Juliana F.W. Cohen

Effects of Choice Architecture and Chef-Enhanced Meals on the Selection and Consumption of Healthier School Foods: A Randomized Clinical Trial

IMPORTANCE Little is known about the long-term effect of a chef-enhanced menu on healthier food selection and consumption in school lunchrooms. In addition, it remains unclear if extended exposure to other strategies to promote healthier foods (eg, choice architecture) also improves food selection or consumption. OBJECTIVE To evaluate the short- and long-term effects of chef-enhanced meals and extended exposure to choice architecture on healthier school food selection and consumption. DESIGN, SETTING, AND PARTICIPANTS A school-based randomized clinical trial was conducted during the 2011-2012 school year among 14 elementary and middle schools in 2 urban, low-income school districts (intent-to-treat analysis). Included in the study were 2638 students in grades 3 through 8 attending participating schools (38.4% of eligible participants). INTERVENTIONS Schools were first randomized to receive a professional chef to improve school meal palatability (chef schools) or to a delayed intervention (control group). To assess the effect of choice architecture (smart café), all schools after 3 months were then randomized to the smart café intervention or to the control group. MAIN OUTCOMES AND MEASURES School food selection was recorded, and consumption was measured using plate waste methods. RESULTS After 3 months, vegetable selection increased in chef vs control schools (odds ratio [OR], 1.75; 95% CI, 1.36-2.24), but there was no effect on the selection of other components or on meal consumption. After long-term or extended exposure to the chef or smart café intervention, fruit selection increased in the chef (OR, 3.08; 95% CI, 2.23-4.25), smart café (OR, 1.45; 95% CI, 1.13-1.87), and chef plus smart café (OR, 3.10; 95% CI, 2.26-4.25) schools compared with the control schools, and consumption increased in the chef schools (OR, 0.17; 95% CI, 0.03-0.30 cups/d). Vegetable selection increased in the chef (OR, 2.54; 95% CI, 1.83-3.54), smart café (OR, 1.91; 95% CI, 1.46-2.50), and chef plus smart café schools (OR, 7.38, 95% CI, 5.26-10.35) compared with the control schools, and consumption also increased in the chef (OR, 0.16; 95% CI, 0.09-0.22 cups/d) and chef plus smart café (OR, 0.13; 95% CI, 0.05-0.19 cups/d) schools; however, the smart café intervention alone had no effect on consumption. CONCLUSIONS AND RELEVANCE Schools should consider both collaborating with chefs and using choice architecture to increase fruit and vegetable selection. Efforts to improve the taste of school foods through chef-enhanced meals should remain a priority because this was the only method that also increased consumption. This was observed only after students were repeatedly exposed to the new foods for 7 months. Therefore, schools should not abandon healthier options if they are initially met with resistance. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02309840.

Amount of Time to Eat Lunch Is Associated with Children’s Selection and Consumption of School Meal Entrée, Fruits, Vegetables, and Milk

BACKGROUND There are currently no national standards for school lunch period length and little is known about the association between the amount of time students have to eat and school food selection and consumption. OBJECTIVE Our aim was to examine plate-waste measurements from students in the control arm of the Modifying Eating and Lifestyles at School study (2011 to 2012 school year) to determine the association between amount of time to eat and school meal selection and consumption. DESIGN We used a prospective study design using up to six repeated measures among students during the school year. PARTICIPANTS/SETTING One thousand and one students in grades 3 to 8 attending six participating elementary and middle schools in an urban, low-income school district where lunch period lengths varied from 20 to 30 minutes were included. MAIN OUTCOME MEASURES School food selection and consumption were collected using plate-waste methodology. STATISTICAL ANALYSES PERFORMED Logistic regression and mixed-model analysis of variance was used to examine food selection and consumption. RESULTS Compared with meal-component selection when students had at least 25 minutes to eat, students were significantly less likely to select a fruit (44% vs 57%; P<0.0001) when they had <20 minutes to eat. There were no significant differences in entrée, milk, or vegetable selections. Among those who selected a meal component, students with <20 minutes to eat consumed 13% less of their entrée (P<0.0001), 10% less of their milk (P<0.0001), and 12% less of their vegetable (P<0.0001) compared with students who had at least 25 minutes to eat. CONCLUSIONS During the school year, a substantial number of students had insufficient time to eat, which was associated with significantly decreased entrée, milk, and vegetable consumption compared with students who had more time to eat. School policies that encourage lunches with at least 25 minutes of seated time might reduce food waste and improve dietary intake.

Maternal trans fatty acid intake and fetal growth

BACKGROUND It is unclear from previous studies whether total or common subtypes of trans fatty acids are associated with fetal growth. OBJECTIVE We examined associations of maternal trans fatty acid intake during pregnancy with fetal growth. DESIGN We studied 1369 mother-child pairs participating in Project Viva-a prospective cohort study of pregnant women and their offspring. We assessed trans fatty acid consumption by using a validated semiquantitative food-frequency questionnaire in each of the first and second trimesters of pregnancy. We estimated fetal growth as the birth-weight-for-gestational-age (BW/GA) z value in infants born at term. RESULTS We observed no associations of first-trimester trans fatty acid consumption with fetal growth. In the second trimester, the estimated mean (±SD) total trans fatty acid intake was 2.35 ± 1.07 g/d, of which 0.11 g was 16:1(n-7t), 1.78 g was 18:1(n-9t), 0.13 g was 18:2(n-6tt), 0.33 g was 18:2(n-6tc), and 0.12 g was 18:2(n-6ct). The mean (±SD) BW/GA was 0.24 ± 0.95 z score units. Total trans fatty acid consumption during the second trimester was positively associated with the fetal growth z score (0.29 units; 95% CI: 0.07, 0.51 units) for each 1% increment in energy from trans fatty acids as a replacement for carbohydrates. The associations were limited to the trans fatty acids 16:1t (0.12 units; 95% CI: 0.02, 0.22 units) and 18:2tc (0.53 units; 95% CI: 0.09, 0.96 units). CONCLUSION A higher maternal intake of trans fatty acids, especially 16:1t and 18:2tc, during the second trimester of pregnancy was associated with greater fetal growth.

Implementation of Competitive Food and Beverage Standards in a Sample of Massachusetts Schools: The NOURISH Study (Nutrition Opportunities to Understand Reforms Involving Student Health)

BACKGROUND During 2012, Massachusetts adopted comprehensive school competitive food and beverage standards that closely align with Institute of Medicine recommendations and Smart Snacks in School national standards. OBJECTIVE We examined the extent to which a sample of Massachusetts middle schools and high schools sold foods and beverages that were compliant with the state competitive food and beverage standards after the first year of implementation, and complied with four additional aspects of the regulations. DESIGN Observational cohort study with data collected before implementation (Spring 2012) and 1 year after implementation (Spring 2013). PARTICIPANTS/SETTING School districts (N=37) with at least one middle school and one high school participated. MAIN OUTCOME MEASURES Percent of competitive foods and beverages that were compliant with Massachusetts standards and compliance with four additional aspects of the regulations. Data were collected via school site visits and a foodservice director questionnaire. STATISTICAL ANALYSES PERFORMED Multilevel models were used to examine change in food and beverage compliance over time. RESULTS More products were available in high schools than middle schools at both time points. The number of competitive beverages and several categories of competitive food products sold in the sample of Massachusetts schools decreased following the implementation of the standards. Multilevel models demonstrated a 47-percentage-point increase in food and 46-percentage-point increase in beverage compliance in Massachusetts schools from 2012 to 2013. Overall, total compliance was higher for beverages than foods. CONCLUSIONS This study of a group of Massachusetts schools demonstrated the feasibility of schools making substantial changes in response to requirements for healthier competitive foods, even in the first year of implementation.

A Food Service Intervention Improves Whole Grain Access at Lunch in Rural Elementary Schools.

BACKGROUND Whole grain (WG) options are often limited in schools, which may impact rural, low-income students who rely on school meals for a substantial portion of their food intake. This study examined the changes in the availability and quantity of WG and refined grain foods offered in schools participating in the Creating Healthy, Active and Nurturing Growing-up Environments (CHANGE) study, a randomized, controlled intervention among rural communities (4 intervention and 4 control). METHODS Foods were assessed using production records, recipes, and nutrition labels from breakfast and lunch over 1 week during fall 2008 and spring 2009. Key informant interviews were conducted with school food service directors in the spring 2009. RESULTS The CHANGE intervention schools significantly increased the average percent of school days WGs were offered (p = .047) and the amount of WGs offered/food item (ounces) at lunch compared with control schools (p = .02). There was a significant decrease in the percent of students with access to refined grains at lunch compared with control schools (p = .049), although there were no significant differences in WG availability during breakfast. CONCLUSIONS The CHANGE schools improved WG availability, enabling students WG consumption to be closer to national recommendations.

How Do We Actually Put Smarter Snacks in Schools? NOURISH (Nutrition Opportunities to Understand Reforms Involving Student Health) Conversations with Food-Service Directors

OBJECTIVE In autumn 2012, Massachusetts schools implemented comprehensive competitive food and beverage standards similar to the US Department of Agricultures Smart Snacks in School standards. We explored major themes raised by food-service directors (FSD) regarding their school-district-wide implementation of the standards. DESIGN For this qualitative study, part of a larger mixed-methods study, compliance was measured via direct observation of foods and beverages during school site visits in spring 2013 and 2014, calculated to ascertain the percentage of compliant products available to students. Semi-structured interviews with school FSD conducted in each year were analysed for major implementation themes; those raised by more than two-thirds of participating school districts were explored in relationship to compliance. SETTING Massachusetts school districts (2013: n 26; 2014: n 21). SUBJECTS Data collected from FSD. RESULTS Seven major themes were raised by more than two-thirds of participating school districts (range 69-100 %): taking measures for successful transition; communicating with vendors/manufacturers; using tools to identify compliant foods and beverages; receiving support from leadership; grappling with issues not covered by the law; anticipating changes in sales of competitive foods and beverages; and anticipating changes in sales of school meals. Each theme was mentioned by the majority of more-compliant school districts (65-81 %), with themes being raised more frequently after the second year of implementation (range increase 4-14 %). CONCLUSIONS FSD in more-compliant districts were more likely to talk about themes than those in less-compliant districts. Identified themes suggest best-practice recommendations likely useful for school districts implementing the final Smart Snacks in School standards, effective July 2016.

Associations of Prenatal and Child Sugar Intake With Child Cognition

INTRODUCTION Sugar consumption among Americans is above recommended limits, and excess sugar intake may influence cognition. The aim of this study was to examine associations of pregnancy and offspring sugar consumption (sucrose, fructose) with child cognition. Additionally, associations of maternal and child consumption of sugar-sweetened beverages (SSBs), other beverages (diet soda, juice), and fruit with child cognition were examined. METHODS Among 1,234 mother-child pairs enrolled 1999-2002 in Project Viva, a pre-birth cohort, in 2017 diet was assessed during pregnancy and early childhood, and cognitive outcomes in early and mid-childhood (median ages 3.3 and 7.7 years). Analyses used linear regression models adjusted for maternal and child characteristics. RESULTS Maternal sucrose consumption (mean 49.8 grams/day [SD=12.9]) was inversely associated with mid-childhood Kaufman Brief Intelligence Test (KBIT-II) non-verbal scores (-1.5 points per 15 grams/day, 95% CI= -2.8, -0.2). Additionally, maternal SSB consumption was inversely associated with mid-childhood cognition, and diet soda was inversely associated with early and mid-childhood cognition scores. Early childhood consumption of SSBs was inversely associated with mid-childhood KBIT-II verbal scores (-2.4 points per serving/day, 95% CI= -4.3, -0.5) while fruit consumption was associated with higher cognitive scores in early and mid-childhood. Maternal and child fructose and juice consumption were not associated with cognition. After adjusting for multiple comparisons, the association between maternal diet soda consumption and mid-childhood KBIT-II verbal scores remained significant. CONCLUSIONS Sugar consumption, especially from SSBs, during pregnancy and childhood, and maternal diet soda consumption may adversely impact child cognition, while child fruit consumption may lead to improvements. Interventions and policies that promote healthier diets may prevent adverse effects on childhood cognition.

Selection Does Not Equate Consumption

Selection Does Not Equate Consumption To the Editor We applaud Turnwald et al1 for their experimental design to test inexpensive interventions to increase healthy food consumption within the Stanford University dining hall. In a Research Letter published in a recent issue of JAMA Internal Medicine, Turnwald et al1 reported that indulgent descriptors of healthy vegetables dramatically increased “consumption” compared with alternatively labeling the same food. The assumption that measuring the quantity of a vegetable selected equates to consumption is flawed and may misrepresent the results and overstate the conclusions. The authors cited a review by Wansink and Johnson2 that found that on average 92% of foods selected are consumed. However, many of the studies reviewed were in a food laboratory and were single experiments without the context of a free-living population on a college campus with repeated exposures to the same food. Additionally, consumption was much lower in studies of individual food items. There is also not adequate literature specifically on vegetable consumption, which traditionally is consumed less than other “healthy” foods, such as fruits, whole grains, lean meats, and dairy2; in our studies,3-5 we observed substantially greater consumption of these healthier items compared with vegetables. For example, in our plate waste study in a cafeteria setting measuring thousands of participants over time, we found that while similar marketing techniques can result in increased selection of vegetables, students consumed on average as little as 18% of these items.3 We found that upgrading the taste through a chef intervention had the best long-term impact on real consumption. While our research was conducted among a younger population, it is still relevant in highlighting the need to measure actual consumption among study participants. While we believe that research that furthers our understanding of effective promotion strategies for healthier foods is critically important, it is equally important for researchers to move beyond measuring just selection and to focus on taste and actual consumption.