Evaluation of Online and In-Person Nutrition Education Related to Salt Knowledge and Behaviors among Special Supplemental Nutrition Program for Women, Infants, and Children Participants.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) differs from other federal nutrition programs in that nutrition education is a required component. WIC programs traditionally provide in-person education, but recently some WIC sites have started offering online education. Education focused on reducing salt intake is an important topic for WIC participants because a high-sodium diet has been associated with high blood pressure, and low-income populations are at increased risk. OBJECTIVE: Our aim was to examine the impacts of traditional in-person and online nutrition education on changes in knowledge, self-efficacy, and behaviors related to reducing salt intake in low-income women enrolled in WIC. DESIGN: Although a comparison of groups was not the primary focus, a randomized trial examining the impact of online and in-person nutrition education on participant knowledge, self-efficacy, and behaviors related to salt intake was conducted. PARTICIPANTS/SETTING: Five hundred fourteen WIC participants from three Los Angeles, CA, WIC clinics received either in-person (n=257) or online (n=257) education. Questionnaires assessing salt-related knowledge, self-efficacy, and behaviors were administered at baseline and 2 to 4 months and 9 months later from November 2014 through October 2015. RESULTS: Positive changes in knowledge and self-efficacy were retained 2 to 4 months and 9 months later for both groups (P<0.05). Both groups reported significant changes in behaviors related to using less salt in cooking (P<0.0001) and eating fewer foods with salt added at the table or during cooking (P<0.001) at 2 to 4 months and 9 months. CONCLUSIONS: Both online and in-person education resulted in improvements during a 9-month period in knowledge, self-efficacy, and reported behaviors associated with reducing salt intake in a low-income population. Offering an online education option for WIC participants could broaden the reach of nutrition education and lead to long-term positive dietary changes.

Eating School Lunch Is Associated with Higher Diet Quality among Elementary School Students.

BACKGROUND: Few studies have assessed the dietary quality of children who eat meals from home compared with school meals according to the 2010 Dietary Guidelines for Americans. OBJECTIVE: The objective of this study was to examine diet quality for elementary school students in relation to source of breakfast and lunch (whether school meal or from an outside source). DESIGN: An observational study was conducted of students in 43 schools in San Diego, CA, during the 2011-2012 school year. PARTICIPANTS/SETTING: Fourth- and fifth-grade students (N=3,944) completed a diary-assisted 24-hour food recall. MAIN OUTCOME MEASURES: The Healthy Eating Index-2010 (HEI-2010) scores of children who ate breakfast and lunch at school were compared with the HEI-2010 scores of children who obtained their meals from home and a combination of both school and home. STATISTICAL ANALYSIS: Analysis of variance, χ2 test, and generalized estimating equation models adjusted for age, sex, race/ethnicity, grade, language, and school level clustering were performed. RESULTS: School lunch eaters had a higher mean±standard deviation overall diet quality score (HEI-2010=49.0±11.3) compared with students who ate a lunch obtained from home (46.1±12.2; P=0.02). There was no difference in overall diet quality score by breakfast groups. Students who ate school breakfast had higher total fruit (P=0.01) and whole fruit (P=0.0008) scores compared with students who only ate breakfast obtained from home. Students who ate school foods had higher scores for dairy (P=0.007 for breakfast and P<0.0001 for lunch) and for empty calories from solid fats and added sugars (P=0.01 for breakfast and P=0.007 for lunch). CONCLUSIONS: Eating school lunch was associated with higher overall diet quality compared with obtaining lunch from home. Future studies are needed that assess the influence of the Healthy Hunger-Free Kids Act on children's diet quality.

Online and In-Person Nutrition Education Improves Breakfast Knowledge, Attitudes, and Behaviors: A Randomized Trial of Participants in the Special Supplemental Nutrition Program for Women, Infants, and Children.

BACKGROUND: Although in-person education is expected to remain central to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) service delivery, effective online nutrition education has the potential for increased exposure to quality education and a positive influence on nutrition behaviors in WIC participants. Education focused on promoting healthy breakfast behaviors is an important topic for WIC participants because breakfast eating compared with breakfast skipping has been associated with a higher-quality diet and decreased risk for obesity. OBJECTIVE: To examine the influences of online and in-person group nutrition education on changes in knowledge, attitudes, and behaviors related to breakfast eating. DESIGN: Randomized-controlled trial comparing the effectiveness of online and in-person nutrition education between March and September 2014. PARTICIPANTS/SETTING: Five hundred ninety WIC participants from two Los Angeles, CA, WIC clinics were randomly assigned to receive in-person group education (n=359) or online education (n=231). Education focused on ways to reduce breakfast skipping and promoted healthy options at breakfast for parents and their 1- to 5-year-old children participating in WIC. Questionnaires assessing breakfast-related knowledge, attitudes, and behaviors were administered before and after education, and at a 2- to 4-month follow-up. STATISTICAL ANALYSIS: Changes within and between in-person and online groups were compared using t tests and χ(2) tests. Analysis of covariance and generalized estimating equations were used to assess differences in change between groups. RESULTS: Changes in knowledge between pretest and follow-up at 2 to 4 months were similar between groups. Both groups reported reductions in barriers to eating breakfast due to time constraints, not having enough foods at home, and difficulty with preparation. Increases in the frequency of eating breakfast were greater for both the parent (P=0.0007) and child (P=0.01) in the online group compared with the in-person group during the same time points. CONCLUSIONS: Overall, this study demonstrates that both in-person and online nutrition education were effective in increasing breakfast-related knowledge in WIC participants, reducing breakfast skipping, and improving other breakfast-related behaviors, showing the potential usefulness for online education modalities for future WIC services.

School Breakfast Policy Is Associated with Dietary Intake of Fourth- and Fifth-Grade Students.

BACKGROUND: Breakfast skipping has been associated with obesity. Schools have adopted breakfast policies to increase breakfast participation. Recently, there have been concerns that students in schools where breakfast is served in the classroom may be eating two breakfasts--one at home and one at school--thereby increasing their risk of excessive energy intake and weight gain. OBJECTIVE: The study objective was to compare the prevalence of not eating breakfast, eating breakfast at home or school only, and eating double breakfasts (home and school) by students in schools with distinct breakfast policies and evaluate the relationship of breakfast policy to energy intake and diet quality. DESIGN: Baseline data were collected in 2011-2012 as part of a cluster randomized controlled trial to evaluate the effectiveness of a school-based intervention to promote fruit and vegetable intake and physical activity in low-resource elementary schools in California. PARTICIPANTS/SETTING: Participants were 3,944 fourth and fifth graders from 43 schools, 20 served breakfast in the cafeteria before school, 17 served breakfast in the classroom at the start of school, and 6 served "second chance" breakfast (in the cafeteria before school and again at first recess). STATISTICAL ANALYSIS: As part of a secondary data analysis, differences in school and individual characteristics by school breakfast policy were assessed by χ(2) test of independence or analysis of variance. Associations between school breakfast policy and breakfast eating patterns were assessed. Outcomes included calorie intake at breakfast, total daily calorie intake, and diet quality as measured by the Healthy Eating Index 2010. Control variables included student race/ethnicity, grade, and language spoken at home, and clustering of students by school. RESULTS: Breakfast in the classroom was associated with fewer students not eating breakfast (P<0.001), but more eating breakfast at both home and school (P<0.001). Students in the breakfast in the classroom group did not have higher mean energy intakes from breakfast or higher daily energy intakes that were higher than other breakfast policy groups. The breakfast in the classroom group had higher overall diet quality (P=0.01). CONCLUSIONS: No evidence was found to support discontinuation of breakfast in the classroom policy on the basis of concerns that children will eat excess calories.

Eat lunch first or play first? Inconsistent associations with fruit and vegetable consumption in elementary school.

Scheduling play before eating lunch has been suggested as a relatively simple environmental strategy to increase fruit and vegetable (FV) intake among elementary school students. However, the few small studies to date have had mixed findings. The primary aim of this observational study was to evaluate the possible relationship between the relative order of play and eating and students' lunch intake of FV. A secondary aim was to examine whether any differences existed in this relationship by student sex, ethnicity, language spoken at home, and school lunch source. A diary-assisted 24-hour recall was collected during the 2011-2012 school year from 2,167 fourth- and fifth-graders attending 31 elementary schools in California. The association of play before eating with FV intake was estimated using Generalized Estimation Equations. Overall, lunch FV intake was not significantly higher for students who had a play-before-eating vs a play-after-eating lunch schedule at school. However, variables included in the model showed significant interaction with play before eating, resulting in the need for separate effect estimates for distinct strata based on sex, ethnicity, language spoken at home, and school lunch source. For 10 of the 16 strata, no significant effect of play before eating was observed on lunch FV intake, while increases in intake were observed in four strata and decreases in two strata. Before rescheduling play before eating for the purpose of improving student FV intake, additional research is recommended.

Passive commuting and dietary intake in fourth and fifth grade students.

BACKGROUND: Promoting active commuting by walking or biking to and from school could increase physical activity and reduce obesity among youth. However, exposure to the retail food environment while commuting may lead to greater dietary intake among active commuters. PURPOSE: To examine the relationship between commute patterns and dietary intake and quality in elementary students. METHODS: Fourth and fifth grade students (N=3,316) in 44 California schools reported commute modes to and from school and dietary intake for the same 24-hour period in 2012. Differences between active and passive commuters in total energy intake (kcal), energy from purchased foods, and energy from sweets and snack-type foods were compared, stratified by after-school program (ASP) participation (analysis conducted in 2013). RESULTS: Twenty-three percent of youth actively commuted to school; 27% actively commuted from school. Passive commuters, 87% of whom traveled by car, consumed 78 more kcal from purchased foods (p<0.01) than active commuters in the 24-hour period, though total energy intake did not differ by commute mode overall or by ASP participation. Among the 72% of students who did not attend an ASP, passive commuters consumed 56 more kcal from purchased foods (p<0.01) and 25 more kcal from sweets and snack-type foods (p=0.02) than active commuters. CONCLUSIONS: Passive commuters consumed more sweets and snack-type foods and more purchased foods than active commuters. These results, which suggest that parents are providing unhealthy foods for their children during the school commute, reinforce the need for multilevel strategies to promote energy balance in youth.

Investigation of shifts in autism reporting in the California Department of Developmental Services.

We investigated if shifts in the coding of qualifying conditions in the California Department of Developmental Services (DDS) have contributed to the increase in California children with autism observed in recent years. Qualifying condition codes for mental retardation (MR) and autism in DDS electronic files were compared to hard-copy records for samples of children born 1987, 1990, 1994, and 1997. Contrary to expectations, we did not find evidence of a coding shift from "MR only" to "both MR and autism" or an increase in the proportion of children with coded autism who lacked supportive diagnostic documentation in records (possible "misclassifications"). These results indicate that changes in DDS coding practices are unlikely to explain the increase in DDS clients with autism.

Infection in the first 2 years of life and autism spectrum disorders.

OBJECTIVE: The purpose of this work was to investigate the association between infections in the first 2 years and subsequent diagnosis of autism spectrum disorders. METHODS: We conducted a case-control study among children born at Kaiser Permanente Northern California from 1995 to 1999. Case subjects (n = 403) were children with an autism diagnosis recorded in Kaiser Permanente databases. Control subjects (n = 2100) were randomly sampled from the remaining children without autism and frequency matched to case subjects on gender, birth year, and birth hospital. Information on infections and covariates were obtained from Kaiser Permanente and birth certificate databases. RESULTS: Overall, infection diagnoses in the first 2 years of life were recorded slightly less often for children with autism than control children (95.0% vs 97.5%). Among specific diagnoses, upper respiratory infections were significantly less frequently diagnosed and genitourinary infections more frequently diagnosed in children with autism. In the first 30 days of life, the frequency of having an infection was slightly higher among children with autism (22.6% vs 18.7%). CONCLUSIONS: Children with subsequent diagnoses of autism do not have more overall infections in the first 2 years of life than children without autism. Data suggest that children with autism may have modestly elevated rates of infection in the first 30 days and that, during the first 2 years, children with autism may be at higher risk for certain types of infections and lower risk for others. Additional studies that explore the associations between prenatal and early childhood infections and autism may help clarify the role of infection and the immune system in the etiology of autism spectrum disorder.