Associations between Changes in Food Acquisition Behaviors, Dietary Intake, and Bodyweight during the COVID-19 Pandemic among Low-Income Parents in California.

COVID-19 disrupted food access, potentially increasing nutritional risk and health inequities. This study aimed to describe and assess associations between changes in food/meal acquisition behaviors and relative changes in dietary intake and bodyweight from before to during the pandemic. Low-income parents (n = 1090) reported these changes by online survey in April-August 2021. Associations were assessed by multinomial logistic regression. Compared to those with no change, those who decreased supermarket shopping had greater odds of decreased fruit and vegetable (FV; OR[95%CI] = 2.4[1.4-4.1]) and increased salty snack intakes (OR[95%CI] = 1.7[1.0-2.8]). Those who decreased farmer's market shopping had greater odds of decreased FV intake (OR[95%CI] = 1.8[1.0-3.1]), increased bodyweight (OR[95%CI] = 1.7[1.1-2.6]), and increased SSB (OR[95%CI] = 1.9[1.1-3.2]) and sweets intakes (OR[95%CI] = 1.8[1.1-2.9]). Those who increased online food ordering had greater odds of increased sweets (OR[95%CI] = 1.7[1.1-2.8]), salty snacks (OR[95%CI] = 1.9[1.2-3.2]), and fast food (OR[95%CI] = 2.0[1.2-3.5]) intakes and bodyweight (OR[95%CI] = 1.8[1.1-2.9]). Those who increased healthy meal preparation had greater odds of increased FV intake (OR[95%CI] = 4.0[2.5-6.5]), decreased SSB (OR[95%CI] = 3.7[2.3-6.0]), sweets (OR[95%CI] = 2.7[1.6-4.4]), salty snacks (OR[95%CI] = 3.0[1.8-5]) and fast food intakes (OR[95%CI] = 2.8[1.7-4.6]) and bodyweight (OR[95%CI] = 2.2[1.2-4.0]). Interventions to address the potentially negative impacts of online food/meal shopping and support healthy home cooking may be needed to improve nutrition-related outcomes and reduce health disparities in the aftermath of the current pandemic and during future emergencies requiring similar restrictions.

Parent perceptions of changes in eating behavior during COVID-19 of school-aged children from Supplemental Assistance Program Education (SNAP-Ed) eligible households in California.

This cross-sectional study examined the associations between parent-reported, perceptions of changes in school-aged children's (ages 5-18) school meal participation, household cooking, fast food consumption, dietary intake, and weight during the COVID-19 pandemic. Respondents with low-income and school-aged children (n = 1040) were enrolled using quota sampling to approximate the distribution of low-income households and race/ethnicity among California residents who completed an on-line questionnaire developed by the authors. Adjusted multinomial models examined associations between parent-reported changes in school meal participation and time spent cooking, with parent-reported changes in child diet and body weight during COVID-19 (from before March 2020 to January-March 2021). During the pandemic, decreased school meal participation was associated with decreased child's fast food intake (OR[95 %CI] = 1.47[1.04-2.07]); conversely, increased school meal participation was associated with increased child's fast food intake (OR[95 %CI] = 1.71[1.09-2.68]). Decreased cooking at home was associated with decreased fruit and vegetable intake (OR[95 %CI] = 2.71[1.62-4.53]), increased sugar-sweetened beverage intake (OR[95 %CI] = 3.83[2.16-6.81]), and increased fast food intake (OR[95 %CI] = 4.09[2.45-6.84]); while increased cooking at home was associated with increased fruit and vegetable (OR[95 %CI] = 2.26[1.59-3.20]), sugar-sweetened beverage (OR[95 %CI] = 1.88[1.20-2.94]), sweets (OR[95 %CI] = 1.46[1.02-2.10]), and salty snack food intake (OR[95 %CI] = 1.87[1.29-2.71]). These parent-reported perceived changes in meal sources during the pandemic for children from low-income California households, and the mixed results in their associations with changes in parent-reported child dietary intake, suggest the need for strengthening policies and programs to support both access to, and healthfulness of, meals from school and home during prolonged school closures.

Latent class analysis identifies a promising combination of Supplemental Nutrition Assistance Program-Education interventions for improving student cardiorespiratory fitness.

OBJECTIVE: To inform Supplemental Nutrition Assistance Program Education (SNAP-Ed) and other school-based interventions aiming to improve youth cardiorespiratory fitness, this study aimed to identify which SNAP-Ed school-based physical activity intervention combinations were associated with better student cardiorespiratory fitness. METHODS: This study, utilizing cross-sectional secondary data, included 5th and 7th grade students who attended SNAP-Ed-eligible public schools in California (n = 442,743 students; 4271 schools) and had complete 2016-17 state-mandated fitness test results. Latent class analysis was used to identify underlying school-based intervention combinations. Propensity score methods were used to ensure comparability of intervention and comparison schools, by calculating inverse probability weights. Multilevel models, using those inverse probability weights, assessed the associations between the identified intervention combinations and student cardiorespiratory fitness, as measured by VO2max. The models were adjusted for school-level variables (urbanicity, percent of students eligible for free- or reduced-price meals, total enrollment, and school type), child-level variables (age, gender, and race/ethnicity), and for clustering of students within schools. RESULTS: We found that students attending schools with interventions focusing on comprehensive policy changes along with improving opportunities for physical activity had, on average, 1.17 mL/kg/min (95% CI: 0.72, 1.62) greater VO2max than students attending schools without any intervention. They also had statistically significantly greater VO2max compared to students attending schools with any other type of intervention combination. CONCLUSION: Our results suggest that comprehensive school-based physical activity interventions that include policy changes along with improving physical activity opportunities may be the most effective approach for improving fitness and may warrant prioritization in SNAP-Ed efforts.

Supplemental Nutrition Assistance Program Education reductions during COVID-19 may have exacerbated health inequities.

Objective: Describe, and assess disparities in, the changes in Supplemental Nutrition Assistance Program Education (SNAP-Ed) that occurred the year before vs. the year when COVID-19 restrictions were implemented. Design: Observational study comparing reach, intensity, and dose of California Local Health Department (LHD) SNAP-Ed interventions in Federal Fiscal years 2019 and 2020 (FFY19, FFY20). Analysis: Student t-tests determined significance of differences in the number of Direct Education (DE) programs, Policy, Systems and Environmental change (PSE) sites, people reached, and intervention intensity and dose between FFY19 and FFY20 using data reported online by LHDs. Linear regression assessed associations between census tract-level characteristics (urbanicity; percentages of population with income <185% of federal poverty level, under 18 years of age, and belonging to various racial/ethnic groups; and California Healthy Places Index) and changes in number of DE programs, PSE sites, people reached, and intervention dose between FFY19 and FFY20. Results: From FFY19 to FFY20, the number of DE programs, PSE sites, people reached, and census tract-level intervention intensity and dose decreased. Higher census tract poverty, higher proportions of Black and Latino residents, and less healthy neighborhood conditions were associated with greater decreases in some intervention characteristics including PSE sites, PSE reach, DE programs, and DE dose. Conclusions and implications: These reductions in LHD SNAP-Ed interventions indicate reduced access to education and environments that support healthy eating and obesity prevention during a time when this support was especially needed to reduce risk of COVID-19 infection and complications. Disproportionately reduced access, may have worsened health disparities in already-disadvantaged communities. Assuring maintenance of SNAP-Ed interventions, especially in disadvantaged communities, should be a priority during public health emergencies.

Addressing nutrition and physical activity in substance use disorder treatment: Client reports from a wellness-oriented, tobacco-free policy intervention.

Introduction: Interest in wellness interventions in substance use disorder (SUD) treatment is growing although evidence remains limited. This study evaluated nutrition, physical activity, nutrition and physical activity counseling, and relationships of counseling with wellness behavior before and after a wellness-oriented, tobacco-free policy intervention in 17 residential SUD programs. Methods: Clients completed cross-sectional surveys reporting sugar-sweetened beverage consumption, physical activity, and receipt of nutrition and physical activity counseling before (n= 434) and after (n = 422) an 18-month intervention. Multivariable regression models assessed pre-post-intervention differences in these variables and examined associations of nutrition counseling with sugar-sweetened beverage consumption and physical activity counseling with physical activity. Results: Post-intervention clients were 83% more likely than pre-intervention clients to report nutrition counseling (p = 0.024). There were no pre-post- differences for other variables. Past week sugar-sweetened beverage consumption was 22% lower among clients reporting nutrition counseling than for those who did not (p = 0.008) and this association did not vary by time (pre/post). There was a significant interaction of physical activity counseling receipt by time on past week physical activity (p = 0.008). Pre-intervention clients reporting physical activity counseling had 22% higher physical activity than those who did not; post-intervention clients reporting physical activity counseling had 47% higher physical activity. Conclusion: A wellness policy intervention was associated with increased nutrition counseling. Nutrition counseling predicted lower sugar-sweetened beverage consumption. Physical activity counseling predicted higher physical activity, an association that was greater post-intervention. Adding wellness components to tobacco-related interventions may promote health among SUD clients.

Adherence to Healthy Default Beverage Laws for Children's Meals in 3 U.S. Cities.

INTRODUCTION: Healthy default beverage laws are relatively new interventions designed to improve the healthfulness of children's meals in restaurants. In this study, researchers assessed adherence to healthy default beverage laws among children's meals ordered online in Los Angeles (California statewide law effective from September 2018), Baltimore (effective from April 2018), and New York City (effective from April 2019) compared with that in Boston, where no law existed. METHODS: Between November and December 2020, researchers ordered children's meals from online ordering platforms (e.g., GrubHub, Uber Eats) from the top-grossing restaurant chains in each location (n=337 meal orders from 106 restaurants), coded these meals using four successively stricter definitions of adherence to the default beverage laws in each respective jurisdiction, and then applied each law to data collected in Boston to simulate different policy scenarios in a city with no such law. The team analyzed these data in late 2021. RESULTS: Differences in adherence existed across jurisdictions, with 15% adherent in Los Angeles, 30% in Baltimore, and 43% in New York City, compared with 7%-30% in Boston, using the most lenient definition of adherence. Fewer than 3% of all meals adhered to laws when applying the strictest definition of adherence. CONCLUSIONS: Overall adherence was low and variable across jurisdictions. Adherence may be lower in jurisdictions with fewer allowable default beverages, although more research is needed to assess this potential causal relation. In addition to increased resources and support for restaurants, additional policy design considerations may be necessary to increase adherence to healthy default beverage laws.

The impact of SNAP-Ed interventions on California students' diet and physical activity during COVID-19.

OBJECTIVE: School-based CalFresh Healthy Living (CFHL) (California's SNAP-Ed) interventions adapted to new learning environments necessitated by COVID-19. We examined the impact of these interventions on student diet and physical activity (PA) outcomes. DESIGN: Quasi-experimental, two-group, pre-post. SETTING: California public schools with ≥50 % of students Free and Reduced Price Meal-eligible (nintervention = 47; ncomparison = 17). PARTICIPANTS: Fourth- and fifth-grade students who completed the online Eating and Activity Tool for Students at pre and post (nintervention = 1087; ncomparison = 846 students). RESULTS: Intervention students reported a significantly greater increase in consumption frequency of total fruit (by 0·16 times/d; P = 0·032), driven primarily by a greater increase in 100 % fruit juice (by 0·11 times/d; P = 0·007). Intervention students reported a significantly greater increase in total vegetable consumption frequency (by 0·45 times/d; P < 0·001) than comparison students. Specifically, intervention students reported increased, whereas comparison students reported decreased, consumption frequencies for starchy vegetables (0·05 v. -0·10 times/d, P < 0·001), salad/green vegetables (0·01 v. -0·11 times/d, P = 0·005) and beans (0·04 v. -0·03 times/d, P = 0·025). Consumption frequency of other vegetables decreased in both groups (-0·01 v. -0·09 times/d) but decreased more among comparison students (P = 0·048). No differences in pre-post change in PA outcomes were detected. CONCLUSIONS: Findings suggest that despite COVID-19-related challenges necessitating programme modifications, CFHL interventions played a role in protecting student consumption of fruit and vegetables during the 2020-2021 school year. Therefore, it appears that school-based CFHL interventions can be a viable means of safeguarding student nutrition at a time when access to nutritious food and PA opportunities are hindered.

Smoking Behavior and Wellness among Individuals in Substance Use Disorder Treatment.

Tobacco-related morbidity and mortality disproportionately affect people with substance use disorders (SUD). Encouraging overall wellness may support tobacco use cessation. We investigated relationships between wellness (health status, physical activity, sugar-sweetened beverage (SSB) consumption), cigarette smoking, and smoking cessation among SUD treatment patients to inform clinical care. Cross-sectional surveys were conducted with 395 patients in 20 California residential SUD programs. Using multivariate regression, we examined associations between smoking status and wellness. Among smokers, we examined associations between lifetime smoking exposure, cessation behaviors and attitudes, and wellness. Compared to nonsmokers (n = 121), smokers (n = 274) reported more SSB consumption, poorer physical health, and more respiratory symptoms. Among smokers, SSB consumption and respiratory symptoms increased per ten pack-years of smoking. Smokers with respiratory symptoms reported higher motivation to quit and more use of nicotine replacement therapy (NRT). Smokers with more days of poor mental health reported lower motivation to quit. Overall, cigarette smoking was associated with other health-risk behaviors among SUD treatment patients. Respiratory symptoms may increase, and poor mental health may decrease, SUD patients' intent to quit smoking. To reduce chronic disease risk among SUD patients, treatment programs should consider promoting overall wellness concurrently with smoking cessation.

School meal access and changes in meal participation during COVID-19 school closures: A stratified random sample of CalFresh Healthy Living Eligible school districts in California.

The National School Lunch and School Breakfast programs are a nutrition safety net for millions of children in the United States, particularly children in households with lower incomes. During Spring 2020 COVID-19 school closures, schools served school meals through the Summer Meal Programs. Despite efforts to increase access, meal participation declined and food insecurity increased. We aimed to (1) describe meal program features as communicated in low-income California school districts' on-line resources (2) examine associations between meal program features and change in meal participation between May 2019 and May 2020 and (3) evaluate equity by describing meal site coverage and placement relative to the size of priority populations. Data from district online resources and meal reimbursement claims were collected for a stratified, random sample of 190 CalFresh Healthy Living-eligible districts. Linear regression was used to examine associations between district meal program features and percent change in meal participation. Meal site location and density were examined in relation to the size of priority populations. In May 2020, compared to May 2019, total meals served decreased by a median 46%. There were gaps in the information provided in district online resources and low variation in measured district meal program features. These features explained little of the variation in the percent change in meal participation. A greater proportion of meal sites were placed in areas with larger priority populations, yet the density of sites was not proportionate to the priority populations' sizes. Findings show actionable areas for improving meal access during school closures.

Limited implementation of California's Healthy Default Beverage law for children's meals sold online.

OBJECTIVE: To reduce children's sugar-sweetened beverage intake, California's Healthy-By-Default Beverage law (SB1192) mandates only unflavoured dairy/non-dairy milk or water be the default drinks with restaurant children's meals. The objective of this study is to examine consistency with this law for meals sold through online platforms from restaurants in low-income California neighbourhoods. DESIGN: This observational, cross-sectional study examines beverage availability, upcharges (additional cost) and presentation of beverage options consistent with SB1192 (using four increasingly restrictive criteria) within a random sample of quick-service restaurants (QSR) in Supplemental Nutrition Assistance Program Education eligible census tracts selling children's meals online from November 2020 to April 2021. SETTING: Low-income California neighbourhoods (n 226 census tracts). PARTICIPANTS: QSR that sold children's meals online via a restaurant-specific platform, DoorDash, GrubHub and/or UberEats (n 631 observations from 254 QSR). RESULTS: Seventy percent of observations offered water; 63 % offered unflavoured milk. Among all beverages, water was most likely to have an upcharge; among observations offering water (n 445), 41 % had an upcharge (average $0·51). Among observations offering unflavoured milk (n 396), 11 % had an upcharge (average $0·38). No observations upcharged for soda (regular or diet). Implementation consistency with SB1192 ranged from 40·5 % (using the least restrictive criteria) to 5·6 % (most restrictive) of observations. CONCLUSIONS: Based on observations from restaurant websites and three of the most popular online ordering platforms, most California QSR located in low-income neighbourhoods are not offering children's meal beverages consistent with the state's Healthy-By-Default Beverage law. As the popularity of online ordering increases, further work to ensure restaurants offering healthy default beverages with children's meals sold online is necessary.

Restaurant kids' meal beverage offerings before and after implementation of healthy default beverage policy statewide in California compared with citywide in Wilmington, Delaware.

OBJECTIVE: In 2019, California and Wilmington, Delaware' implemented policies requiring healthier default beverages with restaurant kids' meals. The current study assessed restaurant beverage offerings and manager perceptions. DESIGN: Pre-post menu observations were conducted in California and Wilmington. Observations of cashiers/servers during orders were conducted pre-post implementation in California and post-implementation in Wilmington. Changes in California were compared using multilevel logistic regression and paired t tests. Post-implementation, managers were interviewed. SETTING: Inside and drive-through ordering venues in a sample of quick-service restaurants in low-income California communities and all restaurants in Wilmington subject to the policy, the month before and 7-12 months after policy implementation. PARTICIPANTS: Restaurant observations (California n 110; Wilmington n 14); managers (California n 75; Wilmington n 15). RESULTS: Pre-implementation, the most common kids' meal beverages on California menus were unflavoured milk and water (78·8 %, 52·0 %); in Wilmington, juice, milk and sugar-sweetened beverages were most common (81·8 %, 66·7 % and 46·2 %). Post-implementation, menus including only policy-consistent beverages significantly increased in California (9·7 % to 66·1 %, P < 0·0001), but remained constant in Wilmington (30·8 %). During orders, cashiers/servers offering only policy-consistent beverages significantly decreased post-implementation in California (5·0 % to 1·0 %, P = 0·002). Few managers (California 29·3 %; Wilmington 0 %) reported policy knowledge, although most expressed support. Most managers wanted additional information for customers and staff. CONCLUSIONS: While the proportion of menus offering only policy-consistent kids' meal default beverages increased in California, offerings did not change in Wilmington. In both jurisdictions, managers lacked policy knowledge, and few cashiers/servers offered only policy-consistent beverages. Additional efforts are needed to strengthen implementation of kids' meal beverage policies.

Validity and Reliability of a Site-Level Assessment Questionnaire to Assess Nutrition and Physical Activity Practices in Schools.

Background: Schools are an ideal setting for policy, systems, and environmental approaches to obesity prevention. Although school health environment assessments exist for planning purposes, we developed and tested a comprehensive questionnaire that is suitable for both evaluation and planning. Methods: Reliability was measured by comparing data collected by school personnel from low-income elementary schools across California at two time points, an average of 2 months apart (n = 23). To assess convergent validity, school responses were compared with the responses completed by the research team (n = 28). A weighted kappa test statistic and percent agreement were calculated for each question and specific groups of questions (questionnaire section, item topic, and response type). Results: Test/retest reliability of the questionnaire yielded kappa statistics that ranged from -0.14 to 1.00 (interquartile range [IQR] 0.36). Percent agreement for reliability ranged from 34.78 to 100.00 (IQR 21.7). Kappa statistics for validity ranged from -0.14 to 1.00 (IQR 0.44). Percent agreement for validity ranged from 14.29 to 100.00 (IQR 39.2). Based on these findings, the tool was revised. Conclusions: Study findings indicate that the Site-Level Assessment Questionnaire as tested is a reliable and accurate instrument for use in low-income elementary schools. Revisions may have improved the validity and reliability. We therefore recommend either version for use to support low-income schools in their efforts to assess needs, evaluate progress, and create action plans; and to supply high-quality, aggregable data for large-scale analysis. Additional testing is recommended to validate the revised version, increase generalizability, and determine sensitivity to detect change over time.

A Harvest of the Month Curriculum Increases Fruit and Vegetable Intake among 4th-6th Grade Students.

BACKGROUND: Most children do not eat enough fruits and vegetables (FV). Schools are a critical setting for supporting children to consume FV. To fill a gap in available materials, a classroom curriculum was developed and evaluated to determine impacts on student FV-related knowledge, attitudes, and behaviors. METHODS: A pre-/post-intervention survey was administered to 4th-6th grade students in 3 intervention and one comparison schools. Post-intervention student focus groups, parent/guardian surveys, and teacher surveys provided complementary information. RESULTS: Intervention students had a significantly greater increase in total FV intake, fruit intake, and 100% juice consumption, and preference for several types of FV relative to comparison group students. Students, teachers, and parents reported overall high levels of satisfaction with the curriculum. CONCLUSIONS: The Harvest of the Month curriculum is effective at increasing fruit intake among a low-income, diverse student population in grades 4-6, is acceptable to students, teachers, and parents, and is feasible to implement. Findings suggest this impact is the result of changes in preferences, skills, and motivation but not self-efficacy or perceived social norms. Some tailoring of the curriculum may be needed to increase its appropriateness for 6th-grade students, increase the impact on vegetable intake, and limit intake of juice.

Factor Analysis Reduces Complex Measures of Nutrition Environments in US Elementary and Middle Schools into Cohesive Dimensions in the Healthy Communities Study.

BACKGROUND: Although it has been recommended that schools be the hub of efforts to improve child nutrition, research describing school nutrition environments in US public schools and their associations with child health is limited. OBJECTIVE: This study aimed to evaluate the applicability of factor analysis methods to characterize school nutrition environments by identifying underlying factors, or dimensions, in the observed data and to examine the relation between school nutrition environment dimensions and child anthropometric and dietary outcomes. METHODS: This study examined a cross-sectional sample of 4635 US children aged 4-15 y from 386 US elementary and middle schools from the Healthy Communities Study (2013-2015). Data collected from schools were used to create 34 variables that assessed the school nutrition environment. To identify dimensions of school nutrition environments, exploratory factor analysis was conducted with orthogonal rotation, and factor scores were derived using methods to account for sporadic missing data. Mixed-effects regression models adjusted for child- and community-level variables and clustered by community and school examined the associations of school nutrition environment dimensions with child anthropometric and dietary outcomes. RESULTS: Six dimensions of school nutrition environments were derived: nutrition education, food options, wellness policies, dining environment, unhealthy food restriction, and nutrition programs. The unhealthy food restriction dimension was negatively associated with added sugar intake (ß = -1.13, P < 0.0001), and the wellness policies dimension was positively associated with waist circumference (ß = 0.57, P = 0.01). CONCLUSIONS: This study demonstrates how factor analysis can reduce multiple measures of complex school nutrition environments into conceptually cohesive dimensions for purposes of assessing the relation of these dimensions to student health-related outcomes. Findings were mixed and indicate that the restriction of unhealthy foods in school is associated with lower added sugar intake. Additional, longitudinal studies are needed to substantiate the utility of this method for identifying promising school nutrition environments.

Nutrition and behavioral health disorders: depression and anxiety.

Suboptimal nutrition has been implicated in the underlying pathology of behavioral health disorders and may impede treatment and recovery. Thus, optimizing nutritional status should be a treatment for these disorders and is likely important for prevention. The purpose of this narrative review is to describe the global burden and features of depression and anxiety, and summarize recent evidence regarding the role of diet and nutrition in the prevention and management of depression and anxiety. Current evidence suggests that healthy eating patterns that meet food-based dietary recommendations and nutrient requirements may assist in the prevention and treatment of depression and anxiety. Randomized controlled trials are needed to better understand how diet and nutrition-related biological mechanisms affect behavioral health disorders, to assist with the development of effective evidence-based nutrition interventions, to reduce the impact of these disorders, and promote well-being for affected individuals.

SNAP-Ed physical activity interventions in low-income schools are associated with greater cardiovascular fitness among 5th and 7th grade students in California.

INTRODUCTION: California's Department of Public Health (CDPH) distributes Supplemental Nutrition Assistance Program-Education (SNAP-Ed) funding, known as CalFresh Healthy Living (CFHL) in California, to local health departments to implement school-based physical activity/nutrition interventions. We determined the association between intervention presence/dose and student cardiorespiratory fitness and BMI. METHODS: This cross-sectional, observational study included 5th and 7th grade students with 2016-17 FitnessGram® results who attended SNAP-Ed eligible California schools. Intervention group students attended schools with CDPH-CFHL interventions during October 2015-September 2016 (n = 904 schools; 97,504 students, 49% female); comparison group students attended schools without CDPH-CFHL interventions (n = 3,506 schools; 372,298 students, 49% female). Adjusted multilevel models determined the association between school-level intervention presence/dose and students' cardiorespiratory fitness (estimated VO2max) and BMI z-score, and tested for effect modification by student grade and sex. RESULTS: Students attending intervention schools demonstrated greater VO2max (males: 0.18 mL/kg per min, 95% CI: 0.03, 0.34; females = 0.26 mL/kg per min, 95% CI: 0.13, 0.39) and lower BMI z-scores (males: -0.03, 95% CI: -0.05, -0.02; females = -0.02, 95% CI: -0.04, -0.01) than students in comparison schools. Students in schools with the highest intervention levels demonstrated higher VO2max (0.37 (95% CI: 0.06, 0.16) and 0.22 (95% CI: 0.02, 0.42), respectively), than comparison students, with the strongest associations seen for females and 7th graders. CONCLUSION: On average, students in schools with CDPH-CFHL physical activity interventions demonstrated better cardiorespiratory fitness and slightly lower BMI z-scores than students in comparable schools without such programing. Investment in these interventions may positively impact students' cardiorespiratory health, though further causal investigation is warranted.

Voluntary Kids' Meal Beverage Standards: Are They Sufficient to Ensure Healthier Restaurant Practices and Consumer Choices?

Many quick-service restaurants (QSRs) instituted voluntary kids' meal default beverage standards (standards) between 2013 to 2017. Little is known about impacts of standards on QSR drive-through practices and on customer choices. This study assessed differences in restaurant practices including kids' meal beverages shown on menu boards, offered by cashiers, and selected by customers in QSRs with and without voluntary standards. Observations (n = 111) and customer surveys (n = 84) were conducted in 2018 at QSRs with standards (n = 70) and without (n = 41) in low-income California, U.S. neighborhoods. Kids' meal beverages on menu boards (n = 149) and offered by cashiers (n = 185) at QSRs with and without standards were analyzed using multilevel logistic regression. Significantly more menu boards at QSRs with standards (n = 103) vs. without (n = 46) featured only milk, water or unsweetened juice (65.1% vs. 4.4%; p < 0.001). Most cashiers at QSRs with standards and QSRs without (53.1%, 62.5%) asked what drink the data collector wanted rather than first offering default beverages. A small sample of customer interviews found that customers at QSRs with standards most commonly ordered juice (37.0%); at QSRs without standards, soda (45.5%). Although menu boards showed healthier kids' meal beverages at QSRs with standards than without, cashier behavior was inconsistent. Results suggest additional measures (legislation, implementation support, enforcement) may be needed to ensure optimal implementation.

Post-Healthy, Hunger-Free Kids Act Adherence to Select School Nutrition Standards by Region and Poverty Level: The Healthy Communities Study.

OBJECTIVE: This study determined the extent to which schools adhered to select nutrition and wellness provisions of the 2010 Healthy, Hunger-Free Kids Act and examined differences by US region and school poverty level. DESIGN: Comparison of cross-sectional observational data from the Healthy Communities Study (2013-2015) by region and school poverty level. PARTICIPANTS: A total of 401 US elementary and middle schools. MAIN OUTCOME MEASURES: Adherence with federal nutrition standards for meals and competitive foods; extent of implementation of select aspects of school wellness policies. ANALYSIS: Descriptive statistics and multivariate regression were used. Differences were examined by school poverty level and region, adjusting for other school- and community-level covariates. RESULTS: Most schools reported meeting reimbursable school meal nutrition standards (74%); more schools in the West met nutrition standards (82%) than in the Midwest (64%). Most grains offered at lunch were whole grain-rich (82%), and most competitive foods complied with standards (78%) before they were required. Most schools had a wellness coordinator (80%). Lowest levels of adherence were reported for guidelines for classroom or school event foods. No differences were observed by school poverty level. CONCLUSIONS AND IMPLICATIONS: Findings suggest that Healthy Hunger-Free Kids Act provisions were feasible across a wide variety of schools, and schools successfully implemented reimbursable school meal nutrition standards regardless of school poverty level.

Access to credentialed elementary physical education teachers in California and students' cardiorespiratory fitness.

Physical education (PE) can improve student health. Schools with credentialed PE teachers receive more PE. However, many schools have reduced PE funding, resulting in fewer teachers and potentially poorer student health. We examined if PE teachers are equally available across school districts, and if availability is associated with higher student cardiorespiratory fitness. We contacted California districts educating students in grades K-6 (n = 894) to determine the number of credentialed elementary PE teachers per district in 2016-17. Public datasets provided demographics and student fitness. Generalized linear models examined associations between district-level demographic characteristics and PE teacher-to-student ratio. Linear regression assessed the relationship between PE teacher-to-student ratio and student fitness. Seventy-five percent of districts (n = 669) responded. On average, there were 0.6 PE teachers for every 500 students, including the half (51%) of districts without elementary PE teachers. Each additional100 students of all racial/ethnic backgrounds in the district was associated with a 0.1% (95% CI -0.2%, -0.1%) decrease in the ratio. Each 10% increase in African American and Latino students was associated with 29% (95% CI -47%, -5%) and 18% (95% CI -31%, -3%) decreases in the ratio, respectively. Each additional PE teacher per 500 students was associated with a 3% increase in aerobically fit students (95% CI 1%, 4%). Elementary PE teachers are lacking in California, particularly in districts with a high proportion of African American and Latino students, which may be contributing to health disparities. Creative action to fund PE should be explored to ensure all students benefit from quality PE.