Removing competitive foods v. nudging and marketing school meals: a pilot study in high-school cafeterias.

OBJECTIVE: To compare federally reimbursable school meals served when competitive foods are removed and when marketing and nudging strategies are used in school cafeterias operating the National School Lunch Program (NSLP). The second objective was to determine how marketing and nudging strategies influence competitive food sales. DESIGN: In the Healthy Choices School, all competitive foods were removed; the Healthy Nudging School retained competitive foods and promoted the school meal programme using marketing and nudging strategies; a third school made no changes. Cafeteria register data were collected from the beginning of the 2013-2014 school year through the four-week intervention. Outcome measures included daily entrées served; share of entrées served with vegetables, fruit and milk; and total competitive food sales. Difference-in-difference models were used to examine outcome measure changes. SETTING: Three high schools in a diverse, Northeast US urban district with universally free meals. PARTICIPANTS: High-school students participating in the NSLP. RESULTS: During the intervention weeks, the average number of entrées served daily was significantly higher in the Healthy Choices School (82·1 (se 33·9)) and the Healthy Nudging School (107·4 (se 28·2)) compared with the control school. The only significant change in meal component selection was a 6 % (se 0·02) higher rate of vegetable servings in the Healthy Choices School compared with the control school. Healthy Nudging School competitive food sales did not change. CONCLUSIONS: Both strategies - removing competitive foods and marketing and nudging - may increase school meal participation. There was no evidence that promoting school meals decreased competitive food sales.

Strength of obesity prevention interventions in early care and education settings: A systematic review.

TIME AND PLACE OF STUDY: 2010-2015; INTERNATIONAL: Given the high levels of obesity in young children, numbers of children in out-of-home care, and data suggesting a link between early care and education (ECE) participation and overweight/obesity, obesity prevention in ECE settings is critical. As the field has progressed, a number of interventions have been reviewed yet there is a need to summarize the data using more sophisticated analyses to answer questions on the effectiveness of interventions. We conducted a systematic review of obesity prevention interventions in center-based ECE settings published between 2010 and 2015. Our goal was to identify promising intervention characteristics associated with successful behavioral and anthropometric outcomes. A rigorous search strategy resulted in 43 interventions that met inclusion criteria. We developed a coding strategy to assess intervention strength, used a validated study quality assessment tool, and presented detailed descriptive information about interventions (e.g., target behaviors, intervention strategies, and mode of delivery). Intervention strength was positively correlated with reporting of positive anthropometric outcomes for physical activity, diet, and combined interventions, and parent engagement components increased the strength of these relationships. Study quality was modestly related to percent successful healthy eating outcomes. Relationships between intervention strength and behavioral outcomes demonstrated negative relationships for all behavioral outcomes. Specific components of intervention strength (number of intervention strategies, potential impact of strategies, frequency of use, and duration of intervention) were correlated with some of the anthropometric and parent engagement outcomes. The review provided tentative evidence that multi-component, multi-level ECE interventions with parental engagement are most likely to be effective with anthropometric outcomes.

Environmental factors associated with physical activity in childcare centers.

BACKGROUND: Child care centers influence physical activity levels among children, yet little is known about the specific aspects of the environment that support generous amounts of activity. The purpose of this study was to examine the practices, and environmental aspects of the child care center that are associated with children's moderate and vigorous physical activity. METHODS: Thirty-five child care centers serving 389 3 to 5 year old children were assessed for: 1) environmental characteristics of the center; and 2) staff practices related to child physical activity. Children's physical activity was measured using accelerometers over a single day in child care. RESULTS: Fourteen percent (an average of 9 minutes per waking hour) were spent in moderate to vigorous physical activity (MVPA). The strongest environmental predictors of MVPA were: time spent in outdoor play, suitability of indoor play space, and teacher encouragement of (but not participation in) indoor play. CONCLUSIONS: In order to reach the U.S. recommended 120 minutes of physical activity per day, significant changes will need to occur in the child care setting, including increased time outdoors and more opportunities for indoor physical activity.

Impact of Connecticut legislation incentivizing elimination of unhealthy competitive foods on National School Lunch Program participation.

OBJECTIVES: We analyzed the impact of Connecticut legislation incentivizing voluntary school district-level elimination of unhealthy competitive foods on National School Lunch Program (NSLP) participation. METHODS: We analyzed data on free, reduced, and paid participation in the NSLP from 904 schools within 154 Connecticut school districts from the 2004-2005 to the 2009-2010 school year, resulting in 5064 observations of annual school-level meal participation. We used multilevel regression modeling techniques to estimate the impact of the state competitive food legislation on the count of NSLP lunches served per student in each school. RESULTS: Overall, the state statute was associated with an increase in school lunch participation. We observed increases between 7% and 23% for middle- and high-school meal programs, and a slight decrease of 2.5% for the elementary school free meal eligibility category, leading to an estimated revenue increase of roughly $30 000 for an average school district per school year. CONCLUSIONS: This study provides support for national implementation of proposed rigorous competitive food standards that can improve the health of students while supporting local school district finances.

Center-Reported Adherence to Nutrition Standards of the Child and Adult Care Food Program.

BACKGROUND: The Child and Adult Care Food Program (CACFP) sets nutrition standards for foods served in participating settings. Licensing regulations in many states, including Connecticut (CT), extend these rules to nonparticipating facilities. This study evaluates the food environment for preschool-age children in CT child care centers and describes center-reported adherence to the CACFP nutrition regulations. METHODS: We surveyed directors of licensed CACFP-participating and non-CACFP centers that served meals and/or snacks. Food served, caregiver feeding behavior, nutrition practices and policies, and CACFP knowledge were reported by 256 non-CACFP and 87 CACFP centers. We conducted bivariate analyses to describe adherence to the CACFP regulations as reported by CACFP and nonparticipating centers. Data were collected in 2015-2016 and analyzed in 2017. RESULTS: CACFP centers reported more engagement in recommended feeding and nutrition practices than non-CACFP centers, including serving more fresh fruit and whole grains at snack time, serving low-fat milk for meals/snacks, and use of family style dining and positive caregiver behaviors. No center reported serving soda, only a few had fruit drinks, and the majority prohibited parents from sending in sugary drinks. Despite the licensing regulations about compliance with the CACFP nutrition standards, 52% of non-CACFP centers had never heard of CACFP and only 21% received information about following the CACFP standards and practices. CONCLUSIONS: CACFP participation is associated with better center-reported adherence to the CACFP nutrition standards and feeding practices. Poor awareness about CACFP among nonparticipating centers needs to be addressed to improve compliance with the CACFP nutrition standards.

Predictors of Nutrition Quality in Early Child Education Settings in Connecticut.

OBJECTIVE: This study assessed the dietary quality of lunches and feeding practices (family-style service, teacher role modeling) in Connecticut child care centers and made comparisons by center participation in the federal Child and Adult Care Food Program (CACFP). DESIGN: Plate waste methods and visual observation of lunches served and consumed. SETTING: A total of 97 randomly selected licensed Connecticut child care centers (53 CACFP and 44 non-CACFP). PARTICIPANTS: A total of 838 preschool-aged children. MAIN OUTCOME MEASURES: Total energy intake, macronutrient intake, and intake by CACFP meal component as well as use of family-style dining, management of additional helpings, and whether and what teachers consumed in view of children. ANALYSIS: Child dietary intake at lunch was compared with dietary and CACFP recommendations using a mixed linear regression model. RESULTS: The CACFP centers were more likely to offer family-style service and have staff eat the same foods as the children. Children in non-CACFP centers consumed more saturated fat (4.1 vs 2.7 g; P < .001) and trans fats (0.1 vs 0.1 g; P = .02) and less milk (3.5 vs 2.7 oz; P < .001) than did children in CACFP centers. Caloric intake and dietary fiber were below recommendations in both groups. Participation in CACFP was a significant predictor of low-fat milk consumption. CONCLUSIONS AND IMPLICATIONS: The CACFP-participating centers confer some nutritional advantages in terms of provider behavior during meals, characteristics of food offerings, and child intake. Current feeding practices in child care settings require further exploration in the context of serving children at risk for food insecurity and in light of recent work on responsive feeding.

Student Acceptance of Plain Milk Increases Significantly 2 Years after Flavored Milk Is Removed from School Cafeterias: An Observational Study.

BACKGROUND: Previous studies document decreases in lunchtime milk consumption immediately after flavored milk is removed. Less is known about longer-term effects. OBJECTIVE: Plain milk selection and consumption were measured the first year flavored milk was removed in a school district (2010 to 2011 [Time 1]) and 2 years later (2012 to 2013 [Time 2]). Four behavioral economic interventions to promote milk were tested in one school at Time 2. DESIGN: This was a longitudinal, observational study. PARTICIPANTS/SETTING: Participants were kindergarten through grade 8 students in two schools in an urban district. Primary data were collected 10 times per school year at Time 1 and Time 2, yielding 40 days of data and 13,883 student observations. The milk promotion interventions were tested on 6 additional days. MAIN OUTCOME MEASURES: Outcomes were the percentage of students selecting milk at lunch, the ounces of milk consumed per carton, and the ounces of milk consumed school-wide per student. STATISTICAL ANALYSES: Logistic regressions were used to assess how sex, grade, time, availability of 100% juice, and behavioral interventions affected milk selection and consumption. RESULTS: At Time One, 51.5% of students selected milk and drank 4 oz (standard deviation=3.2 oz) per carton, indicating school-wide per-student consumption of 2.1 oz (standard deviation=3.0 oz). At Time Two, 72% of students selected milk and consumed 3.4 oz per carton (standard deviation=3.2 oz), significantly increasing the school-wide per-student consumption to 2.5 oz (standard deviation=3.1 oz). Older students and boys consumed significantly more milk. Availability of 100% fruit juice was associated with a 16-percentage point decrease in milk selection. None of the behavioral economic interventions significantly influenced selection. CONCLUSIONS: These data suggest that after flavored milk is removed from school cafeterias, school-wide per-student consumption of plain milk increases over time. In addition, the presence of 100% juice is associated with lower milk selection.

Associations of weight-based teasing history and current eating disorder features and psychological functioning in bariatric surgery patients.

BACKGROUND: The study investigated associations between childhood history of being negatively teased (i.e., being made fun of) about weight with psychiatric history, weight and eating concerns, and psychological functioning in 174 bariatric surgery candidates. METHODS: Bariatric surgery candidates participating in a comprehensive psychiatric evaluation completed a structured diagnostic interview, a psychosocial history interview, and a battery of established self-report measures assessing broad aspects of functioning. Patients who reported a history of being teased during childhood about weight were compared with those who denied having been teased in demographic features, obesity history, dietary and eating patterns and psychological functioning. RESULTS: Of the study group, 88 participants (50.6%) reported a weight-based childhood teasing history and 86 (49.4%) denied such a history. Teasing was not significantly associated with demographic features or current obesity level. As expected, analyses revealed that teasing was associated with younger age of onset of both obesity and dieting. Teasing was significantly associated neither with the frequency of lifetime psychiatric disorders, including eating disorder diagnoses, nor with binge eating. Analyses of covariance controlling for childhood onset of obesity, however, revealed that teasing history was associated with significantly higher current levels of weight and shape concerns, depression, body dissatisfaction, and shame, and with lower levels of self-esteem. CONCLUSION: Health-care providers should recognize the importance of a history of having been teased or made fun of about weight in bariatric surgery candidates. Although the prognostic significance of a history of such negative teasing for bariatric surgery outcomes is unknown, our findings suggest that such experiences are prevalent in this patient group and are associated with negative sequelae.

Psychiatric disorder comorbidity and association with eating disorders in bariatric surgery patients: A cross-sectional study using structured interview-based diagnosis.

OBJECTIVE: This study examined the prevalence of DSM-IV Axis I psychiatric disorders in severely obese bariatric surgery candidates and explored whether eating disorders were associated with psychiatric comorbidity. METHOD: The Structured Clinical Interview for DSM-IV Axis I Disorders was administered to a study group of 174 consecutively evaluated bariatric surgery candidates. All evaluations were completed between September 2002 and November 2004. RESULTS: Overall, 36.8% of the participants met criteria for at least one lifetime psychiatric disorder, with 24.1% meeting criteria for a current disorder. The most commonly observed lifetime psychiatric diagnoses were affective disorders (22.4%), anxiety disorders (15.5%), and eating disorders (13.8%). Participants with eating disorders were significantly more likely than those without eating disorders to meet criteria for psychiatric disorders overall (66.7% vs. 26.7%) and specifically for anxiety disorders (45.8% vs. 10.7%). CONCLUSIONS: Psychiatric disorders are not uncommon among severely obese patients who present for bariatric surgery. The observed prevalence rates based on structured diagnostic interviews are lower than previously reported based on questionnaire, clinical, and chart review methods but are similar to those reported for nationally representative samples. Among bariatric surgery candidates, the presence of eating disorders is associated with higher rates of other psychiatric disorders. The findings highlight the importance of systematic diagnostic assessment using a structured diagnostic interview for determining the full spectrum of Axis I disorders.

Correlates of body image dissatisfaction in extremely obese female bariatric surgery candidates.

BACKGROUND: This study investigated correlates of body image dissatisfaction in 131 extremely obese female bariatric surgery candidates. METHODS: Female gastric bypass surgery candidates participating in a comprehensive psychiatric evaluation completed a battery of established self-report measures of body image and psychosocial functioning. Nine predictors of body image dissatisfaction were considered: body mass index (BMI), ethnicity, childhood onset of obesity, childhood teasing about weight, binge eating, depression, self-esteem, shame, and perfectionism. RESULTS: Stepwise multiple regression analysis revealed that the nine variables jointly accounted for 48% of the variance; three variables, depression, self-esteem and perfectionism, made significant independent contributions. CONCLUSION: Our findings highlight the importance of adult psychological functioning (depression, self-esteem and perfectionism) for predicting body image dissatisfaction in extremely obese female bariatric surgery candidates.

Built environment assessment: Multidisciplinary perspectives.

CONTEXT: As obesity has become increasingly widespread, scientists seek better ways to assess and modify built and social environments to positively impact health. The applicable methods and concepts draw on multiple disciplines and require collaboration and cross-learning. This paper describes the results of an expert team׳s analysis of how key disciplinary perspectives contribute to environmental context-based assessment related to obesity, identifies gaps, and suggests opportunities to encourage effective advances in this arena. EVIDENCE ACQUISITION: A team of experts representing diverse disciplines convened in 2013 to discuss the contributions of their respective disciplines to assessing built environments relevant to obesity prevention. The disciplines include urban planning, public health nutrition, exercise science, physical activity research, public health and epidemiology, behavioral and social sciences, and economics. Each expert identified key concepts and measures from their discipline, and applications to built environment assessment and action. A selective review of published literature and internet-based information was conducted in 2013 and 2014. EVIDENCE SYNTHESIS: The key points that are highlighted in this article were identified in 2014-2015 through discussion, debate and consensus-building among the team of experts. Results focus on the various disciplines׳ perspectives and tools, recommendations, progress and gaps. CONCLUSIONS: There has been significant progress in collaboration across key disciplines that contribute to studies of built environments and obesity, but important gaps remain. Using lessons from interprofessional education and team science, along with appreciation of and attention to other disciplines׳ contributions, can promote more effective cross-disciplinary collaboration in obesity prevention.

Testing Variations on Family-Style Feeding To Increase Whole Fruit and Vegetable Consumption among Preschoolers in Child Care.

BACKGROUND: Preschoolers do not consume whole fruit and vegetables (FVs) in recommended quantities. Two strategies to increase FV intake were tested. METHODS: One Head Start preschool participated. Two variations of family-style feeding were compared to usual practice: (1) Fruits, vegetables, and milk were served before the main meal (first course); and (2) fruits, vegetables, and milk were served before the main meal and meats and grains were removed from the table after the first serving (combination). A within-subject crossover design was used to test each condition for three meals. The amount of food served and consumed was weighed and converted to Child and Adult Care Feeding Program (CACFP) standard serving sizes for analysis. RESULTS: Eighty-five children ages 3-5 participated. The sample was 81% Hispanic with diverse racial backgrounds. Thirty percent of the children were overweight. FV consumption was at CACFP recommended levels at baseline and remained consistent across conditions. The average amount served for each meal component was at or above CACFP recommendations for all foods except milk, which was consistently served in small portions. Meat and grains servings were frequently 2-3 times larger than CACFP recommendations. Milk consumption was significantly higher in the Combined intervention for two meals. Children ate significantly less meat during the Combined intervention for one meal. CONCLUSIONS: The intervention led to significant increases in milk consumption, which was the only underconsumed meal component. These strategies should be tested with children who have lower baseline intake of FVs.

New school meal regulations increase fruit consumption and do not increase total plate waste.

BACKGROUND: The 2010 Healthy, Hunger-Free Kids Act required the USDA to update the nutrition standards of the National School Lunch Program. New policies were implemented in the 2012-2013 school year. These changes were followed by anecdotal reports of increased food waste. Empirical research is needed to reliably measure student intake and plate waste before and after this policy change. METHODS: Food consumption and waste was collected annually from a cohort of middle school students in 12 schools in an urban, low-income school district before (spring 2012) and after (spring 2013 and 2014) policy changes. Generalized linear regression was used to compare pre- versus postpolicy selection and consumption of entrées, fruits, vegetables, and milk. RESULTS: Comparing 2012 to 2014, the percentage of students choosing fruit significantly increased from 54% to 66% and fruit consumption remained high at 74%. Student selection of fruit increased by 9% for each additional type of fruit offered with the meal. The proportion of students who chose a vegetable dropped from 68% to 52%, but students selecting vegetables ate nearly 20% more of them, effectively lowering vegetable waste. Entrée consumption increased significantly from 71% to 84%, thereby also decreasing waste. CONCLUSIONS: Students responded positively to the new lunches. They consumed more fruit, threw away less of the entrees and vegetables, and consumed the same amount of milk. Overall, the revised meal standards and policies appear to have significantly lowered plate waste in school cafeterias.

Comparing Current Practice to Recommendations for the Child and Adult Care Food Program.

BACKGROUND: The federal Child and Adult Care Food Program (CACFP) assists child care centers serving low-income preschoolers and regulates the quality and quantity of food served. The aim of this study was to assess the nutritional quality of lunches served at 38 child care centers and examine how current practices compare to proposed meal pattern recommendations. METHODS: Preschool-aged children (n = 204) were observed eating lunch in 38 CACFP-participating preschools. All foods served and consumed were measured and compared to the 2011 Institute of Medicine (IOM) recommendations to improve CACFP and the 2015 Proposed Rule issued by the USDA. RESULTS: All centers provided access to all required lunch components, but not all components were served (i.e., placed on the child's plate). Vegetables were significantly less likely to be served than meat or grains. Compared with CACFP recommended portion sizes, servings of meat and grain were high, whereas milk was low. Compared with IOM recommendations, average calorie consumption was appropriate, but saturated fat, protein, and sodium intake were high and dietary fiber was low. Meals that offered children both a fruit and a vegetable led to significantly higher produce consumption than meals that offered only one fruit or one vegetable. CONCLUSIONS: Child care centers generally comply with current CACFP regulations, but do not provide lunches consistent with the 2011 IOM recommendations for saturated fat, protein, fiber, and sodium. Decreased use of beef and cheese and increased provision of whole grains, fruits, and vegetables are recommended.

The Relationship between Parental Behaviors and Children's Sugary Drink Consumption Is Moderated by a Television in the Child's Bedroom.

BACKGROUND: The aim of this longitudinal study was to examine the link between perceived authoritative parenting behaviors and sugary drink consumption among children from low-income families who do or do not have televisions (TVs) in their bedrooms. METHODS: Middle school students (N = 480) completed a baseline survey in sixth grade and a follow-up survey in seventh grade. The students were recruited from 12 schools in a low-income, predominantly black (33%) and Latino (48%), urban school district. The survey assessed the children's perception of their parents' controlling and nurturing behaviors, the presence of a TV in their bedrooms, and their level of sugary drink consumption on the previous school day. Children's report of specific controlling and nurturing parental behaviors were used to create an "authoritative parenting" score. Regression analyses were used to test the main and interactive effects of authoritative parenting behaviors and having a TV in the bedroom with sugary drink consumption in seventh grade, controlling for age, race/ethnicity, gender, BMI, and sugary drink consumption in sixth grade. RESULTS: A significant interaction emerged: The authoritative parenting score predicted lower levels of sugary drink consumption in seventh grade, but this relationship was moderated by whether or not there was a TV in the child's bedroom. CONCLUSION: A TV in the child's bedroom may weaken the positive influence of authoritative parenting behaviors on limiting sugary drink consumption among middle school children from low-income families. Stronger initiatives are recommended to educate parents and help them refrain from placing TVs in their children's bedrooms.

Weight- and race-based bullying: health associations among urban adolescents.

Stigma-based bullying is associated with negative mental and physical health outcomes. In a longitudinal study, surveys and physical assessments were conducted with mostly Black and Latino, socioeconomically disadvantaged, urban students. As hypothesized, greater weight- and race-based bullying each was significantly indirectly associated with increased blood pressure and body mass index, as well as decreased overall self-rated health across 2 years, through the mechanism of more negative emotional symptoms. Results support important avenues for future research on mechanisms and longitudinal associations of stigma-based bullying with health. Interventions are needed to reduce stigma-based bullying and buffer adolescents from adverse health effects.

The positive effects of the revised milk and cheese allowances in the special supplemental nutrition program for women, infants, and children.

In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) implemented revisions to the WIC food packages. Milk and cheese allowances were reduced, and whole milk was disallowed for participants older than 23 months. Using a pre-post research design and scanner data from a New England supermarket chain on purchases of WIC households, this article assesses how the new WIC packages affected milk and cheese purchases and saturated fat intake among WIC households in Connecticut and Massachusetts. Milk and cheese volume purchased by 515 WIC households in Connecticut was compared before and after the WIC revisions (2009-2010) using generalized estimating equation models. Analysis for Massachusetts was descriptive. After implementation of the new WIC packages in Connecticut, whole-milk share declined from about 60% to 25% in WIC milk purchases, but remained flat at about 50% for purchases with non-WIC funds. Total milk volume fell by 14.2% (P<0.001), whole milk by half (P<0.001), and WIC-eligible cheese by 37.2% (P<0.001). Restrictions on whole milk shifted WIC purchases to reduced-fat milk in Connecticut and low-fat milk in Massachusetts, where reduced-fat milk is not permitted by WIC. The amounts of saturated fat from purchased milk and cheese declined by 85 g/month per WIC household in Connecticut and 107 g/month in Massachusetts. The 2009 WIC revisions led to a substantial decrease in purchases of whole milk and cheese among WIC families in New England. The related reduction in saturated fat intake could have important public health implications.

Pairing vegetables with a liked food and visually appealing presentation: promising strategies for increasing vegetable consumption among preschoolers.

BACKGROUND: Vegetable consumption among preschool children is below recommended levels. New evidence-based approaches to increase preschoolers' vegetable intake, particularly in the child care setting, are needed. This study tests the effectiveness of two community-based randomized interventions to increase vegetable consumption and willingness to try vegetables: (1) the pairing of a vegetable with a familiar, well-liked food and (2) enhancing the visual appeal of a vegetable. METHODS: Fifty-seven preschoolers enrolled in a Child and Adult Care Food Program-participating child care center participated in the study; complete lunch and snack data were collected from 43 and 42 children, respectively. A within-subjects, randomized design was used, with order of condition counterbalanced. For lunch, steamed broccoli was served either on the side of or on top of cheese pizza. For a snack, raw cucumber was served either as semicircles with chive and an olive garnish or arranged in a visually appealing manner (in the shape of a caterpillar). Paired t-tests were used to determine differences in consumption of meal components, and McNemar's test was performed to compare willingness to taste. RESULTS: Neither visual appeal enhancement nor pairing with a liked food increased vegetable consumption. Pairing increased willingness to try the vegetable from 79% to 95% of children (p=0.07). Greater vegetable intake occurred at snack than at lunch. CONCLUSIONS: Further research should explore the strategy of pairing vegetables with liked foods. Greater consumption at snack underscores snack time as a critical opportunity for increasing preschool children's vegetable intake.

From policy to practice: implementation of water policies in child care centers in Connecticut.

OBJECTIVE: Child care policies may contribute to healthy beverage consumption patterns. This study documented availability and accessibility of water and correspondence with state and federal policy and accreditation standards in child care centers. DESIGN: One-day observations were conducted in a random sample of 40 Child and Adult Care Food Program-participating preschool classrooms in Connecticut. SETTING AND PARTICIPANTS: Child care centers, center directors, and preschool teachers. MAIN OUTCOME MEASURES: Raters observed water availability and teacher behaviors during lunch, physical activity, and in the classroom. National, state, and childcare center water regulations and policies were reviewed. ANALYSIS: Descriptive statistics present data on water availability, promotion, and modeling. Bivariate relationships between water availability and accreditation status, center water policy, location of physical activity, and verbal promotion were assessed using the Fisher exact test (P < .05). RESULTS: Many centers were in violation of water-promoting policies. Water was available in most classrooms (84%) but was only adult accessible in over half of those classrooms. Water was available during one third of physical activity periods observed. Verbal prompts for children to drink water were few. CONCLUSIONS AND IMPLICATIONS: Support is needed to help centers meet existing water policies and new water requirements included in the 2010 Child Nutrition Reauthorization Act.

Effects of reduced juice allowances in food packages for the women, infants, and children program.

OBJECTIVES: In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) implemented revisions to the composition and quantities of WIC food packages. Juice allowances were reduced by approximately half. This report describes changes in purchases of 100% juice and other beverages among WIC participants after the WIC revisions. METHODS: Scanner data from a New England supermarket chain were used to assess juice and other beverage purchases among 2137 WIC-participating households during a 2-year period (N = 36 051 household-months). Purchased beverage amounts were compared before (January-September 2009) and after (January-September 2010) implementation of the revised WIC packages. Generalized estimating equation models were used. RESULTS: Before the revisions, WIC juice accounted for two-thirds of purchased juice volume among WIC households. After implementation of the revisions, WIC juice purchases were reduced on par with allowance changes (43.5% of juice volume, 95% confidence interval [CI] 41.9%-45.1%). This reduction was only partly compensated for by an increase of 13.6% (8.4%-19.0%) in juice purchases using personal and other non-WIC funds. In total, juice purchases declined by 23.5% (21.4%-25.4%) from an adjusted monthly total of 238 oz to 182 oz per household. WIC households increased purchases of fruit drinks by 20.9% (14.9%-27.3%) and other noncarbonated beverages by 21.3% (12.1%-31.2%) but purchased 12.1% (8.1%-15.0%) less soft drinks. CONCLUSIONS: After the WIC revisions, total purchases of 100% juice among WIC households declined by about a quarter, with little compensation occurring from non-WIC funds for juice and other beverages. The public health impact of the shift in beverage purchase patterns could be significant.