Janice Kao

To what extent have sweetened beverages contributed to the obesity epidemic

OBJECTIVE A systematic literature review was conducted to determine whether sweetened beverage intake increases the risk for obesity, and the extent to which it has contributed to recent increases in energy intake and adiposity in the USA. DESIGN The search included studies published between 1970 and 2010 that examined secular trends, mechanisms, observational associations and intervention outcomes. Observational and intervention studies were abstracted and systematically evaluated for quality. SETTING Trends in obesity prevalence in the USA and studies from industrialized (developed) countries were included. SUBJECTS Studies were included for all ages, genders, ethnic and socio-economic groups for which data were available. RESULTS Obesity rates and sweetened beverage intake have increased in tandem in the USA. Studies consistently show that higher intake of sweetened beverages is associated with higher energy intake. Energy in liquid form is not well compensated for by reductions in the intake of other sources of energy. Well-designed observational studies consistently show a significant positive relationship between sweetened beverage intake and adiposity. More importantly, several well-conducted randomized controlled trials have shown statistically significant changes in adiposity as a result of corresponding changes in sweetened beverage intake. CONCLUSIONS All lines of evidence consistently support the conclusion that the consumption of sweetened beverages has contributed to the obesity epidemic. It is estimated that sweetened beverages account for at least one-fifth of the weight gained between 1977 and 2007 in the US population. Actions that are successful in reducing sweetened beverage consumption are likely to have a measurable impact on obesity.

Lessons Learned From Evaluations of California's Statewide School Nutrition Standards

OBJECTIVES We assessed the impact of legislation that established nutrition standards for foods and beverages that compete with reimbursable school meals in California. METHODS We used documentation of available foods and beverages, sales accounts, and surveys of and interviews with students and food service workers to conduct 3 studies measuring pre- and postlegislation food and beverage availability, sales, and student consumption at 99 schools. RESULTS Availability of nutrition standard-compliant foods and beverages increased. Availability of noncompliant items decreased, with the biggest reductions in sodas and other sweetened beverages, regular chips, and candy. At-school consumption of some noncompliant foods dropped; at-home consumption of selected noncompliant foods did not increase. Food and beverage sales decreased at most venues, and food service à la carte revenue losses were usually offset by increased meal program participation. Increased food service expenditures outpaced revenue increases. CONCLUSIONS Regulation of competitive foods improved school food environments and student nutritional intake. Improvements were modest, partly because many compliant items are fat- and sugar-modified products of low nutritional value. Additional policies and actions are needed to achieve more substantive improvements in school nutrition environments and student nutrition and health.

Is scratch-cooking a cost-effective way to prepare healthy school meals with US Department of Agriculture foods?

BACKGROUND Despite the resurgence of interest in scratch-cooking as a way to increase the quality and appeal of school meals, many school districts are concerned about the cost implications of switching to scratch-cooking. US Department of Agriculture (USDA) Foods are the single largest source of ingredients for school meals, and about half of USDA Foods are diverted for processing before being sent to the school district. OBJECTIVE We aimed to determine whether school lunch entrées made in a district from basic or raw USDA Foods ingredients can be healthier and less expensive to prepare than those sent to external processors. DESIGN/SETTING This cross-sectional study examined the relationship between the extent of scratch-cooking and the nutritional content and cost to prepare entrées. Information was gathered by interview with school foodservice personnel and from school foodservice records from a convenience sample of 10 school districts in California that employed varying degrees of scratch-cooking and is diverse in terms of geographic location and the sociodemographics of the student body. The sample included all elementary school lunch entrées that contain USDA Foods offered during October 2010 for a total sample of 146 entrées. STATISTICAL ANALYSES Ordinary least squares regressions were used to test for statistically significant differences in cost and nutrient content of entrées according to the level of scratch-cooking. RESULTS There was no significant relationship between total costs and level of scratch-cooking. Entrées with the highest scratch-cooking scores had significantly lower food costs, higher labor costs, and not significantly different total costs compared with entrées with no scratch-cooking. Nutrient content was not consistently associated with scratch-cooking, but scratch-cooked entrées did include a larger variety of non-fast-food-type entrées. CONCLUSIONS The findings suggest that scratch-cooking can be a cost-effective way to expand the variety of healthy school lunches prepared with USDA Foods.

Does Competitive Food and Beverage Legislation Hurt Meal Participation or Revenues in High Schools

BACKGROUND There is limited evidence to evaluate the influence of competitive food and beverage legislation on school meal program participation and revenues. METHODS A representative sample of 56 California high schools was recruited to collect school-level data before (2006–2007) and the year after (2007–2008) policies regarding limiting competitive foods and beverages were required to be implemented. Data were obtained from school records, observations, and questionnaires. Paired t-tests assessed significance of change between the two time points. RESULTS Average participation in lunch increased from 21.7% to 25.3% (p < 0.001), representing a 17.0% increase, while average participation in breakfast increased from 8.9% to 10.3% (p = 0.02), representing a 16.0% increase. There was a significant (23.0%) increase in average meal revenue, from

Improvements in Physical Activity Opportunities: Results From a Community-Based Family Child Care Intervention

0.70 to

Changes in Nutrition Policies and Dietary Intake in Child Care Homes Participating in Healthy Eating and Active Living Initiative

0.86 (per student per day) (p < 0.001). There was a nonsignificant decrease (18.0%) in average sales from à la carte foods, from

Changes in Consumer Purchases in Stores Participating in an Obesity Prevention Initiative

0.45 to

School Wellness Committees Are Associated With Lower Body Mass Index Z-Scores and Improved Dietary Intakes in US Children: The Healthy Communities Study

0.37 (per student per day). Compliance with food and beverage standards also increased significantly. At end point, compliance with beverage standards was higher (71.0%) than compliance with food standards (65.7%). CONCLUSION Competitive food and beverage legislation can increase food service revenues when accompanied by increased rates of participation in the meal program. Future studies collecting expense data will be needed to determine impact on net revenues.

To What Extent Have High Schools in California Been Able to Implement State-Mandated Nutrition Standards?

INTRODUCTION Reaching preschool-aged children to establish healthy lifestyle habits, including physical activity, is an important component of obesity prevention efforts. However, few studies have examined family child care homes where nearly 1 million children receive care. STUDY DESIGN A pre- and post-intervention evaluation without a control group was conducted to evaluate what changes occurred in family child care homes that participated in the Healthy Eating and Active Living project, a multicomponent obesity prevention initiative, focused on community-driven policy and environmental change in neighborhoods within Kaiser Permanente service areas. SETTING/PARTICIPANTS From 2012 to 2014, a total of 17 family child care homes in Northern California participated in the intervention. INTERVENTION A physical activity workshop for child care staff and technical assistance to develop a policy to promote physical activity and other healthy behaviors. MAIN OUTCOME MEASURES Pre and post observations, questionnaires, and physical activity logs were completed to assess change in physical activity resources available in the family child care homes, the amount of child screen time offered, type and amount of physical activity offered to children, and implementation of physical activity best practices. RESULTS Between baseline and follow-up, providers significantly increased both the number of structured, adult-led activities (2.6 vs 3.2 activities per day) and the number of structured, adult-led minutes of activity in which children participated (49 vs 83 minutes per day). Providers also improved screen time practices and made improvements to the physical activity environment. CONCLUSIONS In this study, a community-based organization designed and implemented multicomponent strategies tailored for participating family child care homes. The successful implementation of the intervention likely contributed to implementation of practices that increased opportunities for physical activity for the young children attending these family child care homes. SUPPLEMENT INFORMATION This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

The Healthy Communities Study Nutrition Assessments: Child Diet and the School Nutrition Environment.

INTRODUCTION From 2012 to 2014, a total of 17 family child care homes participated in a multisector, community-wide initiative to prevent obesity. Strategies included staff workshops, materials, site visits, and technical assistance regarding development and implementation of nutrition policies. The purpose of the evaluation was to examine the impact of the initiative on family child care home nutrition-related policies and practices and child dietary intake. STUDY DESIGN Pre- and post-intervention without control group. Measures taken at baseline and follow-up included structured observations and questionnaires regarding nutrition policies, practices, and environments; documentation of lunch foods served on 5 days; and lunch plate waste observations on 2 days. Paired t-tests were used to determine the significance of change over time. SETTING/PARTICIPANTS Seventeen family child care homes in a low-income diverse community in Northern California; children aged 2-5 years who attended the family child care homes. MAIN OUTCOME MEASURES Change in nutrition-related policies and practices, lunch foods served and consumed. RESULTS Data was collected at 17 sites for an average of 5.2 children aged 2-5 years per site per day at baseline and 4.6 at follow-up for a total of 333 plate waste observations. There were significant increases in staff training, parental involvement, and several of the targeted nutrition-related practices; prevalence of most other practices either improved or was maintained over time. There were significant increases in the number of sites meeting Child and Adult Care Food Program meal guidelines, variety of fruit and frequency of vegetables offered, and reductions in frequency of juice and high-fat processed meats offered. Adequate portions of all food groups were consumed at both time points with no significant change over time. CONCLUSIONS A simple, policy-focused intervention by a child care resource and referral agency was successful at reinforcing and improving upon nutrition-related practices at family child care homes. Children consumed adequate, but not excessive, portions of the balanced meals served to them, suggesting there is no reason to offer unhealthy options. SUPPLEMENT INFORMATION This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.