Meghan O'Connell

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.

Smoking cessation for high school students. Impact evaluation of a novel program.

This pilot study was designed to evaluate the feasibility and the impact of a smoking-cessation program that would meet the specific needs of high school students. Feedback from focus groups conducted with adolescent smokers at a Connecticut high school was used to develop a tailored intervention. Intervention components included commonly used behavioral strategies, with additional options to assist students to quit smoking, including use of bupropion, concomitant support for parent smoking cessation, stress management, and physician counseling. On completion, 20 of the 22 enrolled students remained committed to quitting. Twenty-seven percent of students quit smoking and 69% of those who continued to smoke reduced the number of cigarettes smoked per day by an average of 13. Providing additional options to students and additional support for concomitant parental cessation may enhance the appeal of adolescent smoking-cessation programs. Further investigation into efficacy of bupropion use for adolescent cessation is warranted.

Comparing Current Practice to Recommendations for the Child and Adult Care Food Program

BACKGROUND The federal Child and Adult Care Food Program (CACFP) assists child care centers serving low-income preschoolers and regulates the quality and quantity of food served. The aim of this study was to assess the nutritional quality of lunches served at 38 child care centers and examine how current practices compare to proposed meal pattern recommendations. METHODS Preschool-aged children (n = 204) were observed eating lunch in 38 CACFP-participating preschools. All foods served and consumed were measured and compared to the 2011 Institute of Medicine (IOM) recommendations to improve CACFP and the 2015 Proposed Rule issued by the USDA. RESULTS All centers provided access to all required lunch components, but not all components were served (i.e., placed on the childs plate). Vegetables were significantly less likely to be served than meat or grains. Compared with CACFP recommended portion sizes, servings of meat and grain were high, whereas milk was low. Compared with IOM recommendations, average calorie consumption was appropriate, but saturated fat, protein, and sodium intake were high and dietary fiber was low. Meals that offered children both a fruit and a vegetable led to significantly higher produce consumption than meals that offered only one fruit or one vegetable. CONCLUSIONS Child care centers generally comply with current CACFP regulations, but do not provide lunches consistent with the 2011 IOM recommendations for saturated fat, protein, fiber, and sodium. Decreased use of beef and cheese and increased provision of whole grains, fruits, and vegetables are recommended.

Testing Variations on Family-Style Feeding To Increase Whole Fruit and Vegetable Consumption among Preschoolers in Child Care.

BACKGROUND Preschoolers do not consume whole fruit and vegetables (FVs) in recommended quantities. Two strategies to increase FV intake were tested. METHODS One Head Start preschool participated. Two variations of family-style feeding were compared to usual practice: (1) Fruits, vegetables, and milk were served before the main meal (first course); and (2) fruits, vegetables, and milk were served before the main meal and meats and grains were removed from the table after the first serving (combination). A within-subject crossover design was used to test each condition for three meals. The amount of food served and consumed was weighed and converted to Child and Adult Care Feeding Program (CACFP) standard serving sizes for analysis. RESULTS Eighty-five children ages 3-5 participated. The sample was 81% Hispanic with diverse racial backgrounds. Thirty percent of the children were overweight. FV consumption was at CACFP recommended levels at baseline and remained consistent across conditions. The average amount served for each meal component was at or above CACFP recommendations for all foods except milk, which was consistently served in small portions. Meat and grains servings were frequently 2-3 times larger than CACFP recommendations. Milk consumption was significantly higher in the Combined intervention for two meals. Children ate significantly less meat during the Combined intervention for one meal. CONCLUSIONS The intervention led to significant increases in milk consumption, which was the only underconsumed meal component. These strategies should be tested with children who have lower baseline intake of FVs.

Impediment Profiling for Smoking Cessation: Application in the Worksite

Purpose. To replicate results of a pilot smoking cessation study and demonstrate applicability to a worksite setting. Methods. Smokers employed by a community hospital participated in an onsite smoking cessation program. Participants used an “impediment profiling” instrument to rate personal barriers to cessation and were assigned to between one and seven interventions. Cessation was defined as carbon monoxide concentration in expired air of ≤ 10 ppm. Results. Fifty-one employees participated. Subjects lost to follow-up were assumed to be smoking, resulting in a 39.2% 1-year quit rate; 47.5% of program completers (n = 40) were smoke-free at 1 year. Self-reported quit rate at 2.5 years was 25.5% (17 lost to attrition assumed to be smoking) with 38.2% of program completers smoke-free. Discussion. This study suggests that impediment profiling holds promise for smoking cessation and demonstrates feasibility in a worksite setting. Further evaluation of this intervention in the context of randomized controlled trials is warranted.

Cognitive behavioral therapy for insomnia in stable heart failure: Protocol for a randomized controlled trial

BACKGROUND Chronic insomnia is associated with disabling symptoms and decrements in functional performance. It may contribute to the development of heart failure (HF) and incident mortality. In our previous work, cognitive-behavioral therapy for insomnia (CBT-I), compared to HF self-management education, provided as an attention control condition, was feasible, acceptable, and had large effects on insomnia and fatigue among HF patients. OBJECTIVES The purpose of this randomized controlled trial (RCT) is to evaluate the sustained effects of group CBT-I compared with HF self-management education (attention control) on insomnia severity, sleep characteristics, daytime symptoms, symptom clusters, functional performance, and health care utilization among patients with stable HF. We will estimate the cost-effectiveness of CBT-I and explore the effects of CBT-I on event-free survival (EFS). METHODS Two hundred participants will be randomized in clusters to a single center parallel group (CBT-I vs. attention control) RCT. Wrist actigraphy and self-report will elicit insomnia, sleep characteristics, symptoms, and functional performance. We will use the psychomotor vigilance test to evaluate sleep loss effects and the Six Minute Walk Test to evaluate effects on daytime function. Medical record review and interviews will elicit health care utilization and EFS. Statistical methods will include general linear mixed models and latent transition analysis. Stochastic cost-effectiveness analysis with a competing risk approach will be employed to conduct the cost-effectiveness analysis. DISCUSSION The results will be generalizable to HF patients with chronic comorbid insomnia and pave the way for future research focused on the dissemination and translation of CBT-I into HF settings.

Community partnership for healthy sleep: Research protocol

Beginning early in life, sleep health, including adequate quality, quantity, and consistent sleep routines, is critical to growth and development, behavior, and mental and physical health. Children who live in economically stressed urban environments are at particular risk for sleep deficiency and its negative consequences. Although efficacious sleep health interventions are available, few address the context of economically stressed urban environments. The purpose of this paper is to describe a two-phase protocol for an ongoing NIH/NINR-funded community-engaged study designed to understand the perspectives of parents, community child care and pediatric health care providers about sleep habits, factors that contribute to sleep and sleep habits, sleep difficulty, and potentially useful sleep promotion strategies among children living in economically stressed urban environments. The social-ecological model guides this study. Phase I employs a convergent mixed-methods design, in which we are conducting semi-structured interviews with parents, childcare providers, and primary health care providers. We are collecting 9 days of objective sleep data (wrist actigraphy) from children who are 6-18 months (n = 15) and 19-36 months of age (n = 15) and parent reports of sleep and sleep-related factors using standard questionnaires. In Phase I, we will use a qualitative descriptive approach to analyze the interview data, and descriptive statistics to analyze the survey and actigraph data. In Phase II, we will use the information to develop a contextually relevant program to promote sleep health. Our long-term goal is to improve sleep health and sleep-related outcomes in these children.

Predictors of Nutrition Quality in Early Child Education Settings in Connecticut

Objective: This study assessed the dietary quality of lunches and feeding practices (family‐style service, teacher role modeling) in Connecticut child care centers and made comparisons by center participation in the federal Child and Adult Care Food Program (CACFP). Design: Plate waste methods and visual observation of lunches served and consumed. Setting: A total of 97 randomly selected licensed Connecticut child care centers (53 CACFP and 44 non‐CACFP). Participants: A total of 838 preschool‐aged children. Main Outcome Measures: Total energy intake, macronutrient intake, and intake by CACFP meal component as well as use of family‐style dining, management of additional helpings, and whether and what teachers consumed in view of children. Analysis: Child dietary intake at lunch was compared with dietary and CACFP recommendations using a mixed linear regression model. Results: The CACFP centers were more likely to offer family‐style service and have staff eat the same foods as the children. Children in non‐CACFP centers consumed more saturated fat (4.1 vs 2.7 g; P < .001) and trans fats (0.1 vs 0.1 g; P = .02) and less milk (3.5 vs 2.7 oz; P < .001) than did children in CACFP centers. Caloric intake and dietary fiber were below recommendations in both groups. Participation in CACFP was a significant predictor of low‐fat milk consumption. Conclusions and Implications: The CACFP‐participating centers confer some nutritional advantages in terms of provider behavior during meals, characteristics of food offerings, and child intake. Current feeding practices in child care settings require further exploration in the context of serving children at risk for food insecurity and in light of recent work on responsive feeding.

A bold and comprehensive treatise on the obesity pandemic.

Both media and academia abound with reports of the frighteningly sharp rise worldwide in rates of overweight and obesity and the resulting health impact. Heated debate continues over the cause of this increase and the approach most likely to produce a leveling off or reversal of this trend. Is food or physical activity to blame? Is the environment driving behavior, or are people just plain lazy? What is the role, if any, of government intervention? How might corporate responsibility fit in? The World Is Fat: The Fads, Trends, Policies, and Products That Are Fattening the Human Race by Barry Popkin will be invaluable to anyone interested in understanding the history and trajectory of the obesity pandemic. He describes how the pandemic maps onto global technological advances, food industry growth and proliferation of nutrient-poor foods,