Mary Kay Fox

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.

Nutrient Intakes of US Infants, Toddlers, and Preschoolers Meet or Exceed Dietary Reference Intakes

OBJECTIVES To assess the usual nutrient intakes of 3,273 US infants, toddlers, and preschoolers, aged 0 to 47 months, surveyed in the Feeding Infants and Toddlers Study (FITS) 2008; and to compare data on the usual nutrient intakes for the two waves of FITS conducted in 2002 and 2008. DESIGN The FITS 2008 is a cross-sectional survey of a national random sample of US children from birth through age 47 months. Usual nutrient intakes derived from foods, beverages, and supplements were ascertained using a telephone-administered, multiple-pass 24-hour dietary recall. SUBJECTS Infants aged birth to 5 months (n=382) and 6 to 11 months (n=505), toddlers aged 12 to 23 months (n=925), and preschoolers aged 24 to 47 months (n=1,461) were surveyed. METHODS All primary caregivers completed one 24-hour dietary recall and a random subsample (n=701) completed a second 24-hour dietary recall. The personal computer version of the Software for Intake Distribution Estimation was used to estimate the 10th, 25th, 50th, 75th, and 90th percentiles, as well as the proportions below and above cutoff values defined by the Dietary Reference Intakes or the 2005 Dietary Guidelines for Americans. RESULTS Usual nutrient intakes met or exceeded energy and protein requirements with minimal risk of vitamin and mineral deficiencies. The usual intakes of antioxidants, B vitamins, bone-related nutrients, and other micronutrients were adequate relative to the Adequate Intakes or Estimated Average Requirements, except for iron and zinc in a small subset of older infants, and vitamin E and potassium in toddlers and preschoolers. Intakes of synthetic folate, preformed vitamin A, zinc, and sodium exceeded Tolerable Upper Intake Level in a significant proportion of toddlers and preschoolers. Macronutrient distributions were within acceptable macronutrient distribution ranges, except for dietary fat, in some toddlers and preschoolers. Dietary fiber was low in the vast majority of toddlers and preschoolers, and saturated fat intakes exceeded recommendations for the majority of preschoolers. The prevalence of inadequate intakes, excessive intake, and intakes outside the acceptable macronutrient distribution range was similar in FITS 2002 and FITS 2008. CONCLUSIONS In FITS 2008, usual nutrient intakes were adequate for the majority of US infants, toddlers, and preschoolers, except for a small but important number of infants at risk for inadequate iron and zinc intakes. Diet quality should be improved in the transition from infancy to early childhood, particularly with respect to healthier fats and fiber in the diets of toddlers and preschoolers.

School Meals: Types of Foods Offered to and Consumed by Children at Lunch and Breakfast

BACKGROUND Childrens food intakes do not meet dietary recommendations. Meals offered through the National School Lunch Program and School Breakfast Program make substantial contributions to school-aged childrens diets. OBJECTIVES This article describes foods offered in school meals and consumed by children at lunch and breakfast, and differences in foods consumed by children who did and did not participate in the school meal programs. DESIGN Data were collected as part of the third School Nutrition Dietary Assessment Study, a cross-sectional, nationally representative study conducted in 2005. School menu surveys were used to identify the foods offered in school meals, and 24-hour dietary recalls were used to assess the foods children consumed. SUBJECTS/SETTING Foodservice managers in 398 public schools and 2,314 children (grades 1 to 12) from 287 of these schools participated in the study. STATISTICAL ANALYSES PERFORMED Descriptive tabulations report percentages of daily menus that offered and percentages of children that consumed specific food groups and foods at lunch and breakfast. Two-tailed t tests were used to assess differences between school meal program participants and nonparticipants. RESULTS Most school menus offered nonfat or 1% milk, fruit or 100% juice, and vegetables daily. Starchy vegetables were more common than dark green/orange vegetables or legumes. School lunch participants were significantly more likely than nonparticipants to consume milk, fruit, and vegetables, and significantly less likely to consume desserts, snack items, and beverages other than milk or 100% juice. At breakfast, participants were significantly more likely than nonparticipants to consume milk and fruit (mainly 100% juice), and significantly less likely to consume beverages other than milk or 100% juice. CONCLUSIONS Consumption of school meals is positively related to childrens intakes of key food groups at lunch and breakfast. Offering more fresh fruit, whole grains, and a greater variety of vegetables could lead to additional health benefits.

Food Consumption Patterns of Infants and Toddlers Where Are We Now

OBJECTIVES To describe current infant-feeding practices and current food group consumption patterns of infants and toddlers and to compare 2008 data with 2002 data to identify shifts in these practices and food consumption over time. DESIGN The Feeding Infants and Toddlers Study (FITS) 2008 is a cross-sectional survey of a national random sample of US children from birth up to age 4 years. Data for three age subgroups (infants 4 to 5.9 months and 6 to 11.9 months and toddlers 12 to 23.9 months) were used from the 2002 (n=2,884) and 2008 surveys (n=1,596). STATISTICAL METHODS All analyses use sample weights that reflect the US population aged 4 to 24 months. Descriptive statistics (means, proportions, and standard errors) and t tests were calculated using SUDAAN (release 9, 2005, Research Triangle Park Institute, Research Triangle Park, NC). RESULTS These data show a higher percentage of infants receiving breast milk from 4 to 11.9 months of age with a concurrent decreasing percentage of infants receiving formula, which is significantly different from data for the 9- to 11.9-month-old age group. The use of complementary foods also appears to be delayed in FITS 2008: There is a significantly lower proportion of infants consuming infant cereal at 9 to 11.9 months in FITS 2008 compared to 2002 data. Fruit and vegetable consumption remains lower than desired. Significant reductions in the percentage of infants and toddlers consuming any desserts or candy, sweetened beverages, and salty snacks were seen in 2008. CONCLUSIONS The findings presented here provide important insights to the content of messages and types of interventions that are still needed to improve the diets of infants and toddlers.

Nutritional Quality of the Diets of US Public School Children and the Role of the School Meal Programs

BACKGROUND Good nutrition is essential to healthy childhood. Because the school meal programs--the National School Lunch Program and the School Breakfast Program--are so widely available, they are in a unique position to influence the nutritional quality of childrens diets. OBJECTIVE This article assesses the nutritional quality of the diets of US public school children and explores the relationship between childrens participation in the school meal programs and the nutritional quality of their diets. DESIGN Data were collected as part of the third School Nutrition Dietary Assessment Study (SNDA-III), a nationally representative study fielded during school year 2004-2005. Data on childrens dietary intakes were collected through in-person 24-hour dietary recalls. Nutritional quality of childrens diets was assessed by estimating the prevalence of inadequate and excessive intakes of energy and nutrients. SUBJECTS/SETTING The analysis is based on a nationally representative sample of 2,314 children in grades 1 through 12 from 287 public schools. STATISTICAL ANALYSES PERFORMED Nutrient adequacy and excess were assessed by comparing usual nutrient intake distributions to Dietary Reference Intakes and the Dietary Guidelines for Americans 2005. Propensity score matching was used to examine the relationship between school meal program participation and the prevalence of inadequate and excessive intakes. RESULTS The majority of public school children in the United States had nutritionally adequate diets, but 80% had excessive intakes of saturated fat and 92% had excessive intakes of sodium. School meal program participation was associated with reduced prevalence of nutrient inadequacy but with increased prevalence of excessive sodium intakes. CONCLUSIONS School meal programs play an important role in the nutritional adequacy of childrens diets. However, the association between program participation and excessive sodium intakes, along with the high prevalence of excessive saturated fat intakes among all students, suggest areas for improvement in the meals these programs provide.

Availability and Consumption of Competitive Foods in US Public Schools

BACKGROUND With ongoing efforts to develop and implement school wellness policies, there is a need for information about the availability and consumption of competitive foods in schools. OBJECTIVE To describe the availability of competitive foods in US public schools, consumption of competitive foods by children, and contributions of competitive foods to energy intakes. 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. On-site observations were used to document the availability of competitive foods and a 24-hour recall was used to assess childrens consumption of competitive foods. SUBJECTS/SETTING The study included 287 schools and 2,314 children in grades 1 through 12. STATISTICAL ANALYSES PERFORMED Most analyses were limited to estimation of means and proportions. Two-tailed t tests were used to test the significance of differences between children who did and did not eat a school lunch. RESULTS In school year 2004-2005, competitive foods were widely available in public schools. Overall, 40% of children consumed one or more competitive foods on a typical school day. The most commonly consumed competitive foods were foods and beverages that were low in nutrients and energy-dense. Children who ate a school lunch were significantly less likely than children who did not eat a school lunch to consume competitive foods (36% vs 45%; P<0.01); however, the leading competitive food choices for both groups of children were foods that were low in nutrients and energy-dense. On average, competitive food consumers who ate school lunches obtained 159 calories from competitive foods that were low in nutrients and energy-dense, compared with 201 calories for competitive food consumers who did not eat school lunches (P<0.05). CONCLUSIONS In school year 2004-2005, competitive foods were widely available and consumed in US public schools and the most commonly consumed competitive foods were low in nutrients and energy-dense. These data support the need for improvements in school food environments and policies and provide a useful baseline for monitoring change as schools work to make these improvements.

Food Consumption Patterns of Young Preschoolers: Are They Starting Off on the Right Path?

OBJECTIVE To describe the food consumption patterns of US children aged 2 and 3 years. DESIGN Descriptive analysis of data collected in the Feeding Infants and Toddlers Study 2008 based on a single 24-hour dietary recall collected by telephone. SUBJECTS A national random sample of children aged 2 and 3 years (n=1,461). STATISTICAL ANALYSES PERFORMED The percentage of children consuming foods from specific food groups was estimated for the full sample of children aged 2 and 3 years and separately by year of age. RESULTS About a third of 2-year-olds and a quarter of 3-year-olds consumed whole milk at least once in a day. About 70% of 2- and 3-year-olds consumed vegetables as a distinct food item at least once in day. French fries and other fried potatoes were the most commonly consumed vegetable. Almost three quarters of children (73%) consumed fruit as a distinct food item at least once in a day, and 59% consumed 100% juice. Fresh fruit was the most commonly consumed type of fruit. About 85% of children consumed some type of sweetened beverage, dessert, sweet, or salty snack in a day. Percentages of children consuming such foods were consistently higher for 3-year-olds than for 2-year-olds. CONCLUSIONS Parents and caregivers should be encouraged to expose young children to a wide variety of fruits and vegetables, whole grains, low-fat dairy products, and healthier fats, and to limit consumption of low-nutrient, energy-dense foods and beverages. Dietary guidance should stress the fact that children in this age group have high nutrient needs and relatively low energy requirements, leaving little room for such foods. Parents need advice that is specific, practical, and actionable.

Addressing the Epidemic of Childhood Obesity Through School-Based Interventions: What Has Been Done and Where Do We Go From Here?

Schools are ideal settings for implementing multi-component programs to prevent and control childhood obesity. Thoughtful improvements to proven strategies, coupled with careful evaluation, can contribute to accumulation of evidence needed to design and implement the next generation of optimal interventions.

Comparison of 4 questionnaires for assessment of fruit and vegetable intake

OBJECTIVE This study compared fruit and vegetable assessments derived from 4 self-administered questionnaires. METHODS Among 102 adolescents, servings of fruits and vegetables assessed by 4 questionnaires were compared with estimates from 24-hour recalls. RESULTS The prevalence of consuming 5 or more servings of fruits and vegetables a day was underestimated by the questionnaires. Questionnaires asking subjects to recall their diet over the previous year were more effective in ranking subjects (rs > or = .42) than those assessing previous-day diet (rs > or = .30). CONCLUSIONS Brief assessments of fruit and vegetable intake are more useful for ranking subjects than for estimating prevalence of consumption of 5 or more servings per day.

The Feeding Infants and Toddlers Study 2008: Study Design and Methods

OBJECTIVE Describe the study design, data collection methods, 24-hour dietary recall protocol, and sample characteristics of the Feeding Infants and Toddlers Study (FITS) 2008. DESIGN A cross-sectional study designed to obtain information on the diets and feeding patterns of US infants, toddlers, and preschoolers ages birth to 47 months. Telephone interviews with parents and caregivers were conducted from June 2008 through January 2009 and included a household interview to recruit the household and collect information on household and child demographics and nutrition-related characteristics, and a dietary interview, including a 24-hour dietary recall collected using the 2008 Nutrition Data System for Research. A second dietary recall was collected on a random subsample to estimate usual nutrient intake distributions. Data collection instruments were built on those used in FITS 2002, with expanded survey content to address emerging issues in childhood nutrition and obesity. The dietary protocol was improved to increase reporting accuracy on portion sizes, and a bridging study was conducted to test effects of the changes in the food model booklet and protocol since FITS 2002 (n=240 cases aged 4 to 23 months). SUBJECTS A national random sample of 3,273 infants, toddlers, and preschoolers from birth up to age 4 years, with 2 days of dietary intake data for 701 cases. RESULTS Among sampled households with an age-eligible child, the response rate was 60% for the recruitment interview. Of recruited households, the response rate for the dietary interview was 78%. CONCLUSIONS The FITS 2008 provides rigorous, well-tested methods and survey questions for nutrition researchers to use in other dietary studies of young children. FITS 2008 findings on the food and nutrient intakes of US children from birth up to age 4 years can inform dietetics practitioners, pediatric health practitioners, and policymakers about the dietary issues of young children.