A natural experiment to assess recess frequency on children's physical activity in Arizona (U.S.) elementary schools.

BACKGROUND: In the United States, the number of state policies mandating recess in schools has rapidly increased over the past decade; however, few policies specify recess frequency. Informed by an ecological model of physical activity (PA) policy, this study examined and compared total amounts and intensity of PA expended during recess among children attending schools in compliance with Arizona recess policy ARS§ 15-118 mandating 2 + daily recess periods versus not. METHODS: PA during recess was measured among grade three children (ages 8-10) in four randomly selected elementary schools (two complying averaging 30 daily recess minutes; two non-complying averaging 15 daily recess minutes) in Maricopa County, Arizona. Group-level PA was assessed by direct observation using the System for Observing Play and Leisure (137 observations). A subset of students (N = 134) from all schools wore ActiGraph GT3X + devices during recess to measure individual PA. General linear mixed effects models were used to analyze the impact of recess frequency on group and individual PA during recess. RESULTS: Students attending complying schools spent significantly greater proportions of time in moderate-to-vigorous PA (MVPA) based on direct observation (5%) and accelerometry (15%) and less time being sedentary based on accelerometry (14%) during recess. Across the school day, this would equate to 5.1 more MVPA minutes based on systematic direct observation and 9.5 more MVPA minutes based on accelerometry, and 4.1 less minutes being sedentary based on accelerometry if students received two daily 15-minute recess periods compared to one. CONCLUSIONS: Students attending elementary schools implementing 2 + recesses, in accordance with state policy, demonstrated greater MVPA and less sedentary time, providing preliminary evidence that recess frequency is associated with greater PA intensity among children during recess. Schools that adhere to state-level PA policies may provide a more supportive environment for PA, resulting in increased movement among students. Specifying recess frequency should be considered in statewide recess policy.

The association between unhealthy dietary behaviors and participation in the Supplemental Nutrition Assistance Program (SNAP): No evidence in support of the self-selection hypothesis.

Supplemental Nutrition Assistance Program (SNAP) participants tend to have unhealthier dietary consumption compared to eligible non-participants. It has been suggested, though never empirically tested, that individuals who enroll in SNAP may have unhealthy diets prior to program participation. Using a longitudinal cohort study design, we examined the association between low-income adults' SNAP participation status and prior dietary behaviors to test the argument that individuals with unhealthier dietary consumption self-select into SNAP. A sample of households from predominantly lower-income cities were surveyed at baseline (T1) and 2-4 years later (T2). The main analyses were restricted to adults who did not participate in SNAP at T1 and with household income <200% of the federal poverty line (n = 170) at both T1 and T2. Participants were grouped into two categories, based on their SNAP participation at T2; (a) Non-participants (n = 132): no SNAP participation at T1 or T2, and (b) T2 SNAP participants (n = 38): SNAP participation at T2 but not T1. Daily consumption frequency of whole fruits, fruit juice, vegetables, sugar-sweetened beverages (SSBs), and energy dense snacks were measured through self-reports. To observe dietary differences between the two groups prior to SNAP participation, T1 behaviors were compared. There were no significant differences in dietary behaviors at T1 (prior to SNAP participation) between non-participants and T2 participants, providing no evidence of self-selection of individuals with unhealthier dietary consumption into SNAP among our study sample. Improvements in SNAP participants' diets may benefit from focusing on policy changes that encourage healthy dietary habits during participation in the program.

Food Environments Within and Outside of Schools Play a Critical Role in Curtailing the Rise in Obesity among School-Aged Children over Time.

BACKGROUND: Sound evidence for effective community-based strategies is needed to curtail upward trends in childhood obesity in the United States (US). OBJECTIVES: The aim of the study was to assess the association between school and community food environments and the prevalence of obesity over time. METHODS: Data were collected from K-12 schools in 4 low-income New Jersey cities in the US. School-level obesity prevalence, calculated from nurse-measured heights and weights at 4 time points, was used as the outcome variable. Data on the school food environment (SFE) measured the healthfulness of school lunch and competitive food offerings annually. The community food environment (CFE), i.e., the number of different types of food outlets within 400 m of schools, was also captured annually. The count and presence of food outlets likely to be frequented by students were calculated. Exposure to composite environment profiles both within schools and in communities around schools was assessed using latent class analysis. Data from 106 schools were analyzed using multilevel linear regression. RESULTS: The prevalence of obesity increased from 25% to 29% over the course of the study. Obesity rates were higher in schools that had nearby access to a greater number of limited-service restaurants and lower in schools with access to small grocery stores and upgraded convenience stores participating in initiatives to improve healthful offerings. Interaction analysis showed that schools that offered unhealthier, competitive foods experienced a faster increase in obesity rates over time. Examining composite food environment exposures, schools with unhealthy SFEs and high-density CFEs experienced a steeper time trend (ß = 0.018, P < 0.001) in obesity prevalence compared to schools exposed to healthy SFE and low-density CFEs. CONCLUSIONS: Food environments within and outside of schools are associated with differential obesity trajectories over time and can play an important role in curtailing the rising trends in childhood obesity.

The relationship between changes in neighborhood physical environment and changes in physical activity among children: a prospective cohort study.

BACKGROUND: Physical activity (PA) is associated with positive health outcomes over the entire life course. Many community-based interventions that promote PA focus on implementing incremental changes to existing facilities and infrastructure. The objective of this study was to determine if such upgrades were associated with increases in children's PA. METHODS: Two cohorts of 3- to 15-year-old children (n = 599) living in 4 low-income New Jersey cities were followed during 2- to 5-year periods from 2009 to 2017. Data on children's PA were collected at 2 time points (T1 and T2) from each cohort using telephone survey of parents; data on changes to existing PA facilities were collected yearly from 2009 to 2017 using Open Public Records Act requests, publicly available data sources, and interviews with key stakeholders. PA changes were categorized into six domains (PA facility, park, trail, complete street, sidewalk, or bike lane) and coded as new opportunity, renovated opportunity, or amenity. A scale variable capturing all street-related upgrades (complete street, sidewalk, and bike lane) was constructed. PA was measured as the number of days per week the child engaged in at least 60 min of PA. The association between change in PA between T1 and T2, ranging from - 7 to + 7, and changes to the PA environment was modeled using weighted linear regression controlling for PA at T1, child age, sex, race, as well as household and neighborhood demographic and socioeconomic characteristics. RESULTS: While most measures of the changes to the PA environment were not associated with change in PA between T1 and T2, the street-related upgrades were positively associated with the change in PA; specifically, for each additional standard deviation in street upgrades within a 1-mile radius of their homes, the change in PA was 0.42 (95% CI: 0.02, 0.82; p = 0.039) additional days. This corresponds to an 11% increase over the mean baseline value (3.8 days). CONCLUSIONS: The current study supports funding of projects aimed at improving streets and sidewalks in cities, as it was shown that incremental improvements to the PA environment near children's homes will likely result in increased PA among children.

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.

Determinants of tap water mistrust among Phoenix, Arizona Latinx adults.

The purpose of this investigation was to characterize factors that predict tap water mistrust among Phoenix, Arizona Latinx adults. Participants (n = 492, 28 ± 7 years, 37.4% female) completed water security experience-based scales and an Adapted Survey of Water Issues in Arizona. Binary logistic regression determined odds ratios (OR) with 95% confidence intervals (95% CI) for the odds of perceiving tap water to be unsafe. Of all participants, 51.2% perceived their tap water to be unsafe. The odds of mistrusting tap water were significantly greater for each additional favorable perception of bottled compared to tap water (e.g., tastes/smells better; OR = 1.94, 95% CI = 1.50, 2.50), negative home tap water experience (e.g., hard water mineral deposits and rusty color; OR = 1.32, 95% CI = 1.12, 1.56), use of alternatives to home tap water (OR = 1.25, 95% CI = 1.04, 1.51), and with decreased water quality and acceptability (OR = 1.21, 95% CI = 1.01, 1.45; P < 0.05). The odds of mistrusting tap water were significantly lower for those whose primary source of drinking water is the public supply (municipal) (OR = 0.07, 95% CI = 0.01, 0.63) and with decreased water access (OR = 0.56, 95% CI = 0.48, 0.66; P < 0.05). Latinx mistrust of tap water appears to be associated with organoleptic perceptions and reliance on alternatives to the home drinking water system.

Differential Associations Between Changes in Food Environment and Changes in BMI Among Adults Living in Urban, Low-Income Communities.

BACKGROUND: Food environments can contribute to excess weight gain among adults, but the evidence is mixed. OBJECTIVES: This longitudinal study investigated the associations between changes in the food environment and changes in BMI in adults and whether changes in the food environment differentially impact various subgroups. METHODS: At 2 time points, BMI was calculated using self-reported height and weight data from 517 adults (mean age, 41 years) living in 4 New Jersey cities. The counts of different types of food outlets within 0.4, 0.8, and 1.6 km of respondents' residences were collected at baseline and tracked until follow-up. A binary measure of social standing (social-advantage group, n = 219; social-disadvantage group, n = 298) was created through a latent class analysis using social, economic, and demographic variables. Multivariable linear regression modeled the associations between changes in BMI with measures of the food environment; additionally, interaction terms between the measures of food environment and social standing were examined. RESULTS: Overall, over 18 months, an increase in the number of small grocery stores within 0.4 km of a respondent's residence was associated with a decrease in BMI (ß = -1.0; 95% CI: -1.9, -0.1; P = 0.024), while an increase in the number of fast-food restaurants within 1.6 km was associated with an increase in BMI (ß = 0.1; 95% CI: 0.01, 0.2; P = 0.027). These overall findings, however, masked some group-specific associations. Interaction analyses suggested that associations between changes in the food environment and changes in BMI varied by social standing. For instance, the association between changes in fast-food restaurants and changes in BMI was only observed in the social-disadvantage group (ß = 0.1; 95% CI: 0.02, 0.2; P = 0.021). CONCLUSIONS: In a sample of adults living in New Jersey, changes in the food environment had differential effects on individuals' BMIs, based on their social standing.

Availability, variety and distribution of healthy and unhealthy foods and beverages sold at street food stands in Mexico City.

OBJECTIVE: To examine differences in the availability, variety and distribution of foods and beverages sold at street food stands (SFS) across neighbourhood income levels in Mexico City. DESIGN: Cross-sectional. SETTING: Twenty neighbourhoods representing low-, middle- and high-income levels in Mexico City. PARTICIPANTS: Direct observations of SFS (n 391). RESULTS: The availability of healthy foods such as fruits/vegetables was high in middle- and high-income neighbourhoods, whereas the availability of unhealthy foods such as processed snacks was higher in low-income neighbourhoods. However, statistically significant differences in food availability across neighbourhoods were only observed for dairy and processed snack items (P < 0·05). Similarly, differences in variety were only observed for cereal and processed snacks (P < 0·05). No statistically significant differences were seen for variety of fruits/vegetable across neighbourhood income levels (P > 0·05). No statistically significant differences across neighbourhood income levels were observed for beverage availability and variety (P > 0·05). Although street foods and beverages were often distributed near homes, public transportation centres and worksites, no differences were observed across neighbourhood income levels (P > 0·05). CONCLUSIONS: Findings suggest that SFS can be a source of both unhealthy foods and healthy foods for communities across neighbourhoods in Mexico City. Additional studies are needed to assess the relationship between street food and beverage availability, and consumption.

Psychometric properties of the Food Environment Assessment Survey Tool (FEAST) in people with mobility impairment.

OBJECTIVE: Approximately one in ten adults under the age of 65 in the USA has a mobility impairing disability. People with mobility impairment generally have poorer dietary habits contributing to obesity and related negative health outcomes. This article presents the psychometric properties of the Food Environment Assessment Survey Tool (FEAST) instrument that measures barriers to accessing healthy food from the perspective of people with mobility impairment (PMI). DESIGN: The current study presents cross-sectional data from two sequential independent surveys. SETTING: Surveys were administered online to a national sample of PMI. PARTICIPANTS: Participants represented PMI living throughout the USA. The pilot FEAST survey involved 681 participants and was used to shape the final instrument; 25 % completed a retest survey. After following empirically and theoretically guided item reduction strategies, the final FEAST instrument was administered to a separate sample of 304 PMI. RESULTS: The final twenty-seven-item FEAST instrument includes items measuring Neighbourhood Environment, Home Environment, Personal Control and Access to Support (Having Help, Food Delivery Services, Parking/Transportation). The final four scales had acceptable intra-class correlations, indicating that the scales could be used as reliable measures of the hypothesised constructs in future studies. CONCLUSIONS: The FEAST instrument is the first of its kind developed to assess the food environment from the perspective of PMI themselves. Future studies would benefit from using this measure in research and practice to help guide the development of policy aimed at improving access to healthy food and promoting healthy eating in community-dwelling PMI.

Predicted Impact of the Food and Drug Administration's Menu-Labeling Regulations on Restaurants in 4 New Jersey Cities.

OBJECTIVES: To determine the proportion of restaurants that will be required to post calorie information under the Food and Drug Administration's menu-labeling regulations in 4 New Jersey cities. METHODS: We classified geocoded 2014 data on 1753 restaurant outlets in accordance with the Food and Drug Administration's guidelines, which will require restaurants with 20 or more locations nationwide to post calorie information. We used multivariate logistic regression analyses to assess the association between menu-labeling requirements and census tract characteristics. RESULTS: Only 17.6% of restaurants will be affected by menu labeling; restaurants in higher-income tracts have higher odds than do restaurants in lower-income tracts (odds ratio [OR] = 1.55; P = .02). Restaurants in non-Hispanic Black (OR = 1.62; P = .02) and mixed race/ethnicity (OR = 1.44; P = .05) tracts have higher odds than do restaurants in non-Hispanic White tracts of being affected. CONCLUSIONS: Additional strategies are needed to help consumers make healthy choices at restaurants not affected by the menu-labeling law. These findings have implications for designing implementation strategies for the law and for evaluating its impact.

Impact of the 2010 US Healthy, Hunger-Free Kids Act on School Breakfast and Lunch Participation Rates Between 2008 and 2015.

OBJECTIVES: To evaluate National School Lunch Program (NSLP) and School Breakfast Program (SBP) participation over a 7-year period before and after the implementation of the 2010 Healthy, Hunger-Free Kids Act (HHFKA), which required healthier school lunch options beginning in school year (SY) 2012-2013 and healthier school breakfast options beginning in SY2013-2014. METHODS: Data were gathered from low-income, high-minority public schools in 4 New Jersey cities. We conducted longitudinal analyses of annual average daily participation (ADP) in school meals among enrolled students overall and among those eligible for free or reduced-price meals. We used linear mixed models to compare NSLP and SBP participation rates from SY2008-2009 to SY2014-2015. RESULTS: NSLP participation rates among students overall differed little across years (from 70% to 72%). SBP rates among enrolled students were stable from the beginning of the study period to SY2013-2014 and then increased from 52% to 59%. Among students eligible for free or reduced-price meals, the ADP was lowest in SY2012-2013 (when the HHFKA was implemented) before rebounding. CONCLUSIONS: The HHFKA did not have a negative impact on school meal participation over time. Public Health Implications. The HHFKA-strengthened nutrition standards have not affected school meal participation rates. With time, students are likely to accept healthier options.

The Association among Emotions and Food Choices in First-Year College Students Using mobile-Ecological Momentary Assessments.

BACKGROUND: Studies have examined the associations between emotions and overeating but have only rarely considered associations between emotions and specific food choices. The purpose of this secondary data analysis was to use mobile ecological momentary assessments (mEMAs) to examine associations between emotions and food choices among first-year college students living in residence halls. METHODS: Using an intensive repeated-measures design, mEMAs were used to assess concurrent emotions and food choices in a racially/ethnically diverse sample of first-year college students (n = 663). Emotions were categorized as negative (sad, stressed, tired), positive (happy, energized, relaxed), and apathetic (bored, meh). Assessments were completed multiple times per day on four quasi-randomly selected days (three random weekdays and one random weekend day) during a 7-day period using random prompt times. Generalized estimating equations (GEE) were used to examine between- and within-person associations of emotional status with a variety of healthy and unhealthy food choices (sweets, salty snacks/fried foods, fruits/vegetables, pizza/fast food, sandwiches/wraps, meats/proteins, pasta/rice, cereals), adjusting for gender, day of week, and time of day, accounting for within-person dependencies among repeated measurements of eating behavior. RESULTS: At the between-person level, participants who reported positive emotions more frequently compared to others consumed meats/proteins more often (OR = 1.8; 99% CI = 1.2, 2.8). At the within-person level, on occasions when any negative emotion was reported (versus no negative emotion reported) participants were more likely to consume meats/proteins (OR = 1.5, 99% CI = 1.0, 2.1); on occasions when any positive emotion was reported as compared to occasions with no positive emotions, participants were more likely to consume sweets (OR = 1.7, 99% CI = 1.1, 2.6), but less likely to consume pizza/fast food (OR = 0.6, 99% CI = 0.4, 1.0). CONCLUSIONS: Negative and positive emotions were significantly associated with food choices. mEMA methodology provides a unique opportunity to examine these associations within and between people, providing insights for individual and population-level interventions. These findings can be used to guide future longitudinal studies and to develop and test interventions that encourage healthy food choices among first-year college students and ultimately reduce the risk of weight gain.

Predictors of Farmers' Market Shopping among People Receiving Supplemental Nutrition Assistance Program Benefits.

Promoting use of farmers' markets (FMs) is a promising community-level strategy to increase access to nutritious foods such as fruits and vegetables. Yet, FM shopping among people with Supplemental Nutrition Assistance Program (SNAP) benefits remains low. This research examined predictors of FM shopping among SNAP recipients living within 1 mile of a FM. A cross-sectional survey of SNAP participants (N = 270) was conducted in 2015 in Cleveland and East Cleveland, OH, USA. Multinomial regression and zero-truncated Poisson regression analyses were conducted to examine factors associated with FM shopping. Results indicate 48% reported shopping at a FM at least once in the past year, 26% had shopped at a FM before, but not in the last year, and 26% had never shopped at a FM. The multivariable analyses found awareness of FMs and a healthy food incentive program, and four dimensions of healthy food access are significantly associated with FM shopping among SNAP recipients. The food access dimensions included service delivery, spatial-temporal, personal, and social access. Findings highlight modifiable leverage points for improving the reach of FMs among low-income populations.

Eating behaviors among low-income obese adults in the United States: Does health care provider's advice carry any weight.

The U.S. Preventive Task Force recommends that all patients be screened for obesity and given appropriate weight loss advice, if needed, as nutrition counseling by primary care physicians is a key objective for Healthy People 2020. This study assesses the association between health care provider's (HCP) advice to lose weight and eating behaviors among obese individuals. Data were collected using a household survey of adults in five New Jersey cities in 2009-10. Analyses presented are limited to 548 obese participants. Negative-binomial regression analysis determined the association of participants' eating behaviors and HCP's advice to lose weight, after adjusting for the participant's attempt to lose weight and demographic variables. Despite being obese, only 48% of the participants received weight loss advice from their HCP while 68% stated they were attempting to lose weight. HCP's advice to lose weight was associated with increased salad and fruit consumption (PR 1.3, 95% CI 1.06-1.61; PR 1.23, 95% CI 1.02-1.48). Attempting to lose weight was positively associated with a higher consumption of fruit (PR 1.39, 95% CI 1.13-1.72), vegetables (PR 1.22, 95% CI 1.07-1.39), and with eating fruits and vegetables as snacks (PR 1.62, 95% CI 1.28-2.05). Attempting to lose weight was negatively associated with consumption of sweet snacks (PR 0.68, 95% CI 0.49-0.94), sugar sweetened beverages (PR 0.71, 95% CI 0.58-0.87) and fast food (PR 0.77, 95% CI 0.62-0.97). There were no significant interactions between HCP's advice and attempts to lose weight. Obese adult's attempt to lose weight, and not HCP's advice to lose weight, was a predictor for healthy eating behaviors. Interventions in medical practices should train HCPs on effective strategies for motivating obese patients to adopt healthier lifestyles.

Longitudinal social networks impacts on weight and weight-related behaviors assessed using mobile-based ecological momentary assessments: Study Protocols for the SPARC study.

BACKGROUND: The transition from the home to college is a phase in which emerging adults shift toward more unhealthy eating and physical activity patterns, higher body mass indices, thus increasing risk of overweight/obesity. Currently, little is understood about how changing friendship networks shape weight gain behaviors. This paper describes the recruitment, data collection, and data analytic protocols for the SPARC (Social impact of Physical Activity and nutRition in College) study, a longitudinal examination of the mechanisms by which friends and friendship networks influence nutrition and physical activity behaviors and weight gain in the transition to college life. METHODS: The SPARC study aims to follow 1450 university freshmen from a large university over an academic year, collecting data on multiple aspects of friends and friendship networks. Integrating multiple types of data related to student lives, ecological momentary assessments (EMAs) are administered via a cell phone application, devilSPARC. EMAs collected in four 1-week periods (a total of 4 EMA waves) are integrated with linked data from web-based surveys and anthropometric measurements conducted at four times points (for a total of eight data collection periods including EMAs, separated by ~1 month). University databases will provide student card data, allowing integration of both time-dated data on food purchasing, use of physical activity venues, and geographical information system (GIS) locations of these activities relative to other students in their social networks. DISCUSSION: Findings are intended to guide the development of more effective interventions to enhance behaviors among college students that protect against weight gain during college.

Disparities in Who Receives Weight-Loss Advice From a Health Care Provider: Does Income Make a Difference?

INTRODUCTION: The US Preventive Services Task Force recommends that all patients be screened for obesity and, if needed, be provided weight-loss advice. However, the prevalence of such advice is low and varies by patient demographics. This study aimed to describe the determinants of receiving weight-loss advice among a sample with a high proportion of low-income, racial/ethnic minority individuals. METHODS: Data were collected from a telephone survey of 1,708 households in 2009 and 2010 in 5 cities in New Jersey. Analyses were limited to 1,109 overweight or obese adults. Multivariate logistic regression determined the association of participants' characteristics with receiving weight-loss advice from their health care provider. Two models were used to determine differences by income and insurance status. RESULTS: Of all overweight or obese respondents, 35% reported receiving advice to lose weight. Receiving advice was significantly associated with income in multivariate analysis. Compared with those with an income at or below 100% of the federal poverty level (FPL), those within 200% to 399% of the FPL had 1.60 higher odds of receiving advice (P = .02), and those with an income of 400% or more of the FPL had 1.73 higher odds of receiving advice (P = .03). The strength of the association did not change after adjusting for health insurance. CONCLUSION: Income is a significant predictor of whether or not overweight or obese adults receive weight-loss advice after adjustment for demographic variables, health status, and insurance status. Further work is needed to examine why disparities exist in who receives weight-loss advice. Health care providers should provide weight-loss advice to all patients, regardless of income.

Improvements and Disparities in Types of Foods and Milk Beverages Offered in Elementary School Lunches, 2006-2007 to 2013-2014.

INTRODUCTION: Children consume much of their daily energy intake at school. School district policies, state laws, and national policies, such as revisions to the US Department of Agriculture's school meals standards, may affect the types of foods and beverages offered in school lunches over time. METHODS: This study evaluated changes and disparities in school lunch characteristics from 2006-2007 to 2013-2014. Data were obtained from annual cross-sectional surveys at 4,630 public elementary schools participating in the National School Lunch Program. Multivariate logistic regressions were conducted to examine lunch characteristics. RESULTS: The percentage of schools regularly offering healthful items such as vegetables (other than potatoes), fresh fruit, salad bars, whole grains, and more healthful pizzas increased significantly from 2006-2007 to 2013-2014, and the percentage of schools offering less healthful items such as fried potatoes, regular pizza, and high-fat milks decreased significantly. Nevertheless, disparities were evident in 2013-2014. Schools in the West were significantly more likely to offer salad bars than were schools in the Northeast, Midwest, or South (adjusted prevalence: West, 66.3%; Northeast, 22.3%; Midwest, 20.8%; South, 18.3%). Majority-black or majority-Latino schools were significantly less likely to offer fresh fruit than were predominantly white schools (adjusted prevalence: majority black, 61.3%; majority Latino, 73.0%; predominantly white, 87.8%). Schools with low socioeconomic status were significantly less likely to offer salads regularly than were schools with middle or high socioeconomic status (adjusted prevalence: low, 38.5%; middle, 47.4%; high, 59.3%). CONCLUSION: Much progress has been made in improving the quality of school lunches in US public elementary schools, but additional opportunities for improvement remain.

The relative contribution of layers of the Social Ecological Model to childhood obesity.

OBJECTIVE: The Social Ecological Model (SEM) has been used to describe the aetiology of childhood obesity and to develop a framework for prevention. The current paper applies the SEM to data collected at multiple levels, representing different layers of the SEM, and examines the unique and relative contribution of each layer to children's weight status. DESIGN: Cross-sectional survey of randomly selected households with children living in low-income diverse communities. SETTING: A telephone survey conducted in 2009-2010 collected information on parental perceptions of their neighbourhoods, and household, parent and child demographic characteristics. Parents provided measured height and weight data for their children. Geocoded data were used to calculate proximity of a child's residence to food and physical activity outlets. SUBJECTS: Analysis based on 560 children whose parents participated in the survey and provided measured heights and weights. RESULTS: Multiple logistic regression models were estimated to determine the joint contribution of elements within each layer of the SEM as well as the relative contribution of each layer. Layers of the SEM representing parental perceptions of their neighbourhoods, parent demographics and neighbourhood characteristics made the strongest contributions to predicting whether a child was overweight or obese. Layers of the SEM representing food and physical activity environments made smaller, but still significant, contributions to predicting children's weight status. CONCLUSIONS: The approach used herein supports using the SEM for predicting child weight status and uncovers some of the most promising domains and strategies for childhood obesity prevention that can be used for designing interventions.

Relative and absolute availability of healthier food and beverage alternatives across communities in the United States.

OBJECTIVES: We examined associations between the relative and absolute availability of healthier food and beverage alternatives at food stores and community racial/ethnic, socioeconomic, and urban-rural characteristics. METHODS: We analyzed pooled, annual cross-sectional data collected in 2010 to 2012 from 8462 food stores in 468 communities spanning 46 US states. Relative availability was the ratio of 7 healthier products (e.g., whole-wheat bread) to less healthy counterparts (e.g., white bread); we based absolute availability on the 7 healthier products. RESULTS: The mean healthier food and beverage ratio was 0.71, indicating that stores averaged 29% fewer healthier than less healthy products. Lower relative availability of healthier alternatives was associated with low-income, Black, and Hispanic communities. Small stores had the largest differences: relative availability of healthier alternatives was 0.61 and 0.60, respectively, for very low-income Black and very low-income Hispanic communities, and 0.74 for very high-income White communities. We found fewer associations between absolute availability of healthier products and community characteristics. CONCLUSIONS: Policies to improve the relative availability of healthier alternatives may be needed to improve population health and reduce disparities.

Fast-food menu offerings vary in dietary quality, but are consistently poor.

OBJECTIVE: To evaluate five popular fast-food chains' menus in relation to dietary guidance. DESIGN: Menus posted on chains' websites were coded using the Food and Nutrient Database for Dietary Studies and MyPyramid Equivalents Database to enable Healthy Eating Index-2005 (HEI-2005) scores to be assigned. Dollar or value and kids' menus and sets of items promoted as healthy or nutritious were also assessed. SETTING: Five popular fast-food chains in the USA. SUBJECTS: Not applicable. RESULTS: Full menus scored lower than 50 out of 100 possible points on the HEI-2005. Scores for Total Fruit, Whole Grains and Sodium were particularly dismal. Compared with full menus, scores on dollar or value menus were 3 points higher on average, whereas kids' menus scored 10 points higher on average. Three chains marketed subsets of items as healthy or nutritious; these scored 17 points higher on average compared with the full menus. No menu or subset of menu items received a score higher than 72 out of 100 points. CONCLUSIONS: The poor quality of fast-food menus is a concern in light of increasing away-from-home eating, aggressive marketing to children and minorities, and the tendency for fast-food restaurants to be located in low-income and minority areas. The addition of fruits, vegetables and legumes; replacement of refined with whole grains; and reformulation of offerings high in sodium, solid fats and added sugars are potential strategies to improve fast-food offerings. The HEI may be a useful metric for ongoing monitoring of fast-food menus.