Associations among Food Security, School Meal Participation, and Students' Diet Quality in the First School Nutrition and Meal Cost Study.

The Healthy, Hunger-Free Kids Act of 2010 updated the nutrition standards in the National School Lunch and School Breakfast Programs (NSLP and SBP) and expanded universal free meals' availability in low-income schools. Past studies have shown that school meals are an important resource for children in food-insecure households. This analysis used data from the School Nutrition and Meal Cost Study to classify students as food insecure (FI), marginally secure (MS), or food secure (FS). Diet quality from school and nonschool foods that students consumed was assessed using Healthy Eating Index (HEI)-2010 scores. Chi-squared and two-tailed t-tests were conducted to compare school meal participation, students' energy intakes, and diet quality across food security groups. FI and MS students were significantly more likely to participate in NSLP than FS students (79%, 71%, and 49%, respectively). SBP participation followed a similar pattern but was lower (38% FI, 33% MS, and 16% FS). Compared to FS students, FI and MS students more likely attended schools offering SBP, universal free meals, or afterschool snacks and suppers. School meals contributed significantly more energy to FI and MS students' diets than to FS students (22%, 20%, and 13%, respectively). All groups' dietary intakes from school foods were of higher quality than non-school foods. These findings highlight the role of school meals in meeting the energy and diet quality needs of FI and MS students.

Measuring the Effects of a Demonstration to Reduce Childhood Food Insecurity: A Randomized Controlled Trial of the Nevada Healthy, Hunger Free Kids Project.

BACKGROUND: To reduce childhood hunger, the US Department of Agriculture funded a set of demonstration projects, including the Nevada Healthy, Hunger-Free Kids (HHFK) project. OBJECTIVE: The study objective was to test whether the Nevada HHFK project reduced child food insecurity (FI-C) among low-income households with young children. DESIGN: Households were randomly assigned to treatment and control groups, with outcomes measured using household surveys and administrative data. Survey data were collected at baseline (n=3,088) and follow-up (n=2,074) 8 to 12 months into the project. PARTICIPANTS/SETTING: Eligible households in Las Vegas, NV, had children under age 5 years, received Supplemental Nutrition Assistance Program (SNAP) benefits, and had incomes below 75% of the federal poverty level. INTERVENTION: Between June 2016 and May 2017, treatment households on SNAP received an additional $40 in monthly SNAP benefits per child under age 5 years. MAIN OUTCOME MEASURES: Key outcomes included FI-C (primary), food security among adults and households, and food expenditures (secondary). STATISTICAL ANALYSES PERFORMED: Differences between the treatment and control groups were estimated by a logistic regression model and controlling for baseline characteristics. Analyses were also performed on socioeconomic subgroups. RESULTS: The Nevada HHFK project did not reduce FI-C (treatment=31.2%, control=30.6%; P=0.620), very low food security among children (P=0.915), or food insecurity among adults (P=0.925). The project increased households' monthly food expenditures (including SNAP and out-of-pocket food purchases) by $23 (P<0.001). CONCLUSIONS: A demonstration project to reduce FI-C by increasing SNAP benefits to Las Vegas households with young children and very low income did not reduce FI-C or other food-insecurity measures. This finding runs counter to prior research showing that SNAP and similar forms of food assistance have reduced food insecurity. This project was implemented during a period of substantial economic growth in Las Vegas. Future research should explore the role of the economic context, children's ages, and household income in determining how increases in SNAP benefits affect food insecurity. CLINICALTRIALS. GOV IDENTIFIER: NCT04253743 (http://www.clinicaltrials.gov) FUNDING/SUPPORT: This article is published as part of a supplement supported by the US Department of Agriculture, Food and Nutrition Service.

A Randomized Controlled Trial of Three School Meals and Weekend Food Backpacks on Food Security in Virginia.

BACKGROUND: Food insecurity is a concern for the health and well-being of low-income children in the United States. School-based nutrition assistance programs aim to reduce food insecurity; however, there is limited evidence of their combined impact on food insecurity among children (FI-C). OBJECTIVE: This study tested the impact of the Virginia 365 demonstration project on the food security status of children attending low-income schools. DESIGN: A cluster-randomized trial was conducted from 2016 to 2017 with baseline and follow-up surveys. PARTICIPANTS/SETTING: Households with children who attended a treatment (n = 19) or control (n = 19) school in rural and urban Virginia were included. INTERVENTION: Treatment schools became food hubs where children had access to free breakfast, lunch, and supper on school days, and a food backpack on weekends and school breaks. Control schools implemented a similar, but less robust set of benefits. MAIN OUTCOME MEASURES: The primary outcome was the percentage of children classified as FI-C as measured by the US Department of Agriculture Household Food Security Survey Module. Secondary outcomes included very low food security among children and food security among households and adults. STATISTICAL ANALYSIS PERFORMED: Logistic regression models tested the impact of the demonstration on FI-C and secondary outcomes adjusting for baseline household and individual characteristics. RESULTS: At follow-up, 1,393 treatment households and 1,243 control households completed a survey sufficiently to be included in the analysis. The rate of FI-C in treatment households was higher at 25.9% compared with 23.9% in control households, a difference of 2 percentage points (95% CI 0.1 to 3.9). The rate of very low food security among children in treatment households was lower at 3.2% compared with 3.9% in control households, a difference of -0.7 percentage points (95% CI -1.3 to -0.10). CONCLUSIONS: Although the distinction in nutrition assistance benefits between treatment and control schools was less than planned, providing a suite of school-based nutrition assistance programs targeted broadly to low-income households with children has both positive and negative impacts on child and household food insecurity.

A Cluster Randomized Controlled Trial of a Home-Delivered Food Box on Food Security in Chickasaw Nation.

BACKGROUND: The 2010 Child Nutrition reauthorization called for the independent evaluation of innovative strategies to reduce the risk of childhood hunger or improve the food security status of households with children. OBJECTIVE: The research question was whether the Packed Promise intervention reduces child food insecurity (FI-C) among low-income households with children. DESIGN: This study was a cluster randomized controlled trial of 40 school districts and 4,750 eligible, consented households within treatment and control schools. PARTICIPANTS/SETTING: Data were collected at baseline (n = 2,859) and 2 follow-ups (n = 2,852; n = 2,790) from households with children eligible for free school meals in participating schools in 12 rural counties within the Chickasaw Nation territory in south central Oklahoma in 2016 to 2018. INTERVENTION: Each month of the 25-month intervention, for each eligible child, enrolled households could choose from 5 types of food boxes that contained shelf-stable, nutritious foods ($38 food value) and a $15 check for purchasing fruits and vegetables. MAIN OUTCOME MEASURES: The primary outcome was FI-C. Other outcomes included household and adult food security, very low food security among children, and food expenditures. STATISTICAL ANALYSES PERFORMED: Differences between the treatment and control groups were estimated by a regression model controlling for baseline characteristics. RESULTS: The Packed Promise project did not significantly reduce FI-C at 12 months (29.3% prevalence in the treatment group compared with 30.1% in the control group; P = 0.123) or at 18 months (28.2% vs 28.7%; P = 0.276), but reduced food insecurity for adults by 3 percentage points at 12 months (P = 0.002) but not at 18 months (P = 0.354). The intervention led to a $27 and a $16 decline in median household monthly out-of-pocket food expenditures at 12 and 18 months, respectively. CONCLUSIONS: An innovative intervention successfully delivered nutritious food boxes to low-income households with children in rural Oklahoma, but did not significantly reduce FI-C. Improving economic conditions in the demonstration area and participation in other nutrition assistance programs among treatment and control groups might explain the lack of impact.ClinicalTrials.gov ID: NCT04316819 (http://www.clinicaltrials.gov). FUNDING/SUPPORT: This article is published as part of a supplement supported by the US Department of Agriculture, Food and Nutrition Service.

A Cluster Randomized Controlled Trial of a Home-Delivered Food Box on Children's Diet Quality in the Chickasaw Nation Packed Promise Project.

BACKGROUND: Poor diet quality among children can lead to poor health, development, and academic achievement. Child nutrition assistance programs aim to improve diet quality among children. OBJECTIVE: This study tested the impact of the Packed Promise intervention on diet quality among low-income children in Chickasaw Nation territory. DESIGN: This study was a cluster randomized controlled trial of 40 school districts and 4,750 eligible, consented households within treatment and control districts. PARTICIPANTS/SETTING: Household data were collected at baseline (n = 2,859) and follow-up (n = 2,852) in 12 rural Oklahoma counties. INTERVENTION: Packed Promise treatment households chose from 5 types of home-delivered food boxes that contained nutritious foods ($38 food value) and a $15 check for purchasing fruits and vegetables. MAIN OUTCOME MEASURES: Key outcomes included children's daily consumed amounts of fruits and vegetables, whole grains, and added sugars collected by a dietary screener questionnaire. Other outcomes included food shopping frequency, type of grocery store used, distance traveled from home to grocery stores, and the number of weekly family dinners. All outcomes in this article are secondary to the study's primary outcome-food insecurity among children. STATISTICAL ANALYSES PERFORMED: Differences between the treatment and control groups were estimated by a regression model controlling for baseline characteristics and population-based average portion sizes. RESULTS: Children's mean daily consumption of fruits and vegetables combined was about 2.35-cup equivalents in the treatment group and 2.25-cup equivalents in the control group (P < 0.001). Mean consumption of whole grains was 0.73-ounce equivalents in the treatment group compared with 0.67-ounce equivalents in the control group (P < 0.001). Other outcomes were not statistically significant. CONCLUSION: Packed Promise led to significant but small improvements in children's daily consumption of fruits and vegetables and whole grains. Several factors, including household participation levels in Packed Promise, may have moderated the size of impacts. FUNDING/SUPPORT: This article is published as part of a supplement supported by the US Department of Agriculture, Food and Nutrition Service.

A Randomized Controlled Trial Measuring Effects of Extra Supplemental Nutrition Assistance Program (SNAP) Benefits on Child Food Security in Low-Income Families in Rural Kentucky.

BACKGROUND: To reduce childhood hunger, the US Department of Agriculture funded several innovative demonstration projects, including the Kentucky Ticket to Healthy Food project. OBJECTIVE: The study tested the hypothesis that Ticket to Healthy Food would reduce child food insecurity (FI-C) among rural, low-income households. DESIGN: The study used a randomized controlled trial in which households were randomly assigned to treatment and control groups. Outcomes were measured using household surveys and administrative data. Survey data were collected at baseline (n=2,202) and follow-up (n=1,639) 8 to 11 months into the project. PARTICIPANTS/SETTING: Households in 17 counties in southeastern Kentucky that had at least 1 child younger than 18 years and received a Supplemental Nutrition Assistance Program (SNAP) benefit amount less than the maximum at baseline. INTERVENTION: Between January 2017 and March 2018, treatment households on SNAP received additional monthly benefits ranging from $1 to $122 based on distance to grocery store and earned income. MAIN OUTCOME MEASURES: Key outcomes included FI-C (primary), food insecurity among adults and households, and food expenditures (secondary). STATISTICAL ANALYSES PERFORMED: Logistic and linear regression models were used to estimate differences between the treatment and control groups, controlling for baseline characteristics. Socioeconomic subgroups were also analyzed. RESULTS: The Kentucky Ticket to Healthy Food project did not reduce the primary outcome, FI-C (treatment=37.1%, control=35.2%; P=0.812), or secondary outcomes of very low food security among children (treatment=3.7%, control=4.4%; P=0.204) or food insecurity among adults (treatment=53.9%, control=53.0%; P=0.654). The project increased households' monthly food spending by $20 (P=0.030) and led more households to report that monthly benefits lasted at least 3 weeks (treatment=65%, control=56%; P=0.009). CONCLUSION: A demonstration project to reduce FI-C by raising SNAP benefits for Kentucky households with children did not reduce FI-C or other food insecurity measures. Future research should explore the effect of different increases in SNAP benefits and collect repeated measures of FI-C to assess whether intervention effects change over time. FUNDING/SUPPORT: This article is published as part of a supplement supported by the US Department of Agriculture, Food and Nutrition Service.

American Recovery and Reinvestment Act investments in data infrastructure.

AIM: This article describes American Reinvestment and Recovery Act comparative effectiveness research data infrastructure (DI) investments and identifies facilitators and barriers to implementation. MATERIALS & METHODS: We reviewed original project proposals, conducted an investigator survey and interviewed project officers and principal investigators. RESULTS: DI projects assembled or enhanced existing clinical datasets, established linkages between public and private data sources and built infrastructure. Facilitators included building on existing relationships across organizations and making collection as seamless as possible for clinicians. CONCLUSION: To sustain DI, investigators should reduce the burden of comparative effectiveness research data collection on practices, adequately address data privacy and security issues, resolve or lessen the impact of data-linking issues and build research capacity for other investigators and clinicians.

A review of prenatal home-visiting effectiveness for improving birth outcomes.

OBJECTIVE: To determine the effectiveness of prenatal home visiting for improving prenatal care utilization and preventing preterm birth and low birth weight. DATA SOURCES: Medline, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, and Social Work Abstract databases were searched for articles that examined prenatal home-visiting and prenatal care utilization or neonatal outcomes, with additional ascendancy and descendancy searches. Listservs were also used to identify unpublished evaluations. STUDY SELECTION: Quantitative studies meeting the following criteria were included in the analyses: published between 1985 and 2009, published in English, reported providing prenatal home visiting, and reported on prenatal care utilization or a neonatal outcome. DATA EXTRACTION: Study characteristics and findings related to prenatal care utilization, gestational age, and birth weight were abstracted independently by at least two authors. Study quality was assessed across five domains. DATA SYNTHESIS: The search yielded 28 studies comparing outcomes for women who did and did not receive prenatal home visiting, with 14 (59%) using an RCT design. Five (17%) studies reporting on prenatal care utilization found a statistically significant improvement in use of prenatal care for women with home visiting. Of 24 studies reporting an effect on birth outcomes, five (21%) found a significant positive effect on gestational age, and seven of 17 (41%) found a significant positive effect on birth weight. CONCLUSIONS: More evidence suggests that prenatal home visiting may improve the use of prenatal care, whereas less evidence exists that it improves neonatal birth weight or gestational age. These findings have implications for implementing Title II of the Affordable Care Act.

Energy intake misreporting among children and adolescents: a literature review.

While adults' energy intake misreporting is a well-documented phenomenon, relatively little is known about the nature and extent of misreporting among children and adolescents. Children's and adolescents' dietary reporting patterns are likely to be distinct because of their ongoing cognitive and social development. These developmental differences present unique challenges to aspects of dietary reporting, such as food knowledge, portion size estimation and response editing. This review of 28 articles describes energy intake misreporting among children and adolescents. Like adults, children and adolescents tended to underreport energy, with the largest biases observed with food records. Even when mean reported energy intake was close to its expected value, approximately half of all individuals were classified as misreporters, and overreporting appeared to be more common than it is among adults. Associations between numerous characteristics and misreporting were explored in the literature, with the most consistent findings for age and adiposity. Two predictors for adults, gender and social desirability, were not consistent factors among children and adolescents. The review concludes by highlighting knowledge gaps and recommendations for future research and practice.

Surveying hard-to-reach programs: identifying the population of Medicaid prenatal case management programs.

OBJECTIVES: Community-based prenatal case management (PCM) is a means to improve birth outcomes for medically or socially high-risk pregnant women. To conduct national surveys of PCM programs, a useful sampling frame of existing programs is needed. However, as a relatively small optional Medicaid reimbursed program, PCM programs are hard to reach. Methodological approaches are needed to address issues arising when attempting to access and survey hard-to-reach participants, including programs. METHODS: State Medicaid offices were contacted to determine whether they reimbursed for PCM, and lists of Medicaid providers were obtained from those states. Most providers on the lists were contacted to confirm that they provide PCM and to verify the program director contact information. FINDINGS: Multiple attempts, using different modes of communication, were required to identify states reimbursing for PCM through Medicaid (n = 33). Of providers on the lists obtained from 29 of the 33 states, 34% of those listed provided PCM, suggesting over coverage rather than omissions. Provider contact information was outdated, duplicative, or not specific to PCM. The final count was 1,184 PCM programs in 29 states. CONCLUSION: Identifying hard-to-reach programs requires persistence and creativity, as well as a rigorous approach to generating a census of programs.

Modulation of host innate immune response in the bladder by uropathogenic Escherichia coli.

Uropathogenic Escherichia coli (UPEC), the most frequent cause of urinary tract infection (UTI), is associated with an inflammatory response which includes the induction of cytokine/chemokine secretion by urothelial cells and neutrophil recruitment to the bladder. Recent studies indicate, however, that UPEC can evade the early activation of urothelial innate immune response in vitro. In this study, we report that infection with the prototypic UPEC strain NU14 suppresses tumor necrosis factor alpha (TNF-alpha)-mediated interleukin-8 (CXCL-8) and interleukin-6 (CXCL-6) secretion from urothelial cell cultures compared to infection with a type 1 piliated E. coli K-12 strain. Furthermore, examination of a panel of clinical E. coli isolates revealed that 15 of 17 strains also possessed the ability to suppress cytokine secretion. In a murine model of UTI, NU14 infection resulted in diminished levels of mRNAs encoding keratinocyte-derived chemokine, macrophage inflammatory peptide 2, and CXCL-6 in the bladder relative to infection with an E. coli K-12 strain. Furthermore, reduced stimulation of inflammatory chemokine production during NU14 infection correlated with decreased levels of bladder and urine myeloperoxidase and increased bacterial colonization. These data indicate that a broad phylogenetic range of clinical E. coli isolates, including UPEC, may evade the activation of innate immune response in the urinary tract, thereby providing a pathogenic advantage.

Infectious response to E. coli: molecular and genetic pathways.

Urinary tract infections are most commonly caused by type 1-piliated Escherichia coli (UPEC) and result in urothelial apoptosis, local cytokine release and neutrophil infiltration. A human urothelial cell line was incubated with various E. coli isolates and was then characterized by flow cytometry. UPEC induced rapid urothelial apoptosis that was dependent upon interactions mediated by type 1 pili. Laboratory isolates expressing type 1 pili-induced approximately 50% less apoptosis. UPEC blocked activity of a NF-kappaB-dependent reporter in response to inflammatory stimuli by stabilizing IkappaBalpha and UPEC rapidly altered cellular signalling pathways. Finally, blocking NF-kappaB activity increased the level of the laboratory strain-induced apoptosis to the level of apoptosis induced by UPEC. These results suggest that UPEC blocks NF-kappaB and enhances type 1 pili-induced apoptosis as a component of the uropathogenic programme.

Epithelial differentiation promotes the adherence of type 1-piliated Escherichia coli to human vaginal cells.

Colonization of the vaginal introitus by fecal Escherichia coli is thought to be a key initial event leading to acute urinary tract infection, yet the mannosylated receptor for type 1 pili on the squamous epithelium of vaginal mucosa is unknown. E. coli expressing type 1 pili adhered to sections of normal human vaginal epithelium in a gradient with greatest binding in upper cell layers was observed, which suggests that epithelial differentiation influences bacterial binding. Consistent with this observation, bacterial binding was enhanced in vaginal epithelial cultures that were induced to differentiate, and this enhanced bacterial binding was associated with increased K13 expression levels and increased binding of the mannose-specific lectin Galanthus nivalis agglutinin. These results demonstrate that the binding of type 1-piliated E. coli to vaginal epithelial cells correlates with epithelial differentiation and suggest that the vaginal receptor for type 1 pili is up-regulated during differentiation.

Mast cell activation triggers a urothelial inflammatory response mediated by tumor necrosis factor-alpha.

PURPOSE: Mast cells have been implicated in bladder inflammation and pathogenesis. To determine if mast cell secretion products can modulate urothelial inflammatory responses we developed an in vitro model of mast cell-urothelial cell interactions. MATERIALS AND METHODS: Cultures of the immortalized urothelial cell line TEU-2 were incubated in the conditioned medium of mast cell cultures. The urothelial inflammatory response to mast cell secretion products was then determined by quantifying nuclear factor kappaB activity, the expression of endogenous nuclear factor kappaB dependent genes and the protein expression of inflammation markers. RESULTS: Conditioned medium from RBL-2H3 mast cells induced a 4-fold increase in TEU-2 nuclear factor kappaB activity that was independent of the activation state of the mast cells. In contrast, ribonuclease protection assays revealed that the nuclear factor kappaB dependent transcripts tumor necrosis factor-alpha (TNF-alpha), interleukin (IL) 8 and 1beta, and intracellular adhesion molecule 1 (ICAM-1) were induced by mast cell conditioned medium in a manner that strictly depended on mast cell activation (antigen challenge of IgE sensitized RBL-2H3 cells). The dependence on mast cell activation was confirmed by the observation that IL-8 secretion and ICAM-1 protein expression in TEU-2 cultures were induced only by conditioned medium of stimulated RBL-2H3 cells The induction of TEU-2 IL-8 secretion and ICAM-1 expression by mast cell conditioned medium could be blocked by an anti-TNF-alpha antibody or the cysteine protease inhibitor N-acetyl-leucinyl-leucinyl-norleucinal. CONCLUSIONS: Our data support the hypothesis that mast cells may participate in bladder inflammation. Furthermore, TNF-alpha acting via the nuclear factor kappaB signaling pathway may be a mediator of the urothelial response to mast cell secretion products.