Laura E. Smith

Pre-Sliced Fruit in School Cafeterias: Children's Selection and Intake

BACKGROUND It is often assumed that children avoid fruit in school cafeterias because of higher relative prices and preferences for other foods. Interviews with children reveal that eating whole fresh fruit can be difficult for those with small mouths or braces. Older girls find whole fruits messy and unattractive to eat. PURPOSE To determine the effect of offering pre-sliced fruit in schools on selection and intake. DESIGN Three of six schools were assigned randomly to serve apples in slices. Three control schools served apples whole. Selection, consumption, and waste of apples were measured prior to and during treatment. SETTING/PARTICIPANTS Cafeterias in six public middle schools in Wayne County NY in 2011. Participants included all students who purchased lunch on days when data were collected. INTERVENTION Treatment schools were provided with a standard commercial fruit slicer, and cafeteria staff members were instructed to use it when students requested apples. Trained researchers recorded how much of each apple was consumed and how much was wasted in both control and treatment schools. MAIN OUTCOME MEASURES Daily apple sales, percentage of an apple serving consumed per student, and percentage of an apple serving wasted per student. RESULTS Data were analyzed in 2012. Schools that used fruit slicers to pre-slice fruit increased average daily apple sales by 71% compared to control schools (p<0.01). The percentage of students who selected apples and ate more than half increased by 73% (p=0.02) at schools that served pre-sliced fruit, and the percentage that wasted half or more decreased by 48% (p=0.03). CONCLUSIONS Sliced fruit is more appealing to children than whole fruit because it is easier and tidier to eat. This study applies the principle of convenience from behavioral economics and provides an example of a scalable, low-cost environmental change that promotes healthy eating and decreases waste.

The Potential Role of Mycotoxins as a Contributor to Stunting in the SHINE Trial.

Children in developing countries experience multiple exposures that are harmful to their growth and development. An emerging concern is frequent exposure to mycotoxins that contaminate a wide range of staple foods, including maize and groundnuts. Three mycotoxins are suspected to contribute to poor child health and development: aflatoxin, fumonisin, and deoxynivalenol. We summarize the evidence that mycotoxin exposure is associated with stunting, and propose that the causal pathway may be through environmental enteric dysfunction (EED) and disturbance of the insulin-like growth factor 1 (IGF-1) axis. The objectives of this substudy are to assess the relationship between agricultural and harvest practices and mycotoxin exposure; to evaluate associations between mycotoxin exposure and child stunting; and to investigate EED as a potential pathway linking mycotoxin exposure to child stunting, to inform potential areas for intervention.

Determinants of recent aflatoxin exposure among pregnant women in rural Zimbabwe

SCOPE Aflatoxins (AFs) are toxic secondary metabolites of Aspergillus species that contaminate staple foods such as maize and groundnuts. AF exposure during pregnancy has been associated with adverse birth outcomes in limited-scale surveys in sub-Saharan Africa. The objective of this study was to describe the determinants of AF exposure, using urinary aflatoxin M1 (AFM1) biomarkers and data generated by the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial for rural Zimbabwean women in early pregnancy. Sanitation Hygiene Infant Nutrition Efficacy is a large, cluster-randomized community-based trial in Zimbabwe designed to investigate the independent and combined effects of nutrition and hygiene interventions on early child growth. METHODS AND RESULTS Urine samples collected from 1580 pregnant women in rural Zimbabwe at median gestational age of 13.9 wk were measured for AFM1. AFM1 was detected in 30% of samples (median of exposed, 162 pg AFM1/mg creatinine; range 30-6046 pg AFM1/mg). In multivariable ordinal logistic models, geographical location (p<0.001), seasonality (p < 0.001) and dietary practices (p = 0.011) were significant predictors of urinary AFM1. CONCLUSION This is the largest AF biomarker survey conducted in Zimbabwe, and demonstrated frequent exposure in pregnant women with clear temporal and spatial variability in AF biomarker levels.

Reply to Correspondence: is the strength of association between indicators of dietary quality and the nutritional status of children being underestimated?

To the Editors, We are grateful to Thorne-Lyman et al. (2014) for the insightful comments in response to the Jones et al. (2014) article. We largely agree with observations highlighting important limitations of dietary data drawn from 24-h recall methods and take the opportunity to augment the discussion of the important question posed regarding the potential underestimation of the associations between indicators of dietary quality and child nutritional status. Thorne-Lyman et al. (2014) suggest in particular that low statistical power resulting from random within-person error introduced through the use of single pass 24-h recall data may explain the statistically non-significant relationships observed between the World Health Organization (WHO) minimum dietary diversity (MDD) indicator and child stunting in the recent article by Jones et al. (2014). They further suggest that this within-person error could be corrected for in analyses if at least one additional day of data on the food group diversity of young child diets were collected. We agree with this assertion and suggest also that these challenges are not limited to random withinperson error associated with data derived from 24-h recalls. Taking the MDD indicator as an example, we highlight in the Jones et al. (2014) article that this indicator lacks specificity with respect to the micronutrient adequacy of diets (i.e. it may commonly misclassify adequate diets as inadequate). Therefore, even with sufficient statistical power, classifying the adequacy of diets using a binary categorical variable may not allow for sufficient accuracy when using regression analysis to examine the relationship between diet diversity and nutrition-related health outcomes (Royston et al. 2006). Investing the effort and expense to collect replicate measurements of child dietary diversity will reduce within-person error and can provide a more accurate exposure assessment. Having done this, however, it would be disadvantageous to limit the analysis by using an indicator that lacks specificity and therefore cannot take full advantage of the additional information collected from those replicate measurements. While the WHO indicators provide practitioners, researchers and decision-makers with easy-to-use metrics to draw attention to disparities in child feeding practices, they have specific limitations in assessing diet-health relationships. In highlighting the need to be clear about the use of data, Beaton (1994), in the article cited by Thorne-Lyman et al. (2014), points out that error in dietary assessment may have different consequences depending on the analytic question at hand. In regression analyses, for example, random error resulting from within-person variation may alter both the intercept of an observed relationship and the slope (Beaton 1994). However, if one is only interested in comparing group means (e.g. comparing dietary diversity across countries or subgroups within countries), random error will not bias the relationship, but will rather simply decrease statistical power to detect a difference (Beaton 1994). The WHO infant and young child feeding (IYCF) indicators are especially well suited for this latter purpose, in which case, the random within-person error introduced through single-day 24-h food group recall is not a serious concern in sufficiently large samples. In examining the relationship between diet and health on the other hand, random error is a threat to the actual observed relationship. It is not clear that the MDD indicator is the appropriate metric for representing dietary data collected using the replicate measurements needed for addressing this withinperson error. Indeed, future research efforts and discussions would be well directed towards identifying the most appropriate indicators, especially those that bs_bs_banner

Nutrition Report Cards: An Opportunity to Improve School Lunch Selection

Objective To explore the feasibility and implementation efficiency of Nutritional Report Cards(NRCs) in helping children make healthier food choices at school. Methods Pilot testing was conducted in a rural New York school district (K-12). Over a five-week period, 27 parents received a weekly e-mail containing a NRC listing how many meal components (fruits, vegetables, starches, milk), snacks, and a-la-carte foods their child selected. We analyzed choices of students in the NRC group vs. the control group, both prior to and during the intervention period. Point-of-sale system data for a-la-carte items was analyzed using Generalized Least Squares regressions with clustered standard errors. Results NRCs encouraged more home conversations about nutrition and more awareness of food selections. Despite the small sample, the NRC was associated with reduced selection of some items, such as the percentage of those selecting cookies which decreased from 14.3 to 6.5 percent. Additionally, despite requiring new keys on the check-out registers to generate the NRC, checkout times increased by only 0.16 seconds per transaction, and compiling and sending the NRCs required a total weekly investment of 30 minutes of staff time. Conclusions This test of concept suggests that NRCs are a feasible and inexpensive tool to guide children towards healthier choices.

Aflatoxin Exposure During Pregnancy, Maternal Anemia, and Adverse Birth Outcomes.

Pregnant women and their developing fetuses are vulnerable to multiple environmental insults, including exposure to aflatoxin, a mycotoxin that may contaminate as much as 25% of the world food supply. We reviewed and integrated findings from studies of aflatoxin exposure during pregnancy and evaluated potential links to adverse pregnancy outcomes. We identified 27 studies (10 human cross-sectional studies and 17 animal studies) assessing the relationship between aflatoxin exposure and adverse birth outcomes or anemia. Findings suggest that aflatoxin exposure during pregnancy may impair fetal growth. Only one human study investigated aflatoxin exposure and prematurity, and no studies investigated its relationship with pregnancy loss, but animal studies suggest aflatoxin exposure may increase risk for prematurity and pregnancy loss. The fetus could be affected by maternal aflatoxin exposure through direct toxicity as well as indirect toxicity, via maternal systemic inflammation, impaired placental growth, or elevation of placental cytokines. The cytotoxic and systemic effects of aflatoxin could plausibly mediate maternal anemia, intrauterine growth restriction, fetal loss, and preterm birth. Given the widespread exposure to this toxin in developing countries, longitudinal studies in pregnant women are needed to provide stronger evidence for the role of aflatoxin in adverse pregnancy outcomes, and to explore biological mechanisms. Potential pathways for intervention to reduce aflatoxin exposure are urgently needed, and this might reduce the global burden of stillbirth, preterm birth, and low birthweight.

Measuring wealth in rural communities: Lessons from the Sanitation, Hygiene, Infant Nutrition Efficacy (SHINE) trial

Background Poverty and human capital development are inextricably linked and therefore research on human capital typically incorporates measures of economic well-being. In the context of randomized trials of health interventions, for example, such measures are used to: 1) assess baseline balance; 2) estimate covariate-adjusted analyses; and 3) conduct subgroup analyses. Many factors characterize economic well-being, however, and analysts often generate summary measures such as indices of household socio-economic status or wealth. In this paper, a household wealth index is developed and tested for participants in the cluster-randomized Sanitation, Hygiene, Infant Nutrition Efficacy (SHINE) trial in rural Zimbabwe. Methods Building on the approach used in the Zimbabwe Demographic and Health Survey (ZDHS), we combined a set of housing characteristics, ownership of assets and agricultural resources into a wealth index using principal component analysis (PCA) on binary variables. The index was assessed for internal and external validity. Its sensitivity was examined considering an expanded set of variables and an alternative statistical approach of polychoric PCA. Correlation between indices was determined using the Spearman’s rank correlation coefficient and agreement between quintiles using a linear weighted Kappa statistic. Using the 2015 ZDHS data, we constructed a separate index and applied the loadings resulting from that analysis to the SHINE study population, to compare the wealth distribution in the SHINE study with rural Zimbabwe. Results The derived indices using the different methods were highly correlated (r>0.9), and the wealth quintiles derived from the different indices had substantial to near perfect agreement (linear weighted Kappa>0.7). The indices were strongly associated with a range of assets and other wealth measures, indicating both internal and external validity. Households in SHINE were modestly wealthier than the overall population of households in rural Zimbabwe. Conclusion The SHINE wealth index developed here is a valid and robust measure of wealth in the sample.

Finger Fruits: Pre-Sliced Fruit in Schools Increases Selection and Intake

Laddering interviews indicate that a leading reason younger children do not select fruit is because braces and small mouths make it difficult to eat. Older children – especially females – avoid it because it is messy and makes them look unattractive when eating it. One solution for both sets of reservations would be to offer pre-sliced fruit. The purpose of this study is to determine if offering pre-sliced fruit increases the selection and intake of fruit among elementary students and middle school students. Two studies were conducted. Following a pilot study in elementary schools, three out of six middle schools were randomly given commercial fruit slicers and the selection and consumption of sliced apples was compared to that of the control schools. Researchers collected data in the cafeteria so all students who purchased an apple were included in the study. Only waste data were collected so no personal identifying information was recorded. In both studies, treatment schools were given a standard commercial fruit slicer (also referred to as a “sectionizer”). These slicers have a reservoir into which a piece of fruit is placed (apples, oranges, pears, grapefruit). A plunger with different configurations of steel blades is then pushed down and it cores the fruit and cuts it into six symmetric pieces into a bowl below. The process is quick, taking an average of just over 3 seconds per fruit. The main outcomes that were measured included apple sales, percentages of apples wasted, and percentages of apples consumed. Results from Study 1 show that the fruit slicer increased apples sales in elementary schools by 60.6%. In study 2, apple sales increased by 41% and apple consumption increased by 17%. Therefore, it was concluded that environmental interventions are useful in influencing people to eat more healthful foods. This study relies on the principle of convenience and provides evidence that sliced fruit is more appealing than unsliced fruit, simply due to eating convenience and neatness. There is plenty of opportunity for research to identify effective applications of convenience, or other environmental changes that promote healthy eating behavior.