SNAP Student Rules Are Not So Snappy: Lessons Learned From a Qualitative Study of California County Agency Workers

OBJECTIVE

To examine the college student Supplemental Nutrition Assistance Program (SNAP) application process from the perspective of county agency workers.

DESIGN

A qualitative study that included semistructured individual and group interviews (n = 14) between February and December, 2021.

SETTING

Nine California counties with a University of California campus.

PARTICIPANTS

A total of 24 county agency workers who regularly process or advise on college student SNAP applications.

PHENOMENON OF INTEREST

Facilitators and barriers to processing student SNAP applications.

ANALYSIS

Interviews were recorded, transcribed, and coded using thematic analysis.

RESULTS

Five themes were identified regarding student applications: (1) a need for more consistency in policy dissemination and program administration, (2) student exemptions and the application process are perceived as challenging for students, (3) facilitators of successfully processing student applications, (4) tracking policy changes is burdensome, and (5) eliminate the student rules.

CONCLUSION AND IMPLICATIONS

County agency workers perceived that students experience unnecessary barriers to accessing SNAP benefits and that implementing the student rules was taxing. Expanding SNAP access to low-income college students could be an equitable solution to mitigate the risk of student hunger while they pursue their degrees.

Factors associated with prescription of oral anticoagulation for atrial fibrillation in older people living in care homes in Wales: a routine data linkage study 2003–2018

Background

Prescription of oral anticoagulants (OAC) is paramount for stroke prevention in people with atrial fibrillation (AF), but treatment decisions in older care home residents are complicated by frailty, multi-morbidity and heightened stroke and bleeding risk. There is a paucity of data on factors influencing the decision to prescribe OAC in this high-risk population who are under-represented in research studies.

Purpose

To explore the factors associated with OAC prescription for care home residents aged ≥65 years with AF.

Methods

Nationwide retrospective cohort study of people aged ≥65 years entering a care home in Wales between 1 January 2003 and 31 December 2018, using anonymised individual-level electronic health record and administrative data sources available within the Secure Anonymised Information Linkage Databank. Unadjusted and adjusted logistic regression models were used to explore the association between resident characteristics and OAC prescription or non-prescription.

Results

Between 2003 and 2018, 14,493 people with AF aged ≥65 years became new residents in care homes in Wales and 7,057 (48.7%) were prescribed OAC (32.7% in 2003 compared to 72.7% in 2018), Figure 1. Increasing age and prescription of antiplatelet therapy were associated with lower odds of OAC prescription (adjusted odds ratio [aOR] 0.96 per one year age increase [95% confidence interval, 0.95 to 0.96] and aOR 0.91 [0.84 to 0.98], respectively). Conversely, prior venous thromboembolism (aOR 4.06 [3.17 to 5.20]), advancing frailty (mild: aOR 4.61 [3.95 to 5.38]; moderate: aOR 6.69 [5.74 to 7.80]; severe: aOR 8.42 [7.16 to 9.90]) and year of care home entry in the post-non-vitamin K antagonist oral anticoagulant (NOAC) era from 2011 onwards (aOR 1.91 [1.76 to 2.06]) were associated with higher odds of OAC prescription, Figure 2.

Conclusions

The proportion of care home residents prescribed OAC therapy has increased over time with the introduction of NOACs in 2011, but OAC prescription rates are still sub-optimal. Although there is an expected rise in OAC prescribing for increasingly frail people, further work is needed to investigate the interaction with deprivation and other socio-economic and demographic factors to assess potential inequalities in prescribing across these groups. Targeted educational tools for clinicians are needed to address barriers to OAC prescription for AF, such as older age and separate indications for antiplatelet therapy.

Funding Acknowledgement

Type of funding sources: None.

Impact of a Teacher Intervention to Encourage Students to Eat School Lunch

While school meals are often the healthiest option for students, lunch participation remains relatively low. Few approaches for increasing participation have leveraged teachers' potential social influence. We determined if a teacher intervention about the benefits of school lunch could improve teachers' perceptions of, and participation in, school lunch, and encouragement of students to eat school lunch. This repeated cross-sectional study included teacher/student survey administration in spring of 2016 and 2018 in 19 public secondary schools (9 intervention, 10 comparison) educating students of ages ≈ 11-18. Intervention teachers received monthly newsletters; lunch taste tests; and a promotional video and website. Mixed effects models with a random effect for school showed the proportion of teachers that reported eating with students increased in intervention schools relative to control schools (difference-in-change: 7.6%; 95% CI: 3.578%, 14.861%), as did student agreement that adults at their schools encouraged them to eat school lunch (difference-in-change: 0.15 on a 5-point scale; 95% CI: 0.061, 0.244). There were no between-group differences in teachers' perceptions of school meals or teachers' lunch participation. These findings suggest that teachers' perceptions of school meals do not necessarily need to improve to promote the school lunch program to students. However, to see meaningful change in teacher lunch participation, the taste of school meals likely needs improving.

Larger WIC Cash Value Benefit for Vegetables and Fruit Is Associated With Lower Food Insecurity and Improved Participant Satisfaction in WIC Families With Children

Objectives

In response to the COVID-19 pandemic, the USDA announced a temporary augmentation of the cash value benefit (CVB) for vegetables and fruits across all Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) agencies nationally, increasing the child CVB from $9 to $35/month for 4 months in the summer of 2021. The augmentation has continued since October 2021, with children ages 1 to 4 years receiving a CVB of $24/month. This study aimed to understand if augmenting the value of the WIC CVB for vegetables and fruits is associated with access to fruits and vegetables, fruit and vegetable intake (FVI), household food insecurity, and WIC program satisfaction among WIC participants from Los Angeles County, California.

Methods

This longitudinal, observational study of the 2021 CVB augmentation involved data collection using surveys at three time points: baseline (May 2021), midpoint (September 2021, before the CVB reduced from $35 to $24/month) and endpoint (May 2022, to be conducted). Detailed data on child FVI (using the NHANES Dietary Screener Questionnaire), household food security (using the USDA 6-item food security screener), and parental perception of the CVB changes were collected. Descriptive statistics and changes in study outcomes for respondents from baseline to midpoint were calculated in the full sample and stratified by race and ethnicity.

Results

1,673 families completed both baseline and midpoint surveys. Following the increased CVB amount ($9 to $35), the proportion of families reporting the benefit was ‘not enough’ decreased (89% to 23%) and the proportion saying the benefit was ‘just right’ increased (7% to 73%) (p < 0.0001). Household food insecurity decreased following the increase in CVB (55% to 44%, p < 0.0001). Child FVI decreased between baseline and midpoint surveys (2.43 vs 2.37 cups/day, p < 0.01). Baseline to midpoint change in FVI did not differ significantly by race and ethnicity (p = 0.19).

Conclusions

A short-term increase in WIC CVB was associated with improved participant experience and higher food security in California WIC participants. Longer-term increases in CVB may be needed to improve child fruit and vegetable intake.

Funding Sources

Robert Wood Johnson Foundation Healthy Eating Research Program and The David and Lucile Packard Foundation.

Addressing Barriers to WIC Participation During COVID-19: A Qualitative Examination of California WIC Participants and Local Agency Directors

Objectives

Economic impacts of COVID-19 have intensified the burden of food insecurity amongst low-income minority populations, especially women and children. This study aimed to understand the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participant and local agency director experiences with the adoption of USDA federal waivers, designed to overcome operational barriers during the COVID-19 pandemic in 3 regions in California.

Methods

A qualitative cross-sectional study included structured phone interviews (June 2020-March 2021) in Spanish or English of 182 California WIC participants’ experience and satisfaction with remote interactions, enrollment or recertification in WIC, and shopping for WIC foods. Twenty-two local agency directors were interviewed on how operational challenges were overcome, and preferences on the continuation of specific waivers post-pandemic. The study utilized integrated approach comprised of deductive framework and inductive identification to organize interview responses and identify themes for statistical analysis.

Results

Most WIC participant respondents (69%) were on WIC prior to the pandemic; 39% enrolled in WIC in March 2020 or later. Most participants were moderately (41%) or very (40%) concerned about the pandemic with more than a quarter (29%) experiencing less income due to COVID-19 challenges. A third (30%) reported challenges shopping for WIC foods at the start of the pandemic with the most common being milk (64%), eggs (33%), and fresh fruit (33%). Despite most participants (63%) reporting household food insecurity, 70% reported how easy and quick it was enrolling in WIC services. Most WIC agency directors (59%) reported offering only virtual services. Nearly all (95%) of agency directors wanted to continue the option to certify participants remotely, and all directors desired to continue issuing food benefits remotely, both practices enabled by federal waivers. Directors reported that WIC clinics were successfully able to pivot to remote operations because of the USDA federal waivers.

Conclusions

WIC may attract and retain most families by incorporating a hybrid approach including both on-site services and remote options.

Funding Sources

The David and Lucile Packard Foundation.

The Relationship between Breastfeeding and Initial Vegetable Introduction with Vegetable Consumption in a National Cohort of Children Ages 1–5 Years from Low-Income Households

Compared to other food groups, vegetable intakes are lowest relative to recommendations. Breastfeeding and initial introduction to vegetables may help infants establish long-lasting taste preferences. We examined the relationship between breastfeeding and initial vegetable introduction and vegetable intake in early childhood (ages 13–60 months). This repeated cross-sectional study used data from the national WIC Infant and Toddler Feeding Practices Study-2 collected from low-income mother/caregivers about infants from around birth through age 5 (60 months; n = 3773). Survey-weighted adjusted regression models assessed associations between breastfeeding and vegetable introduction measures with vegetable consumption at child ages 13, 24, 36, 48, and 60 months. Longer breastfeeding duration was associated with a slightly, but significantly, greater variety of vegetables consumed/day in early childhood. There was also a small but positive statistically significant association between the number of different types of vegetables consumed on a given day at 9 months and the amount and variety of vegetables consumed/day in early childhood. Age of initial vegetables introduction and whether vegetables were the first/second food introduced were not consistently related to the amount or variety of vegetables consumed later in childhood. Longer breastfeeding and introduction to a greater variety of vegetables at 9 months may be behaviors to target to increase consumption of a greater variety of vegetables by young children.

Shifts in Sources of Food but Stable Nutritional Outcomes among Children in the Early Months of the COVID-19 Pandemic

Early in the COVID-19 pandemic, the U.S. Department of Agriculture (USDA), State governments, and school districts took unprecedented steps to mitigate the pandemic’s impact on students’ nutrition. To examine the effect of emergency responses on 6-year-old children’s nutritional outcomes, this study analyzed longitudinal data from a national study of children’s feeding practices, the Special Supplemental Nutrition Program for Women, Infants, and Children—Infant and Toddler Feeding Practices Study-2 (WIC ITFPS-2). Findings include no differences in food insecurity prevalence; however, there were shifts in sources of food, with children in the post-COVID-emergency-declaration (post-ED) group consuming more dietary energy from stores and community food programs and less from restaurants and schools than children in the pre-COVID-emergency-declaration (pre-ED) group (p < 0.01 for all comparisons). Examination of within-person mean differences in 2015 Healthy Eating Index scores and nutrient intakes between ages 5 and 6 years revealed few statistically significant differences between the two groups: children in the post-ED group consumed slightly fewer vegetables (p = 0.02) and less sodium (p = 0.01) than their pre-ED peers. Findings suggest emergency efforts to maintain children’s nutrition were largely successful in the early months of the pandemic. Research is needed to understand the mechanisms by which emergency efforts contributed to these findings.

Development of an online curriculum for California early care and education providers on healthy beverages

BACKGROUND

Children's consumption of sugar-sweetened beverages is associated with obesity, diabetes, and dental decay. California's Healthy Beverages in Child Care Act (AB 2084) requires all licensed child care centers and family child care homes to comply with healthy beverages standards, however many licensed providers in California are unaware of the law and few are fully compliant with the law's requirements. The aim of the current project is to describe the development of a self-paced online training on best practices and implementation of AB 2084 in English and Spanish for family child care home and child care center providers; and to evaluate the feasibility, defined as being accessible, acceptable, and satisfactory to providers, of this new online course.

METHODS

The project was broken into two main stages: (1) development of the online course; and (2) evaluation of the final online course. The first stage was completed in five phases: (1) identify relevant course content and develop narration script; (2) conduct in-person focus groups with child care providers to review and edit the content; (3) adapt course content and translate for Spanish-speaking providers; (4) build the online course and resources; and (5) pilot online course and evaluate accessibility. The second stage, evaluation of the acceptability and satisfaction of the final course was rated on a Likert scale from 1 to 4; the evaluation was completed as part of a larger randomized control trial with 43 child care providers. The course features four key requirements of AB 2084 as the main sections of the course (milk, sweetened beverages, juice, and water), plus background information about beverages and children's health, special topics including caring for children with special needs, family engagement, written policies, and child engagement.

RESULTS

The child care providers who completed the evaluation found the online training was easily understandable (median(Q1,Q3,IQR) = 4 (4,4,0)), included new information (3 (1, 3, 4)), provided useful resources (4(4,4,0)), and was rated with high overall satisfaction (3 (1, 3, 4)).

CONCLUSION

Online training in English and Spanish designed for child care providers is a feasible medium to deliver important health messages to child care providers in an accessible, acceptable, and satisfactory manner.

The WIC Infant and Toddler Feeding Practices Study-2 (WIC ITFPS-2) Through Age 5: What We've Learned, What Questions Remain, and How You Can Use This Longitudinal Dataset

Objectives

By the end of the session, attendees will be able to: (1) Articulate the methodology of and notable findings from the USDA WIC Infant and Toddler Feeding Practices Study-2 (WIC ITFPS-2); and (2) Summarize the major domains of data available through age 5 in the WIC ITFPS-2 public use dataset.

Methods

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is the premier public health nutrition program for low-income, nutritionally at-risk pregnant and post-partum women, infants, and children up to age five. To better understand how WIC participation is associated with the health and nutrition outcomes of young children, USDA funded the WIC Infant and Toddler Feeding Practices Study-2 (ITFPS-2) in 2011. WIC ITFPS-2 is a national, longitudinal study of 3775 mother-child dyads who enrolled in WIC either during the mother's pregnancy or shortly after the child was born. The study interviews participants every 2 to 6 months through the child's fifth birthday, with two additional follow-ups at ages 6 and 9 years. The study captures information on children's health and nutrition status, including 24 hour dietary recall data; mothers’ feeding practices and beliefs; household food security; and WIC participation patterns. Data are weighted to produce national estimates. As of June 2021, data through children's fifth birthday (i.e., all years during which children were categorically eligible for WIC) are publicly available.

Results

Using descriptive, univariate, and multivariate techniques, analyses across the first 6 study reports have demonstrated positive associations between WIC and diet outcomes among young children. After controlling for other factors, longer WIC participation was associated with higher Health Eating Index-2015 scores at various time points, with lower daily energy intake, and with meeting the Dietary Guidelines recommendation to limit added sugar.

Conclusions

Across children's first five years of life, WIC participation has been associated with improved dietary intake and better diet quality, among other positive outcomes. The WIC ITFPS-2 dataset is publicly available and should be leveraged by researchers to further explore the health and nutrition status of low-income children during the early years of life.

Funding Sources

WIC ITFPS-2 is funded by USDA contract number AG-3198-B-11–0020 with Westat.

WIC Is Critical During the COVID-19 Pandemic: Lessons Learned From Los Angeles County Participants

Objectives

The COVID-19 pandemic has changed the way that the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) delivers services. The USDA granted multiple waivers to allow flexibility in WIC operations during the pandemic. The objective of this study was to hear from WIC participants about the impact of changes due to COVID-19.

Methods

In the summer of 2020, 60 semi-structured interviews were completed, half with English-speaking and half with Spanish-speaking WIC participants in the Los Angeles area. Interviews were recorded, transcribed, and analyzed using a deductive content analysis approach to describe responses and identify themes.

Results

Four themes emerged: 1) The pandemic has exacerbated the ckhallenges facing low-income families; 2) WIC continues to be a

valued resource especially under the challenging circumstances; 3) WIC's transition to remote service delivery has ensured that families continue to receive not only critical WIC food benefits, but also nutrition education and support; 4) Lessons learned during COVID-19 can inform needed WIC modernizations to maximize WIC's proven benefits post-pandemic. Nearly 75% of WIC participants faced reductions in income due to job loss or reduced work hours. Nearly 60% of households reported experiencing food insecurity. Early in the pandemic, many reported challenges accessing WIC-eligible foods, resulting in lost food benefits. Approximately 43% reported getting food from a food pantry or church, with most (77%) reporting first time usage. Participants shared that even with the change to only remote education, they valued the information and were very satisfied with WIC services. The majority (83%) found the California WIC App helpful in informing what WIC foods they could purchase. Participants also reported that enrolling in WIC remotely was easier than coming in-person and they were comfortable providing documents related to income and eligibility determination remotely.

Conclusions

WIC has been essential in helping families cope with COVID. WIC's transition to remote service delivery has ensured seamless and safe delivery of services, helping families with young children during an unprecedented time of need.

Funding Sources

The David and Lucile Packard Foundation

Evidence review of physical distancing and partition screens to reduce healthcare acquired SARS-CoV-2

We review the evidence base for two newly introduced Infection prevention and control strategies within UK hospitals. The new standard infection control precaution of 2 metres physical distancing and the use of partition screens as a means of source control of infection for SARS-CoV-2. Following review of Ovid-MEDLINE and governmental SAGE outputs there is limited evidence to support the use of 2 metres physical distancing and partition screens within healthcare.

Redefining Basic Needs for Higher Education: It's More Than Minimal Food and Housing According to California University Students

PURPOSE

A student-specific definition of basic needs for higher education is warranted to inform programs and policies for underserved students. The purpose of this study was to: 1) explore how students define basic needs, 2) understand experiences of housing insecurity, and 3) understand experiences of food insecurity within the context of housing insecurity.

DESIGN

Qualitative research elicited student perceptions of basic needs and experiences of housing and food insecurity.

SETTING

Focus group discussions were conducted at 5 University of California campuses between February and March 2019.

PARTICIPANTS

Undergraduate (n = 37) and graduate (n = 21) students were recruited from campus basic needs centers.

METHODS

Each student completed a brief survey. Researchers conducted 11 focus groups using a semi-structured interview guide. Transcripts were coded to identify themes.

RESULTS

Students were female (76%), age 23.6 (SD = 5.8) years; 46% were Pell grant recipients; and 52% were first-generation college students. Most had experienced food insecurity (98%) and 26% had experienced homelessness. Eight themes were identified: 1) students define basic needs as more than minimal food and shelter and as the responsibility of students and the university, 2) students encounter multifaceted housing insecurity issues, 3) affording rent is a priority that most often leads to experiencing food insecurity, 4) transportation barriers interfere with meeting students' basic needs to succeed as students, 5) students with nontraditional characteristics, graduate students, and out-of-state students face unique challenges in meeting basic needs, 6) limited financial aid and lack of financial aid guidance are barriers to meeting basic needs, 7) fees contribute additional challenges to students meeting basic needs, and 8) additional university basic needs services are essential.

CONCLUSION

A student-informed definition of basic needs included food, housing, mental health, sleep, hygiene, and transportation. This understanding of basic needs can inform future research, programs, and policy to address housing insecurity in higher education.

The Role of the Neighborhood Social Environment in Physical Activity among Hispanic Children: Moderation by Cultural Factors and Mediation by Neighborhood Norms

Little is known about how the neighborhood social environment (e.g., safety, crime, traffic) impacts child physical activity. We examine the mechanism by which the neighborhood social environment is associated with child physical activity, moderated by individual-level cultural factors (e.g., language at home, immigrant generation) and mediated by neighborhood physical activity-related social norms (e.g., seeing walkers in the neighborhood). Data included 2749 non-Hispanic White and Hispanic children from the Healthy Communities Study. Multilevel regression was performed. The neighborhood social environment was not associated with physical activity in the full sample. However, Hispanic children speaking both English and Spanish and first- or second-generation Hispanic children engaged in more physical activity when the quality of the neighborhood social environment was higher (b = 1.60, p < 0.001 for Hispanic children speaking English and Spanish; b = 2.03, p < 0.01 for first-generation Hispanic children; b = 1.29, p < 0.01 for second-generation Hispanic children). Neighborhood physical activity-related social norms mediated the association between the neighborhood social environment and physical activity among Hispanic children speaking English and Spanish (b = 0.33, p < 0.001) and second-generation Hispanic children (b = 0.40, p < 0.001). Findings suggest heterogeneity in how neighborhood social environments impact physical activity by cultural factors. Health promotion programs may need to enhance neighborhood social environments to increase Hispanic children’s physical activity.

Community Eligibility Provision and School Meal Participation among Student Subgroups

BACKGROUND

The National School Lunch and Breakfast Programs help to reduce food insecurity and improve nutrition. The Community Eligibility Provision (CEP) enables high-poverty schools to offer breakfast and lunch at no cost to all students. This study examines associations between CEP and participation among students eligible for free or reduced-price meals ("FRPM"), possibly eligible ("near-cutoff"), or ineligible ("full-price").

METHODS

Using data from the 2013-2015 Healthy Communities Study, we compared school breakfast and lunch participation between 842 students in K-8 at 80 CEP schools and 1463 students at 118 schools without CEP. Cross-sectional difference-in-difference (DID) models compared meal participation among near-cutoff and full-price groups to that in the FRPM group.

RESULTS

Overall, FRPM students had high participation in school lunch and breakfast at both types of schools. In adjusted DID models, lunch participation among near-cutoff students was 12 points higher in CEP versus comparison schools (p < .05). Among full-price students, breakfast participation was 20 points higher and lunch participation 19 points higher in CEP than comparison schools (p < .001).

CONCLUSIONS

Community Eligibility Provision improves access to school breakfast and lunch in high-poverty schools, particularly for students who are near or above the cutoff for FRPM eligibility.

Effect of Removing Chocolate Milk on Milk and Nutrient Intake Among Urban Secondary School Students

INTRODUCTION

Schools across the United States have removed sweetened, flavored milk from cafeterias to reduce students' sugar consumption and improve their health. However, evidence on the impact of the removal is limited. We examined the effect of a policy that removed chocolate milk from secondary schools on students' milk consumption and estimated milk-related nutrient intake.

METHODS

We collected data on milk selection and consumption during 1 lunch period in 24 California public secondary schools pre-policy (N = 3,158 students in 2016) and post-policy (N = 2,966 students in 2018). Schools had a student population that was 38% Asian and 29% Latino, with 63% qualifying for free or reduced-price meals. We used linear mixed effects models to assess changes in milk selection and waste, and we estimated related changes in added sugars, calcium, protein, and vitamin D consumed from milk.

RESULTS

The proportion of students selecting milk declined 13.6%, from 89.5% pre-policy to 75.9% post-policy (95% CI for difference, 10.8% tο 16.4%), but the proportion of milk wasted remained stable (37.1% vs 39.3%; 95% CI for difference, -0.2% to 4.6%). Although average per-student milk consumption declined by less than 1 ounce per student (from 4.8 oz to 3.8 oz; 95% CI for difference, -1.1 oz to -0.7 oz), we observed no significant reductions in average per-student intake of calcium, protein, or vitamin D from milk. Estimated added sugars from milk declined significantly, by 3.1 grams per student (95% CI, -3.2 g to -2.9 g).

CONCLUSION

Removing chocolate milk modestly reduced student milk consumption without compromising average intake of key milk-related nutrients, and consumption of added sugars from milk declined significantly. Secondary schools should consider removing chocolate milk to support healthy beverage consumption.

The Impact of a Multipronged Intervention to Increase School Lunch Participation among Secondary School Students in an Urban Public School District

Introduction: Schools meals offer a critical opportunity for improving youths' diets, particularly for economically disadvantaged students. We examine the impact of a multipronged intervention to increase middle and high school students' lunch participation in an urban school district. Methods: In school years 2015-2016 through 2017-2018, a quasi-experimental study was conducted in 24 secondary schools, half (n = 12) of which received the following intervention: cafeteria redesign, additional school lunch points-of-sale (mobile carts and vending machines), and teacher education. Results: From baseline to follow-up, lunch participation dropped 4.1% in intervention and 5.1% in comparison schools (difference-in-difference 1.0%, 95% CI 0.5-1.4). The overall decline in lunch participation occurred simultaneously with a drop-in free or reduced-price meal eligibility (from 72% to 58%) across all schools, which is likely related to changing local economic conditions, including a county-wide minimum wage increase that began in summer 2015. Among students eligible for free or reduced-price meals, participation decreased 1.8% in intervention and 4.9% in comparison schools (difference-in-difference 3.1%, 95% CI: 2.5-3.7), with a larger difference-in-difference seen in high schools (5.0%, 95% CI: 4.2-5.9) than middle schools (1.8%, 95% CI: 0.8-2.6). Conclusions: While this intervention demonstrated a modest, but significant relative increase in school lunch participation, the effect was not sufficient to halt large district-wide declines in participation during this study period. Given the significant time, money, and political capital required to implement the intervention, districts should carefully consider similar investments. Broader public policies or other changes to economic conditions that affect eligibility for means-tested benefits-in this case, a strengthening local economy coupled with an increased local minimum wage-may influence school lunch participation more than school-level interventions.

Dimensions of School Food Environments and Their Association with Anthropometric and Dietary Outcomes in Children: The Healthy Communities Study

Objectives

While it has been recommended that schools be the hub of efforts to improve child nutrition, research describing dimensions of U.S. school nutrition environments is limited. This study used exploratory factor analysis to estimate dimensions of school nutrition environments and examined their association with child anthropometric and dietary measures.

Methods

Cross-sectional analyses of 386 U.S. elementary and middle schools and 4635 children from the national Healthy Communities Study (2013–2015) was conducted. Three complementary instruments to assess the school nutrition environment were used to create 34 variables. Data were collected by observation and surveys. Factor analysis was done with orthogonal rotation. Mixed-effects regression models examined the multivariate-adjusted associations of dimensions of school nutrition environments with child anthropometric and dietary measures accounting for community and school variation.

Results

Six dimensions of school nutrition environments were derived: 1) nutrition education; 2) fruit and vegetable availability; 3) dining environment, including size and crowding; 4) school meal quality, including compliance with competitive food standards, amount of whole grains, and high fat foods; 5) school participation in state and federal nutrition programs; and 6) self-reported implementation of school wellness policies. Higher school meal quality was associated with lower added sugars intake (ß = –0.94, P &lt; 0.01), better dining environment was associated with higher body mass index z scores (ß = 0.04, P = 0.03), and higher implementation of school wellness policies was associated with higher waist circumference (ß = 0.54, P &lt; 0.01).

Conclusions

Schools serving meals of higher nutritional quality had children with lower added sugars intake. Associations between dining environment and BMI-z; and implementation of school wellness policies and waist circumference were counterintuitive and may be due to school selection or the inability of cross-sectional data to capture relationships with longer-term health outcomes. More efforts are needed to identify school nutrition environments that have the greatest impact on child diet and adiposity outcomes.

Funding Sources

National Heart, Lung, and Blood Institute #K01HL131630.

The Impact of a District-Wide Chocolate Milk Removal Policy on Secondary Students’ Milk Purchasing and Consumption

Objectives

Removing chocolate milk from school cafeterias is an increasingly popular policy approach for reducing youth sugar-sweetened beverage consumption and improving health. Evidence on the impact of such policies in urban secondary schools, which is needed to inform future school-based health improvement efforts targeting our highest-need youth, is lacking. The objective of this study is to determine the impact of a school district's chocolate milk removal policy on racially/ethnically and socioeconomically diverse middle and high school students’ milk, calcium, and added sugar consumption.

Methods

Student-level lunch data were collected in the springs of 2016 (pre-chocolate milk removal policy) and 2018 (post-policy) during one lunch period each in 24 middle and high schools in a diverse urban school district. Linear mixed effects models adjusted for school-level demographic characteristics were used to assess changes in the proportion of students who purchased milk; the proportion of milk consumed; and the average grams of added sugar, ounces of milk, and grams of calcium consumed per student.

Results

Pre-policy, 3,158 students (mean 132 per school) participated in lunch data collection across all 24 schools; post-policy, 2,966 students (mean 124 per school) participated. There was a 13.6% (95% CI −16.4, −10.8) decrease in the proportion of students who purchased milk pre-policy (89.5%) to post-policy (75.9%). The proportion of milk consumed remained stable pre- (68.3%) and post-policy (66.3%; 95% CI for difference −4.1, 0.01). There was a statistically significant 3.8g decline in added sugar consumed post- policy (95% CI for change −3.9g, −3.6g) and no significant changes in ounces of milk or grams of calcium consumed.

Conclusions

Immediately post-chocolate milk removal from school cafeterias, fewer secondary students purchased milk. However, among students who purchased milk, consumption remained stable pre- and post-policy, and added sugar consumption significantly declined. Evidence on the longer-term impact of chocolate milk removal policies is necessary.

Funding Sources

This work was funded by the United States Department of Agriculture, National Institute of Food and Agriculture, (Grant ID: 2015-68001-23236); Technology and Design Innovation to Support 21st Century School Nutrition.

Healthy Default Beverages in Kids’ Meals: Evaluating Policy Adherence and Impact in California

Objectives

Healthy default beverage policies for restaurant kids’ meals have been identified as a top strategy to improve beverage intake in young children and reduce obesity and diabetes risk. California passed a statewide policy (SB1192), effective January 2019, specifying kids’ meal default beverages as water, unflavored milk, or a nondairy alternative. Although other localities have adopted similar policies, there have been no studies on their effectiveness. The aim of this study was to assess changes in beverages offered with kids’ meals before and after a healthy default beverage policy took effect and to quantify policy adherence in menus and cashier orders in quick service restaurants (QSR).

Methods

The study employed a pre-post policy design. Baseline data on beverages offered as part of kids’ meals were collected from 111 QSR in low-income areas in California in late 2018, prior to policy implementation. Follow-up data were collected from the same restaurants one year later. Data were collected by menu observation and purchase of kids’ meals. Both walk-in and drive-through settings were assessed where available. Full policy adherence was defined as offering only SB1192-compliant beverages, and was assessed 3 ways: menu board, cashier order, and a combined metric.

Results

At baseline, prior to any legislative requirement, 6 (6.3%) restaurant menu boards, 5 (4.5%) cashier orders, and 0 restaurants overall were already fully adherent. At follow-up, 64 (66.0%) restaurant menu boards, 1 (0.9%) cashier order, and 0 restaurants overall were fully adherent. Generalized estimating equations, clustered by restaurant chain, were used to test pre-post policy changes. Adherence in menu boards increased (59.7%, p = &lt; .0001). There were no changes in adherence in cashier orders or overall adherence.

Conclusions

California's healthy default beverage policy for restaurant kids’ meals was effective in changing QSR menu board offerings but did not impact cashier order processes. Additional staff training may improve policy implementation. Studies are underway to assess the impact of staff training and customer behavior change.

Funding Sources

University of California Division of Agriculture and Natural Resources, Robert Wood Johnson Foundation Healthy Eating Research, CA Department of Public Health/USDA.

0238 Campus Food Pantry Assistance is Related to Better Physical And Mental Health Through Adequate Sleep Among College Students in a Public University System

Introduction

Food insecurity is an issue among students in higher education and has been linked to insufficient sleep, and poor mental and general health. College campuses have quickly responded by establishing campus food pantries. However, the extent to which campus food pantries are ameliorating the impacts of food insecurity is unknown.

Methods

Online survey data were collected from a cross-sectional sample of 1,855 students who were food pantry users in the 10-campus UC system. Students were asked to report their number of visits to a food pantry in the past month, and to rate their general health, depressive symptoms, and number of days of enough sleep (in a week) before and after food pantry access. Changes in days of enough sleep, depressive symptoms and general health were computed. Demographic characteristics were obtained from institutional data. Path analysis was used to examine direct and indirect pathways from food pantry use to depressive symptoms and general health through enough sleep days, controlling for workstudy receipt, Pell grant receipt and family income.

Results

Students on average were 21.7 years old (SD= 3.5), and had more days of adequate sleep (25%), and improved depressive symptoms (43%) and general health (31%) after obtaining services from a campus food pantry. An increase in monthly food pantry use was directly related to a decrease in depressive symptoms (β= 0.08, p&lt;0.001) and an increase in general health (β= 0.07, p=0.001). Additionally, an increase in food pantry use related to an increase in getting more days of enough sleep (β=0.07, p=0.001), which in turn positively related to a decrease in depressive symptoms (β=0.18, p&lt;0.001) and improved general health (β=0.24, p&lt;0.001).

Conclusion

Food pantry use had a positive relationship with student health outcomes, and enough sleep days played an important mediating role. Findings suggest that emergency food access may have a positive impact on student health outcomes.

Support

This study was funded by the UC Campus Basic Needs Committees.

Development and Validation of a Photo-Evidence Tool to Examine Characteristics of Effective Drinking Water Access in Schools

BACKGROUND

Federal law requires water access in schools where meals are served. Schools report high rates of water accessibility in cafeterias, but observations indicate lower adherence. Although observation is costly, it permits a more detailed assessment of a water source to determine whether it provides effective access that encourages water consumption and thus, healthy hydration for students.

METHODS

To offer a less costly alternative to observations, researchers developed and validated a photo-evidence tool to examine characteristics of effective school drinking water access. Two observers recorded characteristics of 200 water sources in 30 schools, including type, wear, cleanliness, and water flow, and examined obstructions and beverage promotion near sources, as well as, drinking vessel availability. Observers photographed sources which were coded by a separate research team. Agreement between observation audits and photograph coding was assessed through percent agreement, and kappa statistics and correlation coefficients.

RESULTS

Kappas indicated substantial (K > 0.60) or near perfect agreement (K > 0.80) for all characteristics of effective drinking water access with exception of wear. There was moderate agreement (r = 0.66) for water source cleanliness.

CONCLUSIONS

Development and validation of a photo-evidence tool to examine characteristics of effective drinking water access in schools.

Household Food Insecurity Is Associated with Higher Adiposity Among U.S. Schoolchildren Ages 10–15 Years (OR02-05-19)

Objectives

This study assesses the relationship between household food insecurity and adiposity, measured as BMI-for-age z-score (BMI-z), overweight/obesity, and waist circumference, as well as dietary intake and diet-related behaviors in US children.

Methods

A total of 5138 US schoolchildren ages 4–15 years from 130 communities in the cross-sectional Healthy Communities Study were included in this analysis. Household food insecurity was self-reported using a validated 2-item screener. Dietary intake was assessed using National Cancer Institute's (NCI) Dietary Screener Questionnaire (DSQ), a 26-item food frequency questionnaire, and dietary behaviors were assessed during a household survey. Data were analyzed using multilevel statistical models, including interaction tests for age, sex, and race/ethnicity.

Results

Food insecure children had a BMI z-score of 0.14 higher (95% CI: 0.06, 0.21) and a waist circumference of 0.91 cm higher (95% CI: 0.18, 1.63) than food secure children. Food insecure children have 1.17 times the odds of being overweight/obesity compared with food secure children (95% CI: 1.02, 1.34). There was no significant interaction by sex or race/ethnicity. Food insecure children consumed more sugar from sugar sweetened beverages (0.36 tsp/day; 95% CI: 0.09, 0.63), and ate breakfast (−0.28 days/week; 95% CI: −0.39, −0.17) and together with family (−0.22 days/week; 95% CI: −0.37, −0.06) less frequently compared to food secure children.

Conclusions

The present study found a significant, positive association between household food insecurity and child adiposity for children ages 10–15 years, as well as for several dietary intake and diet-related behaviors. This research helps disentangle the complex picture of food insecurity as a contributor to childhood obesity and poorer dietary outcomes in diverse populations.

Funding Sources

Research was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL131630. The authors would also like to acknowledge the Global Food Initiative at the University of California Office of the President for their support of this project.

Duration of WIC Participation Is Associated with Higher Dietary Quality at 24 Months (P11-048-19)

Objectives

This study examined how duration of participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is associated with dietary quality at age 24 months using Healthy Eating Index-2015 (HEI-2015) scores.

Methods

Data from the WIC Infant and Toddler Feeding Practices Study-2 (WIC ITFPS-2), a longitudinal study on WIC caregivers and their children, was used to examine WIC participation and diet quality. A weighted sample of 407,416 caregivers (unweighted = 1,349) from 80 WIC sites nationwide was included. Duration of WIC participation reflects the number of interviews during which caregivers responded that they were receiving WIC benefits (9 interviews occurred between 3 and 24 months). Responses were categorized into low (< 4 interviews), intermediate (5-7 interviews), and high (8-9 interviews) duration groups. Dietary intake was assessed using 24-h dietary recalls administered to caregivers. One-way ANOVA was used to compare average HEI component and total scores by WIC duration. Multivariate linear regression was used to examine independent effects of WIC participation duration on HEI-2015 total score, controlling for maternal race, ethnicity, and education, and household poverty status.

Results

The mean total HEI-2015 score of all children at 24 months was 60.5 (SE = 0.4). Total unadjusted HEI-2015 scores were statistically different across WIC duration categories, with more favorable scores among those in the high duration group [Low duration = 55.2 (SE = 1.8), Intermediate duration = 59.2 (SE = 0.8), High duration = 60.9 (SE = 0.4)]. After controlling for sociodemographic factors, high WIC duration was associated with a significantly higher HEI-2015 total score compared with the low WIC duration group (b = 4.06, P < 0.05). Ethnicity was also significantly associated with total HEI; Hispanic participants had higher mean HEI-2015 scores compared with non-Hispanic Whites (b = 6.25, P < 0.05).

Conclusions

Higher dietary quality was significantly positively associated with WIC duration, as reflected in higher scores for total HEI-2015 and in key categories such as total vegetables, refined grains, and saturated fat. Findings suggest that longer participation in WIC contributes to continued nutritional benefits.

Funding Sources

WIC ITFPS-2 is a federally funded study under the direction of the Office of Policy Support in the Food and Nutrition Service, U.S. Department of Agriculture.

Evaluation of an Interactive, Online Training for Child Care Providers on Healthy Beverages for Young Children (P16-039-19)

Objectives

Evaluate if a 30-minute interactive, online training with 6-months of ongoing technical assistance (TA) for early care and education (ECE) providers improves beverage nutrition for young children. The training, developed by health professionals and child development experts, teaches implementation of California's Healthy Beverages in Child Care Act (AB2084) to 1) serve no beverages with added sweeteners, 2) serve no more than one age-appropriate daily serving of 100% juice, 3) serve unflavored nonfat or low-fat milk to children 2 years and older, and 4) make water readily available at all times. We hypothesize that ECE providers who complete the training will exhibit improved knowledge of and compliance with beverage standards than the control group.

Methods

Providers offering care to children age 2–5 years old were recruited from three California counties and randomized to receive the training intervention or no training. Providers complete online and paper surveys at four time-points over six months to assess their training experience, knowledge of healthy beverages, and compliance with AB2084 based on self-reported beverage provision practices.

Results

Providers (N = 66) were mostly English-speaking (97%), female (98%), white (58%), Hispanic or Latino (20%), Asian or Pacific Islander (18%), with a minimum of some college education (97%). Preliminary results of 33 providers who received the training, with no comparison group, show improved compliance with AB2084 at the first time-point, one month post training, compared to baseline for serving no beverages with added sweeteners (100% vs 95%), serving 100% juice no more than once per day (100% vs. 86%), serving only unflavored nonfat or low-fat milk to children 2 years and older (82% vs. 61%), and making water readily available at all times (82% vs. 75%). Providers reported satisfaction with the training (90%), learned something new (95%), understood the training (100%), reported the training length was appropriate (83%) and that the accompanying online resources were helpful (95%).

Conclusions

Preliminary analysis suggests that online training and TA can improve ECE provider's compliance with healthy beverage standards for young children (AB2084). Final process and outcome evaluation results from both groups will be available at the conference.

Funding Sources

UC Agriculture & Natural Resources.

Multi-pronged intervention to increase secondary student participation in school lunch: Design and rationale

BACKGROUND

In the United States, the National School Lunch Program (NSLP) is the healthiest lunch option for students, yet participation is suboptimal and fruit and vegetable waste remains high. Improving school meal convenience, engaging teachers in the school-lunch program, and enhancing the cafeteria environment are promising strategies to improve participation and dietary intake, yet little evidence is available on their impact.

METHODS/DESIGN

The Multi-Pronged Intervention to Increase Secondary Student Participation in School Lunch (MPI) is a 3-year quasi-experimental study in a large urban school district in California. A total of 24 middle and high schools participated in the study: half received the intervention and half served as controls. The intervention consisted of additional school lunch points of sale (vending machines and mobile carts), a school meal outreach program for teachers, and cafeteria redesigns. School meal participation, student-reported fruit and vegetable consumption, and school lunch plate waste were assessed at baseline and in years 1 and 2 of the intervention. Change in meal participation and fruit and vegetable consumption were compared between intervention and control arms to determine the impact of the intervention on school meal participation and dietary intake.

DISCUSSION

This study is positioned to provide evidence on the feasibility and efficacy of a multi-level intervention to increase school meal participation and consumption of fruits and vegetables.

Nano-Magnesium Oxide: A Novel Bactericide Against Copper-Tolerant Xanthomonas perforans Causing Tomato Bacterial Spot

Bacterial spot caused by Xanthomonas perforans causes significant damage on tomato in Florida. Due to the presence of copper (Cu)-tolerant X. perforans strains, Cu bactericides are not effective in disease management. Hence, there is a critical need to find alternatives for Cu. Antibacterial activity of magnesium oxide (Nano-MgO), and other metal oxide nanoparticles, were evaluated against a Cu-tolerant and -sensitive X. perforans strain. In vitro experiments demonstrated high antibacterial activity of Nano-MgO against both strains compared with the commercial Cu. The minimum inhibitory concentration of Nano-MgO is 25 µg/ml and the minimum bactericidal concentration is 100 µg/ml against a Cu-tolerant X. perforans strain after 4 h of exposure. Structural changes in the bacterial membrane following exposure to Nano-MgO treatments compared with the controls were observed using transmission electron microscopy. In two greenhouse experiments with a Cu-tolerant strain, bacterial spot severity was significantly reduced by Nano-MgO at 200 µg/ml compared with Cu-ethylene bis-dithiocarbamate (grower standard), and the untreated control (P = 0.05). In three field experiments, Nano-MgO at 200 µg/ml significantly reduced disease severity with no negative impact on yield compared with the untreated control. Inductively coupled plasma mass spectrometric analysis of the fruit confirmed that Nano-MgO application did not lead to the accumulation of Mg, Cu, Ca, K, Mn, P, and S. This study is the first to demonstrate the potential of Nano-MgO against bacterial spot of tomato.

Assessing the educational impact of the dementia champions programme in Scotland: Implications for evaluating professional dementia education

Increasing numbers of people with dementia are living longer with a higher likelihood of requiring hospital care for physical conditions including falls, infections and stroke (Boaden, 2016). However, the literature is replete with descriptions of poor care and hospital care experiences that have fallen well below the expectations of people with dementia, their families and friends. Although poor care is unacceptable, it is unsurprising given that dementia education for health and social care professionals is often inadequate and inconsistent. This results in most healthcare staff being ill-equipped and lacking the confidence to work with people living with dementia. The first of Scotland's National Dementia Strategies committed to "improve the response to dementia in general hospital settings including alternatives to admission and better planning for discharge" (Scottish Government, 2010). The educational response was the commissioning of the Dementia Champions programme. Since 2011, the programme has developed over 800 health and social care professionals working in general hospital and related settings to be change agents in dementia care. This article will outline the theoretical underpinning of the programme and present pooled results from four cohorts (2014-2017) (n = 524). A repeated measure design (pre and post programme) was used to measure attitudes towards people with dementia; self-efficacy and knowledge of dementia. The findings suggest that the education had a statistically significant positive effect on all intended outcomes, indicating the potential for practice change. We discuss these findings in relation to the literature, and respond to the calls for high quality evaluation to measure the effectiveness of dementia education, the challenges and potential directions for measuring educational effectiveness and capturing transfer of learning.

A quality improvement project to increase self-administration of medicines in an acute hospital

Quality problem or issue

A patient survey found significantly fewer patients reported they had self-administered their medicines while in hospital (20% of 100 patients) than reported that they would like to (44% of 100). We aimed to make self-administration more easily available to patients who wanted it.

Initial assessment

We conducted a failure, modes and effects analysis, collected baseline data on four wards and carried out observations.

Choice of solution

Our initial assessment suggested that the main areas we should focus on were raising patient awareness of self-administration, changing the patient assessment process and creating a storage solution for medicines being self-administered. We developed new patient information leaflets and posters and a doctor’s assessment form using Plan–Do–Study–Act cycles. We developed initial designs for a storage solution.

Implementation

We piloted the new materials on three wards; the fourth withdrew due to staff shortages.

Evaluation

Following collection of baseline data, we continued to collect weekly data. We found that the proportion of patients who wished to self-administer who reported that they were able to do so, significantly increased from 41% (of 155 patients) to 66% (of 118 patients) during the study, despite a period when the hospital was over capacity.

Lessons learned

Raising and maintaining healthcare professionals’ awareness of self-administration can greatly increase the proportion of patients who wish to self-administer who actually do so. Healthcare professionals prefer multi-disciplinary input into the assessment process.

Short and sweet: Associations between self-reported sleep duration and sugar-sweetened beverage consumption among adults in the United States

OBJECTIVES

Sugar sweetened beverages (SSBs) are a major factor in the development of obesity and cardiometabolic disease. Shortened sleep duration has also been linked to increased appetite and obesity. Here, we examined whether there was an association between self-reported sleep duration and SSB consumption among adults aged 18 years and older.

METHODS

Using data from 2005-12 NHANES we examined self- reported sleep duration and beverage intake (types of SSBs, juice, water, coffee, tea) from two 24-hour dietary recalls among 18,779 adults. Adults who slept 7-8 hours/night were considered the reference group. Generalized linear models were computed adjusting for sociodemographics and health characteristics as well as total energy intake.

RESULTS

Thirteen percent slept 5 or fewer hours per night. In fully adjusted models, those who slept 5 hours or less had 21% higher SSB consumption, (RD = 1.21, 95% CI 1.11-1.32). When broken down by beverage type this was due to caffeinated sugary beverages. Longer sleepers (≥9 hour sleepers) consumed fewer servings of coffee and water. There were no associations between self-reported sleep duration and consumption of 100% juice, tea, or diet drinks.

CONCLUSIONS

Short sleep is associated with greater intake of sugared caffeinated sodas, a relationship which may have important, though unrecognized, implications for physical health. Directionality of this relationship cannot be determined from this study. While caffeinated drinks could account for impaired sleep, it is possible that short sleep could influence one's appetitive drive for sugared caffeine drinks. Further examination of this relationship using prospective designs is warranted.

No food for thought: Food insecurity is related to poor mental health and lower academic performance among students in California's public university system

This study examined the relationships between food insecurity, mental health, and academic performance among college students in a California public university system (N = 8705). Structural equation modeling was performed to examine a direct path from food insecurity to student grade point average and an indirect path through mental health, controlling for demographic characteristics. Food insecurity was related to lower student grade point average directly and indirectly through poor mental health. These findings support the need for future interventions and policy on the importance of providing students with the basic needs to succeed both academically and in the future.

Advanced Copper Composites Against Copper-Tolerant Xanthomonas perforans and Tomato Bacterial Spot

Bacterial spot, caused by Xanthomonas spp., is a widespread and damaging bacterial disease of tomato (Solanum lycopersicum). For disease management, growers rely on copper bactericides, which are often ineffective due to the presence of copper-tolerant Xanthomonas strains. This study evaluated the antibacterial activity of the new copper composites core-shell copper (CS-Cu), multivalent copper (MV-Cu), and fixed quaternary ammonium copper (FQ-Cu) as potential alternatives to commercially available micron-sized copper bactericides for controlling copper-tolerant Xanthomonas perforans. In vitro, metallic copper from CS-Cu and FQ-Cu at 100 μg/ml killed the copper-tolerant X. perforans strain within 1 h of exposure. In contrast, none of the micron-sized copper rates (100 to 1,000 μg/ml) from Kocide 3000 significantly reduced copper-tolerant X. perforans populations after 48 h of exposure compared with the water control (P < 0.05). All copper-based treatments killed the copper-sensitive X. perforans strain within 1 h. Greenhouse studies demonstrated that all copper composites significantly reduced bacterial spot disease severity when compared with copper-mancozeb and water controls (P < 0.05). Although there was no significant impact on yield, copper composites significantly reduced disease severity when compared with water controls, using 80% less metallic copper in comparison with copper-mancozeb in field studies (P < 0.05). This study highlights the discovery that copper composites have the potential to manage copper-tolerant X. perforans and tomato bacterial spot.

Validation of a national hand hygiene proxy measure in NHS Scotland

The Scottish national hand hygiene proxy measure uses the volume of alcohol-based hand rub (ABHR) purchased by NHS Scotland boards as an indicator of the number of hand hygiene moments being performed per patient-bed-day. The proxy measure calculation is based on the assumption that 3 mL of ABHR is used per hand hygiene moment. This study aimed to validate the volume of ABHR being used per hand hygiene moment. It found that the median volume of ABHR being used in practice is approximately 1 mL per hand hygiene moment, and that using this validated volume in the calculation substantially increases the proxy measure of hand hygiene compliance.

Excessive Gestational Weight Gain and Subsequent Maternal Obesity at Age 40: A Hypothetical Intervention

OBJECTIVES

To model the hypothetical impact of preventing excessive gestational weight gain on midlife obesity and compare the estimated reduction with the US Healthy People 2020 goal of a 10% reduction of obesity prevalence in adults.

METHODS

We analyzed 3917 women with 1 to 3 pregnancies in the prospective US National Longitudinal Survey of Youth, from 1979 to 2012. We compared the estimated obesity prevalence between 2 scenarios: gestational weight gain as reported and under the scenario of a hypothetical intervention that all women with excessive gestational weight gain instead gained as recommended by the Institute of Medicine (2009).

RESULTS

A hypothetical intervention was associated with a significantly reduced estimated prevalence of obesity for first (3.3 percentage points; 95% confidence interval [CI] = 1.0, 5.6) and second (3.0 percentage points; 95% CI = 0.7, 5.2) births, and twice as high in Black as in White mothers, but not significant in Hispanics. The population attributable fraction was 10.7% (95% CI = 3.3%, 18.1%) in first and 9.3% (95% CI = 2.2%, 16.5%) in second births.

CONCLUSIONS

Development of effective weight-management interventions for childbearing women could lead to meaningful reductions in long-term obesity.

Epidemiology and management of bacterial leaf spot on watermelon caused by Pseudomonas syringae

Bacterial leaf spot of watermelon caused by Pseudomonas syringae has been an emerging disease in the southeastern United States in recent years. Disease outbreaks in Florida were widespread from 2013 to 2014 and resulted in foliar blighting at the early stages of the crop and transplant losses. We conducted a series of field trials at two locations over the course of two years to examine the chemical control options that may be effective in management of this disease, and to investigate the environmental conditions conducive for bacterial leaf spot development. Weekly applications of acibenzolar-S-methyl (ASM) foliar, ASM drip, or copper hydroxide mixed with ethylene bis-dithiocarbamate were effective in reducing the standardized area under the disease progress curve (P < 0.05). Pearson's correlation test demonstrated a negative relationship between the average weekly temperature and disease severity (-0.77, P = 0.0002). When incorporated into a multiple regression model with the square root transformed average weekly rainfall, these two variables accounted for 71% of the variability observed in the weekly disease severity (P < 0.0001). This information should be considered when choosing the planting date for watermelon seedlings as the cool conditions often encountered early in the spring season are conducive for bacterial leaf spot development.

The Fit Study: Design and rationale for a cluster randomized trial of school-based BMI screening and reporting

BACKGROUND

In the U.S., 25 states conduct body mass index (BMI) screening in schools, just under half of which report results to parents. While some experts recommend the practice, evidence demonstrating its efficacy to reduce obesity is lacking, and concerns about weight-related stigma have been raised.

METHODS/DESIGN

The Fit Study is a 3-arm cluster-randomized trial assessing the effectiveness of school-based BMI screening and reporting in reducing pediatric obesity and identifying unintended consequences. Seventy-nine elementary and middle schools across California were randomized to 1 of 3 Arms: 1) BMI screening and reporting; 2) BMI screening only; or 3) no BMI screening or reporting. In Arm 1 schools, students were further randomized to receive reports with BMI results alone or both BMI and fitness test results. Over 3 consecutive years, staff in schools in Arms 1 and 2 will measure students' BMI (grades 3-8) and additional aspects of fitness (grades 5-8), and students in grades 4-8 in all Arms will complete surveys to assess weight-based stigmatization. Change in BMI z-score will be compared between Arm 1 and Arm 2 to determine the impact of BMI reporting on weight status, with sub-analyses stratified by report type (BMI results alone versus BMI plus fitness results) and by race/ethnicity. The potential for BMI reports to lead to weight-based stigma will be assessed by comparing student survey results among the 3 study Arms.

DISCUSSION

This study will provide evidence on both the benefit and potential unintended harms of school-based BMI screening and reporting.

Impact of California Children’s Power Play! Campaign on Fruit and Vegetable Intake and Physical Activity among Fourth- and Fifth-Grade Students

Purpose.

Examine the impact of the Children’s Power Play! Campaign on fruit and vegetable (FV) intake and physical activity (PA).

Design.

Study design was a cluster randomized, controlled trial.

Setting.

Forty-four low-resource public schools in San Diego County, California, were included in the study.

Subjects.

Study subjects comprised a total of 3463 fourth/fifth-graders (1571 intervention, 1892 control), with an 86.9% completion rate.

Intervention.

Throughout 10 weeks, activities were conducted during/after school, including weekly FV/PA lessons and PA breaks; biweekly classroom promotions/taste tests; posters displayed in/around schools; and weekly nutrition materials for parents.

Measures.

Self-reported FV intake (cups/d) and PA (min/d) were collected at baseline and follow-up using a diary-assisted, 24-hour dietary recall and Self-Administered Physical Activity Checklist.

Analysis.

Multivariate regression models adjusted for demographics and cluster design effects were used, with change as the dependent variable.

Results.

Intervention children, compared with controls, showed gains in daily FV intake (.26 cups, p < .001) and PA time at recess/lunch (5.1 minutes, p = .003), but not total daily PA minutes.

Conclusion.

Power Play! can help schools and community organizations improve low-income children’s FV intake and PA during recess/lunch.

The outcome of septorhinoplasty surgery on olfactory function

OBJECTIVES

To assess olfactory outcomes in patients undergoing septorhinoplasty surgery in our unit.

DESIGN

Prospective cohort study.

SETTING

The Royal National Throat Nose and Ear Hospital, London.

PARTICIPANTS

Forty-three patients undergoing functional septorhinoplasty (Males = 26; mean age = 34.1 ± 12.2) were recruited into the study.

MAIN OUTCOME MEASURES

The primary outcome of olfactory function was assessed using 'Sniffin sticks'. Our secondary outcomes were assessment of patient quality of life using the disease specific Sino-nasal Outcome Test-23 questionnaire (SNOT-23) and a visual analogue scale for sense of smell. These measures were repeated at 12 weeks post operatively.

RESULTS

There was a significant change in the Sniffin' sticks score post-operatively (8.3 versus 9.6; P < 0.001). The SNOT-23 score also showed a significant improvement post-operatively (53.5 versus 40.4; P < 0.001). A significant improvement was not found in the smell/taste question (question 21) of the SNOT-23 questionnaire as well as the visual analogue scale for sense of smell. A difference in olfactory outcome was not found between open versus closed approaches, primary versus revision surgery and traumatic versus non traumatic cases.

CONCLUSIONS

The results show a measured significant improvement in olfaction following functional Septorhinoplasty but not a subjective improvement in the patients perception of their sense of smell and hence not a clinically significant difference. The reasons for the measured improvement are not clear and are likely to be multifactorial.

Increasing Child Fruit and Vegetable Intake: Findings from the US Department of Agriculture Fresh Fruit and Vegetable Program

BACKGROUND

Fewer than 10% of US children and adolescents consume the recommended amounts of fruits and vegetables (F/V). The US Department of Agriculture's Fresh Fruit and Vegetable Program (FFVP) is intended to increase child F/V consumption by funding low-income schools to distribute free fresh F/V snacks outside of school mealtimes.

OBJECTIVE

The evaluation assessed FFVP effects on student F/V consumption and total energy intake in and out of school.

DESIGN

The evaluation employed a regression discontinuity design; that is, cross-sectional comparisons of a sample of students in schools just above and just below the FFVP funding cutoff for the program, which depended on the proportion of students eligible for free or reduced-price meals. During the 2010-2011 school year within a randomly selected sample of states, we selected schools in closest proximity to each state-specific FFVP funding cutoff. Interviewers conducted 24-hour diary-assisted recall interviews to assess dietary intake among children in selected schools.

PARTICIPANTS/SETTING

Participants were 4,696 students (grades 4 to 6) from 214 elementary schools in 16 randomly selected states.

STATISTICAL ANALYSES PERFORMED

Analysis proceeded via multivariate regression, comparing adjusted mean student intake in schools just above and just below the funding cutoff.

RESULTS

Adjusted mean daily F/V intake was one-third of a cup per day higher in FFVP-participating schools than in nonparticipating schools (0.32 cups per day; P<0.001), a difference of 15.5%. This included one-quarter cup higher daily F/V intake during school hours (0.26 cups; P<0.001) among students attending FFVP-participating schools. Fresh (but not total) F/V consumption also increased outside of school.

CONCLUSIONS

The FFVP increases child fresh and total F/V intake in school, and fresh F/V intake outside of school.

First Report of Xanthomonas axonopodis Causing Bacterial Leaf Spot on Crape Myrtle

Crape myrtle (Lagerstroemia sp.) is a popular ornamental tree in the United States and the industry produced 2,781,089 trees in 2010 with a value exceeding US $42.8 million (1,4). A new disorder of crape myrtle has been observed since 2011 in numerous nurseries in Florida, which was characterized by dark brown, angular to irregularly shaped, oily-looking spots surrounded by yellow halos. The disease primarily affects lower leaves that eventually turn yellow and can lead to rapid defoliation of susceptible cultivars. Plants examined in field surveys at the University of Florida, North Florida Research and Education Center, Quincy, FL in 2012 and 2013 also had similar symptoms on cvs. Arapaho, Carolina Beauty, Tuscarora, Whit IV Red Rocket, Whit VIII Rhapsody in Pink, and White Chocolate. The disease severity ranged from 20 to 70% and all the plants were infected. A yellow-pigmented, gram-negative, oxidase negative bacterium was consistently isolated from symptomatic leaves (two leaves from each of five plants). Pathogenicity tests were performed using five isolated bacterial strains on potted crape myrtle cv. Arapaho. Three plants were inoculated with a 10⁸ CFU/ml suspension of bacterial strains in sterile deionized water, and covered with transparent plastic bag for 48 h. Two control plants were inoculated with sterile distilled water. The inoculated plants were then incubated in a greenhouse at 30 to 34°C for 14 days. Symptoms of dark brown, angular to irregularly shaped lesions were observed only on the inoculated plants after 7 days. The bacterium was re-isolated from the inoculated symptomatic plants as described above, thus fulfilling Koch's postulates. Fatty acid methyl ester profiling of the five isolated bacteria using GC-MIDI (Microbial IDentification Inc, Newark, DE) revealed the identity of the bacterium as Xanthomonas axonopodis with an identity index of ~0.80, but matched multiple pathovars. Total genomic DNA was extracted from the pure bacterial culture using UltraClean Microbial DNA Isolation Kit (MO BIO Laboratories, Carlsbad, CA). The genomic DNA was subjected to PCR assay using universal primers 27f/1492R (3) targeting the complete 16S rRNA gene and primers 16F945/23R458 (2), which target the partial 16S-23S internal transcribed spacer region. PCR amplification using primer pairs 27f/1492R and 16F945/23R458 resulted in amplicons of 1,450 and 1,500 bp, respectively. The amplicons were gel purified and sequenced directly at Florida State University. BLAST analysis of the sequences (Accession Nos. KF926678, KF926679, KF926680, KF926681, and KF926682) revealed the identity of the bacterium as X. axonopodis, ranging from 98 to 99%, with several strains in the NCBI database. Phylogenetic analysis using the neighbor-joining method showed that our strains were distantly clustered with X. axonopodis pv. dieffenbachiae when compared to other available strains in the database. To our knowledge, this is the first worldwide report of a bacterial leaf spot on crape myrtle caused by X. axonopodis. This information should aid in the development of breeding lines with resistance to bacterial leaf spot and effective disease management practices. References: (1) C. S. Furtado. Garden Bull. 24:185, 1969. (2) C. Guasp. Int. J. Syst. Evol. Microbiol. 50:1629, 2000. (3) D. J. Lane. Page 115 in: Nucleic Acid Techniques in Bacterial Systematics, 1991. (4) USDA. 2007 Census of Agriculture, Washington, DC. 3:25, 2010.