Kathryn E. Henderson

The Need for Bold Action to Prevent Adolescent Obesity

Record levels of obesity in children and adolescents are predictable in light of powerful conditions that promote high consumption of calorie-dense, nutrient-poor foods and discourage physical activity. Default conditions for youth are dangerous, and include multiple and relentless forms of marketing, poor foods promoted in schools, and a variety of other conditions that undermine personal resources, individual responsibility, and parental authority. This article discusses how optimal defaults can be created using five issues as examples: framing of the obesity issue, treating versus preventing obesity, nutrition in schools, marketing, and addressing weight bias and discrimination. By adopting a public health approach that addresses the conditions causing obesity, there is hope of reversing troubling trends in prevalence.

New School Meal Regulations Increase Fruit Consumption and Do Not Increase Total Plate Waste

Abstract 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.

Trying to Lose Weight: Diet Strategies among Americans with Overweight or Obesity in 1996 and 2003

BACKGROUND Health professionals recommend that individuals with overweight and obesity lose weight by reducing energy intake while maintaining a healthful diet. This study was designed to examine trends in weight loss attempts and strategies for adults with overweight or obesity among different sociodemographic groups. METHODS Data from the 1996 and 2003 Behavioral Risk Factor Surveillance System were used to estimate changes in weight loss attempts and strategies across population groups. Data were analyzed in 2009. RESULTS Slightly more adults with overweight or obesity attempted weight loss in 2003 compared to 1996. There were substantial changes in the diet approaches reported: rates of those using energy restriction to lose weight doubled between 1996 and 2003, whereas low-fat dieting decreased by one third. Hispanic and less-educated adults did not shift away from low-fat diets. Attempted weight loss was associated with higher fruit and vegetable consumption for most population groups. CONCLUSIONS Increasingly more adults with overweight or obesity tried to lose weight through energy reduction, but some at-risk groups did not follow this beneficial trend between 1996 and 2003. Dietetics practitioners and public health campaigns should target such groups with concrete recommendations to reduce energy intake while maintaining a healthful diet, including adequate consumption of fruit and vegetables.

Strength and Comprehensiveness of District School Wellness Policies Predict Policy Implementation at the School Level

BACKGROUND In 2006, all local education agencies in the United States participating in federal school meal programs were required to establish school wellness policies. This study documented the strength and comprehensiveness of 1 states written district policies using a coding tool, and tested whether these traits predicted school-level implementation and practices. METHODS School wellness policies from 151 Connecticut districts were evaluated. School principal surveys were collected before and after the writing and expected implementation of wellness policies. Sociodemographic variables were assessed for each district, including enrollment, population density, political climate, racial composition, and socioeconomic status. Changes in school-level policy implementation before and after the federal wellness policy mandate were compared across districts by wellness policy strength; policies were compared based on district-level demographics. RESULTS Statewide, more complete implementation of nutrition and physical activity policies at the school level was reported after adoption of written policies. Districts with stronger, more comprehensive policies were more successful in implementing them at the school level. Some sociodemographic characteristics predicted the strength of wellness policies. CONCLUSIONS Written school wellness policies have the potential to promote significant improvements in the school environment. Future regulation of school wellness policies should focus on the importance of writing strong and comprehensive policies.

Repeated Exposure in a Natural Setting: A Preschool Intervention to Increase Vegetable Consumption

BACKGROUND Laboratory and home-based research suggest that repeated exposure to vegetables may increase consumption among children. Effectiveness of repeated exposure to vegetables has not been tested in a community-based preschool setting. OBJECTIVE This randomized controlled trial tested the hypotheses that children who are served unfamiliar vegetables repeatedly in the preschool lunch setting will increase consumption of them, and that consumption will be influenced by peer eating behaviors and parental feeding behaviors. SUBJECTS/SETTING Data were collected in two private preschools in a small northeastern city in 2007. Ninety-six children (aged 3 to 6 years) participated. DESIGN Schools were randomly assigned to condition. During the first 6 weeks, Preschool A served three vegetables at lunch on 10 separate occasions (ie, 30 days of exposure), while Preschool B continued routine practice. In the 7th week, schools reversed conditions and Preschool B served the vegetables for the next 6 weeks. Consumption data were collected daily in the intervention school and at baseline and post-intervention meals in the control school. PRIMARY OUTCOMES/STATISTICAL ANALYSES: Analysis of variance was used to examine the effect of vegetable exposure on vegetable intake; multilevel models were used to examine the effect of peer eating behaviors and parental feeding practices on vegetable intake. RESULTS Repeated exposure did not increase vegetable consumption. Greater consumption by tablemates was a significant predictor of greater vegetable consumption; across the three vegetables, 1 g of peer intake was associated with roughly a 1/5-g intake increase among the subjects. Overall, children demonstrated wide fluctuation in vegetable consumption from day to day, creating as much variability within subjects as between them. CONCLUSIONS Further research should explore the conditions necessary for repeated exposure to increase vegetable consumption in preschool settings. Creating opportunities for young children to serve as peer models has promise as a strategy to promote vegetable consumption.

Correlates of body image dissatisfaction in extremely obese female bariatric surgery candidates

Background: This study investigated correlates of body image dissatisfaction in 131 extremely obese female bariatric surgery candidates. Methods: Female gastric bypass surgery candidates participating in a comprehensive psychiatric evaluation completed a battery of established self-report measures of body image and psychosocial functioning. Nine predictors of body image dissatisfaction were considered: body mass index (BMI), ethnicity, childhood onset of obesity, childhood teasing about weight, binge eating, depression, self-esteem, shame, and perfectionism. Results: Stepwise multiple regression analysis revealed that the nine variables jointly accounted for 48% of the variance; three variables, depression, self-esteem and perfectionism, made significant independent contributions. Conclusion: Our findings highlight the importance of adult psychological functioning (depression, self-esteem and perfectionism) for predicting body image dissatisfaction in extremely obese female bariatric surgery candidates.

Validity of a Measure to Assess the Child-Care Nutrition and Physical Activity Environment

BACKGROUND Licensed child-care centers represent an opportunity to positively influence childrens health behaviors. Valid and easy-to-use measures of the child-care environment are needed to assess the influence of environmental change on health. OBJECTIVE To develop and validate a self-administered survey to assess the nutrition and physical activity environment of child-care centers, and to identify domains that may be evaluated adequately through self-report. DESIGN A survey was developed to assess four areas related to nutrition and physical activity: center policies, practices related to the social environment, physical environment, and nutrition quality. Development involved review of the literature, existing measures, and regulations/standards as well as collaboration with a working group. The survey was pilot tested and feedback was sought from expert consultants. It was administered statewide and validated against a menu rating tool, interviews with a center director, and a direct observation tool that was developed for this study. PARTICIPANTS/SETTING Participating sites were drawn from Child and Adult Care Food Program-participating licensed Connecticut child-care centers serving 13 or more children aged 3 to 5 years. Survey responses from 146 center directors were included, as were 62 center menus, and director interviews and observational data from 33 sites. PRIMARY OUTCOMES/STATISTICAL ANALYSES: Criterion validity of the survey was assessed through percent agreement with mirroring items in the additional measures. Healthy and unhealthy food scores were calculated for menu and survey tools, and Pearson correlations were computed. RESULTS Percent agreement with criterion outcomes ranged from 39% to 97%, with 61% of items achieving agreement ≥80%. Agreement was highest for nutrition and policy domains, and lowest for physical activity and barriers to promoting health. Correlations between food scores across measures were moderate. CONCLUSIONS The self-report survey demonstrated adequate criterion validity. We make recommendations for improving validity of low-agreement items and for the use of more labor-intensive evaluation procedures for domains not adequately assessed through self-report.

Effects of Reduced Juice Allowances in Food Packages for the Women, Infants, and Children Program

OBJECTIVES: In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) implemented revisions to the composition and quantities of WIC food packages. Juice allowances were reduced by approximately half. This report describes changes in purchases of 100% juice and other beverages among WIC participants after the WIC revisions. METHODS: Scanner data from a New England supermarket chain were used to assess juice and other beverage purchases among 2137 WIC-participating households during a 2-year period (N = 36 051 household-months). Purchased beverage amounts were compared before (January–September 2009) and after (January–September 2010) implementation of the revised WIC packages. Generalized estimating equation models were used. RESULTS: Before the revisions, WIC juice accounted for two-thirds of purchased juice volume among WIC households. After implementation of the revisions, WIC juice purchases were reduced on par with allowance changes (43.5% of juice volume, 95% confidence interval [CI] 41.9%–45.1%). This reduction was only partly compensated for by an increase of 13.6% (8.4%–19.0%) in juice purchases using personal and other non-WIC funds. In total, juice purchases declined by 23.5% (21.4%–25.4%) from an adjusted monthly total of 238 oz to 182 oz per household. WIC households increased purchases of fruit drinks by 20.9% (14.9%–27.3%) and other noncarbonated beverages by 21.3% (12.1%–31.2%) but purchased 12.1% (8.1%–15.0%) less soft drinks. CONCLUSIONS: After the WIC revisions, total purchases of 100% juice among WIC households declined by about a quarter, with little compensation occurring from non-WIC funds for juice and other beverages. The public health impact of the shift in beverage purchase patterns could be significant.

Evaluating the Impact of a Connecticut Program to Reduce Availability of Unhealthy Competitive Food in Schools.

BACKGROUND This article seeks to inform state and local school food policies by evaluating the impact of Connecticuts Healthy Food Certification (HFC), a program which provides monetary incentives to school districts that choose to implement state nutrition standards for all foods sold to students outside reimbursable school meals. METHODS Food service directors from all school districts participating in the National School Lunch Program (NSLP) (N = 151) in Connecticut were surveyed about the availability of competitive foods before and after the 2006-2007 implementation of HFC. Food categories were coded as healthy or unhealthy based on whether they met the Connecticut Nutrition Standards. Data on NSLP participation were provided by the State Department of Education. Changes in NSLP participation and availability of unhealthy competitive foods in elementary, middle, and high schools were compared pre- and post-HFC across districts participating (n = 74) versus not participating (n = 77) in HFC. RESULTS On average, all districts in Connecticut reduced the availability of unhealthy competitive foods, with a significantly greater reduction among HFC districts. Average NSLP participation also increased across the state. Participating in HFC was associated with significantly greater NSLP participation for paid meals in middle school; however, implementing HFC did not increase overall NSLP participation beyond the statewide upward trend. CONCLUSION The 2006-2007 school year was marked by a significant decrease in unhealthy competitive foods and an increase in NSLP participation across the state. Participation in Connecticuts voluntary HFC further reduced the availability of unhealthy competitive foods in local school districts, and had either a positive or neutral effect on NSLP participation.

Physical Activity in Gastric Bypass Patients: Associations with Weight Loss and Psychosocial Functioning at 12-Month Follow-Up

BackgroundThis study examined self-reported frequency and intensity of physical activity in gastric bypass patients, and the relationship between physical activity and weight loss and psychosocial outcomes during 12-month postoperative follow-up.MethodsParticipants were 131 obese patients who underwent gastric bypass surgery and completed psychometrically established measures assessing physical activity, depression, and physical and mental health preoperatively and at a 12-month follow-up assessment.ResultsPreoperatively, 62.6% of patients reported at least one episode of a minimum of 15 minutes of physical activity per week. This figure increased to 92.4% at 12-month postoperative follow-up. Both the frequency and intensity levels of physical activity episodes increased significantly from preoperative to 12-month postoperative assessments. Hierarchical regression analyses, controlling for demographic variables and preoperative body mass index (BMI), revealed that the intensity of physical activity was significantly associated with postoperative weight loss at 12-month follow-up. Both the frequency and intensity of physical activity were significantly associated with depression, and physical and mental well-being at the 12-month postoperative follow-up.ConclusionGastric bypass patients increase both the frequency and intensity of their physical activity during the first 12 months postoperatively. Higher postoperative intensity levels of physical activity are associated with better weight loss outcomes while both increased frequency and intensity levels of physical activity are associated with better psychosocial outcomes.