Allison Hedley Dodd

Association between School Food Environment and Practices and Body Mass Index of US Public School Children

BACKGROUND With the ongoing interest in implementing school policies to address the problem of childhood obesity, there is a need for information about the relationships between school food environments and practices and childrens weight status. OBJECTIVE To examine the association between school food environments and practices and childrens body mass index (BMI; calculated as kg/m(2)). DESIGN The study used data from the third School Nutrition Dietary Assessment Study, a cross-sectional study that included a national sample of public school districts, schools, and children in the 2004-2005 school year. Data on school food environments and practices were collected through on-site observations and interviews with school principals, and children were weighed and measured by trained data collectors. SUBJECTS/SETTING The study included 287 schools and 2,228 children in grades 1 through 12. STATISTICAL ANALYSES PERFORMED Ordinary least squares regression was used to estimate the associations between school food environments and practices and BMI z scores and logistic regression was used to estimate associations between school food environments and practices and the likelihood of obesity (defined as BMI-for-age >or=95th percentile). Models included controls for sociodemographic characteristics of schools and children, to control for potential endogeneity of school environments and practices, as well as controls for childrens dietary and physical activity behaviors outside of school. RESULTS Among elementary school children, offering french fries and similar potato products in subsidized school meals more than once per week and offering dessert more than once per week were each associated with a significantly higher likelihood of obesity. Among middle school children, the availability of low-nutrient, energy-dense foods in vending machines in or near the foodservice area was associated with a higher BMI z score, and the availability of such foods for à la carte purchase in the cafeteria was associated with a lower BMI z score. CONCLUSIONS Findings from this analysis suggest that limiting childrens access to low-nutrient, energy-dense foods at school may hold promise as a tactic for reducing childrens total calorie intake and controlling childrens BMI.

Treatment approach and HbA1c control among US adults with type 2 diabetes: NHANES 1999-2004

ABSTRACT Objective: To examine the distribution of diabetic medications among adults with type 2 diabetes, and the association between glucose control and treatment approach in the US population. Methods: Interview and prescription medication data from the 1999–2004 National Health and Nutrition Examination Survey (NHANES) were used to determine the treatment approach for US adults with type 2 diabetes. Mean glycosylated hemoglobin (HbA1c) and the proportion of adults meeting recommended guidelines for glucose control were estimated for each treatment approach. The most important study limitation was that participants were not asked what type of diabetes they had. Among adults with diabetes, a classification algorithm was used to identify those with type 2 diabetes. Results: During 1999–2004, approximately 60% of adults with type 2 diabetes used oral agents only to manage their diabetes. The distribution of oral treatment therapies changed over time (p < 0.01); the most prevalent treatment shifted from sulfonylurea monotherapy in 1999–2000 (23.0%) to any oral agent regimen containing thiazolidinedione (TZD) in 2003–2004 (21.4%). Overall, only 52.2% of adults with type 2 diabetes met the American Diabetes Association (ADA) goal for HbA1c control (<7.0%) during 1999–2004. Across oral agent treatment categories, the proportion with HbA1c controlled at the 7.0 level was significantly lower (p < 0.01) for those on triple therapy (31.9%) (TZD, sulfonylurea, and metformin), than those on metformin alone (62.2%), likely reflecting a progressive treatment approach of prescribing additional medications for those with uncontrolled HbA1c levels. Conclusions: Use of multiple oral agents among adults with type 2 diabetes has increased (sulfonylurea and metformin, p = 0.03, triple therapy, p = 0.02). However, nearly half of adults with type 2 diabetes have HbA1c levels above ADA guidelines for control, indicating that available treatments could be used more optimally, and new diabetic agents may be needed.

Reducing calories and added sugars by improving children's beverage choices.

Because childhood obesity is such a threat to the physical, mental, and social health of youth, there is a great need to identify effective strategies to reduce its prevalence. The objective of this study was to estimate the mean calories from added sugars that are saved by switching sugar-sweetened beverages (including soda, fruit-flavored drinks, and sport drinks) and flavored milks consumed to unflavored low-fat milk (<1% fat) at meals and water between meals. Simulation analyses used 24-hour dietary recall data from the third School Nutrition Dietary Assessment Study (n=2,314), a 2005 national cross-sectional study of schools and students participating in the National School Lunch Program, to estimate changes in mean calories from added sugars both at and away from school. Overall, these changes translated to a mean of 205 calories or a 10% savings in energy intake across all students (8% among children in elementary school and 11% in middle and high schools). Eighty percent of the daily savings were attributed to beverages consumed away from school, with results consistent across school level, sex, race/ethnicity, and weight status. Childrens consumption of sugar-sweetened beverages at home contributed the greatest share of empty calories from added sugars. Such findings indicate that parental education should focus on the importance of reducing or eliminating sugar-sweetened beverages served at home. This conclusion has implications for improving childrens food and beverage environments for food and nutrition educators and practitioners, other health care professionals, policy makers, researchers, and parents.

Disparities in Consumption of Sugar-Sweetened and Other Beverages by Race/Ethnicity and Obesity Status among United States Schoolchildren.

OBJECTIVE Identify disparities by race/ethnicity and obesity status in the consumption of sugar-sweetened beverages (SSBs) and other beverages among United States schoolchildren to help tailor interventions to reduce childhood obesity. DESIGN Secondary data analysis using beverage intake data from 24-hour dietary recalls and measured height and weight from the third School Nutrition Dietary Assessment Study, a 2004-2005 nationally representative sample of school-aged children and schools. SETTING Schools participating in the National School Lunch Program (n = 287). PARTICIPANTS Children in grades 1-12 with a completed 24-hour dietary recall (n = 2,314). MAIN OUTCOME MEASURE(S) Percentage of children consuming beverages in 8 beverage categories by school level and consumption location. ANALYSIS Two-tailed t tests to determine significant differences (P < .05) between the proportions of children consuming beverages by race/ethnicity and weight status. RESULTS Beverage consumption patterns did not substantially differ across weight status groups, but they differed by race/ethnicity in the home. Non-Hispanic black elementary schoolchildren consumed nonsoda SSBs more often and unflavored, low-fat milk less often at home than non-Hispanic white schoolchildren. CONCLUSIONS AND IMPLICATIONS Higher consumption of SSBs coupled with a lower consumption of milk is disproportionately affecting non-Hispanic black schoolchildren. Targeted interventions by racial/ethnic group are needed to promote more healthful beverage choices among schoolchildren, particularly at home.

National and state trends in enrollment and spending for dual eligibles under age 65 in Medicaid managed care

BACKGROUND To reduce costs and improve care, states are increasingly enrolling individuals with disabilities in Medicaid managed care. Many states allow or require adults who are dually eligible for Medicaid and Medicare to enroll in these plans. OBJECTIVE This study (1) quantifies changes in enrollment by managed care arrangement for duals under age 65, between 2005 and 2008 and (2) compares enrollment and spending between dual eligibles and Medicaid-only beneficiaries. METHODS We used Medicaid Analytic eXtract data to compare the Medicaid enrollment and spending for all-year, full-benefit dual eligibles ages 21-64 with that of Medicaid-only Supplemental Security Income (SSI) and disabled beneficiaries. The study population was classified into 9 types of managed care to quantify enrollment and calculate expenditures by year. RESULTS Nationwide, the proportion of adult duals in managed care increased from 2005 to 2008, with the expansion of prepaid health plans (PHPs) (31.0%-46.6%), particularly behavioral health PHPs, driving the increase. In 2008, Medicaid-only disabled adults were three times as likely as dual adults to enroll in comprehensive managed care (CMC) (35.1% versus 11.7%). Average Medicaid expenditures per enrollee differed markedly by managed care arrangement and state. CONCLUSIONS From 2005 to 2008, there was little expansion of CMC among adult duals, while the use of PHPs to cover carved out services increased greatly. New federal initiatives aim to reduce barriers to enrolling duals into comprehensive, integrated managed care. With expanded enrollment, it will be important to monitor enrollment and evaluate whether integration improves care.