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1.  The nutritional impact of breakfast consumption on the diets of inner-city African-American elementary school children. 
To determine the contribution of breakfast-eating behavior to dietary adequacy among low-income African-American children, 1151 children attending grades two through five at four elementary schools in East Orange, New Jersey were studied. Results of a 4-day eating behavior survey and a 24-hour dietary recall reveal that on any given day, 12% to 26% of children attend school without having eaten anything. Thirty-six percent of the children were obese, which did not vary with breakfast-eating behavior. A significantly greater proportion of the children who skipped breakfast compared to those who ate breakfast failed to achieve dietary adequacy for nearly every nutrient studied. More than one third of breakfast skippers consumed < 50% of the recommended dietary allowance for vitamins A, E, B6, and folacin, and nearly one fourth consumed < 50% of the recommended dietary allowance for calories, vitamin C, calcium, and iron. Not eating breakfast results in substantial deficits in dietary intake of a variety of essential nutrients among low-income African-American school children. Efforts to improve the nutritional status of children should include nutrition education to promote breakfast.
PMCID: PMC2607827  PMID: 7731069
2.  Children's body mass index, participation in school meals, and observed energy intake at school meals 
Data from a dietary-reporting validation study with fourth-grade children were analyzed to investigate a possible relationship of body mass index (BMI) with daily participation in school meals and observed energy intake at school meals, and whether the relationships differed by breakfast location (classroom; cafeteria).
Data were collected in 17, 17, and 8 schools during three school years. For the three years, six, six, and seven of the schools had breakfast in the classroom; all other schools had breakfast in the cafeteria. Information about 180 days of school breakfast and school lunch participation during fourth grade for each of 1,571 children (90% Black; 53% girls) was available in electronic administrative records from the school district. Children were weighed and measured, and BMI was calculated. Each of a subset of 465 children (95% Black; 49% girls) was observed eating school breakfast and school lunch on the same day. Mixed-effects regression was conducted with BMI as the dependent variable and school as the random effect; independent variables were breakfast participation, lunch participation, combined participation (breakfast and lunch on the same day), average observed energy intake for breakfast, average observed energy intake for lunch, sex, age, breakfast location, and school year. Analyses were repeated for BMI category (underweight/healthy weight; overweight; obese; severely obese) using pooled ordered logistic regression models that excluded sex and age.
Breakfast participation, lunch participation, and combined participation were not significantly associated with BMI or BMI category irrespective of whether the model included observed energy intake at school meals. Observed energy intake at school meals was significantly and positively associated with BMI and BMI category. For the total sample and subset, breakfast location was significantly associated with BMI; average BMI was larger for children with breakfast in the classroom than in the cafeteria. Significantly more kilocalories were observed eaten at breakfast in the classroom than in the cafeteria.
For fourth-grade children, results provide evidence of a positive relationship between BMI and observed energy intake at school meals, and between BMI and school breakfast in the classroom; however, BMI and participation in school meals were not significantly associated.
PMCID: PMC2859739  PMID: 20334667
3.  School meals and the nutrition of schoolchildren. 
The contribution of school meals to the nutrition of 778 primary and secondary schoolchildren attending schools in Kent was assessed using information collected during a survey made in 1968-70 which included a weighed diet record, a socioeconomic questionnaire, and a medical examination. Younger children, those from larger families, those without fathers, and those whose mothers worked were more likely to take school meals. Significantly more children from lower social classes and without fathers received them free. School meals made an important contribution to the nutrition of schoolchildren. Children who took them had higher weekday lunchtime nutrient intake during term-time. Children in lower social classes, larger families, and without fathers who took school meals obtained a higher proportion of their weekday intake of nutrients from lunchtime than other children. This applied in particular to nutrients important for growth. School meals consumed by children in the study broadly met the standard set by the Department of Education and Science. The mean energy and protein content of school meals consumed in the study was slightly lower and the mean fat content higher than the standard set for the meal. The mean sugar content was about one-third higher than the suggested amount of sugar to be included in a school meal. There was no evidence that children who took school meals were taller, heavier, had greater skinfold thickness, or were more likely to be assessed as obese than other children.
PMCID: PMC478912  PMID: 1191886
4.  How accurate are parental responses concerning their fourth-grade children's school-meal participation, and what is the relationship between children's body mass index and school-meal participation based on parental responses? 
This article investigated (1) parental response accuracy of fourth-grade children's school-meal participation and whether accuracy differed by children's body mass index (BMI), sex, and race, and (2) the relationship between BMI and school-meal participation (based on parental responses).
Data were from four cross-sectional studies conducted from fall 1999 to spring 2003 with fourth-grade children from 13 schools total. Consent forms asked parents to report children's usual school-meal participation. As two studies' consent forms did not ask about lunch participation, complete data were available for breakfast on 1,496 children (51% Black; 49% boys) and for lunch on 785 children (46% Black; 48% boys). Researchers compiled nametag records (during meal observations) of meal participation on randomly selected days during children's fourth-grade school year for breakfast (average nametag days across studies: 7-35) and for lunch (average nametag days across studies: 4-10) and categorized participation as "usually" (≥ 50% of days) or "not usually" (< 50% of days). Weight and height were measured. Concerning parental response accuracy, marginal regression was used with agreement between parental responses and nametag records as the dependent variable; independent variables were BMI, age, sex, race, and study. Concerning a relationship between BMI and school-meal participation, marginal regression was used with BMI as the dependent variable; independent variables were breakfast participation, lunch participation, age, sex, race, and study.
Concerning breakfast participation and lunch participation, 74% and 92% of parents provided accurate responses, respectively. Parental response accuracy was better for older children for breakfast and lunch participation, and for Black than White children for lunch participation. Usual school-meal participation was significantly related to children's BMI but in opposite directions -- positively for breakfast and inversely for lunch.
Parental response accuracy of children's school-meal participation was moderately high; however, disparate effects for children's age and race warrant caution when relying on parental responses. The BMI results, which showed a relationship between school-meal participation (based on parental responses) and childhood obesity, conflict with results from a recent article that used data from the same four studies and found no significant relationship when participation was based on nametag records compiled for meal observations.
PMCID: PMC3342903  PMID: 22429914
Children; School; Obesity; School-meal participation; Parental response accuracy
5.  Accuracy of children's school-breakfast reports and school-lunch reports (in 24-hour dietary recalls) differs by retention interval 
European journal of clinical nutrition  2009;63(12):1394-1403.
Validation-study data were analyzed to investigate the effect of retention interval (time between the to-be-reported meal and interview) on accuracy of children's school-breakfast reports and school-lunch reports in 24-hour recalls, and to compare accuracy of children's school-breakfast reports for two breakfast locations (classroom; cafeteria).
Each of 374 fourth-grade children was interviewed to obtain a 24-hour recall using one of six conditions from crossing two target periods (prior 24 hours; previous day) with three interview times (morning; afternoon; evening). Each condition had 62 or 64 children (half boys). A recall's target period included one school breakfast and one school lunch, for which the child had been observed. Food-item variables (observed number; reported number; omission rate; intrusion rate) and energy variables (observed; reported; report rate; correspondence rate; inflation ratio) were calculated for each child for school breakfast and school lunch separately.
Accuracy for school-breakfast reports and school-lunch reports was inversely related to retention interval. Specifically, as indicated by smaller omission rates, smaller intrusion rates, larger correspondence rates, and smaller inflation ratios, accuracy for school-breakfast reports was best for prior-24-hour recalls in the morning, and accuracy for school-lunch reports was best for prior-24-hour recalls in the afternoon. For neither school meal was a significant sex effect found for any variable. For school-breakfast reports, there was no significant school-breakfast location effect for any variable.
By shortening the retention interval, accuracy can be improved for school-breakfast reports and school-lunch reports in children's 24-hour recalls.
PMCID: PMC2788046  PMID: 19756033
validation study; school meals; retention interval
6.  Non-significant relationship between participation in school-provided meals and body mass index during the fourth-grade school year 
Journal of the Academy of Nutrition and Dietetics  2011;112(1):10.1016/j.jada.2011.08.037.
Data from four cross-sectional studies involving fourth-grade children were analyzed to investigate the relationship between participation in school-provided meals and body mass index (BMI), and the effect observed energy intake has on that relationship. Participation and BMI data were available on 1,535 children (51% Black; 51% girls) for four school years (Fall 1999 to Spring 2003; one study per school year) at 13 schools total. Direct meal observations were available for a subset of 342 children (54% Black; 50% girls) for one to three breakfasts and one to three lunches per child for a total of 1,268 school meals (50% breakfast). Participation in breakfast, lunch, and combined (both meals on the same day) was determined from nametag records compiled for meal observations for each study. Weight and height were measured. A marginal regression model was fit with BMI as the dependent variable; independent variables were breakfast participation, lunch participation, combined participation, sex, age, race, and study. For the subset of children, observed energy intake at breakfast, lunch, and combined was included in additional analyses. Participation in breakfast, lunch, and combined was not significantly associated with BMI regardless of whether analyses included observed energy intake (P values > 0.181). The relationship between observed energy intake at breakfast and lunch, separately and combined, with BMI was positive (P values < 0.01). In conclusion, these results do not support a relationship between school-meal participation and BMI but do support a relationship between observed energy intake at school meals and BMI during fourth grade.
PMCID: PMC3880248  PMID: 22709640
Children; school; obesity; school meal programs; school-meal observations
7.  Examining variations in fourth-grade children’s participation in school-breakfast and school-lunch programs by student and program demographics 
Analyses were conducted to examine variations in fourth-grade children’s participation in school-breakfast and school-lunch programs by weekday, month, socioeconomic status, absenteeism, sex, and school-breakfast location.
Fourth-grade children were participants in a dietary-reporting validation study during the 2005–2006 or 2006–2007 school years in 17 or 8 schools, respectively, in one South Carolina school district. For the two respective school years, school-breakfast location was the classroom for six and seven schools, and for the remaining schools, the cafeteria. District administrative records provided information about 180 possible days of participation in the school-breakfast and school-lunch programs for each of 1,060 children (91% Black, 52% girls). The state’s Office of Research and Statistics linked data on school-meal participation with information about individual children’s socioeconomic status (eligibility for free or reduced-price school meals) and annual absenteeism from school.
For school-provided breakfast, logistic regression showed participation rate differences by weekday (smallest for Monday [56.1%], largest for Wednesday [57.8%], p<0.0001), month (smallest for April [53.5%], largest for September [60.8%], p<0.0001), socioeconomic status (smallest for full-price status [27.5%], largest for free-meal status [63.4%], p<0.0001), school-breakfast location (smaller for breakfast located in the cafeteria [38%] than classroom [71%], p<0.0001), and absenteeism (p<0.0001). For school-provided lunch, logistic regression showed participation rate differences by weekday (smallest for Friday [81.9%], largest for Thursday [83.3%], p<0.0001), month (smallest for May [78.7%], largest for August [86.0%], p<0.0001), socioeconomic status (smallest for full-price status [72.1%], largest for free-meal status [84.9%], p<0.0001), and absenteeism (p<0.0001). There were no differences in participation rate by sex.
Applications for Child Nutrition Professionals
Administrative participation records are used for forecasting purchasing and production. Using such records in research studies may provide insight into aspects of children’s participation in school-provided meals. Districts and managers are encouraged to share administrative records of children’s participation in school-provided meals with researchers.
PMCID: PMC3972127
8.  Children’s recalls from five dietary-reporting validation studies: Intrusions in correctly reported and misreported options in school breakfast reports 
Appetite  2008;51(3):489-500.
For school breakfast each day, many elementary schools offer a choice between a cold option that includes ready-to-eat (RTE) cereal and a hot option that includes a non-RTE-cereal entrée such as waffles. For breakfast reports, intrusions (reports of uneaten items) in correctly reported and misreported breakfast options were examined using data from five dietary-reporting validation studies. In each study, fourth-grade children were observed eating school breakfast and school lunch and then interviewed to obtain a dietary recall. A breakfast option was correctly reported in 240 breakfast reports for 203 intrusions total, and misreported in 97 breakfast reports for 189 intrusions total. Asymmetry was evident in misreported options; specifically, children observed eating a cold option almost never misreported a hot option, but children observed eating a hot option often misreported a cold option. Proportionately more breakfast reports were intrusion-free when a breakfast option was correctly reported than misreported. Linking of intrusions (i.e., multiple intrusions from the same option in a breakfast report) was especially evident with misreported breakfast options. Methodological aspects of dietary recalls such as target period (prior 24 hours; previous day), interview time (morning; afternoon; evening), and interview format (meal; open) had implications for intrusions and misreported breakfast options.
PMCID: PMC2587267  PMID: 18501992
Children; Dietary recalls; Intrusions; School breakfast; Ready-to-eat cereal; Validation; Meal observations; Accuracy
9.  Nutrition survey of schoolchildren in greater Winnipeg. II. Dietary intake and biochemical assessment. 
The total dietary intake of energy and of individual nutrients of 99 grades 3 and 6 children from 10 greater Winnipeg shcools were generally comparable to those reported by Nutrition Canada for the Manitoba and national samples, although the percentile distributions of total caloric intake and dietary intake of vitamin A for the Winnipeg children tended to be lower. The median daily intake of protein was 212% of the Canadian Dietary Standard and most came from animal sources. Dietary fat was largely from animal sources as well. Hemoglobin concentrations were marginally low in four children, and urinary riboflavin:creatinine ratios were low in six children. There was no biochemical evidence of thiamin deficiency. The results suggest a need for change in dietary patterns and for education in nutrition, including relative nutrient/cost benefits. A well planned school snack program with an education component is a medium by which change could be introduced. This should preferable be part of a total school health program.
PMCID: PMC1879332  PMID: 837315
10.  Examination of the Food and Nutrient Content of School Lunch Menus of Two School Districts in Mississippi 
This study examined the diet quality of the school meals in two Mississippi school districts and compared them to the national guidelines. We examined the lunch menus of the two school districts that participated in the National School Lunch Program and School Breakfast Program focusing on food quality and assessing both healthy and unhealthy foods and eating behaviors. This analysis was completed through a computerized review used to accurately determine the nutrient content. Both the standard and the alternative meals provided by the cafeterias in the two school districts exceeded the minimum requirement for calories for all grade levels. The meals from the urban schools cafeteria provide more calories than meals from the cafeteria in the rural school district. Although schools believe that they are making positive changes to children’s diets, the programs are falling short of the nutrient recommendations. Poor nutrition and improper dietary practices are now regarded as important risk factors in the emerging problems of obesity, diabetes mellitus, hypertension and other chronic diseases, with excessive energy intake listed as a possible reason. Dieticians, school professionals and other health care practitioners need to accurately assess energy intake and adequately promote a dietary responsible lifestyle among children.
PMCID: PMC3807522  PMID: 16968975
Diet; food; nutrient intake; students; Mississippi
11.  Intrusions in Children’s Dietary Recalls: The Roles of Body Mass Index, Sex, Race, Interview Protocol, and Social Desirability 
Obesity (Silver Spring, Md.)  2008;16(9):2169-2174.
Dietary-reporting validation study data and school foodservice production records were used to examine intrusions (reports of uneaten items) in school meals in 24-hour recalls. Fourth-grade children (20 low-body mass index [BMI; ≥5th and <50th percentiles]; 20 high-BMI [≥85th percentile];50% boys; 75% Black) were each observed eating two school meals (breakfast, lunch) and interviewed about the prior 24 hours that evening (24E) or the previous day the next morning (PDM). Social desirability was assessed. Intrusions were classified as stretches (on meal tray), internal confabulations (in school foodservice environment but not on meal tray), and external confabulations (not in school foodservice environment). For breakfast, reported items were less likely to be intrusions for Black than White children, and for low-BMI boys than the other BMI-x-sex groups, and to be external confabulations for high-BMI girls than high-BMI boys. For lunch, reported items and intrusions were more likely to be stretches for 24E than PDM interviews. As social desirability increased, fewer items were reported for breakfast, and reported items and intrusions were more likely to be internal confabulations for lunch. For breakfast, compared to low-BMI girls, as social desirability increased, intruded amounts were larger for high-BMI boys and smaller for high-BMI girls. For lunch, intruded amounts were smaller for high-BMI girls than the other BMI-x-sex groups. Amounts reported were smaller for stretches than internal confabulations and external confabulations for breakfast, and external confabulations for lunch. To better understand intrusions, dietary-reporting validation studies are needed with larger samples by BMI-group, sex, and race.
PMCID: PMC2625306  PMID: 18535542
Childhood Obesity; Dietary Assessment; Youth
12.  Regular Breakfast and Blood Lead Levels among Preschool Children 
Environmental Health  2011;10:28.
Previous studies have shown that fasting increases lead absorption in the gastrointestinal tract of adults. Regular meals/snacks are recommended as a nutritional intervention for lead poisoning in children, but epidemiological evidence of links between fasting and blood lead levels (B-Pb) is rare. The purpose of this study was to examine the association between eating a regular breakfast and B-Pb among children using data from the China Jintan Child Cohort Study.
Parents completed a questionnaire regarding children's breakfast-eating habit (regular or not), demographics, and food frequency. Whole blood samples were collected from 1,344 children for the measurements of B-Pb and micronutrients (iron, copper, zinc, calcium, and magnesium). B-Pb and other measures were compared between children with and without regular breakfast. Linear regression modeling was used to evaluate the association between regular breakfast and log-transformed B-Pb. The association between regular breakfast and risk of lead poisoning (B-Pb≥10 μg/dL) was examined using logistic regression modeling.
Median B-Pb among children who ate breakfast regularly and those who did not eat breakfast regularly were 6.1 μg/dL and 7.2 μg/dL, respectively. Eating breakfast was also associated with greater zinc blood levels. Adjusting for other relevant factors, the linear regression model revealed that eating breakfast regularly was significantly associated with lower B-Pb (beta = -0.10 units of log-transformed B-Pb compared with children who did not eat breakfast regularly, p = 0.02).
The present study provides some initial human data supporting the notion that eating a regular breakfast might reduce B-Pb in young children. To our knowledge, this is the first human study exploring the association between breakfast frequency and B-Pb in young children.
PMCID: PMC3079601  PMID: 21457535
lead exposure lead poisoning nutrition diet nutrients breakfast
13.  Diet, Breakfast, and Academic Performance in Children 
Annals of nutrition & metabolism  2002;46(0 1):24-30.
To determine whether nutrient intake and academic and psychosocial functioning improve after the start of a universal-free school breakfast program (USBP).
Information was gathered from 97 inner city students prior to the start of a USBP and again after the program had been in place for 6 months. Students who had total energy intakes of <50% of the recommended daily allowance (RDA) and/or 2 or more micronutrients of <50% of RDA were considered to be at nutritional risk.
Prior to the USBP, 33% of all study children were classified as being at nutritional risk. Children who were at nutritional risk had significantly poorer attendance, punctuality, and grades at school, more behavior problems, and were less likely to eat breakfast at school than children who were not at nutritional risk. Six months after the start of the free school breakfast programs, students who decreased their nutritional risk showed significantly greater: improvements in attendance and school breakfast participation, decreases in hunger, and improvements in math grades and behavior than children who did not decrease their nutritional risk.
Participation in a school breakfast program enhanced daily nutrient intake and improvements in nutrient intake were associated with significant improvements in student academic performance and psychosocial functioning and decreases in hunger.
PMCID: PMC3275817  PMID: 12428078
School breakfast; Low-income children; Psychosocial functioning; Nutrition; Dietary intake
14.  Which Fourth-Grade Children Participate in School Breakfast and Do Their Parents Know It? 
Objective: To explore fourth-graders' school breakfast participation by gender and race (black, white) and examine the extent to which parents' responses to “Does this child usually eat school breakfast?” reflected their children's participation.
Design: Parents answered “yes” or “no” to the questions printed on consent forms. Observers documented which children participated in school breakfast on 26 to 51 randomly selected days per school during 24 weeks in the 1999-2000 school year.
Subjects: 357 children recruited from all 22 fourth-grade classes from 6 schools in 1 public school district.
Variables Measured: Participation rate, participation rate grouping [usually participated (≥ 50% of days observed), did not usually participate (< 50% of days observed)].
Statistical Analyses Performed: Komolgorov-Smirnov tests, McNemar's test.
Results: Median participation rate was 37.5% overall. Distribution of participation rates differed significantly by race (K-S test, P < .001) but not gender. There was a significant difference in the percentage of parents who said “yes” or “no” compared to children's usual participation grouping (McNemar test, P < .001). Of parents who said “yes,” 66% of children usually participated; of parents who said “no,” 92% of children did not usually participate.
Implications: Children, not parents, must be the source for learning about what children eat at school.
PMCID: PMC1463216  PMID: 12047840
children; parents; School Breakfast Program participation
15.  Fourth-Grade Children are Less Accurate in Reporting School Breakfast than School Lunch during 24-Hour Dietary Recalls 
To compare reporting accuracy for breakfast and lunch in two studies.
Children were observed eating school meals and interviewed the following morning about the previous day. Study 1 – 104 children were each interviewed one to three times with ≥25 days separating any two interviews. Study 2 – 121 children were each interviewed once in forward (morning-to-evening) and once in reverse (evening-to-morning) order, separated by ≥29 days.
12 schools.
Fourth-grade children.
Main Outcome Measures
For each meal: food-item variables – observed number, reported number, omission rate, intrusion rate, total inaccuracy; kilocalorie variables – observed, reported, correspondence rate, inflation ratio.
General linear mixed-models.
For each study, observed and reported numbers of items and kilocalories, and correspondence rate (reporting accuracy), were greater for lunch than breakfast; omission rate, intrusion rate, and inflation ratio (measures of reporting error) were greater for breakfast than lunch. Study 1 – for each meal over interviews, total inaccuracy decreased and correspondence rate increased. Study 2 – for each meal for boys for reverse and girls for forward order, omission rate was lower and correspondence rate was higher.
Conclusions and Implications
Breakfast was reported less accurately than lunch. Despite improvement over interviews (Study 1) and differences for order × sex (Study 2), reporting accuracy was low for breakfast and lunch.
PMCID: PMC2430664  PMID: 17493562
children; dietary recalls; reporting accuracy; school breakfast; school lunch; observation; validation
16.  Twenty-Four Hour Dietary Recalls by Fourth-Grade Children Were Not Influenced by Observations of School Meals 
Journal of clinical epidemiology  2009;62(8):878-885.
To investigate whether school-meal observations influenced children’s 24-hour dietary recalls.
Study Design and Setting
Over three school years, 555 randomly selected fourth-grade children were interviewed to obtain a 24-hour dietary recall; before being interviewed, 374 children were observed eating two school meals (breakfast, lunch) and 181 children were not observed. Within observation-status groups (observed; unobserved), children were randomized within sex to one of six combinations from two target periods (prior-24-hours; previous-day) crossed with three interview times (morning; afternoon; evening).
For each of five variables (interview length, meals/snacks, meal components, items, kilocalories), naïve and adjusted equivalence tests rejected that observation-status groups were different, indicating that school-meal observations did not influence children’s 24-hour dietary recalls. There was a target-period effect on length (P<0.0001) (longer for prior-24-hour recalls), a school year effect on length (P=0.0002) (longer for third year), and a target-period-by-interview-time interaction on items (P=0.0110) and kilocalories (P=0.0047) (both smaller for previous-day recalls in the afternoon than prior-24-hour recalls in the afternoon and previous-day recalls in the evening), indicating that variables were sufficiently sensitive and psychometrically reliable.
Conclusions about 24-hour dietary recalls by fourth-grade children observed eating school meals in validation studies are generalizable to 24-hour dietary recalls by comparable but unobserved children in non-validation studies.
PMCID: PMC2706913  PMID: 19230605
24-hour dietary recalls; children; validation; observation; school breakfast; school lunch
17.  Effectiveness of a diet and physical activity promotion strategy on the prevention of obesity in Mexican school children 
BMC Public Health  2012;12:152.
Overweight and obesity in children in Mexico was among the countries with the highest prevalence's in the world. Mexico currently has few innovative and comprehensive experiences to help curb the growth of this serious public health problem. Therefore, the aim of this study is to assess the effectiveness of a nutrition and physical activity strategy, called "Nutrition on the Go" ("nutrición en movimiento") in maintaining the BMI values of school children in the State of Mexico.
A two-stage cluster trial was carried out. Sixty schools were selected in the State of Mexico, of which 30 were randomly assigned to the intervention group (IG) and 30 to the control group (CG). A total of 1020 fifth grade school children participated. The intervention strategy aimed to decrease the energy content of school breakfasts and include fruits and vegetables, as well as increase physical activity and the consumption of water during the time spent at school. The strategy was implemented over a 6-month period.
The estimated probability (EP) of obesity between baseline and the final stage for the IG decreased 1% (Initial EP = 11.8%, 95%CI 9.0, 15.2, final EP = 10.8, 95%CI 8.4, 13.) For the CG, the probability increased 0.9% (baseline EP = 10.6%; 95%CI 8.1, 13.7; final EP = 11.5, 95%CI 9.0, 14.6). The interaction between the intervention and the stage is the average odd time corrected treatment effect, which is statistically significant (p = 0.01) (OR = 0.68, 95%CI 0.52, 091).
This represents the interaction between intervention and stage, which is highly significant (p = 0.01) (OR = 0.68; 95%CI 0.52, 091). In addition, girls had a protective effect on obesity (OR = 0.56; 95%CI 0.39, 0.80).
The intervention strategy is effective in maintaining the BMI of school children.
PMCID: PMC3314581  PMID: 22381137
Obesity; Scholars; Effectiveness; Mexico; Eating; Physical activity
18.  Secondary analyses of data from four studies with fourth-grade children show that sex, race, amounts eaten of standardized portions, and energy content given in trades explain the positive relationship between BMI and energy intake at school-provided meals 
Results from a 2012 article showed a positive relationship between children’s body mass index (BMI) and energy intake at school-provided meals. To help explain that positive relationship, secondary analyses investigated 1) whether the relationship differed by sex and race, and 2) the relationship between BMI and six aspects of school-provided meals—amounts eaten of standardized portions, energy content given in trades, energy intake received in trades, energy intake from flavored milk, energy intake from a la carte ice cream, and breakfast type. Data were from four studies conducted one per school year (1999–2000 to 2002–2003). Fourth-grade children (n=328; 50% female; 54% Black) from 13 schools total were observed eating school-provided breakfast and lunch on one to three days per child for 1,178 total meals (50% breakfast). Children were weighed and measured. Marginal regression models were fit using BMI as the dependent variable. For Purpose One, independent variables were energy intake at school-provided meals, sex, race, age, and study; additional models included interaction terms involving energy intake and sex/race. For Purpose Two, independent variables were the six aspects of school-provided meals, sex, race, age, and study. The relationship between BMI and energy intake at school-provided meals differed by sex (p<0.0001; stronger for females) and race (p=0.0063; stronger for Black children). BMI was positively related to amounts eaten of standardized portions (p<0.0001) and negatively related to energy content given in trades (p=0.0052). Explaining the positive relationship between BMI and energy intake at school-provided meals may contribute to school-based obesity prevention efforts.
PMCID: PMC3479430  PMID: 23084638
Body Mass Index; Children; Energy Intake; Nutrition Surveys; Primary Schools
19.  Differences in Fourth-Graders' Participation Rates Across Four School-Based Nutrition Studies 
Federal policy has encouraged researchers to include children in research studies; thus, it is important to report experiences recruiting children to participate in studies. This article compares fourth-graders' participation rates across four school-based nutrition studies conducted in one school district in a southeastern state. For each study, children were observed eating school meals (breakfast and lunch); interviewed regarding dietary intake; and weighed and measured. For Study 1, children from 11 schools received $10 per interview for up to two interviews conducted in the morning at school. For Study 2, children from 10 schools received $25 if interviewed once in the evening, either by telephone or in a van parked outside the child's home. For Study 3, children from three schools received $10 per interview for up to three interviews held in the evening by telephone. For Study 4, children from six schools received $15 per interview for up to two interviews conducted either in the morning or afternoon at school, or in the evening by telephone. Recruitment procedures were similar for all studies.
Participation rates were 73% (n=635) for Study 1, 57% (n=432) for Study 2, 66% (n=158) for Study 3, and 71% (n=296) for Study 4. Logistic regression was used to determine whether study (1, 2, 3, 4), race (black, white), or gender (male, female) were significant predictors of participation (agreed, denied). The results indicated that study (p<0.0001), race (p=0.0198), and gender (p=0.0188) were significant predictors, however, no two-factor interactions among these effects were significant. Post hoc pairwise comparisons with Bonferroni adjustment indicated that agreement to participate for Study 2 was lower (p<0.0001) than that for Studies 1, 3, and 4, which did not differ. Agreement to participate across all four studies was higher for black (69%) than white (63%; p=0.0054) children and for females (69%) than males (64%; p=0.0209). Schools provide a natural environment for nutrition research because school foodservice programs feed millions of children one or two meals (breakfast and/or lunch) each school day. Observations of children eating school meals provide a convenient and relatively unobtrusive means of validating children's dietary recalls. Thus, at some point, most child nutrition professionals are likely to be involved in research either directly (i.e. by conducting studies themselves) or indirectly (i.e. by allowing others access to their school cafeterias to collect data).
This paper references the following data: Table 1. Similarities and Differences in the Designs for Each of the Four Studies. Table 2. Number and Percent of Fourth-Grade Children Who Agreed or Denied to Participate by Race and Gender Across all Four Studies Combined. Table 3. Number and Percent of Fourth-Grade Children Who Agreed or Denied to Participate by Gender and Race for Each of the Four Studies Separately.
PMCID: PMC1945013  PMID: 17694161
20.  Effects of a free school breakfast programme on children's attendance, academic achievement and short-term hunger: results from a stepped-wedge, cluster randomised controlled trial 
Free school breakfast programmes (SBPs) exist in a number of high-income countries, but their effects on educational outcomes have rarely been evaluated in randomised controlled trials.
A 1-year stepped-wedge, cluster randomised controlled trial was undertaken in 14 New Zealand schools in low socioeconomic resource areas. Participants were 424 children, mean age 9±2 years, 53% female. The intervention was a free daily SBP. The primary outcome was children's school attendance. Secondary outcomes were academic achievement, self-reported grades, sense of belonging at school, behaviour, short-term hunger, breakfast habits and food security.
There was no statistically significant effect of the breakfast programme on children's school attendance. The odds of children achieving an attendance rate <95% was 0.76 (95% CI 0.56 to 1.02) during the intervention phase and 0.93 (95% CI 0.67 to 1.31) during the control phase, giving an OR of 0.81 (95% CI 0.59 to 1.11), p=0.19. There was a significant decrease in children's self-reported short-term hunger during the intervention phase compared with the control phase, demonstrated by an increase of 8.6 units on the Freddy satiety scale (95% CI 3.4 to 13.7, p=0.001). There were no effects of the intervention on any other outcome.
A free SBP did not have a significant effect on children's school attendance or academic achievement but had significant positive effects on children's short-term satiety ratings. More frequent programme attendance may be required to influence school attendance and academic achievement.
Trial registration
Australian New Zealand Clinical Trials Registry (ANZCTR)—ACTRN12609000854235.
PMCID: PMC3582067  PMID: 23043203
Breakfast; intervention; randomised controlled trial; schools; education; child health; diet; public health; randomised trials; exercise
21.  Lifestyles and psychosomatic symptoms among elementary school students and junior high school students 
To examine the relationship between lifestyles and psychosomatic symptoms in children, we conducted a self-administered questionnaire survey of elementary school students and junior high school students in Japan.
We designed an original questionnaire to investigate the lifestyles and psychosomatic symptoms of children. In 1997, responses to the questionnaires were elicited from public elementary school fourth grade students (then aged 9–10) and public junior high school seventh grade students (then aged 12–13). The survey was repeated annually for three years as the students advanced through school.
For both boys and girls, each cross-sectional analysis revealed a strong relationship between lifestyle behaviors and psychosomatic symptoms. Psychosomatic, symptoms scores varied according to daily hours of sleep, eating of breakfast, having strong likes and dislikes of food, bowel habits, and daily hours of television watching. Both boys and girls with “good” lifestyle, behaviors evaluated by the HPI (Health Practice Index) showed lower scores for psychosomatic symptoms.
These findings show that the lifestyle behaviors of children are significantly associated with psychosomatic symptoms and suggest that poor lifestyle behaviors are likely to increase physical and psychological health risks.
PMCID: PMC2723516  PMID: 21432317
lifestyles; psychosomatic symptoms; elementary school; junior high school; health practice index
22.  Data from a Validation Study of Reporting Accuracy over Multiple Recalls, and School Foodservice Production Records Provide Insight into the Origins of Intrusions (Reports of Uneaten Food Items) in Children’s Dietary Recalls 
Intrusions in dietary recalls may originate in confusion of episodic memories manifested as temporal dating errors.
Data from a validation study (concerning reporting accuracy over multiple recalls) and school foodservice production records were used to investigate origins of intrusions in school meals in children’s 24-hour recalls.
During the 1999–2000 school year, 104 fourth-grade children were observed eating school meals on one to three non-consecutive days separated by ≥25 days, and interviewed about the previous day’s intake in the morning on the day after each observation day.
Statistical analyses performed
For breakfast and lunch separately, logistic regression was used to investigate the effect of time (i.e., days) before the interview day on the probability that intrusions referred to items available in the school foodservice environment. Exploratory analyses were conducted for breakfast options observed and/or reported eaten.
For interviews in which reported meals met criteria to be considered school meals and that contained intrusions, of 634 and 699 items reported eaten at breakfast and lunch, respectively, 394 and 331 were intrusions. Availability in the school foodservice environment of items referred to by intrusions in reports of lunch, but not breakfast, decreased as days increased before the interview day (P values=0.031 and 0.285, respectively). Concerning breakfast, children observed eating a cold option (i.e., ready-to-eat [RTE] cereal, milk, juice, crackers [graham; animal]) almost always reported a cold option, whereas children observed eating a hot option (i.e., non-RTE-cereal entrée [e.g., sausage biscuit], milk, fruit or juice) reported a cold option in approximately 50% of interviews.
In children’s 24-hour recalls, confusion of episodic memories contributes to intrusions in school lunch, and generic dietary information (e.g., cold option items available daily) or confusion of episodic memories may contribute to intrusions in school breakfast. Understanding the origins of intrusions may help in developing interview methods to decrease the occurrence of intrusions.
PMCID: PMC2625290  PMID: 18656570
Children; dietary recalls; intrusions
23.  Parental food-related behaviors and family meal frequencies: associations in Norwegian dyads of parents and preadolescent children 
BMC Public Health  2013;13:820.
Frequent family meals are associated with healthy dietary behaviors and other desirable outcomes in children and adolescents. Therefore, increased knowledge about factors that may increase the occurrence of family meals is warranted. The present study has its focus on the home food environment, and aims to explore potential associations between parent-reported feeding behaviors and child-reported family meal frequencies.
Cross-sectional surveys were performed among 10-12-year-olds and their parents recruited from eighteen schools in southwest Norway. The child questionnaire included measures of family meal frequencies (breakfast, dinner and supper). The parent questionnaire included measures of parental feeding behaviors adapted from the Comprehensive Feeding Practices Questionnaire. A series of multiple linear regression analyses were conducted to examine the relationships between parental feeding behaviors and the frequency of family meals.
The frequency of family breakfasts was associated with three parental feeding variables; home environment (β=.11, p<.05), pressure to eat (β=.11, p<.01), and monitoring (β=.10, p<.05). The frequency of family dinners and suppers was associated with one parental feeding variable; home environment (β=.11, p<.01 and β=.12, p<.01 for dinners and suppers respectively).
The home environment variable was the most important correlate of child-reported family meal frequencies in this study. Although further research is needed, our findings support the evident influence of parents and the home food environment on child and adolescent eating behavior, which in the present study was measured as the frequency of shared family meals.
PMCID: PMC3846792  PMID: 24015833
Child eating; Family meals; Feeding practices; Home food environment
24.  Some intrusions in dietary reports by fourth-grade children are based on specific memories: data from a validation study of the effect of interview modality 
In dietary recall for a specified target period, an intrusion denotes an item reported eaten that was not consumed during that period. Intrusions may denote items available during the specified period, items consumed during other periods, or items from general knowledge of dietary intake. To investigate a cognitive basis of intrusions, we analyzed data from a dietary-reporting validation study in which 69 fourth-grade children were observed eating two school meals (breakfast; lunch) and interviewed that evening about that day’s intake in person or by telephone. Of 450 items reported eaten for school meals, 82 were intrusions. Observations and school foodservice production records were used to determine whether items denoted by intrusions were available in school foodservice environments on the interview day, as many as three school days prior to the interview day, and the day following the interview. Availability of items denoted by intrusions decreased backward over days from the interview day, and decreased from the interview day to the following day. Among 40 children who reported at least one intrusion, mean number of intrusions (controlling for number of items reported) increased as interviews occurred later in the week. These results are consistent with the idea that some intrusions are based on specific memories of items encountered but not eaten during the target period, or encountered before the target period. Other intrusions are likely based on general dietary knowledge. It may be possible to design interview techniques to reduce the occurrence of intrusions that are incorrectly based on specific memories.
PMCID: PMC3418914  PMID: 19083465
validity (epidemiology); nutrition assessment; mental recall; diet surveys; child
25.  Family structure and breakfast consumption of 11-15 year old boys and girls in Scotland, 1994-2010: a repeated cross-sectional study 
BMC Public Health  2012;12:228.
The benefits of breakfast during childhood and adolescence have been reported previously though few studies have considered family structure inequalities in breakfast consumption. The proportion of young people living in non-traditional family types has increased in recent years, strengthening the need to describe and monitor the impact of the changing family unit on adolescent breakfast consumption. This study aimed to describe changes in daily breakfast consumption among adolescents in Scotland between 1994 and 2010, while also considering family structure inequalities, and the degree to which these have changed over time.
Data from the 1994, 1998, 2002, 2006 and 2010 Scottish Health Behaviour in School-aged Children (HBSC) surveys were analysed using logistic multilevel regression models for binary outcome variable daily breakfast consumption.
Daily breakfast consumption among adolescents increased between 1994 and 2010, although there were differences by age and sex. In fact those aged over 14.5 years saw decreases in breakfast consumption, and girls saw significantly larger increases than boys. Daily breakfast consumption was more prevalent among adolescents from 'both parent' families, with lowest prevalence among those from single parent families. Trends in daily breakfast consumption between 1994 and 2010 also varied by family structure. While prevalence of daily breakfast consumption increased among those living with 'both parents', the largest proportion of the population, prevalence decreased over time among adolescents of single parent families, and particularly among those living with their father.
Family structure inequalities in daily breakfast consumption increased between 1994 and 2010, while breakfast consumption across the population as a whole increased. As the proportion of young people living in an alternative family structure continues to grow it is important to understand why these inequalities have increased and how these may be overcome. Possible reasons for family structure inequalities and their increase in recent years are discussed.
PMCID: PMC3373369  PMID: 22440153
Breakfast; Nutrition; Adolescent; Socioeconomic factors; Multilevel modelling; Survey methodology

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