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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 farmers 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.

This cross-sectional study examined the associations between parent-reported, perceptions of changes in school-aged childrens (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 childs fast food intake (OR[95 %CI] = 1.47[1.04-2.07]); conversely, increased school meal participation was associated with increased childs 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.

To determine the effectiveness of Supplemental Nutrition Assistance Program--Education (SNAP-Ed) nutrition and physical activity programming in elementary schools, it is necessary to recruit socioeconomically similar comparison schools not receiving SNAP-Ed programming. We developed a flexible recruitment strategy to tailor our approach to each individual school district and site. Here we discuss the lessons learned during the 10-month recruitment period, including early outreach, emphasizing participation benefits, leveraging and building relationships, and visiting sites.

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.

COVID-related school closures had a big impact on millions of children nationwide, many of whom rely on schools for healthy meals. An online survey of 3,297 fourth- and fifth-grade students in 67 California school sstudied the dietary habits of schoolchildren during the pandemic. The results showed that students who ate one or two school meals a day had significantly higher intakes of vegetables, whole fruits, and 100% fruit juice, compared to students who did not eat school meals. Specifically, students who ate one school meal a day ate more beans and orange vegetables, while those who ate two school meals a day consumed a wider variety of vegetables, including beans and orange vegetables. However, children who ate one school meal a day drank more fruit drinks and flavored milks than those who did not eat school meals. Further, students who ate two school meals consumed more fruit drinks, flavored milks, and sports and energy drinks than those who did not eat school meals. Our findings suggest that, while school meals were an important source of fruits and vegetables during the pandemic, more needs to be done to reduce consumption of sugary drinks.

ObjectiveIn 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.DesignPre-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.SettingInside 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.ParticipantsRestaurant observations (California n 110; Wilmington n 14); managers (California n 75; Wilmington n 15).ResultsPre-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.ConclusionsWhile 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.

ObjectiveTo 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.DesignThis 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.SettingLow-income California neighbourhoods (n 226 census tracts).ParticipantsQSR that sold children's meals online via a restaurant-specific platform, DoorDash, GrubHub and/or UberEats (n 631 observations from 254 QSR).ResultsSeventy 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.ConclusionsBased 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.

Schools are a critical setting for improving child nutrition and food security and preventing obesity in the United States. The U.S. Department of Agriculture mandates that the Supplemental Nutrition Assistance Program--Education, known as CalFresh Healthy Living (CFHL) in California, implements obesity prevention efforts that utilize multicomponent policy, systems, and environmental change interventions supplemented with direct and indirect education. However, evaluation of these complex interventions has proven challenging due to a lack of established evaluation methods, particularly for comprehensively measuring the dose of multicomponent interventions. This article proposes and demonstrates a method to score the dose of multicomponent California Department of Public Health-funded CFHL school interventions received by children attending public schools, using administrative data collected by CFHL in California.

Objective: To promote healthy beverage consumption among 9-12 grade students (ages 14-18) by means of a 4-week curriculum promoting increased awareness of drinks containing added sugar and the association between sugar-sweetened beverage consumption and health risks. Design: Quasi-experimental pre-post design. Setting: High schools in Northern California with at least 50% of students eligible for free or reduced-price meals. Method: A 4-lesson version of the Rethink Your Drink high school curriculum was piloted in three high schools in two northern California counties. Two high schools in the same area served as comparison sites. A survey of beverage-related knowledge, behaviours, perceptions and self-efficacy was administered to intervention and comparison students before and after the intervention. Focus groups with students and an online survey and semi-structured interviews with teachers were conducted following the intervention. Results: Intervention students reported significantly greater frequency of reading Nutrition Facts labels and understanding of beverage choice influences and decreased consumption of diet soda than comparison students. A decrease of 0.26 times per day in consumption of sugar-sweetened beverages relative to the comparison group was not significant. Conclusion: The intervention resulted in some positive outcomes, but improvements in targeted beverage consumption were not significant. Students and teachers want shorter, more engaging and experiential curricula that build on previous learning. Findings point to actionable recommendations for improvement of high school healthy beverage curricula and suggest the need for reinforcement using a multi-level approach.

IntroductionCalifornia'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.MethodsThis 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.ResultsStudents 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.ConclusionOn 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.

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.

ObjectiveThis 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.DesignComparison of cross-sectional observational data from the Healthy Communities Study (2013-2015) by region and school poverty level.ParticipantsA total of 401 US elementary and middle schools.Main outcome measuresAdherence with federal nutrition standards for meals and competitive foods; extent of implementation of select aspects of school wellness policies.AnalysisDescriptive statistics and multivariate regression were used. Differences were examined by school poverty level and region, adjusting for other school- and community-level covariates.ResultsMost 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 implicationsFindings 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.

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.

Site-level assessment questionnaires (SLAQs) were developed to assess nutrition and physical activity practices and environments in schools and other places children spend time in order to facilitate program planning and evaluation. After expert panel review for content validity, questionnaires were feasibility tested by users in six schools, three early care and education programs, and two out-of-school programs. Findings indicate that the questionnaires are feasible and useful for planning interventions. Extension programs can use SLAQs to support policy, systems, and environment change efforts that promote healthful eating and physical activity in children and to measure intervention effectiveness.

BackgroundOur objective was to examine the association between school wellness committees and implementation of nutrition wellness policies and children's weight status and obesity-related dietary outcomes.MethodsA cross-sectional study was conducted of 4790 children aged 4-15 years recruited from 130 communities in the Healthy Communities Study. Multilevel statistical models assessed associations between school wellness policies and anthropometric (body mass index z-score [BMIz]) and nutrition measures, adjusting for child and community-level covariates.ResultsChildren had lower BMI z-scores (-0.11, 95% confidence interval [CI]: -0.19, -0.03) and ate breakfast more frequently (0.14 days/week, 95% CI: 0.02-0.25) if attending a school with a wellness committee that met once or more in the past year compared to attending a school with a wellness committee that did not meet/did not exist. Children had lower added sugar (p < .0001), lower energy-dense foods (p = .0004), lower sugar intake from sugar-sweetened beverages (p = .0002), and lower dairy consumption (p = .001) if attending a school with similar or stronger implementation of the nutrition components of the school wellness policies compared to other schools in the district.ConclusionsA more active wellness committee was associated with lower BMI z-scores in US schoolchildren. Active school engagement in wellness policy implementation appears to play a positive role in efforts to reduce childhood obesity.

Multifaceted community interventions directed at improving food environments are emerging, but their impact on dietary change and obesity prevalence has not been adequately documented. The Healthy Communities Study (HCS) is seeking to identify characteristics and combinations of programs and policies that are associated with children's diets and obesity-related outcomes in various types of communities across the U.S. The purpose of this paper is to describe the methods used in 2013-2015 in the HCS to assess dietary intake, school nutrition environments, and other nutrition-related behaviors. The conceptual framework of the HCS is based on the socioecological model and behaviors shown in previous studies to be related to obesity in children guided selection of domains. Nine domains were identified as essential measures of nutrition in the HCS: (1) intake of selected foods and beverages; (2) food patterns and behaviors; (3) social support; (4) home environment; (5) school environment; (6) community environment; (7) breastfeeding history; (8) household food insecurity; and (9) dieting behaviors and body image. Children's dietary intake was assessed using a dietary screener and up to two automated 24-hour recalls. Dietary-related behaviors were assessed by a survey administered to the parent, child, or both, depending on child age. School nutrition measures were obtained from a combination of school staff surveys and researcher observations. Information from these measures is expected to contribute to a better understanding of "what is working" to improve the dietary behaviors that are likely to prevent obesity and improve health in children.

Background: Our objective was to examine the association between school wellness committees and implementation of nutrition wellness policies and children's weight status and obesity-related dietary outcomes. Methods: A cross-sectional study was conducted of 4790 children aged 4-15 years recruited from 130 communities in the Healthy Communities Study. Multilevel statistical models assessed associations between school wellness policies and anthropometric (body mass index z-score [BMIz]) and nutrition measures, adjusting for child and community-level covariates. Results: Children had lower BMI z-scores (-0.11, 95% confidence interval [CI]: -0.19, -0.03) and ate breakfast more frequently (0.14 days/week, 95% CI: 0.02-0.25) if attending a school with a wellness committee that met once or more in the past year compared to attending a school with a wellness committee that did not meet/did not exist. Children had lower added sugar (p < 0.0001), lower energy-dense foods (p = 0.0004), lower sugar intake from sugar-sweetened beverages (p = 0.0002), and lower dairy consumption (p = 0.001) if attending a school with similar or stronger implementation of the nutrition components of the school wellness policies compared to other schools in the district. Conclusions: A more active wellness committee was associated with lower BMI z-scores in US schoolchildren. Active school engagement in wellness policy implementation appears to play a positive role in efforts to reduce childhood obesity.

Less than 11% of young school-aged children eat the recommended amounts of fruits and vegetables, despite abundant evidence that these foods protect against many types of cancer, heart disease and diabetes, and when combined with other dietary changes can help protect against obesity. In 2005, California became the first state to address the availability of fresh and local produce in the federal School Breakfast Program through state funding. The California Fresh Start Program doubled the number of different fresh fruits offered to students. With the greater variety, the number of fresh fruit servings taken by students in the Fresh Start pilot program more than doubled. Evaluation of the program revealed many lessons, which are especially important now, as schools across the country prepare to increase the number of fruits and vegetables offered in the School Breakfast Program by or before July 2014 as mandated by the Healthy, Hunger-Free Kids Act.

To curb the escalating rates of obesity in California and across the nation, it is imperative to identify dietary behaviors that prevent excessive weight gain. Reports in the press are often conflicting and more often confuse than clarify the issue of what people should eat to prevent obesity. We recently conducted a comprehensive review of the literature published between 1992 and 2003 on the dietary determinants of obesity in children and adults. We examined secular trend data, mechanistic research, observational studies and prevention trials. We found that the dietary factors related to increased obesity were high intakes of dietary fat, sweetened beverages and restaurant-prepared foods, and the increased likelihood of skipping breakfast. Factors most likely to protect against obesity were the higher consumption of dietary fiber, fruits and vegetables, calcium and dairy products.

Background: This study sought to elucidate students' perceptions of school food environments and to assess correlations between perceptions and purchasing and consumption behaviors at school. Methods: Seventh and ninth graders (n = 5365) at 19 schools in multiethnic, low-income California communities participating in the Healthy Eating Active Communities program completed questionnaires assessing their attitudes and behaviors regarding school food environments during spring 2006. Results: Most students (69%) reported that fresh fruit was important to be able to buy at school; more than chips (21%), candy (28%), or soda (31%). Reported importance of food offerings was correlated with the consumption of those items. Most students did not perceive foods/beverages offered at school to be healthy; fewer than a quarter reported eating fruits or vegetables (FV) at school. Students eating school lunch were more than twice as likely to consume FV, though if they also purchased from competitive venues, their consumption of candy, chips, and soda was similar to their peers who purchased only competitive foods. Conclusion: Students report healthy foods to be important to be able to buy at school, but do not perceive their school food environment to be healthy and consume more unhealthy foods at school. Students served healthy items via school lunch are more likely to consume them; however, they also purchase and consume unhealthy items if available. Findings suggest that modifying school food environments to facilitate consumption of healthy foods and limit unhealthy foods will better match students' preferences and could lead to improved dietary intake. (Contains 3 tables and 2 figures.)

This is a comprehensive review of policies and research regarding body mass index (BMI) screening in schools in the United Kingdom and the United States. Although there are potential benefits to conducting screenings in schools, there is also the potential to do harm to the children who are identified as overweight. School administrators need to consider a number of factors discussed in this article before making a decision about committing resources to BMI screening. (Contains 1 table.)