Breakfast in the Classroom Initiative Does Not Improve Attendance or Standardized Test Scores among Urban Students: A Cluster Randomized Trial.

BACKGROUND: The Breakfast in the Classroom (BIC) initiative, a common approach to implementing the federal School Breakfast Program, is advocated as a method to improve students' academic performance. However, the influences of BIC on academic outcomes are unclear. OBJECTIVE: To examine the effect of a BIC initiative which provided free, universal BIC on attendance and standardized test performance over 2.5 years, vs free universal breakfast served in the cafeteria before school, among students in an urban school district serving a low-income population. DESIGN: Secondary analysis of data from a cluster randomized controlled trial conducted between 2013 and 2016; 16 kindergarten through eighth-grade public schools in Philadelphia, PA, were enrolled and randomized to condition. Baseline data for 1,362 fourth- through sixth-grade students were provided by the school district. Midpoint data were collected after 1.5 years and endpoint data after 2.5 years. PARTICIPANTS/SETTING: Schools were eligible in the case that ≥50% of students qualified for free or reduced-priced meals, did not offer BIC, and received programming as part of the US Department of Agriculture Supplemental Nutrition Assistance Program. Parents consented for their children to participate. INTERVENTION: Intervention schools provided BIC and breakfast-related nutrition-promotion activities. Control schools provided breakfast in the cafeteria before the school day. MAIN OUTCOME MEASURES: Student attendance and standardized exam scores. STATISTICAL ANALYSES PERFORMED: Weighted generalized estimating equations were used to evaluate differences in outcomes between conditions at midpoint and endpoint. RESULTS: The BIC initiative did not influence attendance (ß ± standard error = .004 ± .06; P = 0.94) or standardized reading exam scores (ß ± standard error = .02 ± .06; P = 0.79) after 2.5 years. Students in BIC initiative schools had lower standardized math exam scores than those in control schools, although this difference was small (ß ± standard error = -.20 ± .07; P = 0.005). CONCLUSIONS: BIC did not improve academic outcomes among students attending low-income, urban schools.

Breakfast in the Classroom Initiative and Students' Breakfast Consumption Behaviors: A Group Randomized Trial.

Objectives. To identify the effect of a Breakfast in the Classroom (BIC) initiative on the foods and drinks students consume in the morning.Methods. Sixteen public schools in Philadelphia, Pennsylvania, that provide universal breakfast participated in a group randomized trial to examine the effects of BIC with complementary nutrition promotion between 2013 and 2016. Control schools (n = 8) offered breakfast in the cafeteria before school. Baseline data were collected from 1362 students in grades 4 to 6. Endpoint data were collected after 2.5 years. Students self-reported the foods and drinks they consumed in the morning.Results. At endpoint, there was no effect of the intervention on breakfast skipping. Nearly 30% of intervention students consumed breakfast foods or drinks from multiple locations, as compared with 21% of control students. A greater proportion of intervention students than control students consumed 100% juice, and a smaller proportion consumed sugar-sweetened beverages and foods high in saturated fat and added sugar.Conclusions. A BIC initiative led to improvements in the types of foods and drinks students consumed in the morning. However, the program did not reduce breakfast skipping and increased the number of locations where students ate.

Understanding the Socioeconomic and Health Challenges of the Medicaid Expansion Population in Oregon.

Following the Patient Protection and Affordable Care Act, Medicaid eligibility in the United States expanded to include low-income adults. One key challenge for organizations and providers serving the Medicaid population was predicting if and how this change would alter the composition of enrollees. This study characterized demographics, socioeconomic challenges, and health of the expansion and non-expansion Medicaid populations in a metropolitan area in Oregon using a survey and Medicaid claims. Results showed that the expansion population has more men and non-English speakers than the non-expansion population. They also have greater education and employment, but face similar socioeconomic challenges including struggling to meet basic needs and housing instability. This study also found comparable self-reported physical and mental health, but lower prevalence of physical or mental health diagnoses and several ambulatory care reactive conditions including hypertension, obesity, and type 2 diabetes. The authors concluded that expansion and non-expansion populations differ in sex, language, education, employment, and health, but they face similar socioeconomic challenges. This information is useful for organizations coordinating and providing care to Medicaid members so they can understand the needs of the population and set appropriate population health management strategies.

Identifying underlying constructs of childhood adversity in a low-income population.

BACKGROUND: Extensive research has documented the association between adverse childhood experiences (ACEs) and poor outcomes later in life, as well as the high prevalence of ACEs in the American population. Studies consistently find that over half of American adults have experienced at least one ACE. Despite this, research on the long-term impacts of ACEs is challenging due to the complex nature of adversity. OBJECTIVE: Our study aimed to define underlying constructs of adversity, and explore how they changed throughout childhood, in a low-income population. PARTICIPANTS AND SETTING: We fielded a survey to Medicaid-enrolled adults in the Portland, OR metropolitan area. METHODS: Our survey captured different experiences in childhood, including relationships and support, educational challenges, housing and employment stability, neighborhood environment, discrimination, abuse, neglect, and household dysfunction; questions were asked for 6-12 and 13-18 years of age. We then used factor analysis to identify underlying constructs of adversity in the two age ranges. RESULTS: We identified two factors - Inadequate Emotional Support and Instability - in each age range. Inadequate Emotional Support remained consistent in both time periods while the Instability factor changed, expanding from household-centric experiences in childhood to a wider variety of experiences in adolescence. Additionally, a number of variables did not load on either factor in either age range. CONCLUSIONS: These results underscore the importance of expanding how we think about instability specifically, and childhood adversity in general.

Effect of a Breakfast in the Classroom Initiative on Obesity in Urban School-aged Children: A Cluster Randomized Clinical Trial.

Importance: Serving breakfast in the classroom is promoted to increase participation in the federal School Breakfast Program. However, little is known about the effect of breakfast in the classroom on children's weight status. Objective: To evaluate the effect of a breakfast in the classroom initiative, which combined breakfast in the classroom with breakfast-specific nutrition education, on overweight and obesity among urban children in low-income communities. Design, Setting, and Participants: A cluster-randomized clinical trial among 1362 fourth- through sixth-grade students from low-income urban communities across 2.5 years. Sixteen kindergarten through eighth grade Philadelphia public schools with universal breakfast participated. Participants were recruited in September 2013, and the intervention began in January 2014. Data analysis took place from April 1, 2018, to August 30, 2018. Interventions: Intervention schools received a program that included breakfast in the classroom and breakfast-specific nutrition education. Control schools continued breakfast before school in the cafeteria and standard nutrition education. Main Outcomes and Measures: The primary outcome was the combined incidence of overweight and obesity. Secondary outcomes included the combined prevalence of overweight and obesity, incidence and prevalence of obesity, changes in body mass index (BMI) z score, and School Breakfast Program participation. Results: Among the 1362 students, mean (SD) age was 10.8 (0.96) years and 700 (51.4%) were female; 907 (66.6%) were black, 233 (17.1%) were Hispanic, 100 (7.3%) were white, 83 (6.1%) were Asian, and 39 were of multiple or other race/ethnicity. After 2.5 years, students in intervention schools had participated in the School Breakfast Program 53.8% of days, compared with 24.9% of days among students in control schools (ß = 0.33; 95% CI, 0.22-0.42). There was no difference between intervention and control schools in the combined incidence of overweight and obesity after 2.5 years (11.7% vs 9.3%; odds ratio [OR] 1.31; 95% CI, 0.85-2.02; P = .22). However, the incidence (11.6% vs 4.4%; OR, 2.43; 95% CI, 1.47-4.00) and prevalence (28.0% vs 21.2%; OR, 1.46; 95% CI, 1.11-1.92) of obesity were higher in intervention schools than in control schools after 2.5 years. Conclusions and Relevance: A breakfast in the classroom initiative increased participation in the School Breakfast Program and did not affect the combined incidence of overweight and obesity. However, the initiative had an unintended consequence of increasing incident and prevalent obesity. Further research is needed to identify approaches to increase participation in the School Breakfast Program that do not increase obesity among students. Trial Registration: ClinicalTrials.gov identifier: NCT01924130.

Title: efficacy of a food parenting intervention for mothers with low income to reduce preschooler's solid fat and added sugar intakes: a randomized controlled trial.

BACKGROUND: Few interventions have shown efficacy to influence key energy balance behaviors during the preschool years. OBJECTIVE: A randomized controlled trial (RCT) was used to evaluate the efficacy of Food, Fun, and Families (FFF), a 12 week authoritative food parenting intervention for mothers with low-income levels, to reduce preschool-aged children's intake of calories from solid fat and added sugar (SoFAS). METHODS: Mothers were randomly assigned to receive FFF (n = 59) or to a delayed treatment control (n = 60). The primary outcome was children's daily energy intake from SoFAS at the end of the 12 week intervention, controlling for baseline levels, assessed by 24-h dietary recalls. Secondary outcomes included children's daily energy intake, children's BMI z-scores, and meal observations of maternal food parenting practices targeted in FFF (e.g. providing guided choices). RESULTS: Participating mothers were predominantly African American (91%), with 39% educated beyond high school and 66% unemployed. Baseline demographics and child SoFAS intakes did not differ by group. Lost to follow-up was 13% and did not differ between groups. At post-intervention, FFF children consumed ~ 94 kcal or 23% less daily energy from SoFAS than children in the control group, adjusting for baseline levels (307.8 (95%CI = 274.1, 341.5) kcal vs. 401.9 (95%CI = 369.8, 433.9) kcal, FFF vs. control; p < 0.001). FFF mothers also displayed a greater number of authoritative parenting practices when observed post-intervention with their child at a buffet-style meal (Wilcoxon z = - 2.54, p = 0.012). Neither child total daily energy intake nor BMI z-scores differed between groups post-intervention. CONCLUSIONS: Findings demonstrate the initial efficacy of an authoritative food parenting intervention for families with low-income to reduce SoFAS intake in early childhood. Additional research is needed to evaluate longer-term effects on diet and growth. TRIAL REGISTRATION: Retrospectively registered at ClinicalTrials.gov : #NCT03646201.

Breakfast Quality Varies by Location among Low-Income Ethnically Diverse Children in Public Urban Schools.

OBJECTIVE: To evaluate breakfast location and children's food choices. METHODS: Cross-sectional analysis of 1,371 fourth- through sixth-grade students in 2013. Foods and beverages in 17 categories characterized breakfast choices: (1) ≥ 1 fruits or vegetables, (2) ≥ 1 foods high in saturated fats and added sugars (SFAS), and (3) meeting School Breakfast Program (SBP) requirements. RESULTS: Among breakfast eaters (n = 1,133; 82.6%), 46.0% ate at home, 13.1% ate at school, 41.0% ate at multiple locations; and 21.8% ate at a corner store. Those eating at school were more likely to consume ≥1 fruit or vegetable (odds ratio [OR] = 1.90; 95% confidence interval [CI], 1.26-2.87), less likely to eat ≥1 SFAS food (OR = 0.46; 95% CI, 0.22-0.94), and more likely to meet SBP requirements (OR = 2.47; 95% CI, 1.42-4.29). Those eating at corner stores (n = 247) were more likely to consume high-SFAS foods (63.9% vs 9.2%; P < .001). CONCLUSIONS AND IMPLICATIONS: Eating school breakfast increased the odds of consuming fruit, choosing lower SFAS, and meeting nutritional requirements of the SBP relative to other locations.

Body Image and Body Contouring Procedures.

Dissatisfaction with physical appearance and body image is a common psychological phenomena in Western society. Body image dissatisfaction is frequently reported by those who have excess body weight, but also is seen in those of normal body weight. For both groups of individuals, this dissatisfaction impacts self-esteem and quality of life. Furthermore, it is believed to be the motivational catalyst to a range of appearance-enhancing behaviors, including weight loss efforts and physical activity. Body image dissatisfaction is also believed to play a role in the decision to seek the wide range of body contouring procedures offered by aesthetic physicians. Individuals who seek these procedures typically report increased body image dissatisfaction, focus on the feature they wish to alter with treatment, and often experience improvement in body image following treatment. At the same time, extreme body image dissatisfaction is a symptom of a number of recognized psychiatric disorders. These include anorexia nervosa, bulimia nervosa, and body dysmorphic disorder (BDD), all of which can contraindicate aesthetic treatment. This special topic review paper provides an overview of the relationship between body image dissatisfaction and aesthetic procedures designed to improve body contouring. The review specifically focuses on the relationship of body image and body weight, as well as the presentation of body image psychopathology that would contraindicate aesthetic surgery. The overall goal of the paper is to highlight the clinical implications of the existing research and provide suggestions for future research on the psychological aspects of body contouring procedures.

The Psychosocial Burden of Obesity.

Obesity is associated with several comorbidities, including cardiovascular disease, type 2 diabetes, sleep apnea, osteoarthritis, and several forms of cancer. Obesity and its comorbidities also come with a significant psychosocial burden, impacting numerous areas of psychosocial functioning. The evaluation of psychosocial functioning is an important part of the assessment and treatment planning for the patient with obesity. This article provides an overview of the psychosocial burden of obesity. The article also describes the psychological changes typically seen with weight loss. A particular focus is on the psychosocial functioning of individuals with extreme obesity who present for and undergo bariatric surgery.

Breakfast-Skipping and Selecting Low-Nutritional-Quality Foods for Breakfast Are Common among Low-Income Urban Children, Regardless of Food Security Status.

BACKGROUND: Universal access to the School Breakfast Program (SBP) is intended to help low-income and food-insecure students overcome barriers to eating breakfast. However, SBP participation is often still low despite universal access. Further information is needed with regard to these children's breakfast behaviors, and in particular breakfast behaviors among youth from food-insecure families, to inform effective breakfast interventions. OBJECTIVES: The objective of this study was to examine breakfast behaviors among a large sample of urban students with universal access to the SBP and to identify differences in breakfast behaviors among children from food-secure compared with food-insecure households. METHODS: A cross-sectional study of 821 fourth- through sixth-grade students and their parents from 16 schools was conducted. Students reported the foods/drinks selected and location of obtaining food/drink on the morning of data collection, parents reported household food security status using the 6-item Food Security Survey Module, and the school district provided SBP participation data during the fall semester of 2013. Multivariable linear regression models accounting for school-level clustering were used to examine differences in breakfast behaviors across 3 levels of household food security: food secure, low food secure, and very low food secure. RESULTS: Students participated in the SBP 31.2% of possible days, with 13% never participating in the SBP. One-fifth (19.4%) of students purchased something from a corner store for breakfast, and 16.9% skipped breakfast. Forty-six percent of students were food insecure; few differences in breakfast behaviors were observed across levels of food security. CONCLUSIONS: Despite universal access to the SBP, participation in the SBP is low. Breakfast skipping and selection of foods of low nutritional quality in the morning are common, regardless of household food security status. Additional novel implementation of the SBP and addressing students' breakfast preferences may be necessary to further reduce barriers to students obtaining a free, healthful breakfast. This trial was registered at clinicaltrials.gov as NCT01924130.

Breakfast patterns among low-income, ethnically-diverse 4th-6th grade children in an urban area.

BACKGROUND: Increasing school breakfast participation has been advocated as a method to prevent childhood obesity. However, little is known about children's breakfast patterns outside of school (e.g., home, corner store). Policies that increase school breakfast participation without an understanding of children's breakfast habits outside of school may result in children consuming multiple breakfasts and may undermine efforts to prevent obesity. The aim of the current study was to describe morning food and drink consumption patterns among low-income, urban children and their associations with relative weight. METHODS: A cross-sectional analysis was conducted of data obtained from 651 4th-6th graders (51.7% female, 61.2% African American, 10.7 years) in 2012. Students completed surveys at school that included all foods eaten and their locations that morning. Height and weight were measured by trained research staff. RESULTS: On the day surveyed, 12.4% of youth reported not eating breakfast, 49.8% reported eating one breakfast, 25.5% reported eating two breakfasts, and 12.3% reported eating three or more breakfasts. The number of breakfasts consumed and BMI percentile showed a significant curvilinear relationship, with higher mean BMI percentiles observed among children who did not consume any breakfast and those who consumed ≥ 3 breakfasts. Sixth graders were significantly less likely to have consumed breakfast compared to younger children. A greater proportion of obese youth had no breakfast (18.0%) compared to healthy weight (10.1%) and overweight youth (10.7%, p = .01). CONCLUSIONS: When promoting school breakfast, policies will need to be mindful of both over- and under-consumption to effectively address childhood obesity and food insecurity. CLINICAL TRIAL REGISTRATION: NCT01924130 from http://clinicaltrials.gov/.