Feasibility and Acceptability of Standardizing Portions in Restaurants.

Most restaurants serve customers excess calories which significantly contributes to the obesity epidemic. This pilot study tested the feasibility and acceptability of offering customers standardized portions to reduce caloric consumption when dining out in three restaurants. Portions were developed to limit quantity of food served, with lunches and dinners ≤ 700 cal and breakfast ≤ 500 cal. Participating restaurants developed an alternative "Balanced Portions Menu." Training and instructions were provided with respect to the volume and weight of food to be plated following the standardized guidelines and providing at least one cup of vegetables per lunch/dinner. We invited local residents to help us evaluate the new menu. We monitored restaurant adherence to guidelines, obtained feedback from customers, and incentivized customers to complete dietary recalls to determine how the new menus might have impacted their daily caloric consumption. Of the three participating restaurants, all had a positive experience after creating the new menus and received more foot traffic. One restaurant that did not want to change portion sizes simply plated the appropriate amount and packed up the rest to-go, marketing the meals as "Dinner today, lunch tomorrow." Two of the restaurants followed the guidelines precisely, while one sometimes plated more rice than the three-fourths cup that was recommended. A significant number of customers ordered from the Balanced Portions menus. Two of the three restaurants have decided to keep offering the Balanced Portions menus indefinitely. Following standardized portions guidelines is both feasible for restaurants and acceptable to customers.

Physical activity and sleep changes among children during the COVID-19 pandemic.

Daily routines, including in-person school and extracurricular activities, are important for maintaining healthy physical activity and sleep habits in children. The COVID-19 pandemic significantly disrupted daily routines as in-person school and activities closed to prevent spread of SARS-CoV-2. We aimed to examine and assess differences in objectively measured physical activity levels and sleep patterns from wearable sensors in children with obesity before, during, and after a period of school and extracurricular activity closures associated with the COVID-19 pandemic. We compared average step count and sleep patterns (using the Mann-Whitney U Test) before and during the pandemic-associated school closures by using data from activity tracker wristbands (Garmin VivoFit 3). Data were collected from 94 children (aged 5-17) with obesity, who were enrolled in a randomized controlled trial testing a community-based lifestyle intervention for a duration of 12-months. During the period that in-person school and extracurricular activities were closed due to the COVID-19 pandemic, children with obesity experienced objectively-measured decreases in physical activity, and sleep duration. From March 15, 2020 to March 31, 2021, corresponding with local school closures, average daily step count decreased by 1655 steps. Sleep onset and wake time were delayed by about an hour and 45 min, respectively, while sleep duration decreased by over 12 min as compared with the pre-closure period. Step counts increased with the resumption of in-person activities. These findings provide objective evidence for parents, clinicians, and public health professionals on the importance of in-person daily activities and routines on health behaviors, particularly for children with pre-existing obesity. Trial Registration: Clinical trial registration: NCT03339440.

Translating knowledge into action for child obesity treatment in partnership with Parks and Recreation: study protocol for a hybrid type II trial.

BACKGROUND: Safe and effective treatment exists for childhood obesity, but treatment recommendations have largely not been translated into practice, particularly among racial and ethnic minorities and low-wealth populations. A key gap is meeting the recommended treatment of ≥26 h of lifestyle modification over 6-12 months. Fit Together is an effective treatment model that meets these recommendations by integrating healthcare and community resources. Pediatric providers screen children for obesity, deliver counseling, and treat co-morbidities, while Parks and Recreation partners provide recreation space for a community nutrition and physical activity program. METHODS: This study will use a hybrid type II implementation-effectiveness design to evaluate the effectiveness of an online implementation platform (the Playbook) for delivering Fit Together. Clinical and community partners in two North Carolina communities will implement Fit Together, using the Playbook, an implementation package designed to facilitate new partnerships, guide training activities, and provide curricular materials needed to implement Fit Together. An interrupted time series design anchored in the Process Redesign Framework will be used to evaluate implementation and effectiveness outcomes in intervention sites. Implementation measures include semi-structured interviews with partners, before and after the implementation of Fit Together, and quantitative measures assessing several constructs within the Process Redesign Framework. The participants will be children 6-11 years old with obesity and their families (n=400). Effectiveness outcomes include a change in child body mass index and physical activity from baseline to 6 and 12 months, as compared with children receiving usual care. Findings will be used to inform the design of a dissemination strategy guided by the PCORI Dissemination Framework. DISCUSSION: This project addresses the knowledge-to-action gap by developing evidence-based implementation tools that allow clinicians and communities to deliver effective pediatric obesity treatment recommendations. Future dissemination of these tools will allow more children who have obesity and their families to have access to effective, evidence-based care in diverse communities. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05455190 . Registered on 13 July 2022.

Prevalence of food insecurity among students attending four Historically Black Colleges and Universities.

Objective: This study examined the prevalence of food insecurity (FI) among students attending Historically Black Colleges and Universities (HBCUs) in the Southeastern United States. Participants: Students attending four HBCUs (N = 351) completed an anonymous Web-based survey. Methods: Food insecurity was assessed using the 2-item Hunger Vital Sign Tool. Summary statistics were used to quantify FI experiences. Logistic regression was conducted to determine if student demographic characteristics were significantly associated with FI outcomes. Results: Nearly 3 in 4 students (72.9%) reported some level of FI in the past year. Students representing all levels of postsecondary education reported FI. Meal plan participation did not prevent FI. Conclusions: Students attending HBCUs experience FI at levels that exceed estimates reported among students attending predominantly White institutions. More work is needed to understand the lived experience of food-insecure HBCU students as a means to ensure institution-level food policies support student academic success and wellbeing.

An exploration of customers' perceptions, preferences, experiences, and feasibility of offering standardized portions in restaurants.

Excess caloric intake increases the risk of weight gain, and diet-related chronic diseases. Restaurants play an integral role in the portions of food people consume. Standardization of portion sizes in restaurants can help customers recognize appropriate portions. Through customer interviews, we aimed to assess and understand the feasibility, perceptions, and acceptability of standardized portions in restaurants. Kaiser Permanente partnered with three restaurants in Southern California to create alternative menu options of meals that would not exceed 700 calories. Kaiser Permanente members who lived within a 5-mile radius of the restaurants were informed through email about the study. Customers (N=33), who dined at one of the restaurants participated in a one-on-one semi-structured interview. Interviews were recorded, typed, transcribed verbatim, and analyzed using thematic analysis. Four themes emerged from the analysis: 1) Customers perceive standard portions as a better choice and the benefits outweigh regular portions; 2) Individual and restaurant-related factors may influence portion preferences; 3) Restaurant portions are perceived to be in excess of what customers need; and 4) Portion standardization is an evolving area for restaurants. Our findings suggest positive perceptions and acceptance of standardized portions among restaurant customers. Customer awareness and restaurant standardization procedures can improve customers' dining experience.

Nurturing children's development through healthy eating and active living: Time for policies to support effective interventions in the context of responsive emotional support and early learning.

Fostering the growth, development, health, and wellbeing of children is a global priority. The early childhood period presents a critical window to influence lifelong trajectories, however urgent multisectoral action is needed to ensure that families are adequately supported to nurture their children's growth and development. With a shared vision to give every child the best start in life, thus helping them reach their full developmental potential, we have formed the International Healthy Eating Active Living Matters (HEALing Matters) Alliance. Together, we form a global network of academics and practitioners working across child health and development, and who are dedicated to improving health equity for children and their families. Our goal is to ensure that all families are free from structural inequality and oppression and are empowered to nurture their children's growth and development through healthy eating and physical activity within the context of responsive emotional support, safety and security, and opportunities for early learning. To date, there have been disparate approaches to promoting these objectives across the health, community service, and education sectors. The crucial importance of our collective work is to bring these priorities for early childhood together through multisectoral interventions, and in so doing tackle head on siloed approaches. In this Policy paper, we draw upon extensive research and call for collective action to promote equity and foster positive developmental trajectories for all children. We call for the delivery of evidence-based programs, policies, and services that are co-designed to meet the needs of all children and families and address structural and systemic inequalities. Moving beyond the "what" is needed to foster the best start to life for all children, we provide recommendations of "how" we can do this. Such collective impact will facilitate intergenerational progression that builds human capital in future generations.

Emotional and Behavioral Changes and Related Factors of Firstborn School-Aged Compared to Same Age Only Children.

Objective: To compare the emotional and behavioral characteristics of firstborn children during the pregnancy of a second child and only children of school-age in urban districts of Chongqing, China, and to explore the influencing factors of emotional and behavioral problems. Methods: We recruited mothers of firstborn children and only children from two hospitals and one primary school using purposive sampling. Questionnaires and the Parental Child Behavior Checklist (CBCL) were used to collect basic information, family socioeconomic status, family atmosphere and emotional and behavioral characteristics of their children in the survey. Results: The sample consisted of 1,155 children, including 477 firstborn children and 678 only children. The average scores of internalizing (4.47), externalizing (6.05), total problems (22.04), and six emotional and behavioral of firstborn children were significantly lower than those of only children (p < 0.05). When adjusted for children's demographic, socioeconomic and family relationship covariates, the scores of firstborn children internalizing problems (ß = -1.423, p = 0.000), externalizing problems (ß = -0.661, p = 0.048), and total problems (ß = -4.387, p = 0.000) were also significantly lower than those of only children. All children with more difficult parenting and development temperament, greater family economic pressure, poorer relationships between mother and child, less harmonious family atmosphere and father's permissive parenting style had more internalizing problems, externalizing problems and total problems (p < 0.05). Boys had more externalizing problems (ß = 1.939, 95% CI = 1.380-2.497) and total problems (ß = 4.908, 95% CI = 3.045-6.772) than girls. Conclusion: Firstborn children had fewer emotional and behavioral problems than their counterparts who were only children. This research helps to understand the social impact of the implementation of the two-child policy in multiple dimensions.

Healthy Eating Index-2015 Scores Vary by Types of Food Outlets in the United States.

Diet quality in the United States is improving over time but remains poor. Food outlets influence diet quality and represent the environments in which individuals make choices about food purchases and intake. The objective of this study was to use the Healthy Eating Index-2015 (HEI-2015) to evaluate the quality of foods consumed from the four major outlets where food is obtained-stores, full-service restaurants, quick-services restaurants, and schools-and to assess changes over time. This cross-sectional study used 24 h dietary recall data from eight cycles (2003-2004 to 2017-2018) of the National Health and Nutrition Examination Survey (NHANES). Linear trend estimation was used to test for changes in HEI scores over time, and balanced repeated replicate weighted linear regression was used to test for differences in total and component scores between types of food outlets. Overall, Americans are not consuming a mix of foods from any major category of food outlet that aligns with dietary guidelines. The total score for schools (65/100 points) and stores (62/100 points) was significantly higher than full-service (51/100 points) and quick-service (39/100 points) restaurants (p < 0.0001). HEI scores significantly improved over time for schools (p < 0.001), including an increase in whole grains from less than 1 point in 2003-2004 to 7 out of 10 points in 2017-2018. In 2017-2018, schools received the maximum score for total fruits, whole fruits, and dairy. Continued research on strategies for improving the quality of foods consumed from restaurants and stores is warranted.

Development and Application of a Total Diet Quality Index for Toddlers.

For the first time, the 2020-2025 Dietary Guidelines for Americans include recommendations for infants and toddlers under 2 years old. We aimed to create a diet quality index based on a scoring system for ages 12 to 23.9 months, the Toddler Diet Quality Index (DQI), and evaluate its construct validity using 24 h dietary recall data collected from a national sample of children from the Feeding Infants and Toddlers Study (FITS) 2016. The mean (standard error) Toddler DQI was 49 (0.6) out of 100 possible points, indicating room for improvement. Toddlers under-consumed seafood, greens and beans, and plant proteins and over-consumed refined grains and added sugars. Toddler DQI scores were higher among children who were ever breastfed, lived in households with higher incomes, and who were Hispanic. The Toddler DQI performed as expected and offers a measurement tool to assess the dietary quality of young children in accordance with federal nutrition guidelines. This is important for providing guidance that can be used to inform public health nutrition policies, programs, and practices to improve diets of young children.

The School Nutrition and Meal Cost Study-I: Overview of Findings Related to Improving Diet Quality, Weight, and Disparities in US Children and Policy Implications.

The national school breakfast and lunch programs administered by the United States Department of Agriculture (USDA) are a cornerstone of the nation's nutrition safety net for children from low-income families [...].

Weight-Related Behaviors of Children with Obesity during the COVID-19 Pandemic.

Background: During the coronavirus disease 2019 (COVID-19) pandemic, children and families have had to adapt their daily lives. The purpose of this study was to describe changes in the weight-related behaviors of children with obesity after the onset of the COVID-19 pandemic. Methods: Semistructured interviews (n = 51) were conducted from April to June 2020 with parents of children with obesity. Families were participants in a randomized trial testing a clinic-community pediatric obesity treatment model. During interviews, families described their experience during the COVID-19 pandemic, with a particular emphasis on children's diet, physical activity, sleep, and screen time behaviors. Rapid qualitative analysis methods were used to identify themes around changes in children's weight-related behaviors. Results: The mean child age was 9.7 (±2.8) years and the majority of children were Black (46%) or Hispanic (39%) and from low-income families (62%). Most parent participants were mothers (88%). There were differences in the perceived physical activity level of children, with some parents attributing increases in activity or maintenance of activity level to increased outdoor time, whereas others reported a decline due to lack of outdoor time, school, and structured activities. Key dietary changes included increased snacking and more meals prepared and consumed at home. There was a shift in sleep schedules with children going to bed and waking up later and an increase in leisure-based screen time. Parents played a role in promoting activity and managing children's screen time. Conclusions: The COVID-19 pandemic has created unique lifestyle challenges and opportunities for lifestyle modification. Clinical Trials ID: NCT03339440.

Reframing the early childhood obesity prevention narrative through an equitable nurturing approach.

High-quality mother-child interactions during the first 2,000 days, from conception to age 5 years, are considered crucial for preventing obesity development during early life stages. However, mother-child dyads interact within and are influenced by broader socio-ecological contexts involved in shaping child development outcomes, including nutrition. Hence, the coexistence of both undernutrition and obesity has been noted in inequitable social conditions, with drivers of undernutrition and overnutrition in children sharing common elements, such as poverty and food insecurity. To date, a holistic life-course approach to childhood obesity prevention that includes an equitable developmental perspective has not emerged. The World Health Organization (WHO) Nurturing Care Framework provides the foundation for reframing the narrative to understand childhood obesity through the lens of an equitable nurturing care approach to child development from a life-course perspective. In this perspective, we outline our rationale for reframing the childhood narrative by integrating an equitable nurturing care approach to childhood obesity prevention. Four key elements of reframing the narrative include: (a) extending the focus from the current 1,000 to 2,000 days (conception to 5 years); (b) highlighting the importance of nurturing mutually responsive child-caregiver connections to age 5; (c) recognition of racism and related stressors, not solely race/ethnicity, as part of adverse child experiences and social determinants of obesity; and (d) addressing equity by codesigning interventions with socially marginalized families and communities. An equitable, asset-based engagement of families and communities could drive the transformation of policies, systems and social conditions to prevent childhood obesity.

Improving maternal and child nutrition in China: an analysis of nutrition policies and programs initiated during the 2000-2015 Millennium Development Goals era and implications for achieving the Sustainable Development Goals.

BACKGROUND: Although good progress was made in maternal and child nutrition during the Millennium Development Goals (MDGs) era, malnutrition remains one of the major threats on global health. Therefore, the United Nation set several nutrition-related goals in the Sustainable Development Goals (SDGs). There is much to be learned from individual countries in terms of efforts and actions taken to reduce malnutrition. China, as a developing country, launched a number of nutrition improvement policies and programs that resulted in dramatic progress in improving maternal and child nutrition during the MDGs era. This study explored the impact, experiences, and lessons learned from the nutrition policies and programs initiated in China during the MDGs era and implications to achieve the SDGs for China and other developing countries. METHOD: The CNKI database and official websites of Chinese government were searched for reviews on nutrition-related policies and intervention programs. A qualitative study was conducted among key informants from the Chinese government, non-governmental organizations (NGOs), and universities for two major national nutrition intervention programs. RESULTS: The literature review documented that during the MDGs era, six nutrition policies and eight trans-province and nationwide nutrition intervention programs collectively made good progress in improving maternal and child nutrition in China. Nutrition policies tended to be targeted at infants and children, with less attention on reproductive and maternal nutrition. Nutrition intervention programs focused primarily on undernutrition and have achieved positive results, while for breastfeeding improvement and prevention and control on overweight and obesity were limited. Results from the qualitative study indicated that effective nutrition program implementation was facilitated through the cooperation of multiple sectors and by the government and NGO partnerships, however, still face challenges of insufficient operational funds from local governments and inadequacy of program monitoring and management. CONCLUSION: Nutrition policies and intervention programs promulgated in China during the MDGs era have made major contributions to the rapid decline of undernutrition and are in line to achieve the SDGs related to child wasting, stunting, low birth weight, and anemia in reproductive-age women. However, appropriate policies and program implementation are needed to improve exclusive breastfeeding rates and reduce obesity to achieve the SDGs in years to come.

Developing a National Research Agenda to Support Healthy Food Retail.

The food retail environment is an important driver of dietary choices. This article presents a national agenda for research in food retail, with the goal of identifying policies and corporate practices that effectively promote healthy food and beverage purchases and decrease unhealthy purchases. The research agenda was developed through a multi-step process that included (1) convening a scientific advisory committee; (2) commissioned research; (3) in-person expert convening; (4) thematic analysis of meeting notes and refining research questions; (5) follow-up survey of convening participants; and (6) refining the final research agenda. Public health researchers, advocates, food and beverage retailers, and funders participated in the agenda setting process. A total of 37 research questions grouped into ten priority areas emerged. Five priority areas focus on understanding the current food retail environment and consumer behavior and five focus on assessing implementation and effectiveness of interventions and policies to attain healthier retail. Priority topics include how frequency, duration, and impact of retailer promotion practices differ by community characteristics and how to leverage federal nutrition assistance programs to support healthy eating. To improve feasibility, researchers should explore partnerships with retailers and advocacy groups, identify novel data sources, and use a variety of study designs. This agenda can serve as a guide for researchers, food retailers, funders, government agencies, and advocacy organizations.

Rationale and design of "Hearts & Parks": study protocol for a pragmatic randomized clinical trial of an integrated clinic-community intervention to treat pediatric obesity.

BACKGROUND: The prevalence of child and adolescent obesity and severe obesity continues to increase despite decades of policy and research aimed at prevention. Obesity strongly predicts cardiovascular and metabolic disease risk; both begin in childhood. Children who receive intensive behavioral interventions can reduce body mass index (BMI) and reverse disease risk. However, delivering these interventions with fidelity at scale remains a challenge. Clinic-community partnerships offer a promising strategy to provide high-quality clinical care and deliver behavioral treatment in local park and recreation settings. The Hearts & Parks study has three broad objectives: (1) evaluate the effectiveness of the clinic-community model for the treatment of child obesity, (2) define microbiome and metabolomic signatures of obesity and response to lifestyle change, and (3) inform the implementation of similar models in clinical systems. METHODS: Methods are designed for a pragmatic randomized, controlled clinical trial (n = 270) to test the effectiveness of an integrated clinic-community child obesity intervention as compared with usual care. We are powered to detect a difference in body mass index (BMI) between groups at 6 months, with follow up to 12 months. Secondary outcomes include changes in biomarkers for cardiovascular disease, psychosocial risk, and quality of life. Through collection of biospecimens (serum and stool), additional exploratory outcomes include microbiome and metabolomics biomarkers of response to lifestyle modification. DISCUSSION: We present the study design, enrollment strategy, and intervention details for a randomized clinical trial to measure the effectiveness of a clinic-community child obesity treatment intervention. This study will inform a critical area in child obesity and cardiovascular risk research-defining outcomes, implementation feasibility, and identifying potential molecular mechanisms of treatment response. CLINICAL TRIAL REGISTRATION: NCT03339440 .

Child Nutrition Trends Over the Past Two Decades and Challenges for Achieving Nutrition SDGs and National Targets in China.

BACKGROUND: The objectives of the current study were to identify the trends in child nutrition, the gaps in achieving child nutrition-related goals, and implications for program and policy options for the Chinese government. METHODS: Eight child nutrition-related indicators from the Sustainable Development Goals (SDGs) and China's national nutrition plans, and two datasets, Global Burden of Disease 2016 and Chinese National Nutrition and Health Surveillance, were used in our analysis. RESULTS: Over the past 26 years, the prevalence of stunting, wasting, and underweight for children under 5 years was reduced by 58.7%, 53.4%, and 69.2%, respectively. Overweight for children aged 1-4 years increased 88.9% and obesity increased 2.14 times. Exclusive breastfeeding of newborns (7-28 days) was stable, at about 30%. We estimated child wasting would be 3.0% lower than the target of 5.0% based on predictive values for meeting the SDGs in 2025. The number of stunted children under five years would be reduced by 39.7%, while overweight would increase 2.2% throughout China. CONCLUSION: These results highlight the urgent need for targeted policies and interventions to reduce child stunting and overweight and increase exclusive breastfeeding to improve child health and meet the SDG targets and China's national goals.

Developing a national research agenda to reduce consumption of sugar-sweetened beverages and increase safe water access and consumption among 0- to 5-year-olds: a mixed methods approach.

OBJECTIVE: Sugar-sweetened beverage (SSB) consumption in early childhood is a public health concern. Adequate hydration in early childhood is also important. We developed a national research agenda to improve beverage consumption patterns among 0-5-year-olds. This article focuses on the process used to develop this research agenda. DESIGN: A mixed methods, multi-step process was used to develop the research agenda, including: (i) a scientific advisory committee; (ii) systematic reviews on strategies to reduce SSB consumption and increase water access and consumption; (iii) two stakeholder surveys to first identify and then rank strategies to reduce SSB consumption and increase water access and consumption; (iv) key informant interviews to better understand determinants of beverage consumption and strategies to improve beverage consumption patterns among high-risk groups; (v) an in-person convening with experts; and (vi) developing the final research agenda. SETTING: This process included research and stakeholders from across the United States. PARTICIPANTS: A total of 276 participants completed survey 1 and 182 participants completed survey 2. Key informant interviews were conducted with 12 stakeholders. Thirty experts attended the convening, representing academia, government, and non-profit sectors. RESULTS: Thirteen key issue areas and 59 research questions were developed. Priority topics were beverage consumption recommendations, fruit-flavoured drink consumption, interventions tailored to high-risk groups, and family engagement in childcare. CONCLUSIONS: This research agenda lays the groundwork for research efforts to improve beverage patterns of young children. The methods used can be a template to develop research agendas for other public health issues.

Supporting Healthy Eating: Synergistic Effects of Nutrition Education Paired with Policy, Systems, and Environmental Changes.

A healthy diet is central to health and well-being throughout life. The United States and many other countries are undergoing an obesity epidemic and experiencing serious diet-related health problems. There exists a misalignment and wide gap between national dietary recommendations and dietary patterns of Americans, and thus, a need to find new ways to improve diet and nutrition. This article posits that nutrition education combined with policy, systems, and environmental (PSE) change approaches is more effective than either strategy in isolation and both are needed to reduce the global burden of diet-related chronic diseases. This article presents a conceptual framework for understanding the multiple influences on what people eat; discusses the need for PSE strategies to augment direct nutrition education approaches; and highlights examples of synergistic and promising linkages between nutrition education and PSE strategies in 3 areas: federal nutrition assistance programs, food retail settings, and nutrition and calorie labeling. In addition, future directions where this synergistic approach holds promise for improving population health and reducing health inequities are discussed. Nutrition education combined with PSE changes at governmental and community levels, as well as strategic public-private alliances have the potential to change the way people eat and improve health and well-being.