Comparative risk assessment of school food environment policies and childhood diets, childhood obesity, and future cardiometabolic mortality in the United States

Background Promising school policies to improve children’s diets include providing fresh fruits and vegetables (F&V) and competitive food restrictions on sugar-sweetened beverages (SSBs), yet the impact of national implementation of these policies in US schools on cardiometabolic disease (CMD) risk factors and outcomes is not known. Our objective was to estimate the impact of national implementation of F&V provision and SSB restriction in US elementary, middle, and high schools on dietary intake and body mass index (BMI) in children and future CMD mortality. Methods We used comparative risk assessment (CRA) frameworks to model the impacts of these policies with input parameters from nationally representative surveys, randomized-controlled trials, and systematic reviews and meta-analyses. For children ages 5–18 years, this incorporated national data on current dietary intakes and BMI, impacts of these policies on diet, and estimated effects of dietary changes on BMI. In adults ages 25 and older, we further incorporated the sustainability of dietary changes to adulthood, effects of dietary changes on CMD, and national CMD death statistics, modeling effects if these policies had been in place when current US adults were children. Uncertainty across inputs was incorporated using 1000 Monte Carlo simulations. Results National F&V provision would increase daily fruit intake in children by as much as 25.0% (95% uncertainty interval (UI): 15.4, 37.7%), and would have small effects on vegetable intake. SSB restriction would decrease daily SSB intake by as much as 26.5% (95% UI: 6.4, 46.4%), and reduce BMI by as much as 0.7% (95% UI: 0.2, 1.2%). If F&V provision and SSB restriction were nationally implemented, an estimated 22,383 CMD deaths/year (95% UI: 18735, 25930) would be averted. Conclusion National school F&V provision and SSB restriction policies implemented in elementary, middle, and high schools could improve diet and BMI in children and reduce CMD mortality later in life

Assessing the Role of Health Behaviors, Socioeconomic Status, and Cumulative Stress for Racial/Ethnic Disparities in Obesity

Objective: This study aimed to examine the explanatory role of health behaviors, socioeconomic position (SEP), and psychosocial stressors on racial/ethnic obesity disparities in a multiethnic and multiracial sample of adults. Methods: Using data from the Chicago Community Adult Health Study (2001-2003), Oaxaca-Blinder decomposition analysis was conducted to quantify the extent to which health behaviors (fruit and vegetable consumption and physical activity), SEP, and cumulative stressors (e.g., perceived discrimination, financial strain) each explained differences in obesity prevalence in Black, US-born Hispanic, and non-US-born Hispanic compared with non-Hispanic White participants. Results: SEP and health behaviors did not explain obesity differences between racial/ethnic minorities and White individuals. Having high levels of stress in four or more domains explained 4.46% of the differences between Black and White individuals, whereas having high levels of stress in three domains significantly explained 14.13% of differences between US-born Hispanic and White. Together, the predictors explained less than 20% of differences between any racial/ethnic minority group and White individuals. Conclusions: Exposure to stressors may play a role in obesity disparities, particularly among Black and US-born Hispanic individuals. Other obesity-related risk factors need to be examined to understand the underlying mechanisms explaining obesity disparities.The development of the manuscript was partially supported by Cancer Disparities Research Network/Geographic Management Program (GMaP) Region 4 funded by 3 P30 CA006927-52S2 and by Clinical & Translational Science Institute Mentored Career Development Award (KL2 TR002545). The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the NIH

Cross-Sectional Associations between Empirically-Derived Dietary Patterns and Indicators of Disease Risk among University Students

The transition from adolescence to adulthood is a unique period during which lifelong dietary habits are shaped. Dietary patterns (DPs) among young adults attending college have not been adequately described, and associations between DPs and indicators of disease risk are not well understood in this age group. Dietary data were collected from undergraduates participating in the Tufts Longitudinal Health Study (TLHS; 1998–2007) by Food Frequency Questionnaire (FFQ; n = 1323). DPs were derived using principal components analysis with varimax rotation. Scree plots; eigenvalues; factor loadings; and previous studies were used to determine and label the DPs retained. Cross-sectional relationships between DP scores and anthropometric measures (percent body fat (PBF) and (BMI) and lipid biomarkers (total; HDL and LDL cholesterol; and triglycerides) were assessed with multivariable regression models; adjusted for demographics; physical activity; smoking; intention to gain/lose weight; and total energy intake. Effect modification by sex was tested. Three DPs were identified: Prudent; Western; and Alcohol. Greater adherence to the Prudent DP was associated with favorable anthropometric outcomes. The Alcohol DP was associated with a favorable lipid profile. Associations between the Western DP and blood lipids differed by sex; with unfavorable impact observed only among males. Our findings add to the literature linking DPs in young adults with measurable adiposity and cardiometabolic outcomes; suggesting that improving nutrition among college students could reduce chronic disease risk

Behavioral Correlates of Empirically-Derived Dietary Patterns among University Students

Given the importance of young adulthood in establishing lifelong dietary habits, it is imperative to better understand potential underlying drivers of dietary behavior in the university-age population. Dietary patterns have been associated with disease risk, but behavioral predictors of dietary pattern adherence are poorly understood, especially among emerging adults. This study aims to evaluate health-related behaviors associated with dietary pattern scores among freshmen participating in the Tufts Longitudinal Health Study (TLHS; n = 630). We previously derived dietary patterns using principal components analysis and orthogonal rotation from dietary intake data. Health-related behavior data were collected via survey. All data were collected during the Spring semesters of 1998–2007. Unadjusted linear models were used to determine associations between dietary pattern scores and health-related behaviors. Significant correlates were retained in multivariable regression models, which were adjusted for demographic characteristics. We found that never eating meals away from home was associated with higher adherence to the Prudent and lower adherence to the Western and Alcohol patterns. Intention to lose weight was negatively associated with the Western pattern, while intention to gain weight was positively associated with all dietary patterns. These findings suggest that intervention efforts aimed at improving eating out behaviors and engaging in healthy weight management strategies may promote healthier dietary patterns among university students

Select model inputs and estimated changes in child diet and child BMI associated with F&V provision and SSB restriction in US schools¹.

<p>Select model inputs and estimated changes in child diet and child BMI associated with F&V provision and SSB restriction in US schools<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0200378#t001fn002" target="_blank">¹</a>.</p

Estimated cardiometabolic deaths averted associated with F&V provision and SSB restriction in US schools¹.

<p>Estimated cardiometabolic deaths averted associated with F&V provision and SSB restriction in US schools<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0200378#t003fn002" target="_blank">¹</a>.</p

Current and estimated changes in dietary intakes associated with national school policies on F&V provision and SSB restriction among US children by age.

<p>Current intakes are based on NHANES 2009–10 and 2011–12 (N = 4,165 children age 5–18 years), where bars represent the mean and error bars, the 95% confidence intervals. Estimates for dietary intake with policies are based on a comparative risk assessment framework incorporating policy effects from intervention studies, where bars represent the median values from 1,000 Monte Carlo simulations and error bars, the 95% uncertainty intervals.</p

Select model inputs for modeling CMD outcomes in adults.

<p>Select model inputs for modeling CMD outcomes in adults.</p

Estimated annual cardiometabolic deaths averted from implementation of national school policies on F&V provision and SSB restriction, separately and jointly, in US elementary, middle, and high schools.

<p>Bars represent the median values from 1,000 Monte Carlo simulations in a comparative risk assessment framework; and error bars, the 95% uncertainty intervals. Health effects are estimated for the current US adult population if exposed to these school environment policies during their childhood in elementary, middle, and high school. Panel (<b>A)</b> assumes that 25% of the dietary changes achieved in childhood are sustained into adulthood; panel (<b>B)</b>, that 35% of dietary changes are sustained; and panel (<b>C)</b> that 50% of dietary changes are sustained.</p