Publications by authors named "Mary Story"

323 Publications

Development and Application of a Total Diet Quality Index for Toddlers.

Nutrients 2021 Jun 5;13(6). Epub 2021 Jun 5.

Duke Global Health Institute, Duke University, Durham, NC 27708, USA.

For the first time, the 2020-2025 Dietary Guidelines for Americans include recommendations for infants and toddlers under 2 years old. We aimed to create a diet quality index based on a scoring system for ages 12 to 23.9 months, the Toddler Diet Quality Index (DQI), and evaluate its construct validity using 24 h dietary recall data collected from a national sample of children from the Feeding Infants and Toddlers Study (FITS) 2016. The mean (standard error) Toddler DQI was 49 (0.6) out of 100 possible points, indicating room for improvement. Toddlers under-consumed seafood, greens and beans, and plant proteins and over-consumed refined grains and added sugars. Toddler DQI scores were higher among children who were ever breastfed, lived in households with higher incomes, and who were Hispanic. The Toddler DQI performed as expected and offers a measurement tool to assess the dietary quality of young children in accordance with federal nutrition guidelines. This is important for providing guidance that can be used to inform public health nutrition policies, programs, and practices to improve diets of young children.
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http://dx.doi.org/10.3390/nu13061943DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8229507PMC
June 2021

The School Nutrition and Meal Cost Study-I: Overview of Findings Related to Improving Diet Quality, Weight, and Disparities in US Children and Policy Implications.

Nutrients 2021 Apr 19;13(4). Epub 2021 Apr 19.

Healthy Eating Research, Duke Global Health Institute, Duke University, 310 Trent Drive, Duke Box 90519, Durham, NC 27708, USA.

The national school breakfast and lunch programs administered by the United States Department of Agriculture (USDA) are a cornerstone of the nation's nutrition safety net for children from low-income families [...].
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http://dx.doi.org/10.3390/nu13041357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8073026PMC
April 2021

Weight-Related Behaviors of Children with Obesity during the COVID-19 Pandemic.

Child Obes 2021 Apr 26. Epub 2021 Apr 26.

Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.

During the coronavirus disease 2019 (COVID-19) pandemic, children and families have had to adapt their daily lives. The purpose of this study was to describe changes in the weight-related behaviors of children with obesity after the onset of the COVID-19 pandemic. Semistructured interviews ( = 51) were conducted from April to June 2020 with parents of children with obesity. Families were participants in a randomized trial testing a clinic-community pediatric obesity treatment model. During interviews, families described their experience during the COVID-19 pandemic, with a particular emphasis on children's diet, physical activity, sleep, and screen time behaviors. Rapid qualitative analysis methods were used to identify themes around changes in children's weight-related behaviors. The mean child age was 9.7 (±2.8) years and the majority of children were Black (46%) or Hispanic (39%) and from low-income families (62%). Most parent participants were mothers (88%). There were differences in the perceived physical activity level of children, with some parents attributing increases in activity or maintenance of activity level to increased outdoor time, whereas others reported a decline due to lack of outdoor time, school, and structured activities. Key dietary changes included increased snacking and more meals prepared and consumed at home. There was a shift in sleep schedules with children going to bed and waking up later and an increase in leisure-based screen time. Parents played a role in promoting activity and managing children's screen time. The COVID-19 pandemic has created unique lifestyle challenges and opportunities for lifestyle modification. Clinical Trials ID: NCT03339440.
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http://dx.doi.org/10.1089/chi.2021.0038DOI Listing
April 2021

Prevalence of food insecurity among students attending four Historically Black Colleges and Universities.

J Am Coll Health 2021 Mar 24:1-7. Epub 2021 Mar 24.

Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.

This study examined the prevalence of food insecurity (FI) among students attending Historically Black Colleges and Universities (HBCUs) in the Southeastern United States. Students attending four HBCUs ( = 351) completed an anonymous Web-based survey. Food insecurity was assessed using the 2-item Hunger Vital Sign Tool. Summary statistics were used to quantify FI experiences. Logistic regression was conducted to determine if student demographic characteristics were significantly associated with FI outcomes. Nearly 3 in 4 students (72.9%) reported some level of FI in the past year. Students representing all levels of postsecondary education reported FI. Meal plan participation did not prevent FI. Students attending HBCUs experience FI at levels that exceed estimates reported among students attending predominantly White institutions. More work is needed to understand the lived experience of food-insecure HBCU students as a means to ensure institution-level food policies support student academic success and wellbeing.
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http://dx.doi.org/10.1080/07448481.2021.1877144DOI Listing
March 2021

Improving maternal and child nutrition in China: an analysis of nutrition policies and programs initiated during the 2000-2015 Millennium Development Goals era and implications for achieving the Sustainable Development Goals.

J Health Popul Nutr 2020 12 2;39(1):12. Epub 2020 Dec 2.

Department of Family Medicine and Community Health and Duke Global Health Institute, Duke University, Durham, NC, 27708, USA.

Background: Although good progress was made in maternal and child nutrition during the Millennium Development Goals (MDGs) era, malnutrition remains one of the major threats on global health. Therefore, the United Nation set several nutrition-related goals in the Sustainable Development Goals (SDGs). There is much to be learned from individual countries in terms of efforts and actions taken to reduce malnutrition. China, as a developing country, launched a number of nutrition improvement policies and programs that resulted in dramatic progress in improving maternal and child nutrition during the MDGs era. This study explored the impact, experiences, and lessons learned from the nutrition policies and programs initiated in China during the MDGs era and implications to achieve the SDGs for China and other developing countries.

Method: The CNKI database and official websites of Chinese government were searched for reviews on nutrition-related policies and intervention programs. A qualitative study was conducted among key informants from the Chinese government, non-governmental organizations (NGOs), and universities for two major national nutrition intervention programs.

Results: The literature review documented that during the MDGs era, six nutrition policies and eight trans-province and nationwide nutrition intervention programs collectively made good progress in improving maternal and child nutrition in China. Nutrition policies tended to be targeted at infants and children, with less attention on reproductive and maternal nutrition. Nutrition intervention programs focused primarily on undernutrition and have achieved positive results, while for breastfeeding improvement and prevention and control on overweight and obesity were limited. Results from the qualitative study indicated that effective nutrition program implementation was facilitated through the cooperation of multiple sectors and by the government and NGO partnerships, however, still face challenges of insufficient operational funds from local governments and inadequacy of program monitoring and management.

Conclusion: Nutrition policies and intervention programs promulgated in China during the MDGs era have made major contributions to the rapid decline of undernutrition and are in line to achieve the SDGs related to child wasting, stunting, low birth weight, and anemia in reproductive-age women. However, appropriate policies and program implementation are needed to improve exclusive breastfeeding rates and reduce obesity to achieve the SDGs in years to come.
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http://dx.doi.org/10.1186/s41043-020-00221-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7709233PMC
December 2020

Developing a National Research Agenda to Support Healthy Food Retail.

Int J Environ Res Public Health 2020 11 4;17(21). Epub 2020 Nov 4.

Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA.

The food retail environment is an important driver of dietary choices. This article presents a national agenda for research in food retail, with the goal of identifying policies and corporate practices that effectively promote healthy food and beverage purchases and decrease unhealthy purchases. The research agenda was developed through a multi-step process that included (1) convening a scientific advisory committee; (2) commissioned research; (3) in-person expert convening; (4) thematic analysis of meeting notes and refining research questions; (5) follow-up survey of convening participants; and (6) refining the final research agenda. Public health researchers, advocates, food and beverage retailers, and funders participated in the agenda setting process. A total of 37 research questions grouped into ten priority areas emerged. Five priority areas focus on understanding the current food retail environment and consumer behavior and five focus on assessing implementation and effectiveness of interventions and policies to attain healthier retail. Priority topics include how frequency, duration, and impact of retailer promotion practices differ by community characteristics and how to leverage federal nutrition assistance programs to support healthy eating. To improve feasibility, researchers should explore partnerships with retailers and advocacy groups, identify novel data sources, and use a variety of study designs. This agenda can serve as a guide for researchers, food retailers, funders, government agencies, and advocacy organizations.
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http://dx.doi.org/10.3390/ijerph17218141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7663573PMC
November 2020

Reframing the early childhood obesity prevention narrative through an equitable nurturing approach.

Matern Child Nutr 2021 01 17;17(1):e13094. Epub 2020 Oct 17.

Duke Global Health Institute, Duke University, Durham, NC, USA.

High-quality mother-child interactions during the first 2,000 days, from conception to age 5 years, are considered crucial for preventing obesity development during early life stages. However, mother-child dyads interact within and are influenced by broader socio-ecological contexts involved in shaping child development outcomes, including nutrition. Hence, the coexistence of both undernutrition and obesity has been noted in inequitable social conditions, with drivers of undernutrition and overnutrition in children sharing common elements, such as poverty and food insecurity. To date, a holistic life-course approach to childhood obesity prevention that includes an equitable developmental perspective has not emerged. The World Health Organization (WHO) Nurturing Care Framework provides the foundation for reframing the narrative to understand childhood obesity through the lens of an equitable nurturing care approach to child development from a life-course perspective. In this perspective, we outline our rationale for reframing the childhood narrative by integrating an equitable nurturing care approach to childhood obesity prevention. Four key elements of reframing the narrative include: (a) extending the focus from the current 1,000 to 2,000 days (conception to 5 years); (b) highlighting the importance of nurturing mutually responsive child-caregiver connections to age 5; (c) recognition of racism and related stressors, not solely race/ethnicity, as part of adverse child experiences and social determinants of obesity; and (d) addressing equity by codesigning interventions with socially marginalized families and communities. An equitable, asset-based engagement of families and communities could drive the transformation of policies, systems and social conditions to prevent childhood obesity.
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http://dx.doi.org/10.1111/mcn.13094DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7729646PMC
January 2021

Rationale and design of "Hearts & Parks": study protocol for a pragmatic randomized clinical trial of an integrated clinic-community intervention to treat pediatric obesity.

BMC Pediatr 2020 06 26;20(1):308. Epub 2020 Jun 26.

Duke Clinical Research Institute, Duke University, Durham, NC, 27710, USA.

Background: The prevalence of child and adolescent obesity and severe obesity continues to increase despite decades of policy and research aimed at prevention. Obesity strongly predicts cardiovascular and metabolic disease risk; both begin in childhood. Children who receive intensive behavioral interventions can reduce body mass index (BMI) and reverse disease risk. However, delivering these interventions with fidelity at scale remains a challenge. Clinic-community partnerships offer a promising strategy to provide high-quality clinical care and deliver behavioral treatment in local park and recreation settings. The Hearts & Parks study has three broad objectives: (1) evaluate the effectiveness of the clinic-community model for the treatment of child obesity, (2) define microbiome and metabolomic signatures of obesity and response to lifestyle change, and (3) inform the implementation of similar models in clinical systems.

Methods: Methods are designed for a pragmatic randomized, controlled clinical trial (n = 270) to test the effectiveness of an integrated clinic-community child obesity intervention as compared with usual care. We are powered to detect a difference in body mass index (BMI) between groups at 6 months, with follow up to 12 months. Secondary outcomes include changes in biomarkers for cardiovascular disease, psychosocial risk, and quality of life. Through collection of biospecimens (serum and stool), additional exploratory outcomes include microbiome and metabolomics biomarkers of response to lifestyle modification.

Discussion: We present the study design, enrollment strategy, and intervention details for a randomized clinical trial to measure the effectiveness of a clinic-community child obesity treatment intervention. This study will inform a critical area in child obesity and cardiovascular risk research-defining outcomes, implementation feasibility, and identifying potential molecular mechanisms of treatment response.

Clinical Trial Registration: NCT03339440 .
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http://dx.doi.org/10.1186/s12887-020-02190-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7318397PMC
June 2020

Child Nutrition Trends Over the Past Two Decades and Challenges for Achieving Nutrition SDGs and National Targets in China.

Int J Environ Res Public Health 2020 02 11;17(4). Epub 2020 Feb 11.

National Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Xicheng District, Beijing 100050, China.

Background: The objectives of the current study were to identify the trends in child nutrition, the gaps in achieving child nutrition-related goals, and implications for program and policy options for the Chinese government.

Methods: Eight child nutrition-related indicators from the Sustainable Development Goals (SDGs) and China's national nutrition plans, and two datasets, Global Burden of Disease 2016 and Chinese National Nutrition and Health Surveillance, were used in our analysis.

Results: Over the past 26 years, the prevalence of stunting, wasting, and underweight for children under 5 years was reduced by 58.7%, 53.4%, and 69.2%, respectively. Overweight for children aged 1-4 years increased 88.9% and obesity increased 2.14 times. Exclusive breastfeeding of newborns (7-28 days) was stable, at about 30%. We estimated child wasting would be 3.0% lower than the target of 5.0% based on predictive values for meeting the SDGs in 2025. The number of stunted children under five years would be reduced by 39.7%, while overweight would increase 2.2% throughout China.

Conclusion: These results highlight the urgent need for targeted policies and interventions to reduce child stunting and overweight and increase exclusive breastfeeding to improve child health and meet the SDG targets and China's national goals.
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http://dx.doi.org/10.3390/ijerph17041129DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7068302PMC
February 2020

Summary: Nutrition Education in Child Care, Schools and Community Settings.

Authors:
Mary T Story

Nestle Nutr Inst Workshop Ser 2019 28;92:131-132. Epub 2019 Nov 28.

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http://dx.doi.org/10.1159/000501668DOI Listing
November 2019

Supporting Healthy Eating: Synergistic Effects of Nutrition Education Paired with Policy, Systems, and Environmental Changes.

Nestle Nutr Inst Workshop Ser 2019 28;92:69-82. Epub 2019 Nov 28.

Duke Global Health Institute, Duke University, Durham, North Carolina, USA.

A healthy diet is central to health and well-being throughout life. The United States and many other countries are undergoing an obesity epidemic and experiencing serious diet-related health problems. There exists a misalignment and wide gap between national dietary recommendations and dietary patterns of Americans, and thus, a need to find new ways to improve diet and nutrition. This article posits that nutrition education combined with policy, systems, and environmental (PSE) change approaches is more effective than either strategy in isolation and both are needed to reduce the global burden of diet-related chronic diseases. This article presents a conceptual framework for understanding the multiple influences on what people eat; discusses the need for PSE strategies to augment direct nutrition education approaches; and highlights examples of synergistic and promising linkages between nutrition education and PSE strategies in 3 areas: federal nutrition assistance programs, food retail settings, and nutrition and calorie labeling. In addition, future directions where this synergistic approach holds promise for improving population health and reducing health inequities are discussed. Nutrition education combined with PSE changes at governmental and community levels, as well as strategic public-private alliances have the potential to change the way people eat and improve health and well-being.
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http://dx.doi.org/10.1159/000499549DOI Listing
October 2020

Trends in Food Consumption Patterns of US Infants and Toddlers from Feeding Infants and Toddlers Studies (FITS) in 2002, 2008, 2016.

Nutrients 2019 Nov 17;11(11). Epub 2019 Nov 17.

Duke Global Health Institute, Duke University, Durham, NC 27110, USA.

The Feeding Infants and Toddlers Study (FITS) is the largest survey of dietary intake among infants and young children in the United States. Dietary patterns in early childhood are a key component of prevention of diet-related chronic diseases, yet little is known about how food consumption patterns of infants and young children have changed over time. The objective of this study is to examine trends in food and beverage consumption among children ages 6-23.9 months using data from the FITS conducted in 2002, 2008, and 2016. A total of 5963 infants and young children ages 6-23.9 months were included in these analyses. Food consumption data were collected using a multiple-pass 24-h recall by telephone using the Nutrition Data System for Research. Linear trends were assessed using the Wald's test in a multivariable linear regression model. Positive significant findings include increases in breast milk consumption and decreases in the consumption of sweets, sugar-sweetened beverages, and 100% fruit juice. More troubling findings include decreasing infant cereal consumption, stagnant or decreasing whole grain consumption, and stagnant consumption of vegetables. Our findings suggest some promising improvements in dietary intake among infants and toddlers in the United States over the past 15 years, but further policy, programmatic, and industry efforts are still needed.
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http://dx.doi.org/10.3390/nu11112807DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6893614PMC
November 2019

Current situation and progress toward the 2030 health-related Sustainable Development Goals in China: A systematic analysis.

PLoS Med 2019 11 19;16(11):e1002975. Epub 2019 Nov 19.

Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, United States of America.

Background: The Sustainable Development Goals (SDGs), adopted by all United Nations (UN) member states in 2015, established a set of bold and ambitious health-related targets to achieve by 2030. Understanding China's progress toward these targets is critical to improving population health for its 1.4 billion people.

Methods And Findings: We used estimates from the Global Burden of Disease (GBD) Study 2016, national surveys and surveillance data from China, and qualitative data. Twenty-eight of the 37 indicators included in the GBD Study 2016 were analyzed. We developed an attainment index of health-related SDGs, a scale of 0-100 based on the values of indicators. The projection model is adjusted based on the one developed by the GBD Study 2016 SDG collaborators. We found that China has achieved several health-related SDG targets, including decreasing neonatal and under-5 mortality rates and the maternal mortality ratios and reducing wasting and stunting for children. However, China may only achieve 12 out of the 28 health-related SDG targets by 2030. The number of target indicators achieved varies among provinces and municipalities. In 2016, among the seven measured health domains, China performed best in child nutrition and maternal and child health and reproductive health, with the attainment index scores of 93.0 and 91.8, respectively, followed by noncommunicable diseases (NCDs) (69.4), road injuries (63.6), infectious diseases (63.0), environmental health (62.9), and universal health coverage (UHC) (54.4). There are daunting challenges to achieve the targets for child overweight, infectious diseases, NCD risk factors, and environmental exposure factors. China will also have a formidable challenge in achieving UHC, particularly in ensuring access to essential healthcare for all and providing adequate financial protection. The attainment index of child nutrition is projected to drop to 80.5 by 2025 because of worsening child overweight. The index of NCD risk factors is projected to drop to 38.8 by 2025. Regional disparities are substantial, with eastern provinces generally performing better than central and western provinces. Sex disparities are clear, with men at higher risk of excess mortality than women. The primary limitations of this study are the limited data availability and quality for several indicators and the adoption of "business-as-usual" projection methods.

Conclusion: The study found that China has made good progress in improving population health, but challenges lie ahead. China has substantially improved the health of children and women and will continue to make good progress, although geographic disparities remain a great challenge. Meanwhile, China faced challenges in NCDs, mental health, and some infectious diseases. Poor control of health risk factors and worsening environmental threats have posed difficulties in further health improvement. Meanwhile, an inefficient health system is a barrier to tackling these challenges among such a rapidly aging population. The eastern provinces are predicted to perform better than the central and western provinces, and women are predicted to be more likely than men to achieve these targets by 2030. In order to make good progress, China must take a series of concerted actions, including more investments in public goods and services for health and redressing the intracountry inequities.
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http://dx.doi.org/10.1371/journal.pmed.1002975DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7340487PMC
November 2019

Developing a national research agenda to reduce consumption of sugar-sweetened beverages and increase safe water access and consumption among 0- to 5-year-olds: a mixed methods approach.

Public Health Nutr 2020 01 5;23(1):22-33. Epub 2019 Sep 5.

Healthy Eating Research, Community & Family Medicine and Global Health, Duke University, 310 Trent Drive, Durham NC 27708USA.

Objective: Sugar-sweetened beverage (SSB) consumption in early childhood is a public health concern. Adequate hydration in early childhood is also important. We developed a national research agenda to improve beverage consumption patterns among 0-5-year-olds. This article focuses on the process used to develop this research agenda.

Design: A mixed methods, multi-step process was used to develop the research agenda, including: (i) a scientific advisory committee; (ii) systematic reviews on strategies to reduce SSB consumption and increase water access and consumption; (iii) two stakeholder surveys to first identify and then rank strategies to reduce SSB consumption and increase water access and consumption; (iv) key informant interviews to better understand determinants of beverage consumption and strategies to improve beverage consumption patterns among high-risk groups; (v) an in-person convening with experts; and (vi) developing the final research agenda.

Setting: This process included research and stakeholders from across the United States.

Participants: A total of 276 participants completed survey 1 and 182 participants completed survey 2. Key informant interviews were conducted with 12 stakeholders. Thirty experts attended the convening, representing academia, government, and non-profit sectors.

Results: Thirteen key issue areas and 59 research questions were developed. Priority topics were beverage consumption recommendations, fruit-flavoured drink consumption, interventions tailored to high-risk groups, and family engagement in childcare.

Conclusions: This research agenda lays the groundwork for research efforts to improve beverage patterns of young children. The methods used can be a template to develop research agendas for other public health issues.
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http://dx.doi.org/10.1017/S1368980019002106DOI Listing
January 2020

Multisector Approach to Improve Healthy Eating and Physical Activity Policies and Practices in Early Care and Education Programs: The National Early Care and Education Learning Collaboratives Project, 2013-2017.

Prev Chronic Dis 2019 07 25;16:E94. Epub 2019 Jul 25.

Gretchen Swanson Center for Nutrition, Omaha, Nebraska.

Purpose And Objectives: Embedding healthy eating and physical activity best practices in early care and education settings is important for instilling healthy behaviors early in life. A collaborative partnership between Nemours Children's Health System and the Centers for Disease Control and Prevention was created to implement the National Early Care and Education Learning Collaboratives Project (ECELC) in childcare settings in 10 states. We measured improvement at the program level by the self-reported number of best practices implemented related to healthy eating and physical activity.

Intervention Approach: The ECELC implemented a collaborative model with state-level partners (eg, child care resource and referral networks) and early care and education programs. Intervention components received by program directors and lead teachers included 1) self-assessment, 2) in-person learning and training sessions, 3) action planning and implementation, 4) technical assistance, and 5) post-reassessment.

Evaluation Methods: A pre-post design assessed self-reported policies and practices related to breastfeeding and infant feeding, child nutrition, infant and child physical activity, screen time, and outdoor play and learning as measured by the validated Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) best practices instrument. The sample included 1,173 early care and education programs.

Results: The number of best practices met for each of the 5 NAP SACC areas increased from pre-assessment to post-assessment approximately 6 months later and ranged from 1.5 to 4.7 best practices (P < .001). Almost all increases occurred regardless of participation in the Child and Adult Care Food Program, Quality Rating Improvement System, Head Start/Early Head Start, and/or accreditation status.

Implications For Public Health: The innovative and collaborative partnerships led to broad implementation of healthy eating and physical activity-based practices in early care and education settings. Development, implementation, and evaluation of policy and practice-based partnerships to promote healthy eating and physical activity among children attending early care and education programs may contribute to obesity prevention in the United States.
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http://dx.doi.org/10.5888/pcd16.180582DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716417PMC
July 2019

Fill "half your child's plate with fruits and vegetables": Correlations with food-related practices and the home food environment.

Appetite 2019 02 17;133:77-82. Epub 2018 Oct 17.

School of Nursing, University of Minnesota, USA. Electronic address:

This study examined the prevalence of parental report of children's adherence to USDA's MyPlate guidelines of 'half of plate filled with fruits and vegetables (FV)' and associations with child and parent/guardian report of food-related practices and the home food environment. Data for this study represent the baseline assessment (n = 160 parent-child dyads) of the Healthy Home Offerings via the Mealtime Environment (HOME) Plus study, a randomized controlled trial to prevent excess weight gain among 8-12 year-old children. Multiple logistic regression models examined associations between a newly created 'half plate FV' variable 'During the past seven days how many times was half of your child's plate filled with fruits and vegetables at dinner?" and personal and home food environmental factors, including food availability, child fruit/vegetable intake, and healthy eating index (HEI), adjusted for race and receipt of public assistance. Parents reported their children had half their plates filled with FV at dinner on average 2.7 times in the past week. With each reported child intake of FV, the odds of having half their plates filled with FV were almost one and a half times greater; there were significantly higher odds of children having half their plates filled with FV with greater children's HEI, parent and child cooking skills and self-efficacy to cook healthy meals, family meal frequency, and availability of more types of fruits and vegetables in the home. The findings demonstrate that the MyPlate campaign's message of "half the plate filled with FV" can be used in nutrition interventions focusing on improving the home food environment and increasing children's FV intake; the survey item used in the present study may be effective in capturing adherence to the MyPlate message.
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http://dx.doi.org/10.1016/j.appet.2018.10.017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6944192PMC
February 2019

Role of Policies and Practices within Early Care and Education Programs to Support Healthy Food and Physical Activity Practices.

Child Obes 2018 Aug/Sep;14(6):340

2 Community and Family Medicine and Global Health, Duke University, Durham, NC.

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http://dx.doi.org/10.1089/chi.2018.29004.msDOI Listing
September 2019

Beverage Consumption Patterns among Infants and Young Children (0⁻47.9 Months): Data from the Feeding Infants and Toddlers Study, 2016.

Nutrients 2018 Jun 26;10(7). Epub 2018 Jun 26.

Duke Global Health Institute, Duke University, 310 Trent Dr, Durham, NC 27708, USA.

(1) Background: Data about early life beverage intake patterns is sparse. We describe beverage patterns among infants and young children from the Feeding Infants and Toddlers Study (FITS) 2016. (2) Methods: FITS 2016 is a cross-sectional survey of U.S. parents/caregivers of children 0⁻47.9 months ( = 3235). Food and beverage intakes were collected by 24-h dietary recalls to describe beverage consumption patterns including: a) prevalence of consumption, per capita and per consumer intake, b) contribution to intake of calories and key nutrients, and c) prevalence according to eating occasions. (3) Results: Breast milk and infant formula were commonly consumed among <12-month-olds. Among 12⁻23.9-month-olds, the most commonly consumed beverage was whole milk (67% consuming), followed by 100% juice (50% consuming). Plain drinking water was consumed by 70% of 12⁻23.9-month-olds and 78% of 24⁻47.9-month-olds. Among 12⁻47.9-month-olds, milks provided more energy and key nutrients than all other beverages. Across eating occasions, sugar-sweetened beverage (SSB) consumption, especially in the form of fruit-flavored drinks, was higher among 24⁻47.9 compared to 12⁻23.9-month-olds. Only 23⁻32% of ≥12-month-olds consumed milk or water at lunch or dinner. (4) Conclusions: Opportunities exist to improve beverage patterns. Future interventions may benefit from focusing on timely introduction of age-appropriate beverages and reducing consumption of SSBs.
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http://dx.doi.org/10.3390/nu10070825DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6073729PMC
June 2018

Room for Improvement Remains in Food Consumption Patterns of Young Children Aged 2-4 Years.

J Nutr 2018 09;148(9S):1536S-1546S

Duke University, Duke Global Health Institute, Durham, NC.

Background: Healthy food consumption patterns in early childhood support optimal growth and development and promote lifelong health.

Objective: The objective of the Feeding Infants and Toddlers Study (FITS) 2016 is to provide updated information on food consumption patterns of children aged 0 to <4 y. This article focuses on several key aspects of the food consumption patterns of 2- and 3-y-olds and how those patterns differ between racial/ethnic groups.

Methods: The FITS 2016 is a cross-sectional study in caregivers of children aged 0 to <4 y living in the United States. Dietary data were collected in a national random sample of children (n = 3235, of whom 600 were aged 24-47.9 mo) by using a 24-h dietary recall telephone survey with the primary caregiver of the child. Data from the recall were used to calculate the percentage of children consuming specific food groups on the day of the recall and energy from these foods (kilocalories per consumer). Differences in food patterns between racial/ethnic groups were analyzed by using ANOVA and t tests.

Results: On the day of the 24-h dietary recall, 27% of 2- and 3-y-olds did not consume a distinct portion of vegetables. Fried potatoes were the most commonly consumed vegetable. Approximately 75% consumed a distinct portion of fruit and 45% consumed 100% fruit juice. Eighty-one percent of children consumed cow milk. Almost all (95%) consumed a grain product, and 59% consumed a whole grain-rich product. The majority of children (88%) consumed meat or another protein food. Nearly all (90%) consumed a dessert, sugar-sweetened beverage (SSB), or sweet; and 45% consumed an SSB. Thirty-six percent of children consumed a savory snack. There were some differences in food consumption patterns between racial/ethnic groups.

Conclusion: Findings from the FITS 2016 indicate that individual-, community-, and policy-level strategies are needed to improve the diets of young children in the United States.
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http://dx.doi.org/10.1093/jn/nxx053DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6126636PMC
September 2018

Multicontextual correlates of adolescent sugar-sweetened beverage intake.

Eat Behav 2018 08 1;30:42-48. Epub 2018 May 1.

Division of Epidemiology and Community Health, University of Minnesota, 1300 South 2(nd) Street, Suite 300, Minneapolis, MN 55454, USA.

Purpose: To examine personal, home, peer, school, neighborhood, and media correlates of sugar-sweetened beverage (SSB) intake in a diverse sample of adolescents.

Methods: Cross-sectional, population-based study (EAT 2010: Eating and Activity in Teens) of 2793 adolescents (54% female, mean age [SD] = 14.5 [2.0], 80% nonwhite) attending public secondary schools in Minneapolis-St. Paul, Minnesota. Adolescents completed a food frequency questionnaire and answered survey questions about their diet/health perceptions and behaviors. Socio-environmental data were collected from parents/caregivers, peers, school personnel, Geographic Information Systems (e.g., distance to food outlet), and a content analysis of favorite TV shows. Individual and mutually adjusted mixed-effects regression models examined associations between multi-contextual factors and estimated daily servings of SSB, controlling for relevant covariates.

Results: The contextual factors examined accounted for 24% of the variance in adolescents' SSB consumption. The proportion of variance explained by each context was 13% personal, 16% home/family, 3% peer, 1% school, 0.1% media, and 0% neighborhood. The strongest correlate of SSB intake was home soda availability (adjusted for covariates: β = 0.26, p < 0.01; adjusted for all multi-contextual factors: β = 0.18, p < 0.01). Other significant correlates of SSB intake included personal behaviors (e.g., fast food intake, sleep), home/family factors (e.g., parent modeling) and peer influences (e.g., friends' SSB intake).

Conclusions: Public health policies and programs to reduce adolescent SSB intake should target personal behaviors (e.g., limit fast food, encourage adequate sleep), address the home setting (e.g., help parents to reduce SSB availability and model healthy eating habits) and involve peers (e.g., identify and enable peers to model healthy eating behaviors).
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http://dx.doi.org/10.1016/j.eatbeh.2018.04.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6314180PMC
August 2018

Worksite physical activity breaks: Perspectives on feasibility of implementation.

Work 2018 ;59(4):491-499

University of Minnesota, Minneapolis, MN, USA.

Background: Worksites offer a unique opportunity to increase physical activity in persons with both active and sedentary lifestyles.

Objective: The objective of this study was to examine employee and supervisor perspectives on feasibility and acceptability of 10-minute Instant Recess ® physical activity videos in the worksite.

Methods: Convenience sample of public and private worksites in Minneapolis/St. Paul, MN. Employees (n = 187) at 13 worksites were recruited by a one-time email invitation to participate in a group Instant Recess break and complete a 15-question survey. One supervisor per site participated in a one-on-one interview to assess suggestions for feasibility of implementation. Likert-type survey responses were averaged per worksite and overall. Interview results were recorded, transcribed, and coded by two authors.

Results: Employees were extremely positive about enjoyment, increased productivity, comfort, and feasibility of doing Instant Recess at the same time and place every day (score = 4.29, 4.17, 4.25, and 4.37 out of 5, respectively). However, they did not feel comfortable leading an Instant Recess break (score = 2.68 out of 5). Supervisors voiced during the one-on-one interviews that they enjoyed Instant Recess (13 out of 13 supervisors), were enthusiastic about Instant Recess as a simple and cost-effective entry into worksite wellness (11 out of 13 supervisors), and felt that Instant Recess could be institutionalized by offering it daily at a set time and place (13 out of 13 supervisors).

Conclusions: Employees and supervisors at various worksites believed that it is feasible and desirable to offer 10-minute physical activity breaks using videos during the workday.
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http://dx.doi.org/10.3233/WOR-182704DOI Listing
October 2018

Effectiveness of school food environment policies on children's dietary behaviors: A systematic review and meta-analysis.

PLoS One 2018 29;13(3):e0194555. Epub 2018 Mar 29.

Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, United States of America.

Background: School food environment policies may be a critical tool to promote healthy diets in children, yet their effectiveness remains unclear.

Objective: To systematically review and quantify the impact of school food environment policies on dietary habits, adiposity, and metabolic risk in children.

Methods: We systematically searched online databases for randomized or quasi-experimental interventions assessing effects of school food environment policies on children's dietary habits, adiposity, or metabolic risk factors. Data were extracted independently and in duplicate, and pooled using inverse-variance random-effects meta-analysis. Habitual (within+outside school) dietary intakes were the primary outcome. Heterogeneity was explored using meta-regression and subgroup analysis. Funnel plots, Begg's and Egger's test evaluated potential publication bias.

Results: From 6,636 abstracts, 91 interventions (55 in US/Canada, 36 in Europe/New Zealand) were included, on direct provision of healthful foods/beverages (N = 39 studies), competitive food/beverage standards (N = 29), and school meal standards (N = 39) (some interventions assessed multiple policies). Direct provision policies, which largely targeted fruits and vegetables, increased consumption of fruits by 0.27 servings/d (n = 15 estimates (95%CI: 0.17, 0.36)) and combined fruits and vegetables by 0.28 servings/d (n = 16 (0.17, 0.40)); with a slight impact on vegetables (n = 11; 0.04 (0.01, 0.08)), and no effects on total calories (n = 6; -56 kcal/d (-174, 62)). In interventions targeting water, habitual intake was unchanged (n = 3; 0.33 glasses/d (-0.27, 0.93)). Competitive food/beverage standards reduced sugar-sweetened beverage intake by 0.18 servings/d (n = 3 (-0.31, -0.05)); and unhealthy snacks by 0.17 servings/d (n = 2 (-0.22, -0.13)), without effects on total calories (n = 5; -79 kcal/d (-179, 21)). School meal standards (mainly lunch) increased fruit intake (n = 2; 0.76 servings/d (0.37, 1.16)) and reduced total fat (-1.49%energy; n = 6 (-2.42, -0.57)), saturated fat (n = 4; -0.93%energy (-1.15, -0.70)) and sodium (n = 4; -170 mg/d (-242, -98)); but not total calories (n = 8; -38 kcal/d (-137, 62)). In 17 studies evaluating adiposity, significant decreases were generally not identified; few studies assessed metabolic factors (blood lipids/glucose/pressure), with mixed findings. Significant sources of heterogeneity or publication bias were not identified.

Conclusions: Specific school food environment policies can improve targeted dietary behaviors; effects on adiposity and metabolic risk require further investigation. These findings inform ongoing policy discussions and debates on best practices to improve childhood dietary habits and health.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0194555PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5875768PMC
July 2018

An Integrated Clinic-Community Partnership for Child Obesity Treatment: A Randomized Pilot Trial.

Pediatrics 2018 01 13;141(1). Epub 2017 Dec 13.

Department of Pediatrics, and.

Background And Objectives: Effective treatment of childhood obesity remains elusive. Integration of clinical and community systems may achieve effective and sustainable treatment. However, the feasibility and effectiveness of this integrated model are unknown.

Methods: We conducted a randomized clinical trial among children aged 5 to 11 presenting for obesity treatment. We randomized participants to clinical care or clinical care plus community-based programming at a local parks and recreation facility. Primary outcomes were the change in child BMI at 6 months and the intensity of the program in treatment hours. Secondary outcomes included health behaviors, fitness, attrition, and quality of life.

Results: We enrolled 97 children with obesity, and retention at 6 months was 70%. Participants had a mean age of 9.1 years and a mean baseline BMI score of 2.28, and 70% were living in poverty. Intervention participants achieved more treatment hours than controls (11.4 vs 4.4, SD: 15.3 and 1.6, respectively). We did not observe differences in child BMI score or percent of the 95th percentile at 6 months. Intervention participants had significantly greater improvements in physical activity ( = .010) and quality of life ( = .008).

Conclusions: An integrated clinic-community model of child obesity treatment is feasible to deliver in a low-income and racially diverse population. As compared with multidisciplinary treatment, the integrated model provides more treatment hours, improves physical activity, and increases quality of life. Parks and recreation departments hold significant promise as a partner agency to deliver child obesity treatment.
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http://dx.doi.org/10.1542/peds.2017-1444DOI Listing
January 2018

Association between Obesity and Puberty Timing: A Systematic Review and Meta-Analysis.

Int J Environ Res Public Health 2017 10 24;14(10). Epub 2017 Oct 24.

Department of Community and Family Medicine, Duke University, Durham, NC 27708, USA.

This systematic review and meta-analysis examined the associations between obesity and puberty timing based on scientific evidence. Eight electronic databases were searched up to February 2017 for eligible studies, and two reviewers screened the articles and extracted the data independently. A total of 11 cohort studies with 4841 subjects met the inclusion criteria. Compared with the group of normal-weight girls, the obese group had more girls with menarche (RR: 1.87, 95% CI: 1.59-2.19, 2 studies). The number of girls with early puberty was significantly higher in the obese group than the normal weight group (RR: 2.44, 95% CI: 1.32-4.52, 5 studies). However, no differences were detected between girls who were obese or normal weight at age of menarche (WMD: -0.53 years, 95% CI: -1.24-0.19, 2 studies). There is no consistent result in the relationship between obesity and timing of pubertal onset in boys. Obesity may contribute to early onset of puberty in girls, while in boys, there is insufficient data. Given the limited number of cohort studies included in this meta-analysis, high-quality studies with strong markers of puberty onset, as well as standardized criteria for defining obesity are needed.
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http://dx.doi.org/10.3390/ijerph14101266DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5664767PMC
October 2017

A Systematic Review of Calorie Labeling and Modified Calorie Labeling Interventions: Impact on Consumer and Restaurant Behavior.

Obesity (Silver Spring) 2017 12 17;25(12):2018-2044. Epub 2017 Oct 17.

Department of Medical Ethics & Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Objective: Evidence on the effects of restaurant calorie labeling on consumer and restaurant behavior is mixed. This paper examined: (1) consumer responses to calorie information alone or compared to modified calorie information and (2) changes in restaurant offerings following or in advance of menu labeling implementation.

Methods: Searches were conducted in PubMed, Web of Science, Policy File, and PAIS International to identify restaurant calorie labeling studies through October 1, 2016, that measured calories ordered, consumed, or available for purchase on restaurant menus. The reference lists of calorie labeling articles were also searched.

Results: Fifty-three studies were included: 18 in real-world restaurants, 9 in cafeterias, and 21 in laboratory or simulation settings. Five examined restaurant offerings.

Conclusions: Because of a lack of well-powered studies with strong designs, the degree to which menu labeling encourages lower-calorie purchases and whether that translates to a healthier population are unclear. Although there is limited evidence that menu labeling affects calories purchased at fast-food restaurants, some evidence demonstrates that it lowers calories purchased at certain types of restaurants and in cafeteria settings. The limited data on modified calorie labels find that such labels can encourage lower-calorie purchases but may not differ in effects relative to calorie labels alone.
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http://dx.doi.org/10.1002/oby.21940DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5752125PMC
December 2017

Foods and Beverages Available at SNAP-Authorized Drugstores in Sections of North Carolina.

J Nutr Educ Behav 2017 09;49(8):674-683.e1

Department of Community and Family Medicine and Global Health, Duke University, Durham, NC.

Objective: To assess healthy food availability in Supplemental Nutrition Assistance Program-authorized drugstores by store chain and neighborhood income level in 3 regions of North Carolina.

Design: Cross-sectional, descriptive study.

Setting: Twenty-five counties in North Carolina.

Participants: A total of 108 drugstores (36 CVS Health, 36 Rite Aid, and 36 Walgreens).

Main Outcome Measure(s): Fifty foods and beverages offered at drugstores, categorized as healthier and less healthy.

Analysis: Kruskal-Wallis tests were used to test differences in the availability of foods and beverages by chain and neighborhood income.

Results: Of the 50 foods/beverages observed, 11 were available at all drugstores. Three of the 36 (8%) healthier items were available at all stores (100% fruit juice, water, and high-fiber cereal) whereas 8 of the 14 less healthy items (57%) were available at all stores (chips, sports drinks, energy drinks, regular soda, diet soda, sugar-sweetened beverages, beer, and wine). Only 3% of drugstores offered fresh vegetables and 4% offered fresh fruits. Less than 20% offered frozen chicken or beef. For 36 healthier foods, 11 differed by chain (28%); for less healthy foods 2 of 14 differed by chain (7%). Foods and beverages offered did not vary by neighborhood income.

Conclusions And Implications: Although drugstores offer some healthier items, few offer fresh produce. As the drugstore industry changes, it is important for the nutrition community to study the impact of these changes on food purchasing behavior and ultimately health.
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http://dx.doi.org/10.1016/j.jneb.2017.05.360DOI Listing
September 2017

What Can Be Learned from Existing Investigations of Weight-Related Practices and Policies with the Potential to Impact Disparities in US Child-Care Settings? A Narrative Review and Call for Surveillance and Evaluation Efforts.

J Acad Nutr Diet 2017 Oct 1;117(10):1554-1577. Epub 2017 Aug 1.

Child-care settings and the combination of policies and regulations under which they operate may reduce or perpetuate disparities in weight-related health, depending on the environmental supports they provide for healthy eating and activity. The objectives of this review are to summarize research on state and local policies germane to weight-related health equity among young children in the United States and on how federal policies and regulations may provide supports for child-care providers serving families with the most limited resources. In addition, a third objective is to comprehensively review studies of whether there are differences in practices and policies within US child-care facilities according to the location or demographics of providers and children. The review found there is growing evidence addressing disparities in the social and physical child-care environments provided for young children, but scientific gaps are present in the current understanding of how resources should best be allocated and policies designed to promote health equity. Additional research is needed to address limitations of prior studies relating to the measurement of supports for weight-related health; complexities of categorizing socioeconomic position, ethnicity/race, and urban and rural areas; exclusion of legally nonlicensed care settings from most research; and the cross-sectional nature of most study designs. There is a particularly great need for the development of strong surveillance systems to allow for better monitoring and evaluation of state policies that may impact weight-related aspects of child-care environments, implementation at the program level, and needed implementation supports.
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http://dx.doi.org/10.1016/j.jand.2017.06.011DOI Listing
October 2017

Family Home Food Environment and Nutrition-Related Parent and Child Personal and Behavioral Outcomes of the Healthy Home Offerings via the Mealtime Environment (HOME) Plus Program: A Randomized Controlled Trial.

J Acad Nutr Diet 2018 02 1;118(2):240-251. Epub 2017 Jun 1.

Background: Research has demonstrated a significant positive association between frequent family meals and children's dietary intake; however, the promotion of healthful family meals has not been rigorously tested for key food environment and nutrition-related behavioral outcomes in a randomized trial.

Objective: To describe family home food environment and nutrition-related parent and child personal and behavioral outcomes of the Healthy Home Offerings via the Mealtime Environment Plus program, the first rigorously tested family meals intervention targeting childhood obesity prevention.

Design: Randomized controlled trial. Baseline, postintervention (12 months, 93% retention), and follow-up (21 months, 89% retention) data (surveys and dietary recalls) were collected.

Participants/setting: Children aged 8 to 12 years (N=160) and their parents were randomized to intervention (n=81) or control (n=79) groups.

Intervention: The intervention included five parent goal-setting calls and 10 monthly sessions delivered to families in community settings that focused on experiential nutrition activities and education, meal planning, cooking skill development, and reducing screen time.

Main Outcome Measures: Family home food environment outcomes and nutrition-related child and parent personal and behavioral outcomes.

Statistical Analyses Performed: Analyses used generalized linear mixed models. Primary comparisons were contrasts between intervention and control groups at postintervention and follow-up, with adjustments for child age and parent education.

Results: Compared with control parents, intervention parents showed greater improvement over time in scores of self-efficacy for identifying appropriate portion sizes, with significant differences in adjusted means at both post-intervention (P=0.002) and follow-up (P=0.01). Intervention children were less likely to consume at least one sugar-sweetened beverage daily at post-intervention than control children (P=0.04).

Conclusions: The Healthy Home Offerings via the Mealtime Environment Plus program involved the entire family and targeted personal, behavioral, and environment factors important for healthful changes in the home food environment and children's dietary intake. The intervention improved two nutrition-related behaviors and this may inform the design of future family meal interventions.
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http://dx.doi.org/10.1016/j.jand.2017.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5711643PMC
February 2018
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