Search

Introduction: Amid national efforts to align priorities for nutrition and food assistance programs, little is known about the implementation of community-led efforts for children. This study aimed to estimate U.S. public school participation in weekend backpack programs (WBPs), to document program structure, and to consider characteristics of programs with more nutritious food offerings., Methods: The prevalence of WBP participation in 2022 was estimated using a state-stratified, random sample of n=413 public schools. Administrators from WBPs at 49 schools completed measures of implementation characteristics and nutritional quality of foods offered. In 2022-2023, using a multivariable-adjusted linear regression model, the authors explored the association between hypothesized implementation characteristics and Healthy Eating Index-2015 scores of foods provided., Results: Half of public schools (53.7%, 95% CI: 46.8%, 60.7%) in the national sample reported participating in WBPs. Many WBPs in the subsample were affiliated with anti-hunger organizations (41%), led by school counselors and volunteers (55%), and funded by grants (51%). WBPs spent an average of $0.56 (sd=$0.36) per item. Foods provided averaged a Healthy Eating Index-2015 score of 58.4 (sd=12.3), similar to children's average diets. About half of WBPs (41%) reported accessing nutrition resources., Conclusions: Despite the decentralized structure and absence of dedicated funding mechanisms, WBPs were common in our national sample of schools, suggesting widespread perceptions of unmet food needs and extensive efforts from community members to mitigate weekend hunger. Further research on food procurement methods and program impacts on child nutrition outcomes is needed to advance national priorities for nutrition and food security., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Importance: The White House National Strategy on Hunger, Nutrition, and Health included expanding free school meals to all students, regardless of income, which has sparked debate in the United States., Objective: To assess the association between universal free school meals (UFSMs) and school and student outcomes in the United States., Evidence Review: An expert panel-informed protocol was developed to evaluate intervention or cohort studies comparing UFSM programs, such as the Community Eligibility Provision (CEP), with non-UFSM programs in US schools from August 2012 (excluding 2020-2021 due to the COVID-19 pandemic) in peer-reviewed publications or government reports. Outcomes included meal participation rates, attendance, dietary intake and quality, food waste, economic impact, food insecurity, anthropometrics, disciplinary actions, stigma, and shaming. A search of Medline, Econlit, Business Source Ultimate, ERIC, Agricola, Cab Abstracts, and CINAHL was performed in April 2024. Two researchers screened articles for inclusion, extracted data, and assessed risk of bias, using the Risk of Bias in Nonrandomized Studies of Interventions tool, for each included study. Grading of Recommendations, Assessment, Development, and Evaluations was used to assess the certainty of evidence for each outcome., Findings: The search identified 2784 records, with 6 studies included, representing more than 11 000 elementary, middle, and high schools. Nonrandomized intervention studies performed difference-in-difference or rate ratio analysis to investigate CEP participation rates, attendance, anthropometrics, and/or suspensions. CEP was associated with increased lunch (3 studies; moderate certainty) and breakfast (1 study; very low certainty) participation. School attendance was unchanged or improved in schools with CEP compared with schools without UFSM (2 studies; low certainty). CEP was associated with lower obesity prevalence (1 study; very low certainty) and fewer suspensions (1 study; very low certainty). Reasons for downgrading the certainty ratings included indirectness (data not fully representative of the United States) and inconsistency (small number of studies limiting ability to assess consistency). Despite the limitations, the evidence reflected well-designed longitudinal intervention studies appropriate for decision-making., Conclusions and Relevance: In this systematic review, UFSMs were associated with increased meal participation, no or slight improvements in attendance, and decreased obesity prevalence and suspension rates; certainty of evidence was moderate for lunch participation and low or very low for other outcomes. Studies did not report several important outcomes, such as diet quality and food security, suggesting the need for more high-quality research encompassing policy-relevant indicators.

Introduction: Children's diets in the U.S. typically fail to meet dietary recommendations, contributing to associated adverse health outcomes. The Healthy, Hunger-Free Kids Act (HHFKA) of 2010 required the U.S. government to update nutrition standards for school meals to align with the Dietary Guidelines for Americans (DGAs). This study estimates the evolving impact of substituting school-prepared food for home-prepared food on overall daily diet quality and by subcomponents of diet quality. Subgroup analyses are performed by race/ethnicity and income., Methods: Two, nonconsecutive days of dietary recall data from the National Health and Nutrition Examination Survey (2005-March 2020) are used to calculate schoolchildren's Healthy Eating Index (HEI)-2020 scores. The study includes children with complete two-day dietary intakes who attend kindergarten through twelfth grade in a school offering lunch. An individual-level fixed effects regression is employed to examine the relationship of school food consumption on HEI-2020 scores before and after HHFKA-mandated changes in nutrition standards. Analyses were conducted on September 23, 2023., Results: Prior to changes in standards (2005-2008), school food did not impact diet quality within the overall group of children. In 2009-2012, positive associations between school food and diet quality emerged for low-income students and for non-Hispanic Black students. By 2013-2020, improvements were seen across all groups. The association between school food and diet quality was most attributable to more favorable consumption of dairy, fruit, whole grains, refined grains, added sugars and saturated fats., Conclusions: HHFKA-based nutrition standards were associated with beneficial dietary changes and reduced dietary disparities for children across diverse backgrounds., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: The US Department of Agriculture's (USDA) summer meal programs are designed to provide meals at no cost while school is out of session. In response to the COVID-19 pandemic, several regulatory waivers were enacted to facilitate meal distribution. The aim of this study was to assess the rates of meal distribution before and after these waivers were in effect., Methods: Meal distribution patterns for 2019, 2020, and 2021 were examined through (1) a descriptive comparison of the number of participating districts, sponsors, meal sites, and meals distributed statewide, and (2) repeated measures ANOVAs to examine changes among districts in operation all years., Results: The waivers were associated with an increase in the total number of participating districts, sponsors, and meal sites; an increase in the total number of meals distributed to children during the summer months; and an increase in meal distribution among sponsors that had been in place since 2019., Conclusion: Expanding the area eligibility criteria and enabling flexibility in meal distribution methods increased the number of meals provided. This study provides important preliminary evidence to suggest that the USDA should consider permanent regulatory changes to this program to maximize its reach., (© 2024 The Authors. Journal of School Health published by Wiley Periodicals LLC on behalf of American School Health Association.)

Objective: This study aimed to discover the prevalence of school nutrition state legislation and to identify the correlates of enactment., Design, Setting, and Participants: An online legislative database, Legiscan, was used to collect bills related to school nutrition from the US from 2010 to 2019. Bills were coded and compiled into a study database with state-level dietary variables (obesity prevalence, fruit, and vegetable intake, sugar-sweetened beverage consumption), community variables (percent White, poverty), and bill-characteristic variables (party affiliation in legislature, strength of language, party of governor, school gardens, vegetable intake, and other salient variables). Multivariable models were built to examine predictors of bill enactment., Results: Of the 462 bills introduced, 38.7% (n = 156) were enacted. In a multivariable model, the strength of bill language, political party affiliation, implementation of school gardens, and vegetable intake were the variables associated with bill passage. Bills with strong language were less likely to be enacted (P <0.001). Bills introduced by Democrats were more likely to be enacted (P = 0.01)., Conclusion and Implication: This study showed a better understanding of legislative support for child nutrition via policy surveillance of bills and their correlates of enactment. This information can be used to prioritize advocacy efforts and identify ways research can better inform policy., (Copyright © 2024 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Diet quality in the United States is improving over time but remains poor. Food outlets influence diet quality and represent the environments in which individuals make choices about food purchases and intake. The objective of this study was to use the Healthy Eating Index-2015 (HEI-2015) to evaluate the quality of foods consumed from the four major outlets where food is obtained-stores, full-service restaurants, quick-services restaurants, and schools-and to assess changes over time. This cross-sectional study used 24 h dietary recall data from eight cycles (2003-2004 to 2017-2018) of the National Health and Nutrition Examination Survey (NHANES). Linear trend estimation was used to test for changes in HEI scores over time, and balanced repeated replicate weighted linear regression was used to test for differences in total and component scores between types of food outlets. Overall, Americans are not consuming a mix of foods from any major category of food outlet that aligns with dietary guidelines. The total score for schools (65/100 points) and stores (62/100 points) was significantly higher than full-service (51/100 points) and quick-service (39/100 points) restaurants ( p < 0.0001). HEI scores significantly improved over time for schools ( p < 0.001), including an increase in whole grains from less than 1 point in 2003-2004 to 7 out of 10 points in 2017-2018. In 2017-2018, schools received the maximum score for total fruits, whole fruits, and dairy. Continued research on strategies for improving the quality of foods consumed from restaurants and stores is warranted.

The United States Department of Agriculture (USDA) National School Lunch and Breakfast Programs are critical for the health and food security of U.S. schoolchildren, but access to these programs was disrupted by COVID-19 pandemic-related school closures in spring 2020. While temporary policy changes to the programs enabled school food authorities (SFAs) to pivot towards distributing meals throughout their communities instead of within school buildings, SFAs faced complex challenges during COVID-19 with minimal external support. This mixed methods study investigates the implementation and financial challenges experienced by twelve of the largest urban SFAs in the U.S. during COVID-19. We conducted semi-structured interviews with SFA leaders and analyzed alongside quantitative financial data. We found that SFAs reconfigured their usual operations with nearly no preparation time while simultaneously trying to keep staff from contracting COVID-19, accommodate stakeholders with sometimes competing priorities, and remain financially solvent. Because student participation was much lower than during regular times, and revenue is tied to the number of meals served, SFAs saw drastic decreases in revenue even as they carried regular operating costs. For future crises, disaster preparedness plans that help SFAs better navigate the switch to financially viable community distribution methods are needed.

Changes in school meal programs can affect well-being of millions of American children. Since 2014, high-poverty schools and districts nationwide had an option to provide universal free meals (UFM) through the Community Eligibility Provision (CEP). The COVID-19 pandemic expanded UFM to all schools in 2020-2022. Using nationally representative data from the Early Childhood Longitudinal Study: Kindergarten Class of 2010-2011, we measured CEP effects on school meal participation, attendance, academic achievement, children's body weight, and household food security. To provide plausibly causal estimates, we leveraged the exogenous variation in the timing of CEP implementation across states and estimated a difference-in-difference model with child random effects, school and year fixed effects. On average, CEP participation increased the probability of children's eating free school lunch by 9.3% and daily school attendance by 0.24 percentage points ( p < 0.01). We find no evidence that, overall, CEP affected body weight, test scores and household food security among elementary schoolchildren. However, CEP benefited children in low-income families by decreasing the probability of being overweight by 3.1% ( p < 0.05) and improving reading scores of Hispanic children by 0.055 standard deviations. UFM expansion can particularly benefit at-risk children and help improve equity in educational and health outcomes.

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 (β = -1.13, P < 0.0001), and the wellness policies dimension was positively associated with waist circumference (β = 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., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Research is limited on added sugars in school meals and children's dietary intakes after the 2015-2020 Dietary Guidelines for Americans (DGA) recommended that added sugars be limited to less than 10% of total calories. This analysis uses data from the School Nutrition and Meal Cost Study (SNMCS) to examine levels of added sugars in: (1) school meals and (2) children's dietary intakes at breakfast, lunch, and over 24 h on school days. SNMCS data were collected in the 2014-2015 school year after updated nutrition standards for school meals were implemented. Most schools exceeded the DGA limit for added sugars at breakfast (92%), while 69% exceeded the limit at lunch. The leading source of added sugars in school meals (both breakfasts and lunches) was flavored skim milk. More than 62% of children consumed breakfasts that exceeded the DGA limit, and almost half (47%) consumed lunches that exceeded the limit. Leading sources of added sugars in the breakfasts consumed by children were sweetened cold cereals and condiments and toppings; leading sources of added sugars in children's lunches were flavored skim milk and cake. Over 24 h, 63% of children exceeded the DGA limit. These findings show that school meals and children's dietary intakes are high in added sugars relative to the DGA limit and provide insights into the types of foods that should be targeted in order to decrease levels of added sugars.

Objective: To explore the real-time personal/employee safety experiences and perspectives of school nutrition professionals ranging from frontline staff to state leadership across the US as they responded to the initial weeks of the coronavirus pandemic., Methods: A cross-sectional survey was administered electronically March 31-April 20, 2020, to school nutrition staff, managers, directors, and state agency personnel. Descriptive statistics were calculated, and a thematic analysis of an open-ended item was conducted., Results: School nutrition professionals (n = 504) from 47 states responded. Most (86.6%) reported that ensuring employee safety was somewhat or much more difficult during the pandemic, and they were unaware of an emergency plan. Themes from open-ended responses regarding employee safety concerns included, exposure and transmission risk, processes, and personal concerns., Conclusions and Implications: Attention to the safety and concerns of school nutrition employees is vital for continuation of these programs during this pandemic and for future emergency situations., (Copyright © 2020 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

The Nutrition Services Program is the largest program that provides prepared meals to older adults in need. However, little is known about the factors associated with participants' continued receipt of meals. This study uses longitudinal nationally representative survey data and residential location information to examine the factors associated with continuing to receive congregate meals ( N  = 383). 71.6% of participants in a given month continued to receive program meals in all of the next 12 months. Participants with geographic access to food proximate to their home were significantly more likely to stop receiving meals than those with more limited access (OR = 0.37, CI 0.16, 0.85); this was true among participants who lived alone, were older, had lower income, or lived in an urban area. Understanding the factors associated with continuing to receive congregate meals will ensure that older adults can meet their food needs and have a primary access point for community services.

The emergence of COVID-19 in the United States led most states to close or severely limit the capacity of their early child-care and education (ECE) programs. This loss affected millions of young children, including many of the 4.6 million low-income children who are provided free meals and snacks by their ECE programs through support from the federal Child and Adult Care Food Program (CACFP).Although Congress swiftly authorized waivers that would allow CACFP-participating ECE programs to continue distributing food to children, early evidence suggests that most ECE programs did not have the capacity to do so, leaving a fragmented system of federal, state, and local food programs to fill the gaps created by this loss.Critical steps are needed to repair our nation's fragile ECE system, including greater investment in CACFP, to ensure the nutrition, health, and development of young children during the COVID-19 pandemic and beyond.

Prior research has shown that participation in the United States' National School Lunch Program (NSLP) is associated with consuming higher-quality lunches and diets overall, but little is known about differences by income and race/ethnicity. This analysis used 24 h dietary recall data from the School Nutrition and Meal Cost Study to examine how NSLP participation affects the diet quality of students in different income and racial/ethnic subgroups. Diet quality at lunch and over 24 h was assessed using the Healthy Eating Index (HEI)-2010, where higher scores indicate higher-quality intakes. HEI-2010 scores for NSLP participants and nonparticipants in each subgroup were estimated, and two-tailed t -tests were conducted to determine whether participant-nonparticipant differences in scores within each subgroup were statistically significant. NSLP participants' lunches received significantly higher total HEI-2010 scores than those of nonparticipants for lower-income, higher-income, non-Hispanic White, and non-Hispanic Black students, suggesting that participating in the NSLP helps most students consume healthier lunches. These significantly higher total scores for participants' lunch intakes persisted over 24 h for higher-income students and non-Hispanic White students but not for lower-income students or students of other races/ethnicities. For NSLP participants in all subgroups, the nutritional quality of their 24 h intakes was much lower than at lunch, suggesting that the positive influence of the NSLP on their overall diet quality was negatively influenced by foods consumed the rest of the day (outside of lunch).

Reduced access to school meals during public health emergencies can accelerate food insecurity and nutritional status, particularly for low-income children in urban areas. To prevent the exacerbation of health disparities, there is a need to understand the implementation of meal distribution among large urban school districts during emergencies and to what degree these strategies provide equitable meal access. Our case study of four large urban school districts during the COVID-19 pandemic aims to address these knowledge gaps. Guided by the Getting to Equity (GTE) framework, we conducted a mixed-methods study evaluating emergency meal distribution and strategy implementation in four large urban school districts (Chicago Public Schools, Houston Independent School District, Los Angeles Unified School District, and New York City Department of Education). We gathered data from school district websites on (1) meal service and delivery sites and (2) district documents, policies, communication, and resources. Using qualitative coding approaches, we identified unique and shared district strategies to address meal distribution and communications during the pandemic according to the four components of the GTE framework: increase healthy options, reduce deterrents, build on community capacity, and increase social and economic resources. We matched district census tract boundaries to demographic data from the 2018 American Community Survey and United States Department of Agriculture food desert data, and used geographic information systems (GIS) software to identify meal site locations relative to student population, areas of high poverty and high minority populations, and food deserts. We found that all districts developed strategies to optimize meal provision, which varied across case site. Strategies to increase healthy options included serving adults and other members of the general public, providing timely information on meal site locations, and promoting consumption of a balanced diet. The quantity and frequency of meals served varied, and the degree to which districts promoted high-quality nutrition was limited. Reducing deterrents related to using inclusive language and images and providing safety information on social distancing practices in multiple languages. Districts built community capacity through partnering with first responder, relief, and other community organizations. Increased social and economic resources were illustrated by providing technology assistance to families, childcare referrals for essential workers, and other wellness resources. Geospatial analysis suggests that service locations across cities varied to some degree by demographics and food environment, with potential gaps in reach. This study identifies strategies that have the potential to increase equitable access to nutrition assistance programs. Our findings can support (1) ongoing efforts to address child food insecurity during the pandemic and (2) future meal provision through programs like the Summer Food Service Program and Seamless Summer Option. Future research should further examine the rationale behind meal site placement and how site availability changed over time.

In 2019, the National School Lunch Program and School Breakfast Program served approximately 15 million breakfasts and 30 million lunches daily at low or no cost to students.Access to these meals has been disrupted as a result of long-term school closures related to the COVID-19 pandemic, potentially decreasing both student nutrient intake and household food security. By the week of March 23, 2020, all states had mandated statewide school closures as a result of the pandemic, and the number of weekly missed breakfasts and lunches served at school reached a peak of approximately 169.6 million; this weekly estimate remained steady through the final week of April.We highlight strategies that states and school districts are using to replace these missed meals, including a case study from Maryland and the US Department of Agriculture waivers that, in many cases, have introduced flexibility to allow for innovation. Also, we explore lessons learned from the pandemic with the goal of informing and strengthening future school nutrition policies for out-of-school time, such as over the summer.

The U.S. Department of Agriculture's (USDA) Child and Adult Care Food Program (CACFP) updated meal pattern standards took effect in October 2017. The aim of this quasi-experimental, pre-post study is to identify changes in food and beverage practices of CACFP-participating centers due to implementation of updated CACFP meal patterns over a 21-month period. Eight hundred and fifty-eight centers located in 47 states and the District of Columbia completed a survey (primarily electronic) at both time points (67.6% follow-up response rate). Multivariable logistic regressions with robust standard errors assessed changes over time, accounting for repeated observations within each site. From baseline to follow-up, centers reported the increased familiarity and implementation, albeit with time, money, and staffing-related challenges. Significant improvements were seen in not serving sugary cereals or flavored milk, in serving 100% whole grains, and serving processed meats less than once a week. While CACFP-participating centers reported making significant progress in meeting the updated meal pattern standards and suggested best practices within 15-19 months of their effective date, reported compliance and adherence to the standards and best practices was not universal. USDA, state agencies, and technical assistance providers should work to provide centers with additional guidance to help them with implementation.

Objective: In October 2017, substantial changes were made to improve the nutritional quality of meals served in the Child and Adult Care Food Program (CACFP). This study describes the experience of child care providers and sponsors during the first year of implementation., Methods: A 1-time survey was administered to CACFP sponsors in Delaware 1 year after implementation of the changes. Data analysis included frequencies and chi-square tests of independence., Results: Among respondents (n = 137), 21% faced moderate or significant challenges. Food cost (53.1%) and communicating with parents about changes (44.6%) were the most common challenges faced. The majority reported that parents supported the changes and that children and teachers generally ate the new food., Conclusions and Implications: A minority of providers in Delaware faced significant challenges, suggesting that broad changes to CACFP may be feasibly implemented across settings. Training focused on food cost and parent communication may be warranted., (Copyright © 2019 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Navajo (Diné) and other American Indian children are more affected by overweight and obesity than their U.S. counterparts. In this descriptive study, the authors combined a socioecological and Navajo cultural framework to analyze the various factors that influence food choices available to children in schools. The Healthy Hunger-Free Kids Act of 2010 updated nutrition standards for school meals and all other foods and beverages sold in schools. Some studies have shown that improved nutrition standards were not favorably received by students and school food programs. To better understand these broader trends in a Navajo context, the researcher administered in-person surveys to 6 principals and 14 food service workers from a sample of 6 schools and performed on-site observations of two schools. Data were analyzed using a combination of descriptive statistics, matrix analysis, and thematic analysis techniques. Results showed that schools were offering more healthy food options in school lunches and that some schools were still serving unhealthy foods, such as pizza, tater tots, and French fries. Classroom and fundraising events provided other sources for low-nutrient foods and beverages. Participants had mixed responses about the updated nutrition standards, and food waste of healthy foods was a major concern. This study proposes opportunities for nurses to engage in research and advance stronger policies that increase healthy food options and limit access to less healthy foods.

Background: A nutritious diet can prevent obesity and chronic disease and improve academic performance, yet many children have energy-dense, nutrient-poor diets. The objective of this study was to assess nutrition policies, practices, and environments in Georgia Supplemental Nutrition Assistance Program Education (SNAP-Ed) elementary schools and compare them across school-level demographic characteristics., Methods: We distributed a cross-sectional online survey to administrators, grade level chairs, and nutrition managers from 113 Georgia SNAP-Ed elementary schools during 2015-2017. Logistic regression, one-way ANOVA, and Tukey's tests were performed to assess differences by free and reduced-price lunch eligibility and percentage black. Fisher's exact and Rao-Scott chi-square tests were performed to assess differences by school size and geography., Results: The majority of schools established wellness policies and committees, provided nutrition education, and offered fresh fruits and/or vegetables daily. Fewer schools had policies limiting sugar-sweetened foods within classrooms or had established a school garden. There were minimal significant differences in survey responses across school-level demographics., Conclusions: Georgia SNAP-Ed elementary schools are providing healthy nutrition settings for their students in a number of areas, and can further improve by establishing more comprehensive wellness policies, a committee to enforce them, and engaging children in hands-on nutrition education activities., (© 2020, American School Health Association.)

Background: Implementation of updated nutrition standards for school meals began during school year (SY) 2012-2013. The standards were designed to improve the nutritional quality of the meals and their consistency with the Dietary Guidelines for Americans., Objective: To assess the nutritional quality of school lunches and breakfasts after the updated standards were in place and compare it with the nutritional quality of the meals before the updated standards., Design: School menu data were used from two cross-sectional, nationally representative studies of schools participating in the National School Lunch Program during SY 2014-2015 (School Nutrition and Meal Cost Study) and SY 2009-2010 (fourth School Nutrition Dietary Assessment Study)., Participants/setting: The analysis used 1 week of school menu data from 1,206 schools at lunch and 1,110 schools at breakfast for SY 2014-2015, and 884 schools at lunch and 802 schools at breakfast for SY 2009-2010., Outcome Measures: Healthy Eating Index 2010 scores were estimated., Statistical Analyses: Descriptive analyses were conducted to estimate mean Healthy Eating Index 2010 total and component scores for school meals. Scores are expressed as a percentage of maximum possible scores. Two-tailed t tests were used to assess differences in scores before and after updated standards were in place., Results: Total Healthy Eating Index 2010 scores for school lunches and breakfasts increased significantly after the updated standards. Between SY 2009-2010 and SY 2014-2015, the total score for school lunches increased from 58% of the maximum score to 82%, and the total score for school breakfasts increased from 50% to 71% (P<0.05). For both meals, component scores increased by more than 20 percentage points for whole grains, refined grains, and empty calories, as well as for greens and beans for lunches and whole fruit and sodium for breakfasts., Conclusions: The updated nutrition standards for schools meals significantly improved the nutritional quality of the meals and their consistency with the Dietary Guidelines for Americans., (Copyright © 2020 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2019 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Objective: To identify the prevalence of state-level share table policies, assess the quality of available policies, and determine common policy characteristics., Design: In this qualitative policy analysis, state-level share table policies and resources were collected from March to June, 2018 from the State Department of Education Child Nutrition Office Web sites and/or staff communication across 50 states and Washington, DC., Variables Measured: Frequency of state-level policy documents assessed, as well as the allowable share table items, marketing and outreach guidance, and requirements for health code clearance, critical limits, monitoring, corrective actions, record keeping, redistribution plans, and allergy considerations., Analysis: After a deductive analysis approach, each collected policy document was scored on 10 a priori components primarily derived from existing food safety policies. Descriptive statistics were used to present common policy characteristics., Results: About half of the US (n = 27) had a state-level share table policy document. Most states with a policy document (81%; n = 22) allowed unused share table items to be redistributed through reservice, food donation, or use as a cooked ingredient in future meals. Few states provided adequate guidance on monitoring, corrective actions, record keeping, allergy considerations, and best practices for share table marketing and outreach., Conclusions and Implications: The high prevalence of state share table guidance suggests that this is a common food recovery strategy. Yet, states differed in allowable share table items and on permitted future use of share table items., (Copyright © 2019 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Pork products from animals "raised without antibiotics" (RWA) are assumed to harbor lower levels of antimicrobial resistance (AMR) than conventional (CONV) pork products with no claims regarding use of antimicrobial agents during production. A total of 372 pork chop samples from CONV ( n = 190) and RWA ( n = 182) production systems were collected over 13 months from three food service suppliers. The following bacteria were cultured: Escherichia coli, tetracycline-resistant (TET r ) E. coli, third-generation cephalosporin-resistant (3GC r ) E. coli, Salmonella enterica, TET r Salmonella, 3GC r Salmonella, nalidixic acid-resistant Salmonella, Enterococcus spp., TET r Enterococcus, erythromycin-resistant Enterococcus, Staphylococcus aureus, and methicillin-resistant S. aureus . Production system did not significantly impact the detection of cultured bacteria ( P > 0.05). Metagenomic DNA was isolated from each sample, and equal amounts of metagenomic DNA were pooled by supplier, month, and production system for 75 pooled samples (38 CONV, 37 RWA). Quantitative PCR was used to assess the abundances of the following 10 AMR genes: aac(6')-Ie-aph(2″)-Ia, aadA1, bla CMY-2 , bla CTX-M , bla KPC-2 , erm (B), mecA, tet (A), tet (B), and tet (M). For all 10 AMR genes, abundances did not differ significantly ( P > 0.05) between production systems. These results suggest that use of antimicrobial agents during swine production minimally impacts the AMR of bacteria in pork chops.

Objective: Experts recommend that products containing artificial sweeteners are not marketed to children or sold at schools. The present study aimed to provide a baseline assessment of the extent to which state laws and local school district wellness policies (LWP) address restrictions on the use of artificial sweeteners in competitive foods and beverages (CF&B) sold at schools., Design: A descriptive, cross-sectional study of policies in place for the 2014-15 school year., Setting: Data were collected on laws in all fifty states and Washington, DC. LWP were compiled for 496/518 school food authorities (SFA) for which data were collected as part of the US Department of Agriculture's School Nutrition and Meal Cost Study., Subjects: State laws and LWP respectively were coded on a 0-3 ordinal scale for the strength of their restrictions on artificial sweeteners in CF&B sold in each of five CF&B venues, separately by grade level. Prevalence of state laws and LWP for SFA nationwide was computed., Results: Thirteen states addressed the use of artificial sweeteners. Six states addressed the use of artificial sweeteners in both CF&B. District-level artificial sweetener policies were most frequently addressed for beverages in elementary schools' vending machines. District policies also were more likely to address artificial sweeteners in states with laws addressing artificial sweeteners., Conclusions: Most state laws and LWP do not address artificial sweeteners in CF&B. This is not surprising given the Food and Drug Administration has approved eight artificial sweeteners for consumption and the Smart Snacks regulation does not limit artificial sweeteners for CF&B.

Objective: The US Department of Agriculture's Summer Food Service Program and Seamless Summer Option (summer nutrition programmes (SNP)) aim to relieve food insecurity for children and teens during summer months. More needs to be known about when and where SNP are available, and how availability varies by community characteristics, particularly in rural areas where food insecurity and reduced food access are more prevalent., Design: The present study examined the geographic availability of SNP and summer meal uptake rates in 2016, using state-wide administrative claims data., Setting: Public schools and SNP in California, USA.ParticipantsSchools (n 8842) and SNP (n 4685)., Results: Urban counties were more likely than rural counties to have higher summer uptake rates, calculated as the percentage of summer meals served relative to eligible students utilizing school meal programmes during the academic school year, but uptake overall was low at 18·2 % of target populations. Geographic availability analyses showed that 63·9 % of public urban schools had an SNP available within 1·6 km (1 mile), but availability was significantly higher within the proximity of larger, higher-poverty high schools with diverse or majority non-White students, and those with higher school-year breakfast participation rates. Availability of an SNP within 16 km (10 miles) of rural schools averaged 68·1 % but was significantly higher around larger schools, higher-poverty schools and those with diverse or majority non-White students., Conclusions: While many communities have SNP available, much more work is needed to increase the availability of these programmes to reduce summer food insecurity for children, particularly in rural communities.

Purpose: As part of wellness efforts, employers may seek to improve the nutritional quality of foods offered and consumed in cafeterias and vending machines. However, little is known about who consumes food from these venues and the types and dietary quality of the foods consumed., Design: Cross-sectional., Setting: Nonschool cafeterias and vending machines., Participants: US adults ≥20 years old., Measures: Prevalence of consuming foods, most common foods eaten, leading calorie sources, 2010 Healthy Eating Index., Analysis: Using 24-hour dietary recall data from NHANES 2005-2014 (N = 25,549 adults), we estimated the prevalence of consuming foods, assessed the most commonly consumed foods, and calculated dietary quality of foods., Results: On a given day, 3.1% of adults consumed foods from cafeterias and 3.9% from vending machines. Consumers averaged 692 kcal from cafeterias and 264 kcal from vending machines. Cafeteria consumers had higher income and education, while vending consumers were more likely to be male and younger adults. Common cafeteria foods included vegetables and fruits, but cafeteria foods were generally high in sodium and low in whole grains. Sugar-sweetened beverages and candies accounted for approximately half of all vending calories., Conclusion: Foods chosen from cafeterias and vending machines do not align well with the Dietary Guidelines for Americans. Improving the dietary quality of foods consumed from these venues could impact millions of adults.

Objectives: To estimate economic and environmental effects of reducing milk waste from the US Breakfast in the Classroom (BIC) School Breakfast Program by replacing conventional milk with shelf-stable dairy or soy milk., Methods: We estimated net greenhouse gas emissions (GHGE; kg CO 2 equivalents [e]) from replacing conventional milk with shelf-stable dairy or soy milk by adapting existing life cycle assessments and US Environmental Protection Agency Waste Reduction Model estimates to BIC parameters. We estimated net cost with school meal purchasing data., Results: Replacing conventional dairy milk with shelf-stable dairy or soy milk would reduce milk-associated GHGE by 28.5% (0.133 kg CO 2 e) or 79.8% (0.372 kg CO 2 e) per student per meal, respectively. Nationally, this equates to driving 248 million or 693 million fewer miles annually, respectively. This change would increase milk costs 1.9% ($0.005) or 59.4% ($0.163) per student per meal, respectively., Conclusions: Replacing conventional milk with shelf-stable dairy or soy milk could substantially reduce waste and concomitant GHGE in BIC; switching to shelf-stable dairy has low net costs. Pilot tests of these options are warranted to optimize the nutritional value, cost, and sustainability of BIC.

Background: Access to social services (eg, nutrition) can impact older adults' health care utilization and health outcomes. However, data documenting the relationship between receiving services and objective measures of health care utilization remain limited., Objectives: To link Meals on Wheels (MOW) program data to Medicare claims to enable examination of clients' health and health care utilization and to highlight the utility of this linked dataset., Research Design: Using probabilistic linking techniques, we matched MOW client data to Medicare enrollment and claims data. Descriptive information is presented on clients' health and health care utilization before and after receiving services from MOW., Subjects: In total, 29,501 clients were from 13 MOW programs., Measures: Clients' demographics, chronic conditions, and hospitalization, emergency department (ED), and nursing home (NH) utilization rates., Results: We obtained a one-to-one link for 25,279 clients. Among these, 14,019 were Medicare fee-for-service (FFS) beneficiaries and met inclusion criteria for additional analyses. MOW clients had high rates of chronic conditions (eg, almost 90% of FFS clients were diagnosed with hypertension, compared with 63% of FFS beneficiaries in their communities). In the 6 months before receiving MOW services, 31.6% of clients were hospitalized, 24.9% were admitted to the ED and 13% received care in a NH. In the 6 months after receiving meals, 24.2% were hospitalized, 19.3% were admitted to the ED, and 9.5% received care in a NH., Conclusions: Linking MOW data to Medicare claims has the potential to shed additional light on the relationships among social services, health status, health care use, and benefits to clients' well-being.

Background: Strategies to reduce childhood obesity and improve nutrition include creating school food environments that promote healthy eating. Despite well-documented health benefits of fruit and vegetable (FV) consumption, many U.S. school-aged children, especially low-income youth, fail to meet national dietary guidelines for FV intake. The Cafeteria Assessment for Elementary Schools (CAFES) was developed to quantify physical attributes of elementary school cafeteria environments associated with students' selection and consumption of FV. CAFES procedures require observation of the cafeteria environment where preparation, serving, and eating occur; staff interviews; photography; and scoring., Methods: CAFES development included three phases. First, assessment items were identified via a literature review, expert panel review, and pilot testing. Second, reliability testing included calculating inter-item correlations, internal consistency (Kuder-Richardson-21 coefficients), and inter-rater reliability (percent agreement) based on data collected from 50 elementary schools in low-income communities and 3187 National School Lunch Program participants in four U.S. states. At least 43% of each participating school's students qualified for free- or reduced-price meals. Third, FV servings and consumption data, obtained from lunch tray photography, and multi-level modeling were used to assess the predictive validity of CAFES., Results: CAFES' 198 items (grouped into 108 questions) capture four environmental scales: room (50 points), table/display (133 points), plate (4 points), and food (11 points). Internal consistency (KR-21) was 0.88 (overall), 0.80 (room), 0.72 (table), 0.83 (plate), and 0.58 (food). Room subscales include ambient environment, appearance, windows, layout/visibility, healthy signage, and kitchen/serving area. Table subscales include furniture, availability, display layout/presentation, serving method, and variety. Inter-rater reliability (percent agreement) of the final CAFES tool was 90%. Predictive validity analyses indicated that the total CAFES and four measurement scale scores were significantly associated with percentage consumed of FV served (p < .05)., Conclusions: CAFES offers a practical and low-cost measurement tool for school staff, design and public health practitioners, and researchers to identify critical areas for intervention; suggest low- and no-cost intervention strategies; and contribute to guidelines for cafeteria design, food presentation and layout, and operations aimed at promoting healthy eating among elementary school students.

Weight gain and obesity among female prisoners is of public health concern. This study analyzed the nutritional quality of commissary food and recipes cooked within eight women's prisons in the United States. Food items from commissary lists were categorized into the MyPlate food groups. Nutrition Data System for Research was used to analyze the nutritional content of recipes ( N = 175). Mean nutrient content, percent Daily Values, and food group servings were calculated. Recipes were generally high in sodium, saturated fat, added sugars, and calories but low in vitamin D. Commissary items and recipes were both low in fruits, vegetables, and whole grains and excessive in refined grains. Additional research is needed to inform policies that ensure commissary offerings better reflect dietary recommendations.

Childhood obesity is a major public health concern in the US. More than a third of young children 2-5 years old are placed in nonrelative child care for the majority of the day, making the child care setting an important venue to spearhead obesity prevention. Much of the obesity research in child care has focused on center-based facilities, with emerging research on Family Child Care Homes (FCCHs)-child care operated in a home setting outside the child's home. The purpose of this review was to assess the obesogenic attributes of the FCCH environment. A search of the PubMed, Embase, CINHAL, and PsycINFO electronic databases identified 3,281 citations; 35 eligible for full-text review, and 18 articles from 17 studies in the analysis. This review found a lack of comprehensive written nutrition and physical activity policies within FCCHs, lack of FCCH providers trained in nutrition and physical activity best practices, lack of adequate equipment and space for indoor and outdoor playtime activities in FCCHs, inaccurate nutrition-related beliefs and perceptions among FCCH providers, poor nutrition-related communication with families, and poor feeding practices. Future research focusing on interventions aimed at addressing these problem areas can contribute to obesity prevention.

Delivering food to nutritionally vulnerable patients is important for addressing these patients' social determinants of health. However, it is not known whether food delivery programs can reduce the use of costly health services and decrease medical spending among these patients. We sought to determine whether home delivery of either medically tailored meals or nontailored food reduces the use of selected health care services and medical spending in a sample of adults dually eligible for Medicare and Medicaid. Compared with matched nonparticipants, participants had fewer emergency department visits in both the medically tailored meal program and the nontailored food program. Participants in the medically tailored meal program also had fewer inpatient admissions and lower medical spending. Participation in the nontailored food program was not associated with fewer inpatient admissions but was associated with lower medical spending. These findings suggest the potential for meal delivery programs to reduce the use of costly health care and decrease spending for vulnerable patients.

Objective: To evaluate breakfast location and children's food choices., Methods: Cross-sectional analysis of 1,371 fourth- through sixth-grade students in 2013. Foods and beverages in 17 categories characterized breakfast choices: (1) ≥ 1 fruits or vegetables, (2) ≥ 1 foods high in saturated fats and added sugars (SFAS), and (3) meeting School Breakfast Program (SBP) requirements., Results: Among breakfast eaters (n = 1,133; 82.6%), 46.0% ate at home, 13.1% ate at school, 41.0% ate at multiple locations; and 21.8% ate at a corner store. Those eating at school were more likely to consume ≥1 fruit or vegetable (odds ratio [OR] = 1.90; 95% confidence interval [CI], 1.26-2.87), less likely to eat ≥1 SFAS food (OR = 0.46; 95% CI, 0.22-0.94), and more likely to meet SBP requirements (OR = 2.47; 95% CI, 1.42-4.29). Those eating at corner stores (n = 247) were more likely to consume high-SFAS foods (63.9% vs 9.2%; P < .001)., Conclusions and Implications: Eating school breakfast increased the odds of consuming fruit, choosing lower SFAS, and meeting nutritional requirements of the SBP relative to other locations., (Copyright © 2017 Society for Nutrition Education and Behavior. Published by Elsevier Inc. All rights reserved.)

Background: Louisiana has one of the highest rates of overweight and obese children in the United States. The Healthy School Food Collaborative (HSFC) was created to allow New Orleans's schools to select their own healthy school Food Service Provider (FSP) with requirements for higher nutritional standards than traditional options. The goal of this cross-sectional study was to examine whether HSFC membership was associated with lunch consumption rates in elementary school children., Methods: An 8-week plate waste study examining 18,070 trays of food among fourth and fifth graders was conducted. Participants included 7 schools and the 3 FSPs (2 HSFC and 1 non-HSFC member) that serviced them. Mixed models analysis examined whether consumption rates of food items differed among FSPs., Results: On average, students consumed 307 cal during lunch. Analyses showed significant differences in consumption rates of entrée, vegetables, fruit, and milk between the 3 FSPs (p < .01). The highest consumption rate was among entrées at 65%. One HSFC provider had consumption levels consistent with the non-HSFC FSP., Conclusions: Overall, students consumed less than 60% of the US Department of Agriculture recommended calories for school lunch. While overall caloric consumption was higher among the non-HSFC schools, interventions to increase lunch consumption across all schools are needed., (© 2018, American School Health Association.)

Purpose: To examine the workplace food and physical activity (PA) environments and wellness culture reported by employed United States adults, overall and by employer size., Design: Cross-sectional study using web-based survey on wellness policies and environmental supports for healthy eating and PA., Setting: Worksites in the United States., Participants: A total of 2101 adults employed outside the home., Measures: Survey items were based on the Centers for Disease Control and Prevention Worksite Health ScoreCard and Checklist of Health Promotion Environments and included the availability and promotion of healthy food items, nutrition education, promotion of breast-feeding, availability of PA amenities and programs, facility discounts, time for PA, stairwell signage, health promotion programs, and health risk assessments., Analysis: Descriptive statistics were used to examine the prevalence of worksite environmental and facility supports by employer size (<100 or ≥100 employees). Chi-square tests were used to examine the differences by employer size., Results: Among employed respondents with workplace food or drink vending machines, approximately 35% indicated the availability of healthy items. Regarding PA, 30.9% of respondents reported that their employer provided opportunities to be physically active and 17.6% reported worksite exercise facilities. Wellness programs were reported by 53.2% working for large employers, compared to 18.1% for smaller employers., Conclusion: Employee reports suggested that workplace supports for healthy eating, PA, and wellness were limited and were less common among smaller employers.

Purpose: To examine differences in students' access to school salad bars across sociodemographic groups and changes in availability over time., Design: Nonexperimental., Setting: Nationally representative 2011 and 2014 YouthStyles surveys., Participants: A total of 833 (2011) and 994 (2014) US youth aged 12 to 17 years., Measures: Youth-reported availability of school salad bars., Analysis: Multivariable logistic regression models were used to assess differences in school salad bar availability by sociodemographics and changes in availability from 2011 to 2014., Results: Youth-reported salad bar availability differed by age in 2011 and race/ethnicity in 2014, but not by sex, income, metropolitan residence, or region in either year. Salad bars were reported by 62% of youth in 2011 and 67% in 2014; the increase was not statistically significant ( P = .07). Significant increases from 2011 to 2014 were noted among youth aged 12 to 14 years (56%-69%; P < .01), youth of non-Hispanic other races (60%-85%; P < .01), and youth in the Midwest (58%-72%; P = .01)., Conclusion: These results suggest that youth-reported access to school salad bars does not differ significantly across most sociodemographic groups. Although overall salad bar availability did not increase significantly from 2011 to 2014, some increases were observed among subgroups. Continued efforts to promote school salad bars through initiatives such as Let's Move Salad Bars to Schools could help increase access for the nearly one-third of US youth reporting no access.

The purpose of this study was to characterize the population of seniors on Meals on Wheels' (MOW) waiting lists and identify their rate of depression, anxiety, falls, and fear of falling. Data come from surveys of 626 seniors on waiting lists across the country and the 2013 National Health and Aging Trends Study (NHATS). Results suggest that seniors on waiting lists for MOW were more likely to be widowed, less educated, older, Black, Hispanic, and receive Medicaid than the population of community-dwelling older adults. In addition, 31% of seniors on MOW waiting lists were depressed, compared with 12% of seniors in the national population ( p < .001), and 28% exhibited signs and symptoms of anxiety, compared with 10% of the national population of seniors ( p < .001). Seniors on waiting lists were significantly more likely to have fallen in the last month and be fearful of falling than the national population of seniors ( p < .001). Individuals on MOW waiting lists are a vulnerable and high-risk group. By seeking to better understand clients' needs, appropriate services can be tailored to promote independent living and improve older adults' well-being.

Background: We attempted to determine effects of the United States Department of Agriculture (USDA) Fresh Fruit and Vegetable Program (FFVP) on variety and frequency of fruit and vegetable intake by students in schools from different locales., Methods: Data were derived from the 2011-2012 Indiana FFVP Student Survey completed by 4229 fourth-sixth graders. Effects were studied within 2 groups, 39 city and suburb schools, and 12 town and rural schools. Differences in students' responses over time to 2 items measuring variety and 10 items measuring fruit and vegetable intake frequency were determined with multilevel regression models., Results: Town and rural students were 1.2 times more likely to eat different kinds of fruit (p = .04) and vegetables (p = .01) daily, and increased fruit (+1.0 time/day; p < .01) and vegetable intake frequency (+0.5 times/day; p = .03). City and suburb students increased fruit intake frequency (∼0.8 times/day; p < .01) but not vegetable intake frequency or daily variety (p > .05)., Conclusions: FFVP improved fruit and vegetable eating behaviors in the "town and rural" group, but was only partially effective in the "city and suburb" group. Strategies to implement FFVP may need to differ depending on school locale., (© 2016, American School Health Association.)

Students consume up to half of their daily calories at school, often through the federal school meal programs (e.g., National School Lunch Program) administered by the U.S. Department of Agriculture (USDA). In 2012, USDA published new required nutrition standards for school meals.* These standards were the first major revision to the school meal programs in >15 years and reflect current national dietary guidance and Institute of Medicine recommendations to meet students' nutrition needs. The standards require serving more fruits, vegetables, and whole grains and gradually reducing sodium content over 10 years. To examine the prevalence of school-level practices related to implementation of the nutrition standards, CDC analyzed data from the 2000, 2006, and 2014 School Health Policies and Practices Study (SHPPS) on school nutrition services practices related to fruits, vegetables, whole grains, and sodium. Almost all schools offered whole grain foods each day for breakfast and lunch, and most offered two or more vegetables and two or more fruits each day for lunch. The percentage of schools implementing practices to increase availability of fruits and vegetables and decrease sodium content in school meals increased from 2000-2014. However, opportunities exist to increase the percentage of schools nationwide implementing these practices.

Tobacco use is the leading cause of preventable disease and death in the United States. One of the Healthy People 2020 objectives calls for reducing the proportion of U.S. adults who smoke cigarettes to ≤12% (objective TU-1.1). Despite progress in reducing smoking prevalence over the past several decades, nearly one in five U.S. adults, including millions of workers, still smoke cigarettes. During 2004-2010, nearly one fifth (19.6%) of U.S. working adults aged ≥18 years smoked cigarettes, and of all the industry sectors, current smoking prevalence among the accommodation and food services sector workers (30%) was the highest. CDC analyzed National Health Interview Survey (NHIS) data for 2011-2013 to estimate current cigarette smoking prevalence among adults working in the accommodation and food services sector, and found that these workers had higher cigarette smoking prevalence (25.9%) than all other workers (17.3%). Among workers in accommodation and food services sector, the highest smoking prevalences were observed among males, non-Hispanic whites, those aged 25-44 years, those with a high school diploma or a General Educational Development (GED) certificate and no college education, those with an annual family income <$35,000, those with no health insurance, and those working in the food services and drinking places industry. These results indicate a need to better understand the reasons for higher smoking prevalence observed among accommodation and food services workers (e.g., workplace culture), so that appropriate intervention strategies can be developed and implemented. Evidence suggests that smoke-free worksites and workplace cessation programs, including comprehensive worksite smoke-free policies, health promotion, access to smoking cessation programs, and increasing the cost of tobacco products, can substantially reduce smoking among workers.

Background: The 2010 Healthy, Hunger-Free Kids Act required the USDA to update the nutrition standards of the National School Lunch Program. New policies were implemented in the 2012-2013 school year. These changes were followed by anecdotal reports of increased food waste. Empirical research is needed to reliably measure student intake and plate waste before and after this policy change., Methods: Food consumption and waste was collected annually from a cohort of middle school students in 12 schools in an urban, low-income school district before (spring 2012) and after (spring 2013 and 2014) policy changes. Generalized linear regression was used to compare pre- versus postpolicy selection and consumption of entrées, fruits, vegetables, and milk., Results: Comparing 2012 to 2014, the percentage of students choosing fruit significantly increased from 54% to 66% and fruit consumption remained high at 74%. Student selection of fruit increased by 9% for each additional type of fruit offered with the meal. The proportion of students who chose a vegetable dropped from 68% to 52%, but students selecting vegetables ate nearly 20% more of them, effectively lowering vegetable waste. Entrée consumption increased significantly from 71% to 84%, thereby also decreasing waste., Conclusions: Students responded positively to the new lunches. They consumed more fruit, threw away less of the entrees and vegetables, and consumed the same amount of milk. Overall, the revised meal standards and policies appear to have significantly lowered plate waste in school cafeterias.

Introduction: Joint use or shared use of public school facilities provides community access to facilities for varied purposes. We examined a nationally representative sample of school districts in the United States to identify characteristics associated with having a formal joint use agreement (JUA) and with the kinds of uses to which JUAs apply., Methods: We analyzed data from the 2012 School Health Policies and Practices Study. The response rate for the module containing questions about formal JUAs was 60.1% (N = 630). We used multivariate logistic regression models to examine the adjusted odds of having a formal JUA and χ(2) analyses to examine differences in district characteristics associated with the uses of the JUA., Results: Among the 61.6% of school districts with a formal JUA, more than 80% had an agreement for the use of indoor and outdoor recreation facilities; other uses also were identified. JUAs were more common in urban than rural areas, in large than small school districts, and in the West compared with the Midwest, South, and Northeast., Conclusion: In many districts, school facilities appear to be an untapped resource for community members. Formal JUAs provide an opportunity for shared use while addressing issues of liability, cost, and logistics.

Importance: The latest US Department of Agriculture school meal and competitive venue standards (USDA standards) aim to improve student nutrition and health. However, significant opposition has been raised to their implementation., Objective: To examine (1) the percentages of US middle and high school students who currently attend schools that have specific components of the USDA standards; (2) evidence that the identified USDA standard components may be associated with student overweight/obesity; and (3) evidence of sociodemographic differences in the observed associations., Design, Setting, and Participants: We used data from annual nationally representative cross-sectional studies of students and school administrators in US public middle and high schools from the 2007-2008 through 2011-2012 school years., Exposures: Administrator-reported school meal and competitive venue food and beverage availability., Main Outcomes and Measures: Body mass index and overweight/obesity calculated from student self-reported height and weight., Results: Analytical samples included 22716 eighth grade students in 313 schools and 30596 tenth and 12th grade students in 511 schools. The mean student response rate was 86.5%; mean school administrator response rate, 83.1%. During the study period, 21.1% of middle school and 30.1% of high school students attended schools without any of the identified components; all 5 identified components were in schools attended by only 1.8% and 0.3% of middle school and high school students, respectively. No significant associations between standard components and self-reported overweight/obesity were observed among middle school students overall. Among high school students, significantly lower odds of overweight/obesity were associated with having fruits or vegetables available wherever foods were sold (adjusted odds ratio [AOR], 0.86 [95% CI, 0.77-0.96]; P=.009), the absence of milk with higher fat levels (AOR, 0.92 [95% CI, 0.85-1.00]; P=.04), and having 3 or more USDA standard components (AOR, 0.89 [95% CI, 0.79-1.00]; P=.04). A significant association between the absence of sugar-sweetened beverages and lower overweight/obesity was found for Hispanic middle school students (AOR, 0.65 [95% CI, 0.51-0.82]; P<.001) and nonwhite high school students (AOR, 0.80 [95% CI, 0.70-0.91]; P=.001)., Conclusions and Relevance: Because only 2% of middle school and less than 1% of high school students attended schools with all 5 identified USDA standard components in place, full implementation has the potential to substantially improve school nutritional environments. Some USDA standard components were associated with a lower risk for student overweight/obesity, especially for high school and nonwhite students.

Importance: Short-term impacts of breakfast consumption on diet quality and cognitive functioning have been reported, but more evidence is needed to draw causal inferences about long-term impacts of school breakfast on indicators of school engagement and academic achievement., Objective: To estimate the impact of a Breakfast in the Classroom (BIC) program on School Breakfast Program participation, school attendance, and academic achievement., Design, Setting, and Participants: This quasi-experimental study included a sample of 446 public elementary schools from a large, urban US school district that served predominantly low-income, racial/ethnic minority students., Interventions: A total of 257 schools (57.6%) implemented a BIC program during the 2012-2013 academic year, whereas 189 (42.4%) did not., Main Outcomes and Measures: School- and grade-level data from 2012-2013 and grade-level achievement data from the prior year were collected from school district records across the elementary schools. Hypotheses that a BIC program would improve school breakfast participation at the school level, school attendance at the grade level (kindergarten through sixth grade), and academic achievement at the grade level (second through sixth grades) were tested using propensity score weights to adjust for demographic differences between the BIC and non-BIC schools., Results: The BIC program was linked with increased breakfast participation during the academic year (F10,414=136.90, P<.001), with mean participation rates of 73.7% in the BIC group vs 42.9% in the non-BIC group. The BIC program was also linked with greater overall school attendance rates (95.5% vs 95.3% in the non-BIC group; F1,2772=8.40, P = .004). When performing attendance analyses in the subset of grade levels for which achievement data were available, results were mostly consistent, although there was a group × time interaction (F10,1891=1.94, P=.04) such that differences between least squares means in the BIC vs non-BIC groups did not reach statistical significance at every month. There were no group differences in standardized test performance in math (57.9% in the BIC group vs 57.4% in the non-BIC group; F1,1890=0.41, P=.52) or reading (44.9% in the BIC group vs 44.7% in the non-BIC group; F1,1890=0.15, P=.70)., Conclusions and Relevance: Findings add to the evidence that BIC can increase school breakfast participation substantially and suggest that it has the potential to improve overall school attendance rates. Additional research is needed to explore the generalizability of these findings and the potential impacts on achievement for longer periods and on additional outcomes, such as weight status.

Nutrition interventions are important as the older population, most of whom live in the community, increases in size and diversity. They are key to leading a healthy, functional life and mitigating chronic health conditions. The Older Americans Act Nutrition Program served 86.3 million congregate and 137.4 million home-delivered meals to 1.6 million and 850,000 older adults, respectively (2012). Congregate and home-delivered participants were older, poorer, sicker, more functionally impaired, and at a greater risk of institutionalization than the general U.S. older population. The Nutrition Program is publically and privately funded. About 44% of congregate and 30% of home-delivered expenditures are from federal sources, which dropped from $25 per older adult in 1990 to $12 in 2013. Despite multiple funding sources, funding is insufficient for the expanding older population. Health, nutrition, and social service professionals need to coordinate their community-based services to truly help older adults remain in their homes.

Objective: To compare changes in nutrient levels of school meals before and after implementation of nutrition interventions at five school districts in two, large U.S. counties. School menu changes were compared against national school meal recommendations., Methods: A large urban school district in Los Angeles County (LAC), California and four school districts in suburban Cook County (SCC), Illinois implemented school meal nutrition interventions. Nutrition analyses were conducted for school breakfast and lunch before and after changes were made to the meal programs. Means, % change, and net calories (kilocalories or kcal) offered as a result of the nutrition interventions were calculated., Results: School districts in both counties made district-wide changes in their school breakfast and lunch menus. Menu changes resulted in a net reduction of calories, sugar, and sodium content offered in the meals. Net fewer calories offered as a result of the nutrition interventions were estimated to be about 64,075kcal per student per year for LAC and 22,887kcal per student per year for SCC., Conclusions: Nutrition interventions can have broad reach through changes in menu offerings to school-aged children and adolescents. However, further research is needed to examine how these changes affect student food selection and consumption., (Copyright © 2014 Elsevier Inc. All rights reserved.)

The U.S. social safety net is formed by governmental and nonprofit organizations, which are trying to respond to record levels of need. This is especially true for local level organizations, such as food pantries. The organizational capacity literature has not covered front-line, local, mostly volunteer and low resource organizations in the same depth as larger ones. This analysis is a consideration of whether grassroots nonprofit organizations have the ability to be a strong component of the social safety net. Based on the literature on organizational capacity, a model is developed to examine how service delivery at the local level is affected by organizational capacity. Surprisingly, we find few of the characteristics previously identified as important are statistically significant in this study. Even when so, the material effect is negligible. Current organizational capacity research may apply to larger nonprofits, but not to the tens of thousands of small community nonprofits, a significant limitation to the research to date.

Background: The U.S Department of Agriculture (USDA) recently made substantial changes to the school meal standards. The media and public outcry have suggested that this has led to substantially more food waste., Purpose: School meal selection, consumption, and waste were assessed before and after implementation of the new school meal standards., Methods: Plate waste data were collected in four schools in an urban, low-income school district. Logistic regression and mixed-model ANOVA were used to estimate the differences in selection and consumption of school meals before (fall 2011) and after implementation (fall 2012) of the new standards among 1030 elementary and middle school children. Analyses were conducted in 2013., Results: After the new standards were implemented, fruit selection increased by 23.0% and entrée and vegetable selection remained unchanged. Additionally, post-implementation entrée consumption increased by 15.6%, vegetable consumption increased by 16.2%, and fruit consumption remained the same. Milk selection and consumption decreased owing to an unrelated milk policy change., Conclusions: Although food waste levels were substantial both pre- and post-implementation, the new guidelines have positively affected school meal selection and consumption. Despite the increased vegetable portion size requirement, consumption increased and led to significantly more cups of vegetables consumed. Significantly more students selected a fruit, whereas the overall percentage of fruit consumed remained the same, resulting in more students consuming fruits. Contrary to media reports, these results suggest that the new school meal standards have improved students' overall diet quality. Legislation to weaken the standards is not warranted., (Copyright © 2014 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to examine non-robbery-related occupational homicides in the retail industry from 2003 to 2008., Methods: Data were abstracted from the Census of Fatal Occupational Injuries. Motive (robbery- or non-robbery-related) and workplace violence (WPV) typology (Type I-IV) were assigned using narrative text fields. Non-robbery-related homicide rates were calculated and compared among WPV types, demographic characteristics, and occupation., Results: Twenty-eight percent of homicides that occurred in the retail industry were non-robbery-related. The leading event associated with non-robbery-related homicides was Type II (perpetrated by customers) (34%), followed by Type IV (perpetrated by personal relationship) (31%). The majority of homicides were due to arguments (50%). Security guards and workers in drinking establishments had the highest homicide rates per 100,000 workers (14.3 and 6.0, respectively)., Conclusions: Non-robbery-related homicides comprised a meaningful proportion of workplace homicides in the retail industry. Research is needed to develop strategies to prevent non-robbery-related homicides specifically., (© 2013 Wiley Periodicals, Inc.)