Increasing access to fruits and vegetables: perspectives from the New York City experience.

Broad recognition now exists that price, availability, and other structural factors are meaningful barriers to fruit and vegetable consumption, particularly among low-income adults. Beginning in 2005, the New York City Department of Health and Mental Hygiene used the social-ecological model to develop a multifaceted effort to increase fruit and vegetable access citywide, with emphasis in low-income neighborhoods. Overall, the percentage of New York City adults who reported consuming no fruits and vegetables in the previous day decreased slightly over a 10-year period (2002: 14.3% [95% confidence interval = 13.4%, 15.2%]; 2012: 12.5% [95% confidence interval = 11.4%, 13.6%]; P for trend < .001). Our approach hypothesizes that complementary initiatives, implemented simultaneously, will create a citywide food environment that fuels changes in social norms and cultural preferences, increases consumer demand, and supports sustainable access to affordable produce.

Reducing sugary drink consumption: New York City's approach.

Studies have linked the consumption of sugary drinks to weight gain, obesity, and type 2 diabetes. Since 2006, New York City has taken several actions to reduce consumption. Nutrition standards limited sugary drinks served by city agencies. Mass media campaigns educated New Yorkers on the added sugars in sugary drinks and their health impact. Policy proposals included an excise tax, a restriction on use of Supplemental Nutrition Assistance Program benefits, and a cap on sugary drink portion sizes in food service establishments. These initiatives were accompanied by a 35% decrease in the number of New York City adults consuming one or more sugary drinks a day and a 27% decrease in public high school students doing so from 2007 to 2013.

A water availability intervention in New York City public schools: influence on youths' water and milk behaviors.

OBJECTIVES: We determined the influence of "water jets" on observed water and milk taking and self-reported fluid consumption in New York City public schools. METHODS: From 2010 to 2011, before and 3 months after water jet installation in 9 schools, we observed water and milk taking in cafeterias (mean 1000 students per school) and surveyed students in grades 5, 8, and 11 (n=2899) in the 9 schools that received water jets and 10 schools that did not. We performed an observation 1 year after implementation (2011-2012) with a subset of schools. We also interviewed cafeteria workers regarding the intervention. RESULTS: Three months after implementation we observed a 3-fold increase in water taking (increase of 21.63 events per 100 students; P<.001) and a much smaller decline in milk taking (-6.73 events per 100 students; P=.012), relative to comparison schools. At 1 year, relative to baseline, there was a similar increase in water taking and no decrease in milk taking. Cafeteria workers reported that the water jets were simple to clean and operate. CONCLUSIONS: An environmental intervention in New York City public schools increased water taking and was simple to implement.

Evaluation of the New York City Green Carts program.

Access to fresh fruits and vegetables is a concern, particularly among low-income populations. Mobile vending is one strategy to expand produce availability and access to increase consumption. In 2008, New York City launched a mobile vending initiative, Green Carts. We report on the evaluation. Three waves of cross-sectional observational surveys of produce availability, variety, and quality were conducted during the summers of 2008, 2009, and 2011 in a stratified random sample of stores and carts comparing establishments in Green Cart neighborhoods (n = 13) with comparison neighborhoods (n = 3). Bivariate analyses for availability, variety, and quality comparing Green Cart and comparison neighborhoods were presented across years, and logistic and negative binomial regressions were used to test whether fruit and vegetable availability, variety, and quality increased in Green Cart compared with comparison neighborhoods, adjusting for clustering and neighborhood demographics. Establishments selling fruits and vegetables in Green Cart neighborhoods increased between 2008 and 2011 (50% to 69%, p <0.0001); there was no comparable increase in comparison neighborhoods. Establishments selling more than 10 fruits and vegetables types increased from 31% to 38% (p = 0.0414) in Green Cart neighborhoods; there was no change in comparison neighborhoods. Produce quality was high among comparison establishments, with 95% and 94% meeting the quality threshold in 2008 and 2011, while declining in Green Cart neighborhood establishments from 96% to 88% (p < 0.0001). Sustained produce availability was found in Green Cart neighborhoods between 2008-2011. Green Carts are one strategy contributing to improving produce access among New Yorkers.

Insights and implications for health departments from the evaluation of New York City's regulations on nutrition, physical activity, and screen time in child care centers.

In 2006, the New York City Department of Health and Mental Hygiene, seeking to address the epidemic of childhood obesity, issued new regulations on beverages, physical activity, and screen time in group child care centers. An evaluation was conducted to identify characteristics of New York City child care centers that have implemented these regulations and to examine how varying degrees of implementation affected children's behaviors. This article discusses results of this evaluation and how findings can be useful for other public health agencies. Knowing the characteristics of centers that are more likely to comply can help other jurisdictions identify centers that may need additional support and training. Results indicated that compliance may improve when rules established by governing agencies, national standards, and local regulatory bodies are complementary or additive. Therefore, the establishment of clear standards for obesity prevention for child care providers can be a significant public health achievement.

Rationale for New York City's regulations on nutrition, physical activity, and screen time in early child care centers.

Childhood obesity is associated with health risks in childhood, and it increases the risk of adult obesity, which is associated with many chronic diseases. Therefore, implementing policies that may prevent obesity at young ages is important. In 2007, the New York City Department of Health and Mental Hygiene implemented new regulations for early childhood centers to increase physical activity, limit screen time, and provide healthful beverage offerings (ie, restrict sugar-sweetened beverages for all children, restrict whole milk for those older than 2 years, restrict juice to beverages that are 100% juice and limit serving of juice to only 6 ounces per day, and make water available and accessible at all times). This article explains why these amendments to the Health Code were created, how information about these changes was disseminated, and what training programs were used to help ensure implementation, particularly in high-need neighborhoods.

Evaluation design of New York City's regulations on nutrition, physical activity, and screen time in early child care centers.

This article describes the multi-method cross-sectional design used to evaluate New York City Department of Health and Mental Hygiene's regulations of nutrition, physical activity, and screen time for children aged 3 years or older in licensed group child care centers. The Center Evaluation Component collected data from a stratified random sample of 176 licensed group child care centers in New York City. Compliance with the regulations was measured through a review of center records, a facility inventory, and interviews of center directors, lead teachers, and food service staff. The Classroom Evaluation Component included an observational and biometric study of a sample of approximately 1,400 children aged 3 or 4 years attending 110 child care centers and was designed to complement the center component at the classroom and child level. The study methodology detailed in this paper may aid researchers in designing policy evaluation studies that can inform other jurisdictions considering similar policies.

Measurement of compliance with New York City's regulations on beverages, physical activity, and screen time in early child care centers.

INTRODUCTION: Policy interventions designed to change the nutrition environment and increase physical activity in child care centers are becoming more common, but an understanding of the implementation of these interventions is yet to be developed. The objective of this study was to explore the extent and consistency of compliance with a policy intervention designed to promote nutrition and physical activity among licensed child care centers in New York City. METHODS: We used a multimethod cross-sectional approach and 2 independent components of data collection (Center Evaluation Component and Classroom Evaluation Component). The methods were designed to evaluate the impact of regulations on beverages served, physical activity, and screen time at child care centers. We calculated compliance scores for each evaluation component and each regulation and percentage agreement between compliance in the center and classroom components. RESULTS: Compliance with certain requirements of the beverage regulations was high and fairly consistent between components, whereas compliance with the physical activity regulation varied according to the data collection component. Compliance with the regulation on amount and content of screen time was high and consistent. CONCLUSION: Compliance with the physical activity regulation may be a more fluid, day-to-day issue, whereas compliance with the regulations on beverages and television viewing may be easier to control at the center level. Multiple indicators over multiple time points may provide a more complete picture of compliance - especially in the assessment of compliance with physical activity policies.

The effects of changes in physical fitness on academic performance among New York City youth.

PURPOSE: To evaluate whether a change in fitness is associated with academic outcomes in New York City (NYC) middle-school students using longitudinal data and to evaluate whether this relationship is modified by student household poverty. METHODS: This was a longitudinal study of 83,111 New York City middle-school students enrolled between 2006-2007 and 2011-2012. Fitness was measured as a composite percentile based on three fitness tests and categorized based on change from the previous year. The effect of the fitness change level on academic outcomes, measured as a composite percentile based on state standardized mathematics and English Language Arts test scores, was estimated using a multilevel growth model. Models were stratified by sex, and additional models were tested stratified by student household poverty. RESULTS: For both girls and boys, a substantial increase in fitness from the previous year resulted in a greater improvement in academic ranking than was seen in the reference group (girls: .36 greater percentile point improvement, 95% confidence interval: .09-.63; boys: .38 greater percentile point improvement, 95% confidence interval: .09-.66). A substantial decrease in fitness was associated with a decrease in academics in both boys and girls. Effects of fitness on academics were stronger in high-poverty boys and girls than in low-poverty boys and girls. CONCLUSIONS: Academic rankings improved for boys and girls who increased their fitness level by >20 percentile points compared to other students. Opportunities for increased physical fitness may be important to support academic performance.

Severe obesity among children in New York City public elementary and middle schools, school years 2006-07 through 2010-11.

INTRODUCTION: Although studies have shown that childhood obesity overall is on the decline among New York City (NYC) public school children, the prevalence of severe childhood obesity has not been studied. METHODS: We used height and weight measurements of 947,765 NYC public school students aged 5 to 14 years in kindergarten through 8th grade (K-8), from school years 2006-07 through 2010-11. We used age- and sex-specific body mass index (BMI) percentiles according to Centers for Disease Control and Prevention growth charts to define childhood obesity (BMI ≥ 95th percentile) and severe childhood obesity (BMI ≥120% of 95th percentile) and to identify biologically implausible values (BIV). Multivariable logistic models tested for trends in obesity and severe obesity prevalence. To evaluate misclassification, we recalculated prevalence estimates for the most recent school year (2010-11) including the student records identified as BIV who were also declared severely obese (BMI ≥ 120% of 95th percentile). We refer to this subgroup of BIVs as "high BIV." RESULTS: Severe obesity among NYC public school students in grades K-8 decreased 9.5% from the 2006-07 school year (6.3%) to the 2010-11 school year (5.7%), and obesity decreased 5.5% (from 21.9% to 20.7%). The prevalence of severe obesity and obesity was highest among minority, poor, and male children. Severe obesity declined in prevalence among every subgroup, with the greatest effect among white students and wealthy students. Severe obesity prevalence increased with age, and obesity prevalence peaked among those aged 7 to 10 years. For the 2010-11 school year, including high BIVs increased severe obesity prevalence from 5.7% to 6.6% and increased obesity prevalence from 20.7% to 21.5%. CONCLUSION: Among all subgroups of NYC public school children in grades K-8, the reduction in severe obesity was greater than the reduction in overall obesity. Efforts to decrease obesity in NYC have affected the severely obese; however, monitoring of this specific subgroup should continue because of differences in trends and greater health risks.

The impact of New York City's Health Bucks Program on electronic benefit transfer spending at farmers markets, 2006-2009.

INTRODUCTION: Increasing the accessibility and affordability of fresh produce is an important strategy for municipalities combatting obesity and related health conditions. Farmers markets offer a promising venue for intervention in urban settings, and in recent years, an increasing number of programs have provided financial incentives to Supplemental Nutrition Assistance Program (SNAP) recipients. However, few studies have explored the impact of these programs on use of SNAP benefits at farmers markets. METHODS: New York City's Health Bucks Program provides SNAP recipients with a $2 coupon for every $5 spent using SNAP benefits at participating farmers markets. We analyzed approximately 4 years of electronic benefit transfer (EBT) sales data, from July 2006 through November 2009, to develop a preliminary assessment of the effect of the Health Bucks Program on EBT spending at participating markets. RESULTS: Farmers markets that offered Health Bucks coupons to SNAP recipients averaged higher daily EBT sales than markets without the incentive ($383.07, 95% confidence interval [CI], 333.1-433.1, vs $273.97, 95% CI, 243.4-304.5, P < 0.001) following the introduction of a direct point-of-purchase incentive. Multivariate analysis indicated this difference remained after adjusting for the year the market was held and the neighborhood poverty level. CONCLUSION: When a $2 financial incentive was distributed with EBT, use of SNAP benefits increased at participating New York City farmers markets. We encourage other urban jurisdictions to consider adapting the Health Bucks Program to encourage low-income shoppers to purchase fresh produce as one potential strategy in a comprehensive approach to increasing healthful food access and affordability in low-income neighborhoods.

A menu for health: changes to New York City school food, 2001 to 2011.

BACKGROUND: The high prevalence of obesity puts children at risk for chronic diseases, increases health care costs, and threatens to reduce life expectancy. As part of the response to this epidemic, the New York City (NYC) Department of Education (DOE)--the nation's largest school district--has worked to improve the appeal and nutritional quality of school food. This article highlights some of the structural and policy changes that have improved the school food environment over the past decade, with the aim to share lessons learned and provide recommendations and resources for other districts interested in making similar modifications. METHODS: This article details changes DOE has implemented over 10 years, including revised nutrition standards for school meals and competitive foods; new school food department staffing; food reformulations, substitutions, and additions; and transitions to healthier beverages. RESULTS: NYC's revised nutrition standards and hiring of expert staff increased availability of fruits and vegetables, whole grains, and low-fat dairy and decreased sugary beverages, and foods high in saturated fats and added sugars--the major contributors to discretionary calorie intake. DOE also introduced healthier beverages: switching from high-calorie, high-fat whole milk to low-fat milk and increasing access to water. CONCLUSIONS: NYC has successfully improved the quality of its school food environment and shown that healthier food service is possible, even under budgetary constraints. Several broad factors facilitated these efforts: fostering community partnerships and inter-agency collaboration, implementing policies and initiatives that target multiple sectors for greater impact, and working to make incremental improvements each year.

An observational evaluation of move-to-improve, a classroom-based physical activity program, New York City schools, 2010.

INTRODUCTION: Few children in the United States achieve the recommended 60 minutes of physical activity per day. Identifying successful interventions that increase physical activity for children is critical. This observational study evaluated the effects of Move-To-Improve (MTI), a classroom-based physical education program designed for kindergarten to third-grade teachers in New York City public schools. MTI organizes 3-hour trainings for teachers that demonstrate strategies for integrating activity into daily classroom schedules. METHODS: Randomly sampled elementary schools (N = 39) with classrooms trained in MTI in spring 2010 participated in the evaluation. In each school, we observed 2 classrooms trained in MTI and 2 untrained classrooms in the same school matched by grade level for 1 full school day. We analyzed data from 72 trained and 72 untrained classrooms. RESULTS: Ninety-nine percent of MTI-trained classroom teachers led their students in physical activity. MTI-trained classrooms spent an average of 9.5 minutes in physical activity per day, compared with 2.4 minutes in untrained classrooms (P < .001), an almost fourfold increase in activity. Levels of activity were higher in trained versus untrained classrooms regardless of grade level or class size. CONCLUSION: Teachers trained in MTI led their classrooms in significantly more physical activity compared with teachers who were not trained. The MTI program is an effective strategy for increasing physical activity during the school day. A curriculum that empowers classroom teachers to incorporate activity into their regular day is a practical approach to promoting healthier living for children.