Home-grown school feeding: promoting local production systems diversification through nutrition sensitive agriculture.

The consumption of some non-staple crops such as legumes and dark, green leafy vegetables can address common deficiencies in key nutrients such as vitamin A and iron; however, limited markets and supply chain development impede their production and accessibility to consumers. This study investigates the pathways to promote agricultural production and dietary diversity for a local market intervention called Home-Grown School Feeding (HGSF). School feeding menus from 24 districts across 10 regions in Ghana during the 2014-15 school year were analysed in terms of food groups and several individual foods. The menus were then compared with food groups produced by households during the past year or consumed in the past seven days using data collected from a household survey. Greater inter-food group diversity in the menus was associated with higher production levels for tubers and dark, leafy green vegetables in the South and cereals in the North. A correspondence between the frequency in which a food group appeared in a menu and the share of households who consumed foods from the food group was also noted. Key issues, such as optimizing supply chains, enabling farm linkages and supporting diverse nutrient rich food groups, that underlie the success of Home-Grown School Feeding and other agricultural policies with similar goals of promoting production and dietary diversity are highlighted through commodity specific examples. The findings of this study may help strengthen operational linkages between agriculture production and nutrition for HGSF and other similar interventions.

A free lunch or a walk back home? The school food environment and dietary behaviours among children and adolescents in Ghana.

Food environments can play an important roles in shaping nutrition and health outcomes. One such environment that has potential to affect youth is the school food environment. In contrast to higher-income countries, however, there is a critical evidence gap on the role of school food environments on children and adolescents in low- and middle-income countries. This mixed-methods study contributes to filling this gap by investigating the role of school food environments on dietary behaviours of children and adolescents in Ghana. It draws on data from household and school questionnaires as well as focus group discussions collected as part of the baseline for an impact evaluation of the Ghana School Feeding Programme (GSFP). Multi-level regression models were fitted with random intercepts at the individual, household and community levels. Excerpts from the focus group discussions provided a deeper understanding of quantitative findings. Children and adolescents who received free school meals provided by the GSFP or who lived further away from school were less likely to go home for lunch. More than half of sampled schools reported offering foods for sale by independent vendors, the most common being meals followed by confectionery, fruit and sugar-sweetened beverages. Predictors of bringing money to school to buy food included non-receipt of free school meals, adolescence, greater commuting distance from home, household asset score, and urban location. Policy efforts focusing on the school food environment may contribute to healthy dietary behaviours for children and adolescents with positive impacts over the lifecourse.

Enhancing Linkages Between Healthy Diets, Local Agriculture, and Sustainable Food Systems: The School Meals Planner Package in Ghana.

BACKGROUND: Interventions that enhance linkages between healthy diets and local agriculture can promote sustainable food systems. Home-grown school feeding programs present a promising entry point for such interventions, through the delivery of nutritious menus and meals. OBJECTIVE: To describe the adaptation of the School Meals Planner Package to the programmatic and environmental reality in Ghana during the 2014 to 2015 school year. METHODS: Guided by a conceptual framework highlighting key considerations and trade-offs in menu design, an open-source software was developed that could be easily understood by program implementers. Readily available containers from markets were calibrated into "handy measures" to support the provision of adequate quantities of food indicated by menus. Schools and communities were sensitized to the benefits of locally sourced, nutrient-rich diets. A behavior change communication campaign including posters and songs promoting healthy diets was designed and disseminated in schools and communities. RESULTS: The School Meals Planner Package was introduced in 42 districts in Ghana, reaching more than 320 000 children. Monitoring reports and feedback on its use were positive, demonstrating how the tool can be used by planners and implementers alike to deliver nutritious, locally-sourced meals to schoolchildren. The value of the tool has been recognized at the highest levels by Ghana's government who have adopted it as official policy. CONCLUSIONS: The School Meals Planner Package supported the design of nutritious, locally sourced menus for the school feeding program in Ghana. The tool can be similarly adapted for other countries to meet context-specific needs.

Evaluation of bias in estimates of early childhood obesity from parent-reported heights and weights.

OBJECTIVES: We evaluated bias in estimated obesity prevalence owing to error in parental reporting. We also evaluated bias mitigation through application of Centers for Disease Control and Prevention's biologically implausible value (BIV) cutoffs. METHODS: We simulated obesity prevalence of children aged 2 to 5 years in 2 panel surveys after counterfactually substituting parameters estimated from 1999-2008 National Health and Nutrition Examination Survey data for prevalence of extreme height and weight and for proportions obese in extreme height or weight categories. RESULTS: Heights reported below the first and fifth height-for-age percentiles explained between one half and two thirds, respectively, of total bias in obesity prevalence. Bias was reduced by one tenth when excluding cases with height-for-age and weight-for-age BIVs and by one fifth when excluding cases with body mass-index-for-age BIVs. Applying BIVs, however, resulted in incorrect exclusion of nonnegligible proportions of obese children. CONCLUSIONS: Correcting the reporting of children's heights in the first percentile alone may reduce overestimation of early childhood obesity prevalence in surveys with parental reporting by one half to two thirds. Excluding BIVs has limited effectiveness in mitigating this bias.

Parent-reported height and weight as sources of bias in survey estimates of childhood obesity.

Parental reporting of height and weight was evaluated for US children aged 2-13 years. The prevalence of obesity (defined as a body mass index value (calculated as weight (kg)/height (m)(2)) in the 95th percentile or higher) and its height and weight components were compared in child supplements of 2 nationally representative surveys: the 1996-2008 Children of the National Longitudinal Survey of Youth 1979 Cohort (NLSY79-Child) and the 1997 Child Development Supplement of the Panel Study of Income Dynamics (PSID-CDS). Sociodemographic differences in parent reporting error were analyzed. Error was largest for children aged 2-5 years. Underreporting of height, not overreporting of weight, generated a strong upward bias in obesity prevalence at those ages. Frequencies of parent-reported heights below the Centers for Disease Control and Prevention's (Atlanta, Georgia) first percentile were implausibly high at 16.5% (95% confidence interval (CI): 14.3, 19.0) in the NLSY79-Child and 20.6% (95% CI: 16.0, 26.3) in the PSID-CDS. They were highest among low-income children at 33.2% (95% CI: 22.4, 46.1) in the PSID-CDS and 26.2% (95% CI: 20.2, 33.2) in the NLSY79-Child. Bias in the reporting of obesity decreased with children's age and reversed direction at ages 12-13 years. Underreporting of weight increased with age, and underreporting of height decreased with age. We recommend caution to researchers who use parent-reported heights, especially for very young children, and offer practical solutions for survey data collection and research on child obesity.

A national evaluation of the impact of state policies on competitive foods in schools.

BACKGROUND: Since 2003, many states have introduced policies to improve the nutritional content and restrict the availability of competitive foods, which are foods offered outside of the National School Lunch and Breakfast Programs. This article evaluates the impact of 2 types of state-level policies on the availability of competitive foods in a national sample of schools. METHODS: Annual state-level data on limits, which restrict the time or venue of competitive foods sales, and standards, which regulate the nutrient content of competitive foods, was obtained from the Trust for America's Health and mapped to a national sample from the Early Childhood Longitudinal Study who were in fifth grade in 2004 and eighth grade in 2007. A logistic regression model with child fixed effects tested the association between policy enactments and changes in reported availability of competitive foods in schools. The analyses controlled for child and school characteristics. RESULTS: Nineteen states introduced a standard or a limit between 2004 and 2007. After adjusting for child and school characteristics, standards were associated with lower child-reported availability of soft drinks (16.5%, p < .001), low-nutrient snacks (22.0%, p < .05), and sweets (18.1%, p < .001). The impact of limits was not statistically significant. CONCLUSION: Standards introduced between 2004 and 2007 were associated with a decline in the availability of soft drinks, low-nutrient snacks, and sweets as reported by a national sample of children. School compliance with state competitive food policies may increase over time. Research on the impact of existing state policies could inform the development of a national policy to regulate competitive foods in schools.

Relationship of white potato to other vegetable consumption by schoolchildren and adolescents in the U.S.A: National Health and Nutrition Examination Survey, 2003-2008.

OBJECTIVE: Intake of white potatoes in and out of school was estimated to provide context for a recent proposal by the U.S. Department of Agriculture to limit provision of white potatoes in U.S. school meals. DESIGN: Mean daily servings of white potatoes and other vegetables consumed in and out of school for school-aged children were estimated from two days of 24 h dietary recall data from the National Health and Nutrition Examination Surveys (NHANES). Total energy intake and percentage energy contribution from discretionary oils and solid fats were also estimated for all white potato dishes consumed. SETTING: The NHANES is nationally representative of the U.S. civilian noninstitutionalized population. SUBJECTS: Children and adolescents aged 6­19 years (n 8466) from three combined NHANES cycles (2003­2004, 2005­2006 and 2007­2008). RESULTS: White potatoes represented 32% of all vegetable servings consumed by U.S. children and adolescents. Preparations high in fats and oils, including French fries, were most popular both in and out of school. Mean consumption of white potatoes obtained from school cafeterias was approximately 0.05 servings/d among all children and adolescents, and about 0.15 servings/d among children and adolescents acquiring at least one item from the school cafeteria, implying current weekly intake levels well below the limit of 2 servings/week proposed by the U.S. Department of Agriculture. CONCLUSIONS: Although white potatoes represent a substantial proportion of vegetable consumption among school-aged children, it is unclear that proposed limits would influence white potato intake from school cafeterias. Policy makers should consider targeting preparation methods to improve the healthfulness of white potato dishes.

Effect of the Supplemental Nutrition Assistance Program (SNAP) on frequency of beverage consumption among youth in the United States.

As the largest federal food assistance program, the Supplemental Nutrition Assistance Program (SNAP) has potential to improve food choices among low-income populations. The program's impact on youth is important because they are represented in more than half of all SNAP households. This study estimates the impact of participation in SNAP, also known as the Food Stamp Program, on the frequency of soft drink, 100% fruit juice, and milk consumption among youth (ages 11 through 14) in the United States. A cohort of 3,126 youth from the Early Childhood Longitudinal Survey who were surveyed in 2004 (5th grade) and 2007 (8th grade) were used for the analysis. Multivariate linear regression with individual fixed effects was conducted to estimate the effect of SNAP participation on the frequency of consumption of each beverage type in the preceding week. The fixed effects controlled for factors specific to the youth, such as sex, race/ethnicity, and time-invariant bias in reporting SNAP participation or beverage consumption. Overall participation in SNAP increased from 19.5% to 20.3% between 2004 and 2007, with 14.4% reporting a different participation status in 2007 as compared with 2004. SNAP participation was not found to be predictive of the frequency of soft drink, 100% fruit juice, or milk consumption among youth. In its current state, SNAP may serve to replace lost income for qualifying households, but not alter their food and beverage choices. Interventions that support access to and incentivize the consumption of more healthful foods and beverages may be successful in improving the nutritional quality of intake.

The Women's Health Initiative: The food environment, neighborhood socioeconomic status, BMI, and blood pressure.

Using data (n = 60,775 women) from the Women's Health Initiative Clinical Trial (WHI CT)-a national study of postmenopausal women aged 50-79 years-we analyzed cross-sectional associations between the availability of different types of food outlets in the 1.5 miles surrounding a woman's residence, census tract neighborhood socioeconomic status (NSES), BMI, and blood pressure (BP). We simultaneously modeled NSES and food outlets using linear and logistic regression models, adjusting for multiple sociodemographic factors, population density and random effects at the tract and metropolitan statistical area (MSA) level. We found significant associations between NSES, availability of food outlets and individual-level measurements of BMI and BP. As grocery store/supermarket availability increased from the 10th to the 90th percentile of its distribution, controlling for confounders, BMI was lower by 0.30 kg/m(2). Conversely, as fast-food outlet availability increased from the 10th to the 90th percentile, BMI was higher by 0.28 kg/m(2). When NSES increased from the 10th to the 90th percentile of its distribution, BMI was lower by 1.26 kg/m(2). As NSES increased from the 10th to the 90th percentile, systolic and diastolic BP were lower by 1.11 mm Hg and 0.40 mm Hg, respectively. As grocery store/supermarket outlet availability increased from the 10th and 90th percentiles, diastolic BP was lower by 0.31 mm Hg. In this national sample of postmenopausal women, we found important independent associations between the food and socioeconomic environments and BMI and BP. These findings suggest that changes in the neighborhood environment may contribute to efforts to control obesity and hypertension.

The role of school physical activity programs in child body mass trajectory.

BACKGROUND: Physical activity at school can support obesity prevention among youth. This paper assesses the role of existing school physical activity programs for a national cohort from first grade to fifth grade. METHODS: We analyzed a cohort from the Early Childhood Longitudinal Survey-Kindergarten Cohort which included 8246 children in 970 schools across the country. Growth curve models estimate the effect of physical education (PE) and recess on individual child body mass trajectories controlling for child and school characteristics. Hierarchical models allow for unobserved school and child effects. RESULTS: Among first graders, 7.0% met the National Association of Sport and Physical Education (NASPE) recommended time for PE and 70.7% met the recommended time for recess in the previous week. Boys experienced a greater increase in body mass than girls. Meeting the NASPE recommended time for recess was associated with a 0.74 unit decrease in BMI (body mass index) percentile for children overall. Meeting the NASPE recommendation for physical education was associated with 1.56 unit decrease in BMI percentile among boys but not girls. CONCLUSIONS: We find evidence that meeting the national recommendations for PE and recess is effective in mitigating body mass increase among children.

Facility provision in elementary schools: correlates with physical education, recess, and obesity.

OBJECTIVES: The objectives were to: (1) document correlations among facility provision (availability and adequacy) in elementary schools, child sociodemographic factors, and school characteristics nationwide; and (2) investigate whether facility provision is associated with physical education (PE) time, recess time, and obesity trajectory. METHODS: The analytic sample included 8935 fifth graders from the Early Childhood Longitudinal Survey Kindergarten Cohort. School teachers and administrators were surveyed about facility provision, PE, and recess time in April 2004. Multivariate linear and logistic regressions that accounted for the nesting of children within schools were used. RESULTS: Children from disadvantaged backgrounds were more likely to attend a school with worse gymnasium and playground provision. Gymnasium availability was associated with an additional 8.3 min overall and at least an additional 25 min of PE per week for schools in humid climate zones. These figures represent 10.8 and 32.5%, respectively, of the average time spent in PE. No significant findings were obtained for gymnasium and playground adequacy in relation to PE and recess time, and facility provision in relation to obesity trajectory. CONCLUSIONS: Poor facility provision is a potential barrier for school physical activity programs and facility provision is lower in schools that most need them: urban, high minority, and high enrollment schools.

The effect of soft drink availability in elementary schools on consumption.

OBJECTIVE: To quantify the association among soft drink availability, school-based purchases, and overall consumption for elementary school children in the United States. DESIGN: The study is a cross-sectional, descriptive analysis of children in fifth grade across the United States. Measures of soft drink availability, purchases, and consumption are reported by the child in direct assessments by interviewers. SUBJECTS/SETTING: Subjects in the analysis are from the Early Childhood Longitudinal Survey-Kindergarten Cohort. The baseline sample from this survey is nationally representative of kindergarten students in the 1998-1999 school year. The analytic sample obtained from the sixth wave includes 10,215 children in fifth grade in 2,303 schools across 40 states. MAIN OUTCOME MEASURES: Consumption of any soft drink in the past week, purchase of any soft drink at school in the past week, overall consumption of soft drinks in the past week, overall purchases of soft drinks at school in the past week, and share of all consumption that was school-based. STATISTICAL ANALYSES PERFORMED: chi(2) square tests and t tests were conducted to determine significant differences across sociodemographic groups. Multivariate logistic regressions were conducted to estimate the effect of availability on the odds of any soft drink consumption and overall consumption level. RESULTS: In this study, 26% of children who have access to soft drinks at school consume them. Those who consume more soft drinks at school, such as low-income and black non-Hispanic children, are more likely to consume more soft drinks overall. Controlling for covariates, limiting availability of soft drinks at school is associated with a 4% decrease (odds ratio 1.38) in the rate of any consumption overall. CONCLUSIONS: These findings suggest that soft drink availability at school may have limited impact on overall consumption for elementary school children. Further research about predictors of consumption, how children respond to reduced availability, as well as food environments at home and at school, may identify next steps toward improving the diets of children.