Changes in children's and adolescents' dietary intake after the implementation of Chile's law of food labeling, advertising and sales in schools: a longitudinal study.

BACKGROUND: In June 2016, a comprehensive food policy was implemented in Chile that included front-of-package warning labels on key nutrients of concern (total sugars, added saturated fats, sodium, and calories), child-directed food advertisement bans, and school regulations. The policy was implemented in 3 phases from 2016 to 2019 and the primary objective was to improve children's food environments. This study's objective was to assess changes in child and adolescent intake of key nutrients of concern (total sugars, saturated fats, and sodium) at school after the initial implementation of Chile's Law of Food Labeling and Advertisement. METHODS: Longitudinal study of 349 children from the Food Environment Chilean Cohort (FECHIC) and 294 adolescents from the Growth and Obesity Cohort Study (GOCS). Data were from single 24-hour dietary recalls collected from 2016 to 2019. Fixed-effects models stratified by school, home, and other locations compared nutrient consumption in each year to consumption at the pre-policy 2016 baseline. Nutrient intakes are expressed as percent of total energy. RESULTS: Compared to 2016 (pre-policy), total sugars consumed by children at school decreased 4.5 [-8.0, -0.9] percentage points (pp) and 11.8 [-15.4, -8.3] pp in 2018 and 2019 respectively. In 2019, children's saturated fats and sodium intake at school also decreased (1.1 [-1.9, -0.2] pp and 10.3 [-18.1, -2.5] mg/100 kcal respectively). Likewise, in adolescents, total sugars and saturated fats consumed at school decreased in 2018 (5.3 [-8.4, -2.2] pp and 1.5 [-2.7, -0.3] pp respectively). However, consumption of key nutrients of concern at other locations increased after implementation of the policy. CONCLUSIONS: After initial implementation of Chile's Labeling Law, intake of most key nutrients of concern significantly declined at school. However, we found evidence of compensatory behavior in out-of-school settings. Further research is needed to evaluate what other actions are needed to impact overall diets in the long term both at schools and out of school.

Vitamin D supplementation and cardiometabolic risk factors among diverse schoolchildren: a randomized clinical trial.

BACKGROUND: There remains a lack of evidence demonstrating a potential relationship between vitamin D and cardiometabolic risk among children. OBJECTIVES: We examined the effect of 3 different dosages of vitamin D on cardiometabolic risk factors among children at risk of deficiency. METHODS: Racially diverse schoolchildren aged 8-15 y were randomly assigned in a double-blind fashion to supplementation with 600, 1000, or 2000 IU vitamin D3/d for 6 mo. Changes in HDL cholesterol, triglycerides, LDL cholesterol, total cholesterol, and blood glucose over 6 mo and at 12 mo (6 mo post-supplementation) were assessed. Subgroup analyses were also performed by weight status and race. RESULTS: Among 604 children, 40.9% were vitamin D-inadequate at baseline (<20 ng/mL; mean ± SD: 22.0 ± 6.8 ng/mL), 46.4% were overweight/obese, and 60.9% had ≥1 suboptimal blood lipids or glucose. Over 6 mo, serum 25-hydroxyvitamin D increased in all 3 dosage groups from baseline (mean ± SE change: 4.4 ± 0.6 ng/mL, 5.7 ± 0.7 ng/mL, and 10.7 ± 0.6 ng/mL for 600, 1000, and 2000 IU/d, respectively; P < 0.001). Whereas HDL cholesterol and triglycerides increased in the 600 IU group (P = 0.002 and P = 0.02, respectively), LDL cholesterol and total cholesterol decreased across dosage groups. At 6 mo post-supplementation, HDL cholesterol remained elevated in the 600 and 1000 IU groups ( P < 0.001 and P = 0.02, respectively) whereas triglycerides remained elevated in the 1000 and 2000 IU groups (P = 0.04 and P = 0.006, respectively). The suppression of LDL cholesterol and total cholesterol persisted in the 2000 IU group only (P = 0.04 and P < 0.001, respectively). There were no significant changes in blood glucose and similar responses were observed overall by weight status and racial groups across dosages. CONCLUSIONS: Vitamin D supplementation demonstrated generally positive effects on HDL cholesterol, LDL cholesterol, and total cholesterol, especially at the lower dosage of 600 IU/d, with several significant changes persisting during the post-supplementation period. Increases in triglycerides across dosage groups may be due to natural changes during adolescence warranting further study.This trial was registered at clinicaltrials.gov as NCT01537809.

Design and methods of Shape Up Under 5: Integration of systems science and community-engaged research to prevent early childhood obesity.

Shape Up Under 5 (SUU5) was a two-year early childhood obesity prevention pilot study in Somerville, Massachusetts (2015-2017) designed to test a novel conceptual framework called Stakeholder-driven Community Diffusion. For whole-of-community interventions, this framework posits that diffusion of stakeholders' knowledge about and engagement with childhood obesity prevention efforts through their social networks will improve the implementation of health-promoting policy and practice changes intended to reduce obesity risk. SUU5 used systems science methods (agent-based modeling, group model building, social network analysis) to design, facilitate, and evaluate the work of 16 multisector stakeholders ('the Committee'). In this paper, we describe the design and methods of SUU5 using the conceptual framework: the approach to data collection, and methods and rationale for study inputs, activities and evaluation, which together may further our understanding of the hypothesized processes within Stakeholder-driven Community Diffusion. We also present a generalizable conceptual framework for addressing childhood obesity and similar complex public health issues through whole-of-community interventions.

Theoretical Food and Nutrient Composition of Whole-Food Plant-Based and Vegan Diets Compared to Current Dietary Recommendations.

Public interest in popular diets is increasing, in particular whole-food plant-based (WFPB) and vegan diets. Whether these diets, as theoretically implemented, meet current food-based and nutrient-based recommendations has not been evaluated in detail. Self-identified WFPB and vegan diet followers in the Adhering to Dietary Approaches for Personal Taste (ADAPT) Feasibility Survey reported their most frequently used sources of information on nutrition and cooking. Thirty representative days of meal plans were created for each diet. Weighted mean food group and nutrient levels were calculated using the Nutrition Data System for Research (NDSR) and data were compared to DRIs and/or USDA Dietary Guidelines/MyPlate meal plan recommendations. The calculated HEI-2015 scores were 88 out of 100 for both WFPB and vegan meal plans. Because of similar nutrient composition, only WFPB results are presented. In comparison to MyPlate, WFPB meal plans provide more total vegetables (180%), green leafy vegetables (238%), legumes (460%), whole fruit (100%), whole grains (132%), and less refined grains (-74%). Fiber level exceeds the adequate intakes (AI) across all age groups. WFPB meal plans failed to meet the Recommended Dietary Allowances (RDA)s for vitamin B12 and D without supplementation, as well as the RDA for calcium for women aged 51⁻70. Individuals who adhere to WFBP meal plans would have higher overall dietary quality as defined by the HEI-2015 score as compared to typical US intakes with the exceptions of calcium for older women and vitamins B12 and D without supplementation. Future research should compare actual self-reported dietary intakes to theoretical targets.

Impact of Three Doses of Vitamin D3 on Serum 25(OH)D Deficiency and Insufficiency in At-Risk Schoolchildren.

Objective: We investigated the daily dose of vitamin D needed to achieve serum 25-hydroxyvitamin D [25(OH)D] sufficiency among schoolchildren at risk for deficiency. Study Design: The Daily D Health Study was a randomized double-blind vitamin D supplementation trial among racially/ethnically diverse schoolchildren (n = 685) in the northeastern United States. Children were supplemented with vitamin D3 at 600, 1000, or 2000 IU/d for 6 months. Measurements included serum 25(OH)D at baseline (October to December), 3 months (January to March), 6 months (April to June), and 12 months (6 months after supplementation). Results: At baseline, mean ± standard deviation serum 25(OH)D level was 22.0 ± 6.8 ng/mL, with 5.5% severely vitamin D deficient (<12 ng/mL), 34.1% deficient (12 to 19 ng/mL), 49.0% insufficient (20 to 29 ng/mL), and 11.4% sufficient (≥30 ng/mL). The lowest levels of serum 25(OH)D were found among black (17.9 ± 6.7 ng/mL) and Asian children (18.9 ± 4.8 ng/mL), with no baseline differences by weight status. Serum 25(OH)D increased over 6 months in all three dose groups. The 2000 IU/d group achieved a higher mean serum 25(OH)D level than the other two dose groups (33.1 vs 26.3 and 27.5 ng/mL; P < 0.001), with 59.9% of this group attaining sufficiency at 3 months and only 5.3% remaining severely deficient/deficient at 6 months. All dose groups demonstrated a fall in 25(OH)D at 12 months. Conclusions: Children at risk for vitamin D deficiency benefited from daily sustained supplementation of 2000 IU/d compared with lower doses closer to the current recommended daily allowance for vitamin D intake. This benefit occurred over the winter months, when serum 25(OH)D level tend to fall.

Restaurant Menu Labeling Policy: Review of Evidence and Controversies.

In response to high rates of obesity in the USA, several American cities, counties, and states have passed laws requiring restaurant chains to post labels identifying the energy content of items on menus, and nationwide implementation of menu labeling is expected in late 2016. In this review, we identify and summarize the results of 16 studies that have assessed the impact of real-world numeric calorie posting. We also discuss several controversies surrounding the US Food and Drug Administration's implementation of federally mandated menu labeling. Overall, the evidence regarding menu labeling is mixed, showing that labels may reduce the energy content of food purchased in some contexts, but have little effect in other contexts. However, more data on a range of ong-term consumption habits and restaurant responses is needed to fully understand the impact menu labeling laws will have on the US population's diet.

Recruitment and retention of urban schoolchildren into a randomized double-blind vitamin D supplementation trial.

BACKGROUND: While rarely used for supplementation trials in the United States, schools present a practical alternative to a clinical setting. PURPOSE: We describe the successful recruitment and retention of urban schoolchildren into a 6-month randomized, double-blind vitamin D3 supplementation trial. METHODS: Boston-area urban schoolchildren, aged 8-15 years, were recruited in 2011-2012 through classroom and auditorium presentations. Informed consent forms in five languages were sent home to parents. Retention methods included regular telephone calls and gift cards for completed study visits. RESULTS: In total, 691 schoolchildren enrolled. Their mean (standard deviation) age was 11.7 (1.4) years; 59% were racial/ethnic minorities and 68% qualified for free or reduced-price school meals. Multi-level, culturally sensitive, creative approaches contributed to success in recruitment and retention. Of 691 participants, 81% completed the 6-month intervention period. Reasons for attrition included missed appointments and fear of a blood draw. More children from households with higher incomes were retained than those from households with lower incomes (85% vs 79%, respectively, P = 0.04). LIMITATIONS: The need for three fasting blood draws over the 6-month supplementation period was a limiting factor in the recruitment and retention of children in this study. CONCLUSION: Recruitment of urban children into a school-based randomized controlled trial represents a feasible approach for a supplementation study. Particular attention to children of lower socioeconomic status may enhance participation and retention when conducting intervention studies among diverse populations.

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.

Multinutrient-fortified juices improve vitamin D and vitamin E status in children: a randomized controlled trial.

BACKGROUND: Provision of fortified juices may provide a convenient method to maintain and increase blood fat-soluble vitamins. OBJECTIVE: To determine whether children consuming orange juice fortified with calcium and combinations of vitamins D, E, and A could increase serum 25-hydroxyvitamin D [25(OH)D], α-tocopherol, and retinol levels. DESIGN: A 12-week randomized, double-blind, controlled trial. PARTICIPANTS/SETTING: One hundred eighty participants (aged 8.04±1.42 years) were recruited at Tufts (n=70) and Boston University (n=110) during 2005-2006. Of those recruited, 176 children were randomized into three groups: CaD (700 mg calcium+200 IU vitamin D), CaDEA (700 mg calcium+200 IU vitamin D+12 IU vitamin E+2,000 IU vitamin A as beta carotene), or Ca (700 mg calcium). Children consumed two 240-mL glasses of CaD, CaDEA, or Ca fortified orange juice daily for 12 weeks. MAIN OUTCOME MEASURES: Serum 25(OH)D, α-tocopherol, and retinol concentrations. STATISTICAL ANALYSES: Changes in 25(OH)D, α-tocopherol, retinol, and parathyroid hormone concentrations were examined. Covariates included sex, age, race/ethnicity, body mass index, and baseline 25(OH)D, α-tocopherol, retinol, or parathyroid hormone levels. Multivariate models and repeated measures analysis of variance tested for group differences with pre-post measures (n=141). RESULTS: Baseline 25(OH)D was 68.4±27.7 nmol/L (27.4±11.10 ng/mL) ), with 21.7% of participants having inadequate 25(OH)D (<50 nmol/L [20.03 ng/mL]). The CaD group's 25(OH)D increase was greater than that of the Ca group (12.7 nmol/L [5.09 ng/mL], 95% CI 1.3 to 24.1; P=0.029). The CaDEA group's increase in α-tocopherol concentration was greater than that in the Ca or CaD groups (3.79 µmol/L [0.16 µg/mL], 95% CI 2.5 to 5.1 and 3.09 µmol/L [0.13 µg/mL], 95% CI -1.8 to 4.3), respectively (P<0.0001). Retinol levels did not change, and body weight remained as expected for growth. CONCLUSIONS: Daily consumption of orange juice providing 200 IU vitamin D and 12 IU vitamin E increased 25(OH)D and α-tocopherol concentrations in young children within 12 weeks.

Promoting health at the community level: thinking globally, acting locally.

Prevention of childhood obesity is a societal priority. Despite our knowledge about the scope of the problem and the determinants that lead to it, we have yet to produce meaningful declines in obesity rates. Recent attention has been given to interventions that employ multiple strategies across multiple settings involving whole communities given their promising results. The next era of science calls for interdisciplinary teams who will envision a whole system approach to advance the community-based obesity prevention model. This perspective describes some of the more recent discussions of community-based methodologies such as the ANGELO (Analysis Grid for Environments Linked to Obesity) framework, best-practice principles, and a whole system intervention approach to obesity prevention. The proposed required elements to advance community-based research to address childhood obesity are: A systems perspective and approach, training of future leaders in community research methodology and social change, applying transdisciplinary strategies, funding to conduct rigorous trials to determine efficacy and effectiveness, enhanced design and analysis approaches, new and improved tools and methodologies to collect quantitative and qualitative data, enhanced community engagement models and sustainability frameworks, advancement of a bold public policy agenda, economic modeling, and acknowledgment of the approach as viable. To reverse childhood obesity, we need to embrace and integrate complex strategies at multiple levels within communities across the globe.

Validity and reliability of a calcium checklist in early elementary-school children.

OBJECTIVE: To create, validate and assess the reliability of a checklist to measure calcium intake in children. DESIGN: Calcium intakes from a checklist and parent-assisted 24-h dietary recall were compared. Checklist reliability was assessed separately. SETTING: After-school programmes in the United States. SUBJECTS: Forty-two children (18 males, 24 females, age = 8.0 +/- 0.9 years) participated in the validation analysis and 49 children (28 males, 21 females, age = 7.5 +/- 0.9 years) in the reliability analysis. RESULTS: No differences in mean calcium intakes were found by method or gender. The checklist correlated well with recall among girls (r = 0.65, P = 0.01) but not boys (r = -0.33, P = 0.19). Agreement over time was above 80% for most foods. CONCLUSION: The calcium checklist is useful for assessing calcium intake among groups of 6-10-year-old children in settings that preclude parental assistance. More research is needed to improve accuracy among boys.