Food (in)security in relation to nutrition (in)security in a national cross-sectional sample of Supplemental Nutrition Assistance Program participants: considerations of an emerging construct.

BACKGROUND: Food insecurity, lack of access to sufficient food for an active, healthy life, is a persistent problem in the United States. Recently, nutrition security has emerged as a new concept. However, limited research exists examining how nutrition security relates to the established concept of food security. OBJECTIVES: This study assessed a recent metric of nutrition security and explored how well it describes the underlying construct among a sample of Supplemental Nutrition Assistance Program (SNAP) participants. We examined the correlation between food and nutrition security and demographic predictors of joint food and nutrition security status. METHODS: We conducted a national, web-based survey (Qualtrics; 30 September-19 October, 2022) in English and Spanish of adults aged ≥18 y (n = 1454) who reported receiving SNAP benefits in the past 12 mo. We measured food security using the US Department of Agriculture 6-item Food Security Survey and assessed nutrition security using the Gretchen Swanson Center for Nutrition Household Nutrition Security measure. We used multinominal logistic regression to examine demographic predictors of food and nutrition security. RESULTS: The majority (80.4%) of SNAP participants experienced food insecurity, and 59.1% reported experiencing nutrition insecurity. Food and nutrition security were moderately correlated (0.41); 55.6% of SNAP participants were both food and nutrition insecure, 3.5% were food secure but nutrition insecure, 24.8% were food insecure but nutrition secure, and 16.1% were both food and nutrition secure. Of SNAP participants, 24.8% reported experiencing food insecurity but not nutrition insecurity. Hispanic ethnicity and Southern residence were associated with joint food and nutrition insecurity. CONCLUSIONS: These findings raise questions about how nutrition security is conceptualized and measured and its added value beyond existing food security measurement scales. Further research is needed to understand differences in food and nutrition security experiences and risk factors and determine a validated definition and measure of nutrition security for future policy solutions.

Parents' and Caregivers' Support for in-School COVID-19 Mitigation Strategies: A Socioecological Perspective.

Informed by the social ecological model, which asserts that health behaviors and beliefs are the result of multiple levels of influence, we examined factors related to parents' support for in-school COVID-19 mitigation strategies. Using data from a survey of 567 parents/caregivers of public elementary and middle school students in eight Maryland counties, we employed regression models to examine relationships between parent-, child-, family-, school-, and community-level factors and acceptability of mitigation strategies. Acceptance of COVID-19 mitigation strategies was positively correlated with child- and family-level factors, including child racial identity (parents of Black children were more accepting than those of White children, odds ratio [OR]: 2.5, 95% confidence interval [CI] = [1.5, 4.1]), parent receipt of the COVID-19 vaccine (OR: 2.4, 95% CI = [1.5, 3.7]), and parent Democrat or Independent political affiliation (compared with Republican affiliation, OR: 4.2, 95% CI = [2.6, 6.7]; OR: 2.2, 95%CI = [1.3, 3.8], respectively). Acceptance was also positively associated with parents' perceptions of their school's mitigation approach, including higher school mitigation score, indicating more intensive mitigation policies (OR: 1.1, 95% CI = [1.0, 1.1]), better school communication about COVID-19 (OR: 1.7, 95% CI = [1.4, 1.9]) and better school capacity to address COVID-19 (OR: 1.9, 95% CI = [1.5, 2.4]). Community-level factors were not associated with acceptance. Child- and parent-level factors identified suggest potential groups for messaging regarding mitigation strategies. School-level factors may play an important role in parents' acceptance of in-school mitigation strategies. Schools' capacity to address public health threats may offer an underappreciated and modifiable setting for disseminating and reinforcing public health guidance.

Prevalence of Recess and Supportive Practices at a Nationwide Sample of Public Elementary Schools in the United States.

BACKGROUND: Recess provides an important opportunity for children to be physically active during weekdays. Updated, nationally representative, prevalence estimates of elementary school recess practices in the United States are needed. METHODS: Surveys were sent to a nationally representative sample of 1010 public elementary schools in the 2019-2020 school year. Results were compared by region (Northeast, Midwest, South, West), urbanicity, size, racial and ethnic composition, and socioeconomic status (percent eligible for free/reduced-priced meals). RESULTS: A total of 559 responses were obtained. About 87.9% of schools provided at least 20 minutes of daily recess and 26.6% had trained recess supervisors. Most schools did not allow students to voluntarily stay inside during recess (71.6%) and around half prohibited withholding recess for poor behavior (45.6%) or to complete schoolwork (49.5%). Several practices varied by region, and withholding recess was more prevalent among schools with lower student socioeconomic makeup. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Regular national surveillance of recess practices can inform policy needs and efforts to advance equitable access to recess. Quality and access should be considered when developing recess policies. CONCLUSIONS: Most United States elementary schools provide recess. However, regional and economic disparities exist. Promoting supportive practices for recess, particularly for schools serving lower-income communities, is necessary.

Studying the impact of COVID-19 mitigation policies on childhood obesity, health behaviors, and disparities in an observational cohort: Protocol for the COVID-19 Family Study.

BACKGROUND: COVID-19 pandemic control policies, including school closures, suspended extra-curricular activities, and social distancing, were introduced to prevent viral transmission, and disrupted children's daily routines, health behaviors, and wellness. This observational cohort study among 697 families with children or adolescents, based on the Family Stress Model, aims to: 1) evaluate pre- to during-pandemic changes in child health behaviors (diet, physical activity, sleep) and weight gain, 2) identify mechanisms explaining the changes, and 3) determine projected healthcare costs on weight gain and obesity. Each aim includes an examination by racial and ethnic, socioeconomic, and geographic disparities. METHODS: The study employs a mixed methods design, recruiting children and their caregivers from two obesity prevention trials halted in 2020. Enrolled participants complete annual surveys to assess child health behaviors, family resources, routines, and demographics, and home environment in 2020-2022. Height and weight are measured annually in 2021-2022. Annual semi-structured interviews are conducted within a subsample to understand mechanisms of observed changes. Multilevel mixed models and mediation analyses are used to examine changes in child health behaviors and weight gain and mechanisms underlying the changes. Qualitative data are analyzed within and across time points and integrated with quantitative findings to further explain mechanisms. Markov models are used to determine healthcare costs for unhealthy child behaviors and weight gain. CONCLUSION: Findings from this study will aid in understanding pandemic-related changes in child health behaviors and weight status and will provide insights for the implementation of future programs and policies to improve child and family wellness.

Parents' Trust in COVID-19 Messengers and Implications for Vaccination.

PURPOSE: To characterize factors associated with parents' trust in messengers of COVID-19 guidance and determine whether trust in their doctors is associated with COVID-19 vaccination. DESIGN: Web-based and mailed survey (January-June 2022). SETTING: Maryland, USA. SUBJECTS: 567 parents/caregivers of public elementary and middle school students. MEASURES: Parents rated trust in 9 messengers on a 4-point scale ["not at all" (0) to "a great deal" (3)], dichotomized into low (0-1) vs high (2-3). They reported on health insurance, income, race, ethnicity, education, sex, urbanicity, political affiliation, and COVID-19 vaccination. ANALYSIS: ANOVA and t-tests were computed to compare overall trust by parent characteristics. Multivariable logistic regression was run to evaluate factors associated with high trust for each messenger. Multivariable logistic regression was used to evaluate the relationship between trust in doctors and odds of COVID-19 vaccination. RESULTS: Most trusted messengers were doctors (M = 2.65), family members (M = 1.87), and schools (M = 1.81). Parents' trust varied by racial identity, sex, urbanicity, health insurance, and political affiliation. Greater trust in their or their child's doctor was associated with greater odds of child (aOR: 2.97; 95% CI: 1.10, 7.98) and parent (aOR: 3.30; 95% CI: 1.23, 1.47) vaccination. CONCLUSION: Parent characteristics were associated with trust, and trust was linked to vaccination. Public health professionals should anticipate variability in trusted messengers to optimize uptake of public health guidance.

Perceptions of Parental Support for Physical Activity and Healthy Eating among School-age Children During COVID-19 pandemic.

Family routines play a key role in promoting child health behaviors. This study 1) describes changes in children's perceptions of physical activity (PA) and healthy eating family routines across three time points: pre-pandemic (2017-2020), early pandemic (2020), and mid-pandemic (2021); and 2) explores how sex, age, and pandemic-related economic stressors relate to changes. Children's perceptions of family routines were assessed using four subscales adapted from the Comprehensive Home Environment Survey: PA-policies, Diet-policies, Diet-rules, and PA-Diet-role-model. Linear mixed models assessed changes in perceptions and associated factors (child age and sex; caregiver(s) job loss during pandemic). Children (N=277) were aged 9.3-15.5y at pandemic onset (March 2020), dichotomized by median age (12.1y) as younger and older. Children's perceptions of PA-policies (pre-pandemic mean=15.4) and Diet-policies (pre-pandemic mean=26.3) increased significantly from pre- to early (b=1.2 and 2.3, respectively) and mid-pandemic (b=1.0 and 1.2, respectively). Diet-rules (pre-pandemic mean=10.8) decreased significantly from pre- to early (b=-1.1) and mid-pandemic (b=-2.0), with no PA-Diet-role-model changes. Younger children had a greater increase in perceived PA-policies and Diet-policies across the pandemic. Females (59.9%) had a greater decrease in perceived Diet-rules across the pandemic and less increase in Diet-policies and PA-Diet-role-model from pre- to early pandemic. Children whose caregiver(s) lost employment (51.8%) perceived a greater increase in PA-policies. Overall, children reported increased parental policies to support PA and healthy eating and decreased parental rules for diet during the pandemic. Future research is needed to understand how changes in family routines relate to PA and healthy eating behaviors.

Development of a community-informed communication toolkit to prevent spread of viral illness in schools, including SARS-COV-2.

Introduction: Schools were uniquely impacted during the COVID-19 (SARS-COV-2) pandemic. We sought to elucidate how parents/guardians of elementary and middle school students in Maryland navigated the return to in-person school following remote instruction. We also sought to understand how they perceived communication about school-based COVID-19 mitigation strategies and their preferences for the content and format of public health communication about COVID-19 mitigation in schools. Methods: We engaged a community advisory board comprised of key partners and implemented a survey and focus groups. Results: Results indicated that parents/guardians wanted clearer communication about COVID-19 mitigation policies in schools and were experiencing fatigue and confusion. These insights informed the development of a tailorable communication toolkit. The toolkit was designed to (1) inform parents/guardians about the importance and effectiveness of mitigation strategies for preventing viral spread to keep children in school, (2) promote a sense of community and support, and (3) help school communication teams effectively communicate information about mitigation strategies being implemented. Discussion: We describe a process for leveraging schools as a trusted messenger, engaging school communities in the development of communication messages, and utilizing a tailorable communication toolkit in the context of shifting public health guidance and local needs. The toolkit development and dissemination process offers a model for targeting public health messaging to parents/guardians in school settings.

Identifying and preventing fraudulent responses in online public health surveys: Lessons learned during the COVID-19 pandemic.

Web-based survey data collection has become increasingly popular, and limitations on in-person data collection during the COVID-19 pandemic have fueled this growth. However, the anonymity of the online environment increases the risk of fraudulent responses provided by bots or those who complete surveys to receive incentives, a major risk to data integrity. As part of a study of COVID-19 and the return to in-person school, we implemented a web-based survey of parents in Maryland between December 2021 and July 2022. Recruitment relied, in part, on social media advertisements. Despite implementing many existing best practices, we found the survey challenged by sophisticated fraudsters. In response, we iteratively improved survey security. In this paper, we describe efforts to identify and prevent fraudulent online survey responses. Informed by this experience, we provide specific, actionable recommendations for identifying and preventing online survey fraud in future research. Some strategies can be deployed within the data collection platform such as careful crafting of survey links, Internet Protocol address logging to identify duplicate responses, and comparison of client-side and server-side time stamps to identify responses that may have been completed by respondents outside of the survey's target geography. Other strategies can be implemented during the survey design phase. These approaches include the use of a 2-stage design in which respondents must be eligible on a preliminary screener before receiving a personalized link. Other design-based strategies include within-survey and cross-survey validation questions, the addition of "speed bump" questions to thwart careless or computerized responders, and the use of optional open-ended survey questions to identify fraudsters. We describe best practices for ongoing monitoring and post-completion survey data review and verification, including algorithms to expedite some aspects of data review and quality assurance. Such strategies are increasingly critical to safeguarding survey-based public health research.

Alternative School Breakfast Service Models and Associations with Breakfast Participation, Diet Quality, Body Mass Index, Attendance, Behavior, and Academic Performance: A Systematic Review.

The United States (US) School Breakfast Program provides Breakfast After The Bell (BATB) to alleviate hunger, provide nutrition, and ensure students have a healthy start to the day. This study aims to review the evidence regarding the impact of BATB on students' diet and academic outcomes, including participation, diet quality and consumption, body mass index (BMI) and weight status, attendance, classroom behavior, and academic performance. The articles were extracted from three electronic databases and published since the start of the literature through December 2022. Studies were peer-reviewed; quantitative research articles or government reports; and conducted in public or private elementary, middle, and high schools. Quality was assessed using the Newcastle-Ottawa Scale. Thirty-seven studies were included in this review. This review found BATB increased school breakfast participation, improved diet quality, and improved classroom behavior particularly among students from racial and ethnic minority backgrounds and students eligible for free or reduced-price meals. The impact of BATB on BMI and weight status, academic achievement and attendance was mixed. This review is particularly timely given free school meals and updated school nutrition standards are being prioritized over the next decade in the US. Thus, it is important to evaluate the nutritional and educational outcomes of BATB. (PROSPERO registration: CRD42021289719).

Physical Activity, Confidence, and Social Norms Associated With Teachers' Classroom Physical Activity Break Implementation.

Despite the benefits of classroom physical activity breaks on student health and academic outcomes, more research is needed to understand what factors may be associated with classroom physical activity break implementation, to bolster buy-in from school stakeholders and increase implementation. This quantitative study examined frequency of classroom physical activity break implementation in relation to (1) objectively measured teachers' physical activity and sedentary behaviors, (2) confidence for leading classroom physical activity breaks, (3) social norms (perceptions of other teachers' classroom physical activity break implementation), and (4) teacher- and school-level demographics. In total, 153 classroom teachers in 20 elementary and middle schools completed a survey including classroom physical activity break frequency, confidence, and social norms, one item each, dichotomized (1 = "most/all the time" OR "agree/strongly agree"). Accelerometry assessed total activity and daytime sedentary behavior. Analyses included multilevel binary logistic regression. Teachers were 90% female, 68% White, and 55% in elementary schools. Odds of implementing classroom physical activity breaks were lower among middle school teachers, 14 times greater among those with greater confidence, and over 17 times greater when teachers perceived others frequently implementing classroom physical activity breaks. Teacher activity was not associated with classroom physical activity break implementation. Future interventions to increase classroom physical activity break implementation should focus on increasing teachers' confidence to lead classroom physical activity breaks and creating more buy-in from classroom teachers to enhance each school's culture of health. By enhancing teacher confidence and social norms for implementing classroom physical activity breaks, we may increase school-based physical activity opportunities.

Geospatial Reach of the Maryland COVID-19 School Meals Response: Spring 2020.

OBJECTIVE: Examine characteristics of pandemic meal site (n = 602) location and meals served per site in Maryland, Spring 2020, following federal/state waivers for local meal site placement decision-making. METHODS: Using geographic information systems, we connected meal sites to census tract-level data and generated service areas from sites and distances from population-weighted census tract centroids to the closest pandemic meal site. Regression analysis determined associations of census tract pandemic meal site count and meals served per site with socioeconomic and demographic variables. RESULTS: Census tracts with more meal sites were urban (P < 0.001), food deserts (P < 0.001), and had higher percentages of children in poverty (P < 0.001). Sites serving fewer meals were in food deserts (P < 0.001) and areas with more children in poverty (P < 0.001). CONCLUSIONS AND IMPLICATIONS: Waivers allowing local meal site placement decision-making supported meal sites in high-need areas. Geospatial approaches could optimize site locations to ensure maximum reach to populations in need. Additional supports may be needed to ensure children in poverty areas receive meals distributed at these sites.

A click too far from fresh foods: A mixed methods comparison of online and in-store grocery behaviors among low-income households.

A recent policy in the U.S. authorized monthly benefits from a nutrition assistance program - Supplemental Nutrition Assistance Program (SNAP) - to be used online to increase grocery access and promote healthy eating. This study examined online grocery attitudes and purchasing behaviors among low-income SNAP-eligible households with young children with and without online grocery experience. An explanatory sequential mixed methods design was used, including a survey informed by the theory of planned behavior (TPB) and focus groups conducted between November-March 2021. In the quantitative phase, 310 Maryland residents completed an online survey assessing TPB constructs (attitudes, social norms, perceived control), and food purchase frequency online and in-store. Subsequently, 42 participated in the qualitative phase. Differences in TPB constructs and food purchases were compared between families with and without online grocery experience. Online food selection and fees were a common obstacle to online grocery purchasing. Families who had purchased groceries online (57%) had more positive attitudes and perceived fewer barriers to online shopping than those who had not. Self-reported frequency of buying fresh produce (OR = 0.34, p < 0.001), meat and seafood (OR = 0.29, p < 0.001), and sweets (OR = 0.54, p = 0.005) were lower online than in-store. Families discussed mistrust of online hired shoppers and fewer impulse purchases online as reasons for less frequent purchases of produce and sweets, respectively. Successful scale-up of the U.S. policy must address barriers to healthier purchasing behaviors to effectively promote equitable food access, such as decreasing delivery fees and improving the online food selection.

Estimates of the Nutritional Impact of Non-Participation in the National School Lunch Program during COVID-19 School Closures.

The COVID-19 pandemic resulted in widespread school closures, reducing access to school meals for millions of students previously participating in the US Department of Agriculture (USDA) National School Lunch Program (NSLP). School-prepared meals are, on average, more nutritious than home-prepared meals. In the absence of recent data measuring changes in children's diets during the pandemic, this article aims to provide conservative, back-of-the-envelope estimates of the nutritional impacts of the pandemic for school-aged children in the United States. We used administrative data from the USDA on the number of NSLP lunches served in 2019 and 2020 and nationally representative data from the USDA School Nutrition and Meal Cost Study on the quality of school-prepared and home-prepared lunches. We estimate changes in lunchtime calories and nutrients consumed by NSLP participants from March to November 2020, compared to the same months in 2019. We estimate that an NSLP participant receiving no school meals would increase their caloric consumption by 640 calories per week and reduce their consumption of nutrients such as calcium and vitamin D. Because 27 to 78 million fewer lunches were served per week in March-November 2020 compared to the previous year, nationally, students may have consumed 3 to 10 billion additional calories per week. As students return to school, it is vital to increase school meal participation and update nutrition policies to address potentially widening nutrition disparities.

Maternal depressive symptoms, attendance of sessions and reduction of home safety problems in a randomized toddler safety promotion intervention trial: A latent class analysis.

OBJECTIVE: Little is known about the association between maternal depressive symptoms and attendance at safety promotion interventions. This study used latent class analysis (LCA) to identify the profile of attendance within a toddler safety intervention and assessed its relation with maternal depressive symptoms at baseline and reduction of home safety problems over time, separately. METHODS: The analytic sample included 91 mothers of toddlers (mean maternal age 28.16 years) who were assigned to the safety promotion intervention group as part of a randomized trial and assessed at baseline, 6-month and 12-month follow-ups. Using LCA, we classified mothers into low and high attendance classes based on their attendance at 8 intervention sessions. We assessed maternal depressive symptoms with the Beck Depression Inventory (BDI) and home safety problems with a 9-item home safety problem observation. RESULTS: The mothers were classified into low attendance (45%) and high attendance classes (55%). The posterior probability of attending each session ranged from 0-0.29 for the low attendance class and 0.68-0.92 for the high attendance class. Each one unit increase of BDI sum score at baseline was associated with an 8% reduced odds of being in the high attendance class (aOR = 0.92, 95% CI: 0.86, 1.00, p = 0.037). The home safety problem score reduction was greater among high attendance class participants than low attendance class participants at the 6-month follow-up (b = -1.15, 95% CI:-2.09, -0.20, p = 0.018). CONCLUSION: Maternal depressive symptoms were associated with the reduced probability of maternal attendance at toddler safety promotion sessions; high session attendance was related to greater reduction of toddler home safety problems. Identifying risk factors for maternal low attendance to interventions and developing strategies to promote attendance should lead to reductions in home safety problems and reductions in unintentional injuries among young children.

Physical Education Teachers' Perceived Effectiveness in Association with Student Attendance, Teacher Adaptability, External Educational Supports, and Teaching Format During the COVID-19 Pandemic.

Spring 2020 pandemic-control policies included an abrupt shift to remote teaching, which may have affected physical education (PE) teachers' perceived effectiveness. This study examined K-12 PE teachers' perceived effectiveness in association with student attendance, teacher adaptability, PE supports, teaching format (in-person, remote synchronous, remote asynchronous, etc.), and teacher- and school-level demographics at three time points (pre-pandemic 2019-early 2020, Spring 2020, 2020-2021 school year). An electronic survey was developed by an expert panel and distributed to U.S. public school PE teachers (convenience sampling via school health-related organizations). For analyses, teacher perceived effectiveness was dichotomized (very/extremely effective= "1"; not at all/slightly/moderately effective= "0"). Logistic regression models assessed associations between perceived effectiveness and independent variables (student attendance, teacher adaptability, PE supports, teaching format, and demographic variables) at each time point. Respondents (n=134; M age=46) were mostly female (62%), general PE teachers (82%, versus adapted), had a graduate degree (66%), had >11 years of teaching experience (63%), and from 26 states. Perception of being very/extremely effective was highest pre-pandemic 2019-early 2020 (93%), lowest in Spring 2020 (12%), and recovered somewhat in 2020-2021 (45%). During the 2020-2021 school year, teachers had greater odds of perceiving they were more effective if they reported having higher student attendance (OR 1.06 [CI:1.02-1.09], p>.001) and higher adaptability (OR 1.22 [CI: 1.09-1.37], p>.001), adjusting for gender, education level, years of experience, grade level taught, and Title I status. Professional development opportunities are needed for remote teaching of PE to enhance teachers' adaptability and perceived effectiveness during potential future school closures.

Pre-pandemic to early-pandemic changes in risk of household food insecurity among Maryland families with children.

OBJECTIVE: The objective was to examine risk and protective factors associated with pre- to early-pandemic changes in risk of household food insecurity (FI). DESIGN: We re-enrolled families from two statewide studies (2017-2020) in an observational cohort (May-August 2020). Caregivers reported on risk of household FI, demographics, pandemic-related hardships, and participation in safety net programs (e.g. CARES stimulus payment, school meals). SETTING: Maryland, United States. PARTICIPANTS: Economically, geographically, and racially/ethnically diverse families with preschool to adolescent-age children. Eligibility included reported receipt or expected receipt of the CARES stimulus payment or a pandemic-related economic hardship (n=496). RESULTS: Prevalence of risk of FI was unchanged (pre-pandemic: 22%, early-pandemic: 25%, p=0.27). Risk of early-pandemic FI was elevated for non-Hispanic Black (aRR=2.1 [95% CI 1.1, 4.0]) and Other families (aRR=2.6 [1.3, 5.4]) and families earning ≤300% federal poverty level. Among pre-pandemic food secure families, decreased income, job loss, and reduced hours were associated with increased early-pandemic FI risk (aRR=2.1 [1.2, 3.6] to 2.5 [1.5, 4.1]); CARES stimulus payment (aRR=0.5 [0.3, 0.9]) and continued school meal participation (aRR=0.2 [0.1, 0.9]) were associated with decreased risk. Among families at risk of FI pre-pandemic, safety net program participation was not associated with early-pandemic FI risk. CONCLUSIONS: The CARES stimulus payment and continued school meal participation protected pre-pandemic food secure families from early-pandemic FI risk but did not protect families who were at risk of FI pre-pandemic. Mitigating pre-pandemic FI risk and providing stimulus payments and school meals may support children's health and reduce disparities in response to pandemics.

Strategies to Improve School Meal Consumption: A Systematic Review.

School meals can play an integral role in improving children's diets and addressing health disparities. Initiatives and policies to increase consumption have the potential to ensure students benefit from the healthy school foods available. This systematic review evaluates studies examining initiatives, interventions, and policies to increase school meal consumption. Following PRISMA guidelines, this review was conducted using four databases and resulted in a total of 96 studies. The research evidence supports the following strategies to increase school meal consumption: (1) offering students more menu choices; (2) adapting recipes to improve the palatability and/or cultural appropriateness of foods; (3) providing pre-sliced fruits; (4) rewarding students who try fruits and vegetables; (5) enabling students to have sufficient time to eat with longer (~30 min) lunch periods; (6) having recess before lunch; and (7) limiting students' access to competitive foods during the school day. Research findings were mixed when examining the impact of nutrition education and/or offering taste tests to students, although multiple benefits for nutrition education outside the cafeteria were documented. There is some evidence that choice architecture (i.e., "Smarter Lunchroom") techniques increase the proportion of students who select targeted meal components; however, there is not evidence that these techniques alone increase consumption. There were limited studies of the impact of increasing portion sizes; serving vegetables before other meal components; and strengthening local district and/or school wellness policies, suggesting that further research is necessary. Additionally, longer-term studies are needed to understand the impact of policies that limit students' access to flavored milk. Several studies found increases in students' meal consumption following the Healthy Hunger-Free Kids Act (HHFKA) and concerns regarding an increase in food waste following the HHFKA were not supported. Overall, there are a range of effective strategies to increase school meal consumption that can be implemented by schools, districts, and policymakers at the local, state, and federal levels (PROSPERO registration: CRD42021244688).

Home and Neighborhood Physical Activity Location Availability among African American Adolescent Girls Living in Low-Income, Urban Communities: Associations with Objectively Measured Physical Activity.

Based on the ecological model of active living, the neighborhood environment may relate to individual physical activity (PA) behaviors. The purposes of this study were to (1) generate a replicable neighborhood-level physical activity location availability score (PALAS) from data variables associated with physical activity among adolescents and adults, and apply this score to Baltimore City, Maryland, and (2) determine if relationships exist between PA and PA location availability. Geographic information systems (GISs) were used to create the PALAS. Using linear regression models, we examined relations between objectively measured PA among low-income, urban, predominantly African American adolescent girls (n = 555, 2009-2012 data collection), and the PALAS rating of their neighborhood environment (neighborhood PALAS) and their home neighborhood area (PALAS variables/subcomponents within 0.25 miles of the home). A PALAS map of the study area was created, illustrating neighborhoods varying in availability and variety of PA locations. After adjusting for confounders, a higher neighborhood PALAS (ß = 0.10, p = 0.041) and the presence of a recreation center in the home neighborhood area (ß = 0.46, p = 0.011) were associated with more minutes per day spent in moderate to vigorous PA. Policy makers and stakeholders should consider increasing access to PA locations as a strategy to promote PA among adolescent girls.

Associations between elementary and middle school teachers' physical activity promoting practices and teacher- and school-level factors.

BACKGROUND: Few studies have evaluated teacher- and school-level characteristics associated with implementation of recommended physical activity (PA) promoting practices. The purpose of this study is to examine associations between teachers' PA practices and: [1] teacher-level factors, including their own PA, and [2] school-level factors. METHODS: This cross-sectional study examined time spent daily in light PA (LPA) and moderate-vigorous PA (MVPA) in association with 7 teacher PA practices among 288 classroom/special area teachers and teaching assistants in 20 urban, suburban and rural schools (recruited through a school wellness trial) in 4 districts. LPA and MVPA was assessed using 24-h ankle accelerometry (up to seven consecutive days). A sum score for teacher PA practices was assessed via survey (7 items; sum score range: 7-35; Cronbach's alpha = 0.73; higher scores indicate more PA promoting practices). Teacher-level factors included gender, race, self-reported height/weight, years teaching, and education. School-level factors included school type, free-and-reduced-price meal eligibility, student racial/ethnic composition, and urbanicity. Analyses included multilevel regression models, accounting for clustering within schools and adjusting for demographic covariates and school district. RESULTS: Teachers were 91% female, 63% elementary, 60% white, mean age 43.2 years (SD = 11.3), and 41% obese). Teachers wore accelerometers an average of 5.8 days, spent 399.6 min in LPA (SD = 85.0) per day, 24.1 min in MVPA (SD = 14.4) per day, and the mean teacher PA practices sum score was 22.4 (SD = 5.0). Every 15-min increase in MVPA was related to an increase in teacher PA practices sum score (coeff =1.07; SE = 0.28; p < 0.001). Female gender (versus males; coeff = - 1.95; SE = 0.92, p = 0.034), an obese weight status (versus non-obese; coeff = - 1.38; SE = 0.54, p = 0.010), and teaching in a middle school (versus elementary; coeff = - 3.86; SE = 0.54, p < 0.001) were associated with lower teacher PA practices scores. LPA was not associated with teacher PA promoting practices. CONCLUSIONS: Teachers with higher MVPA, but not higher LPA, and those without obesity were more likely to implement PA promoting practices that could positively impact their students' PA. Similar to prior studies, these practices were more commonly implemented in elementary schools and by male teachers. Future studies in schools should explore whether improvement of teacher health behaviors subsequently impacts student health behaviors. TRIAL REGISTRATION: Clinical Trials, NCT03432715 ; Registered on 02/2/2018.

An ecological momentary assessment study of physical activity behaviors among mothers of toddlers from low-income households.

BACKGROUND: Mothers of young children from low-income communities may be vulnerable to barriers associated with low physical activity. The purpose of this study was to examine associations between home environment factors and maternal physical activity among mothers of toddlers. METHODS: Mothers of toddlers (n = 200) recruited from low-income communities simultaneously wore an ankle-placed accelerometer and were given a personal digital assistant for ecological momentary assessment. Mothers received randomly prompted questions about their current environment, activity, and social setting several times a day over eight consecutive days. Data were analyzed using linear mixed-effects regression models with random intercepts; within-group and between-group relations between physical activity and environment factors were disaggregated. RESULTS: Within-group relations included higher physical activity counts for specific mothers with television off versus on (95% CI = 130.45, 199.17), children absent versus present (95% CI = 82.00, 3.43), engaging with a child versus not (95% CI = 52.66, 127.63), and outside versus inside location (95% CI = 277.74, 392.67). Between-group relations included higher physical activity on average when other adults were absent versus present (95% CI = - 282.63, - 46.95). Recruitment site (urban vs. semi-urban) significantly moderated the within-group relation between being outside versus inside and activity count (ß = - 243.12, 95% CI = - 358.74, - 127.47), and showed stronger relations among urban mothers (ß = 440.33, 95% CI = 358.41, 522.25), than semi-urban (ß = 190.37, 95% CI = 109.64, 271.11). Maternal body weight significantly moderated the within-group relation between being located outside versus inside the home and activity count (ß for interaction = - 188.67, 95% CI = - 308.95, - 68.39), with a stronger relation among mothers with normal weight (ß = 451.62, 95% CI = 345.51, 557.73), than mothers with overweight/obesity (ß = 271.95, 95% CI = 204.26, 339.64). CONCLUSIONS: This study highlights home environmental factors, including screen time, the presence of others (adults and children), and location (i.e., outside versus inside) that may relate to maternal physical activity behaviors. Understanding factors associated with physical activity could reduce physical activity disparities. Trial registry ClinicalTrials. NCT02615158, April 2006.