weight status in children.

A qualitative exploration of potential determinants of accelerated summer weight gain among school-age children: perspectives from parents.

BACKGROUND: There is growing evidence that school children in the United States gain weight more rapidly during the summer than the school year, but few studies have explored the causes of this phenomenon. The goal of this study was to qualitatively explore potential determinants of accelerated summer weight gain by interviewing parents of school-age children. METHODS: Key informant interviews were conducted with parents of third and fourth grade students enrolled in a school-based physical activity intervention in three peri-urban communities in Eastern Massachusetts. A structured interview guide was developed to assess school year and summertime differences in child diet, physical activity, daily routine, and family rules. Interviews were recorded and transcribed verbatim. Transcripts were coded and major themes were identified using thematic analysis. RESULTS: Summer activities varied substantially by family. Many parents characterized summer as a time with less structure and more relaxed rules, particularly around bedtime and screen use. Parents perceived their child to be more physically active in the summer and reported few barriers to summertime physical activity. Parents reported increases in both positive (increased consumption of fruits and vegetables) and negative (increased consumption of "sweets" and "junk foods") dietary behaviors. They highlighted several stressors unique to summer, such as the high cost of camps and the need to coordinate childcare and manage children's time. CONCLUSIONS: Parents perceived their children to be more physically active in the summer and consume more fruits and vegetables than during the school year. However, they also perceived children to consume more energy-dense, nutrient poor foods, engage in more screen time, and have later bedtimes during the summer. These behaviors are important targets for summertime obesity prevention interventions. Large-scale quantitative studies are needed to determine whether these parent perceptions reflect meaningful risk factors for accelerated summer weight gain.

Nutritional, Economic, and Environmental Costs of Milk Waste in a Classroom School Breakfast Program.

OBJECTIVES: To measure fluid milk waste in a US School Breakfast in the Classroom Program and estimate its nutritional, economic, and environmental effects. METHODS: Fluid milk waste was directly measured on 60 elementary school classroom days in a medium-sized, urban district. The US Department of Agriculture nutrition database, district cost data, and carbon dioxide equivalent (CO2e) emissions and water footprint estimates for fluid milk were used to calculate the associated nutritional, economic, and environmental costs. RESULTS: Of the total milk offered to School Breakfast Program participants, 45% was wasted. A considerably smaller portion of served milk was wasted (26%). The amount of milk wasted translated into 27% of vitamin D and 41% of calcium required of School Breakfast Program meals. The economic and environmental costs amounted to an estimated $274 782 (16% of the district's total annual School Breakfast Program food expenditures), 644 893 kilograms of CO2e, and 192 260 155 liters of water over the school year in the district. CONCLUSIONS: These substantial effects of milk waste undermine the School Breakfast Program's capacity to ensure short- and long-term food security and federal food waste reduction targets. Interventions that reduce waste are urgently needed.

National Dissemination of StrongWomen-Healthy Hearts: A Community-Based Program to Reduce Risk of Cardiovascular Disease Among Midlife and Older Women.

OBJECTIVES: We describe the national dissemination of an evidence-based community cardiovascular disease prevention program for midlife and older women using the RE-AIM (reach effectiveness adoption implementation maintenance) framework and share key lessons learned during translation. METHODS: In a 2010 to 2014 collaboration between the StrongWomen program and the National Extension Association of Family and Consumer Sciences, we assessed reach, adoption, implementation, and maintenance using survey methods, and we assessed effectiveness using a pretest-posttest within-participants design, with weight change as the primary outcome. RESULTS: Overall reach into the population was 15 per 10,000. Of 85 trained leaders, 41 (48%) adopted the program. During the 12-week intervention, weight decreased by 0.5 kilograms, fruit and vegetable intake increased by 2.1 servings per day, and physical activity increased by 1238 metabolic equivalent (MET)-minutes per week (all P < .001). Average fidelity score was 4.7 (out of possible 5). Eleven of 41 adopting leaders (27%) maintained the program. CONCLUSIONS: The StrongWomen-Healthy Hearts program can be implemented with high fidelity in a variety of settings while remaining effective. These data provide direction for program modification to improve impact as dissemination continues.

Great Taste, Less Waste: a cluster-randomized trial using a communications campaign to improve the quality of foods brought from home to school by elementary school children.

OBJECTIVE: Great Taste, Less Waste (GTLW), a communications campaign, capitalized on the synergy between healthy eating and eco-friendly behaviors to motivate children to bring more fruits and vegetables and fewer sugar-sweetened beverages (SSBs) to school. METHODS: A cluster-randomized trial in Eastern Massachusetts elementary schools in 2011-2012 tested the hypothesis that GTLW would improve the quality of foods from home more than a nutrition-only campaign--Foods 2 Choose (F2C)--or control. Lunch and snack items from home were measured at baseline and 7 months later using digital photography. Mixed linear models compared change in mean servings of fruits, vegetables, and SSBs among groups, and change in mean prevalence of packaging type. Change in prevalence of food items of interest was compared among groups using generalized linear models. RESULTS: Five hundred and eighty-two third and fourth graders from 82 classrooms in 12 schools participated. At follow-up, no significant differences were observed between groups in change in mean servings or change in prevalence of items of interest. No packaging differences were observed. CONCLUSION: GTLW was well received, but no significant changes were observed in the quality of food brought to school. Whether classrooms are an effective environment for change remains to be explored. ClinicalTrials.gov identifier: NCT0157384.

Household and family factors related to weight status in first through third graders: a cross-sectional study in Eastern Massachusetts.

BACKGROUND: Early environmental influences have been linked to child weight status, however further understanding of associations in diverse populations is needed. METHODS: A cross-sectional analysis of household and family factors associated with overweight was conducted on a culturally diverse, urban dwelling sample of 820 first through third graders (mean age 7.6 ± 1.0 years) residing in three eastern Massachusetts cities. Overweight was defined as BMI > 85th percentile, based on measured height and weight, and the CDC growth reference. Multivariate logistic regression was used to identify demographic, behavioral, and social environmental variables significantly related to weight status. Independent variables included race-ethnicity, age, sex, servings of sugar-sweetened beverages/week, hours of screen time/week, parent overweight, (calculated from self-reported weight/height), parent education, household food restriction rules regarding snacking and/or kitchen access, frequency of having dinner as a family (reported as "a lot" vs. "sometimes/rarely/never") and child vitamin/mineral supplement use. Selected interactions were explored based on prior studies. RESULTS: Prevalence of overweight was 35.5% in girls and 40.8% in boys. In the final, adjusted model, compared to white children, the odds of overweight were higher in children of Hispanic race-ethnicity (odds ratio (OR) = 2.4, 95% CI = 1.4 - 4.1). In the same adjusted model, compared to children with no household food restriction rules, the odds of overweight were 2.6 (95% CI = 1.3-5.1) times higher and 3.5 (95% CI = 1.9-6.4) times higher for children having one rule or two rules, respectively. Parent report of frequent family dinner and child vitamin use were protective, with a halving of risk for overweight for each behavior (OR = 0.47, 95% CI = 0.31-0.71 and OR = 0.54, 95% CI = 0.37-0.78, respectively). CONCLUSIONS: In the presence of other factors, frequent family dinner and vitamin use were associated with lower risk of overweight and household food restriction rules with higher risk. Although such relationships have previously been reported, this investigation is among the first to demonstrate these associations in a low-income, racially-diverse early elementary school population, and suggest potential targets of opportunity within the family context that could reduce child overweight risk in a subgroup of children at elevated risk of obesity.

Shape Up Somerville two-year results: a community-based environmental change intervention sustains weight reduction in children.

OBJECTIVE: The objective of this study was to test the hypothesis that community-based environmental change intervention prevents undesirable weight gain in children. METHOD: The method used in this study was a two-year, non-randomized, controlled trial (2003-2005) using community-based participatory methodology in three diverse cities in Massachusetts: one intervention and two socio-demographically-matched control communities (pooled for analysis). Children (n=1028), with a mean age=7.61+1.04years participated. Interventions were made to improve energy balance by increasing physical activity options and availability of healthful foods (Year 1). To firmly secure sustainability, the study team supported policies and shifted intervention work to community members (Year 2). RESULTS: Change in body mass index z-score (BMIz) was assessed by multiple regression, accounting for clustering within communities and adjusting for baseline covariates. Sex-specific overweight/obesity prevalence, incidence and remission were assessed. Over the two-year period, BMIz of children in the intervention community decreased by -0.06 [p=0.005, 95% confidence interval: -0.08 to -0.04] compared to controls. Prevalence of overweight/obesity decreased in males (OR=0.61, p=0.01) and females (OR=0.78, p=0.01) and remission increased in males (OR 3.18, p=0.03) and females (OR 1.93, p=0.03) in intervention compared to controls. CONCLUSION: Results demonstrate promise for preventing childhood obesity using a sustainable multi-level community-based model and reinforce the need for wide-reaching environmental and policy interventions.

Changes in diet and physical activity resulting from the Shape Up Somerville community intervention.

BACKGROUND: The purpose of this study is to describe the behavioral changes in children resulting from Shape Up Somerville (SUS), a community-based, participatory obesity prevention intervention that used a multi-level, systems-based approach. It was set in Somerville, an urban, culturally diverse community in Massachusetts, USA. METHODS: This was a non-randomized, controlled 2-year community-based intervention trial with children enrolled in grades 1 to 3 (ages 6-8 years). Overall, the SUS intervention was designed to create environmental and policy change to impact all aspects of a child's day. Pre-post outcomes were compared between Somerville and two control communities that were chosen based on socio-demographic similarities. Behavioral outcomes were fruit and vegetable and sugar-sweetened beverage consumption; number of organized sports and physical activities per year; walking to and from school; screen and television time; television in bedroom; and dinner in room with television on. These measures were assessed by parent/caregiver report using a 68-item Family Survey Form. Data were analyzed using multiple linear regression, accounting for covariates and clustering by community. RESULTS: Intervention group children, compared to the control group, significantly reduced sugar-sweetened beverage consumption (-2.0 ounces per day; 95% CI -3.8 to -0.2), increased participation in organized sports and physical activities (0.20 sports or activities per year; 95% CI 0.06 to 0.33), and reduced their screen time (-0.24 hours per day; 95% CI -0.42 to -0.06). CONCLUSIONS: Results of this study, particularly intake of sugar-sweetened beverages and screen time, are similar to others that used a multi-level approach to realize change in behavior. These results support the efficacy of a multi-level and systems-based approach for promoting the behavioral changes necessary for childhood obesity prevention. This study is registered at ClinicalTrials.gov as NCT00153322.

Using the Community Readiness Model to select communities for a community-wide obesity prevention intervention.

To build on a growing interest in community-based obesity prevention programs, methods are needed for matching intervention strategies to local needs and assets. We used the Community Readiness Model (CRM), a structured interview guide and scoring system, to assess community readiness to act on childhood obesity prevention, furthering a replication study of a successful intervention. Using the CRM protocol, we conducted interviews with 4 stakeholders in each of 10 communities of similar size, socioeconomic status, and perceived readiness to implement a community-wide obesity prevention intervention. Communities were in California, Florida, Illinois, Massachusetts, New York, North Carolina, Pennsylvania, and Tennessee. The 4 stakeholders were the mayor or city manager, the school superintendent, the school food service director, and a community coalition representative. Interviews were recorded and professionally transcribed. Pairs of trained reviewers scored the transcriptions according to CRM protocol. The CRM assesses 9 stages of readiness for 6 dimensions: existing community efforts to prevent childhood obesity, community knowledge about the efforts, leadership, community climate, knowledge about the issue, and resources. We calculated an overall readiness score for each community from the dimension scores. Overall readiness scores ranged from 2.97 to 5.36 on the 9-point scale. The mean readiness score, 4.28 (SD, 0.68), corresponds with a "preplanning" level of readiness. Of the 6 dimensions, community climate varied the least (mean score, 3.11; SD, 0.64); leadership varied the most (mean score, 4.79; SD, 1.13). The CRM quantified a subjective concept, allowing for comparison among 10 communities. Dimension scores and qualitative data from interviews helped in the selection of 6 communities for a replication study.

The effects of school garden experiences on middle school-aged students' knowledge, attitudes, and behaviors associated with vegetable consumption.

This study describes the effects of garden-based education on children's vegetable consumption. As part of a pre-post panel study, 236 students complete the Garden Vegetable Frequency Questionnaire and 161 complete a taste test. Results indicate that school gardening may affect children's vegetable consumption, including improved recognition of, attitudes toward, preferences for, and willingness to taste vegetables. Gardening also increases the variety of vegetables eaten. Future research should explore whether effects persist over time and if and how changes in children's behavior affect the behavior of their caregivers. Implications of study findings for policy and practice are discussed. Suggestions for applying results to future health promotions are provided.

Processed and Packed: How Refined Are the Foods That Children Bring to School for Snack and Lunch?

BACKGROUND: Increasing consumption of highly processed foods has been associated with adverse health outcomes among children. In the US, children consume up to half of their daily energy intake at school. OBJECTIVES: We sought to characterize foods that children bring from home to school according to processing level and to evaluate the effectiveness of a school-based intervention, Great Taste Less Waste (GTLW), in reducing the proportion of energy brought from highly processed foods from home compared with control. DESIGN: Secondary data analysis of a 7-month school-based, cluster-randomized trial. PARTICIPANTS/SETTING: Third- and fourth-grade students (n = 502, mean age: 9.0 ± 0.62 years) at 10 public elementary schools in Eastern Massachusetts (school year 2012-2013). INTERVENTION: GTLW included a 22-lesson classroom curriculum, homework activities, monthly parent newsletters, a food shopping and packing guide for parents, food demonstrations, school-wide announcements, and a poster contest. MAIN OUTCOME MEASURES: The energy content of foods brought to school was estimated from digital photographs, and foods were assigned to 1 of 3 processing levels (less processed or unprocessed, moderately processed, or highly processed) based on an established classification system. STATISTICAL ANALYSES PERFORMED: The percentage of energy brought from foods categorized into each processing level was calculated and compared pre- and postintervention using hierarchical linear models. RESULTS: Most of the food brought from home to school was highly processed (70% of food energy brought). Foods categorized as snack foods and desserts contributed the greatest percentage of total energy to the highly processed category at baseline and follow-up (72% and 69%, respectively). Energy from foods brought for snack tended to be more highly processed than those brought for lunch. No significant differences were observed from pre- to postintervention in the GTLW group compared with control for the percentage of energy brought from highly processed foods in adjusted models (ß: -1.1, standard error: 2.2, P = .6) or any other processing level. CONCLUSIONS: Highly processed foods were prevalent in home-packed lunches and snacks, and these patterns persisted after a targeted intervention. Further research is needed to identify strategies to improve the healthfulness of foods brought from home to school.

Parent-child interactions and objectively measured child physical activity: a cross-sectional study.

BACKGROUND: Parents influence their children's behaviors directly through specific parenting practices and indirectly through their parenting style. Some practices such as logistical and emotional support have been shown to be positively associated with child physical activity (PA) levels, while for others (e.g. monitoring) the relationship is not clear. The objectives of this study were to determine the relationship between parent's PA-related practices, general parenting style, and children's PA level. METHODS: During the spring of 2007 a diverse group of 99 parent-child dyads (29% White, 49% Black, 22% Hispanic; 89% mothers) living in low-income rural areas of the US participated in a cross-sectional study. Using validated questionnaires, parents self-reported their parenting style (authoritative, authoritarian, permissive, and uninvolved) and activity-related parenting practices. Height and weight were measured for each dyad and parents reported demographic information. Child PA was measured objectively through accelerometers and expressed as absolute counts and minutes engaged in intensity-specific activity. RESULTS: Seventy-six children had valid accelerometer data. Children engaged in 113.4 ± 37.0 min. of moderate-vigorous physical activity (MVPA) per day. Children of permissive parents accumulated more minutes of MVPA than those of uninvolved parents (127.5 vs. 97.1, p < 0.05), while parents who provided above average levels of support had children who participated in more minutes of MVPA (114.2 vs. 98.3, p = 0.03). While controlling for known covariates, an uninvolved parenting style was the only parenting behavior associated with child physical activity. Parenting style moderated the association between two parenting practices - reinforcement and monitoring - and child physical activity. Specifically, post-hoc analyses revealed that for the permissive parenting style group, higher levels of parental reinforcement or monitoring were associated with higher levels of child physical activity. CONCLUSIONS: This work extends the current literature by demonstrating the potential moderating role of parenting style on the relationship between activity-related parenting practices and children's objectively measured physical activity, while controlling for known covariates. Future studies in this area are warranted and, if confirmed, may help to identify the mechanism by which parents influence their child's physical activity behavior.

Parent behavior and child weight status among a diverse group of underserved rural families.

The purpose of this study was threefold: to investigate the association between three parenting behaviors (parenting style, feeding style, and feeding practices), to evaluate whether these behaviors were associated with child weight, and to determine whether style (parenting and feeding) moderated the relationship between feeding practice and child weight. Ninety-nine parent-child dyads were recruited for a cross-sectional study where parents self-reported their parenting style, feeding style, and feeding practices along with demographic characteristics. Height and weight were measured for each dyad. The relationship between parenting style and feeding style showed modest agreement. Feeding style, but not parenting style, was associated with child BMI z-score while controlling for known covariates. An indulgent feeding style was associated with a higher child weight status. Multiple regression analysis demonstrated that feeding style moderated the association between restrictive feeding practices and child BMI z-score. No moderating relationship was found between feeding style and the practices of pressure to eat or monitoring and child weight. This research suggests that an indulgent feeding style may be predictive of higher child weight and that future studies should examine the possible moderating role of feeding style in the parent feeding practice-child weight relationship.

Comparison of online and face-to-face dissemination of a theory-based after school nutrition and physical activity training and curriculum.

This study was conducted to compare two different online delivery methods to train after school program leaders (ASPLs) to implement a nutrition and physical activity curriculum for children to each other and to a face-to-face (FTF) training model. A three-group design was used in which ASPLs from 12 states were randomized to either standard (n = 34) or an enhanced interaction (n = 31) online training, while a FTF group (n = 24) served as comparison. All ASPLs completed training and implemented curriculum lessons over 16 weeks from March to June 2007. Weekly evaluations and pre and post-intervention questionnaires compared number of lessons implemented, subjective ratings of lesson success, and pre and post leader nutrition and physical activity knowledge. Multivariate linear regression analyses were used for among-group comparisons, paired Ttests for within-group knowledge change. Knowledge scores increased significantly (p < .001) within each group. All ASPLs fulfilled the goal of conducting at least 9 lessons, and they rated 64% of lessons successful. After adjustment, knowledge change and success scores did not differ among groups. Implementation was significantly higher for FTF (+2.23 lessons, p = .013) than for enhanced interaction, but not for standard. Online training for ASPLs, such as the standard condition, are viable means of nutrition and physical activity education and program dissemination.

Addressing Challenges with the Categorization of Foods Processed at Home: A Pilot Methodology to Inform Consumer-Facing Guidance.

The objective of this study was to inform consumer-facing dietary guidance by (1) adapting the current University of North Carolina at Chapel Hill (UNC) food processing framework to include a home processing (HP) component and (2) pilot testing the adapted version using a nationally representative sample of foods consumed in the U.S. The UNC framework was adapted to include guidelines for categorizing home-prepared (HP) foods. The original UNC and adapted HP frameworks were used to code dietary recalls from a random sample of National Health and Nutrition Examination Survey (2015-2016 cycle) participants (n = 100; ages 2-80 years). Percent changes between the UNC and HP adapted frameworks for each processing category were calculated using Microsoft Excel, version 16.23. Participants were 56% female, 35% non-Hispanic white (mean age = 31.3 ± 23.8). There were 1,376 foods with 651 unique foods reported. Using the HP compared to the UNC framework, unprocessed/minimally processed foods declined by 11.7% (UNC: 31.0% vs. HP: 27.4%); basic processed foods increased by 116.8% (UNC: 8.2% vs. HP: 17.8%); moderately processed foods increased by 16.3% (UNC: 14.2% vs. HP: 16.6%); and highly processed foods decreased by 17.8% (UNC: 46.5% vs. HP: 38.2%). Home-prepared foods should be considered as distinct from industrially produced foods when coding dietary data by processing category. This has implications for consumer-facing dietary guidance that incorporates processing level as an indicator of diet quality.

The StrongWomen-Healthy Hearts program: reducing cardiovascular disease risk factors in rural sedentary, overweight, and obese midlife and older women.

OBJECTIVES: We tested a community-based intervention designed to reduce cardiovascular disease risk in sedentary midlife and older women who were overweight or obese. METHODS: In a randomized controlled trial conducted in 8 counties in Arkansas and Kansas, counties were assigned to the intervention (a 12-week twice-weekly heart health program) group or to the delayed-intervention control group. Ten to fifteen women were selected from each site, and participants' weight, waist circumference, diet, physical activity, and self-efficacy were measured before and after the intervention. Data were analyzed with multiple regressions. RESULTS: Compared with the control group, participants in the intervention group had a significant decrease in body weight (-2.1 kg; 95% confidence interval [CI] = -3.2, -1.0), waist circumference (-2.3 in; 95% CI = -4.2, -0.5), and energy intake (-390 kcal/day; 95% CI = -598, -183); an increase in activity (+1637 steps/day; 95% CI = 712, 2562); and an increase in self-efficacy for dietary and physical activity behaviors. CONCLUSIONS: Our results suggest that a community-based program can improve self-efficacy, increase physical activity, and decrease energy intake, resulting in decreased waist circumference and body weight among at-risk women.

Retooling food service for early elementary school students in Somerville, Massachusetts: the Shape Up Somerville experience.

BACKGROUND: Changes in the school food environment are a logical target to prevent childhood overweight. We describe the food service component of a 2-year research intervention to prevent excess weight gain in children. CONTEXT: The goals of the food service component were to improve the presentation and nutrient quality of school meals and to incorporate more fruits and vegetables into students' diets. The project engaged food service staff, students, parents, teachers, and school leaders to improve school nutrition. METHODS: Modifications addressed needs and barriers identified though dialogue with the food service director, focus groups, key informant interviews, and surveys of school employees, students, and parents and guardians. Attitudes and behavior changes were measured through surveys, direct observation, and sales data. CONSEQUENCES: More fruits, vegetables, whole grains, and low-fat dairy products were available during the intervention years; menus and à la carte choices were brought into closer compliance with recommended guidelines for children; attitudes of students, parents and guardians, school faculty, and food service staff improved; and policies related to food service were adopted. INTERPRETATION: Strategic modification to improve nutrition and increase acceptability of the food served in schools is feasible and sustainable. These results demonstrate that changes to food service can lead to improved nutrient profiles and more favorable attitudes toward food served at school meals. Such changes can help prevent childhood obesity.

Accelerated Summer Weight Gain in a Low-Income, Ethnically Diverse Sample of Elementary School Children in Massachusetts.

Background: Several studies have found that children in the United States gain weight at a faster rate in the summer than in the school year, but little is known about the prevalence of this problem, its effect on high-risk subgroups, or its determinants. This study compares school year and summer weight change in a low-income, ethnically diverse sample of school-age children in Massachusetts and explores differences by race/ethnicity, weight status, and exposure to school year physical activity (PA) programming. Diet and PA are examined as potential mediators of summer weight gain. Methods: Children participating in a school-based PA program evaluation (in which weight change was not a primary outcome) had their height and weight measured three times between October 2015 and September 2016 to capture a school year and summer interval. Diet and PA patterns were assessed mid-school year and mid-summer in a subsample of children. Mixed linear models were used to estimate the effect of season (school year vs. summer) on change in BMI and to examine the influence of race/ethnicity, weight status, and program (walk/run, classroom activity breaks, or control) on any observed effects. Structural equation models were used to explore diet and PA as mediators of seasonal weight change in a subsample of participants. Results: Of 769 participants, 53% were non-Caucasian, 40% were overweight or obese, and 58% were eligible for free or reduced-price school meals. BMI increased in both the school year and summer but increased more rapidly in the summer (0.046 kg/m2 more per month, p = 0.007). Of the three tested interactions, statistical significance was only observed between season and program (χ2 = 14.90, p < 0.001); on average, children exposed to a school year walk/run program did not gain weight more rapidly during the summer, whereas children in the control group and a classroom activity breaks program did. Poorer diet and PA patterns were observed in the summer, but neither diet nor PA was statistically significant mediators of BMI change. Conclusions: Children in this high-risk sample gained weight at a faster rate during the summer than during the school year, with no discernable demographic differences. However, this phenomenon was not observed in the subgroup exposed to a school year walk/run program. More research is needed to clarify the determinants of summer weight gain and understand how school year programming and its effects can be transferred to the summer months.

Factors related to cardiovascular disease risk reduction in midlife and older women: a qualitative study.

INTRODUCTION: Cardiovascular disease (CVD) is the leading cause of death for women in the United States. A healthy diet and appropriate physical activity can help reduce the risk for CVD. However, many women do not follow recommendations for these behaviors. In this study, we used qualitative methods to better understand knowledge and awareness about CVD in women, perceived threat of CVD, barriers to heart-healthy eating and physical activity, and intervention strategies for behavior change. METHODS: We conducted four focus groups with 38 white women aged 40 years or older in Kansas and Arkansas. We also interviewed 25 Cooperative State Research, Education, and Extension Service agents in those states. Environmental audits of grocery stores and the physical environment were done in three communities. RESULTS: Most women were aware of the modifiable risk factors for CVD. Although they realized they were susceptible, they thought CVD was something they could overcome. Common barriers to achieving a heart-healthy diet included time and concern about wasting food. Most women had positive attitudes toward physical activity and reported exercising in the past, but found it difficult to resume when their routine was disrupted. The environmental audits suggested that there are opportunities to be physically active and that with the exception of fresh fish in Kansas, healthful foods are readily available in local food stores. CONCLUSION: Interventions to change behavior should be hands-on, have a goal-setting component, and include opportunities for social interaction. It is especially important to offer interventions as awareness increases and women seek opportunities to build skills to change behavior.