Relationship Between Plate Waste and Food Preferences Among Primary School Students Aged 7–10 Years

ObjectiveTo assess differences in the amount of plate waste (PW) and food preferences among food categories containing vegetables and fruit and which of the student-centered reasons may influence PW.DesignA cross-sectional study (from December, 2017 to June, 2018); the aggregate selective plate waste method; the taste-and-rate method (food preferences); the multiple-choice survey (student-centered reasons for the PW occurrence).SettingFourteen primary schools (Zagreb).ParticipantsStudents aged 7–10 years; 17,163 meals (PW); 11,960 meals (PW and food preferences for meals containing vegetables and fruit); 6,507 meals (student-centered factors).Main Outcome MeasuresPlate waste, preferences, and student-centered reasons for PW occurrence.AnalysisContinuous and categorical data were analyzed using a 1-way analysis of variance for nonnormal distribution with post hoc Dunnett's test and chi-square test of homogeneity, respectively. Spearman's rank correlation coefficient was performed to examine the correlation between the amount of PW and served food. All statistical analyses were constructed with robust standard errors clustered at the school level.ResultsAmong the different types of vegetables and fruit meals, students wasted lower amounts of fruit (10.3%; P = 0.005). Plate waste was positively correlated with the amount of served food (r = 0.93; P < 0.001) containing vegetables and fruit. Students preferred fruit and starchy food with vegetables. Among personal factors for not finishing meals, the most frequent reason was they did not like the taste of the food.Conclusion and ImplicationsFindings highlight the importance of food preferences and other student-centered reasons in explaining PW by primary school students.     

Prenatal Cigarette Smoking and Smokeless Tobacco Use Among Alaska Native and White Women in Alaska, 1996–2003

Objective To examine trends in prenatal cigarette smoking and smokeless tobacco use among Alaska Native (AN) and white women in Alaska. Methods Using 1996–2003 data from the population-based Pregnancy Risk Assessment Monitoring System, we determined trends in self-reported prenatal tobacco use among AN and white women and used chi-square tests and multiple variable logistic regression analysis to identify maternal factors associated with prenatal tobacco use. Results Over the study period, prevalence of any tobacco use during pregnancy declined by 27% among AN women (from 55.8 to 40.9%) (P < 0.0001) and by 17% among white women (from 18.8 to 15.6%) (P < 0.0001). In 2003, among AN women the prevalence of self-reported smokeless tobacco use was 16.9%, cigarette smoking was 25.7%, and any tobacco use was 40.9%; corresponding values for white women were 0.4, 15.0, and 15.6%, respectively. Western Alaska had the highest prevalence of tobacco use. Conclusion The prevalence of tobacco use decreased between 1996 and 2003, but remained higher among AN women than white women, especially for smokeless tobacco. Support for cessation interventions targeting pregnant women should be made a public health priority in Alaska. The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.     

Increasing non-susceptibility to antibiotics within carried pneumococcal serotypes — Alaska, 2008–2015

BackgroundIn Alaska, while introduction of 13-valent pneumococcal conjugate vaccine led to declines in invasive pneumococcal disease, carriage prevalence remained stable because of replacement with non-vaccine serotypes. We assessed antibiotic non-susceptibility of carried pneumococci during serotype redistribution, determined the contributions of within-serotype shifts, and assessed factors that could explain changes in non-susceptibility.MethodsEach year from 2008 to 2015, at multiple sites in Alaska, we collected nasopharyngeal swabs and completed surveys for a convenience sample of participants. Pneumococcal serotyping and antimicrobial susceptibility testing for penicillin and erythromycin were performed. We described changes in non-susceptibility of isolates from 2008–2011 to 2012–2015, and assessed the contributions of serotype redistribution and within-serotype changes in non-susceptibility by comparing observed data to modeled data removing either factor. We used weighted logistic regression to assess whether reported risk factors could explain changes over time in non-susceptibility within serotypes.ResultsFrom 2008–2011 to 2012–2015, the overall proportion of isolates non-susceptible to penicillin or erythromycin increased by 3%, from 23% (n = 1,183) to 26% (n = 1,589; P < 0.05). However, a decrease of 3% would be expected if serotype redistribution occurred without within-serotype changes in non-susceptibility. Standardization by either factor produced hypothetical data significantly different to observed data. Within serotypes, the average annual increase in odds of non-susceptibility to penicillin or erythromycin was 1.08 (95% CI 1.05–1.11). Recent antibiotic exposure, urban residence and increased household size of participants predicted isolate non-susceptibility but did not explain the increase over time.DiscussionAn overall increase in non-susceptibility of carried pneumococcal isolates to penicillin or erythromycin resulted from increases in non-susceptibility within serotypes, which outweighed a protective effect of serotype redistribution. Characterization of emerging resistant clones within carried non-vaccine serotypes, including risk factors for colonization and disease, would support disease prevention efforts and inform vaccine strategies.     

Outbreak of Pulmonary Tuberculosis in a Chinese High School, 2009–2010

Background

In February 2009, a high school student was diagnosed with sputum-smear positive pulmonary tuberculosis (TB). One year later, 2 other students in the same grade developed sputum-smear positive TB.

Methods

We used tuberculin skin testing (TST), chest radiography, sputum smear, and symptomatology for case identification. We defined latent TB infection (LTBI) as a TST induration of 15 mm or larger, probable TB as a chest radiograph indicative of TB plus productive cough/hemoptysis for at least 2 weeks or TST induration of 15 mm or larger, and confirmed TB as 2 or more positive sputum smears or 1 positive sputum smear plus a chest radiograph indicative of TB.

Results

Of students in the same grade as the primary case-student, 26% (122/476) had LTBI and 4.8% (23/476) had probable/confirmed TB. Of teachers, 43% (18/42) had LTBI and none had probable/confirmed TB. Sharing a classroom with the primary case-student increased risk for LTBI (rate ratio = 2.5; 95% CI: 1.9–3.4) and probable/confirmed TB (rate ratio = 17, 95% CI: 7.8–39). Of students with LTBI in February 2009 who refused prophylaxis, 50% (11/22) had probable/confirmed TB in April 2010.

Conclusions

This TB outbreak was likely started by delayed diagnosis of TB in the case-student and was facilitated by lack of post-exposure chemoprophylaxis. Post-exposure prophylaxis is strongly recommended for all TST-positive students.Key words: epidemiology, outbreak, students, tuberculosis     

Overweight and Obesity Among Hawai‘i Children Aged 4 to 5 Years Enrolled in Public Schools in 2007–2008 and Comparison with a Similar 2002–2003 Cohort

This assessment provides the most recent estimates of overweight and obesity among children 4 to 5 years old who were enrolled in public schools in the 2007–2008 school year, using data obtained from Student Health Records for 12,823 children, which represents 91% of the 14,070 children who were enrolled in kindergarten in 2007–2008. This assessment is a census of 4 to 5 year olds that entered public schools in Hawai‘i in 2007–2008 and represents approximately 38% of the total Hawai‘i population for those aged 4 to 5 years, since kindergarten is not a requirement. A limited data set with data on age, sex, height, and weight was used to calculate BMI (body mass index) percentiles. We compare this data with age and sex-specific BMI obtained from Student Health Records from 10,199 children aged 4 to 5 years entering public schools during 2002–2003. The results illustrate that like the 2002–2003 data (28.5%), over one in four (28.6%) of the children aged 4 to 5 years entering Hawai‘i public schools in 2007–2008 were either overweight or obese. Total proportions overweight and obese were persistently higher (32.5% or more in both 2002–2003 and 2007–2008) in some specific school complexes on O‘ahu as well as in some rural and Neighbor Island school complexes. Physicians, public health and school health professionals, advocates, schools, and communities should be vigilant about this persistent problem and seek to implement practices to combat overweight and obesity. In addition, the use of Student Health Records for on-going pediatric obesity surveillance should be explored more fully.     

Patterns of Cigarette and Smokeless Tobacco Use Before, During, and After Pregnancy Among Alaska Native and White Women in Alaska, 2000–2003

Objective To examine patterns of cigarette and smokeless tobacco use before, during, and after pregnancy among Alaska Native (AN) and white women living in Alaska. Methods We used data from the 2000–2003 population-based Pregnancy Risk Assessment Monitoring System to describe patterns of self-reported prenatal tobacco use among AN and white women. We used multiple variable logistic regression analysis to identify maternal factors associated with quitting and relapse. The final sample included 5,458 women. Results During 2000–2003, the prevalence of any tobacco use before pregnancy was twofold higher among AN women than among white women (60.0 vs. 27.5%), and the prevalence of any tobacco use during pregnancy and after pregnancy were each nearly threefold higher. Of the 25.8% (SE 0.9) of white women who smoked before pregnancy, 49.0% (SE 2.1) reported that they quit during pregnancy and of those, 41.1% (SE 2.9) relapsed postpartum. Of the 38.5% (SE 0.9) of AN women who smoked before pregnancy, 35.7% (SE 1.4) quit, and of those 57.0% (SE 2.4) relapsed. Of the 14.2% of AN women who chewed tobacco before pregnancy, 15.7% (SE 1.7) quit, and of those, 52.9% (SE 5.9) relapsed. Conclusion During 2000–2003, the prevalence of tobacco use was two to three times higher among AN women than among white women before, during, and after pregnancy. In addition, AN women had lower quit rates and higher relapse rates than white women. Comprehensive, culturally appropriate tobacco control approaches targeting AN women are needed to increase cessation during pregnancy and to decrease relapse.     

Change in School Nutrition–Related Laws From 2003 to 2008: Evidence From the School Nutrition–Environment State Policy Classification System

Objectives. We examined state laws affecting the school food environment and changes in these laws between 2003 to 2008.Methods. We used the Westlaw legal database to identify state-codified laws, with scoring derived from the updated School Nutrition–Environment State Policy Classification System, obtained from the Classification of Laws Associated With School Students Web site.Results. States significantly changed their school nutrition laws from 2003 to 2008, and many increased the stringency of the laws targeting competitive foods (snacks and entrées sold in competition with the school meal) and beverages sold in school and for in-school fundraising. Many states enacted laws that mandated the establishment of a coordinating or advisory wellness team or council. Stronger laws were enacted for elementary grades. We found tremendous variability in the strength of the laws and plenty of room for improvement.Conclusions. State law governing school nutrition policies significantly changed from 2003 to 2008, primarily affecting the competitive food environment in schools. The extent to which changes in school nutrition laws will lead to desired health outcomes is an area for additional research.Childhood obesity is on the rise in many industrialized nations, and prevalence in the United States has reached alarming proportions.1 Obesity is a complex and multifactorial problem that requires population-based preventive solutions.2,3 Focusing on the school food environment is considered to be an important starting point because almost all children attend school, and they consume about one third of their caloric requirements there.4 In the past decade, ideas about school nutrition policies to optimize the nutritional environment of schools have undergone a drastic shift.In the intervention literature, modification of the school nutrition environment has been associated with student eating behaviors, but its influence on obesity is unclear.5–7 Evidence suggests that food and beverage availability,8–12 quality of the food offered in schools,13,14 length of the lunch period,15 and pricing and marketing practices16–19 in schools have had an impact on student eating behaviors (total intake, fat consumption, and food preferences). In cross-sectional studies, the school nutrition environment has been linked with children''s eating behaviors and body mass index (BMI).20,21 In light of this evidence, it is not surprising that policymakers are resorting to strategies to modify the school nutrition environment to ultimately affect childhood obesity.As school nutrition policies are increasingly being used to curb the rise in childhood obesity, support for such policies in the scientific literature is emerging.22–29 State laws and district policies have been found to influence the school nutrition environment: studies reveal an inverse association between school nutrition policies and the availability of less healthy foods and beverages at school.22–29 For example, Mendoza et al. noted significant improvements in the energy density of the foods and beverages consumed at lunchtime among sixth and eighth graders after the Texas nutrition policy was implemented.28 In addition, school nutrition policies have been favorably associated with the prevalence of overweight and obesity in children; some studies report that the increase in prevalence has been halted as a result of these policies.16,26,30–32 When researchers have evaluated the influence of both state and district school nutrition policies, state laws have been found to be more important in influencing behaviors and BMI.33 Because state laws and policies will likely have wider influence on the school environment, it is essential to monitor the enactment of laws and the strength of these laws across states.We aimed to (1) update the status of state laws for school nutrition–related policies with the revised School Nutrition–Environment State Policy Classification System (SNESPCS), which was previously published in 2007,34 and (2) examine whether state laws focused on school nutrition–related policies changed from 2003 to 2008. Improvements were expected during this period because the US Congress mandated significant improvement in the school environment as part of the Child Nutrition and Women, Infants, and Children Reauthorization Act of 2004.35 Specifically, Congress required all school districts that participate in the National School Lunch Program and other federal child nutrition programs to develop and implement a local school wellness policy by the 2006 to 2007 school year that includes, but is not limited to

1. goals for nutrition education,
2. guidelines for food and beverage availability at school,
3. assurance that federal regulations for the reimbursable school meal are followed,
4. a plan for assessing implementation of the policy as well as designation of staff responsible for the implementation of the wellness policy, and
5. involvement of the school community in the development of the policy.

Although the wellness policy was required at the district level, many states enacted laws around this time related to the school nutrition environment to provide a framework for districts to follow. Our previous assessment of state laws in this area indicated wide variations by grade,34 so we examined changes by elementary, middle, and high school levels.     

Socioeconomic Status,Sex, and Obesity in a Large National Cohort of 15–87-Year-Old Open University Students in Thailand

Background

As obesity increases, middle-income countries are undergoing a health-risk transition. We examine the association between socioeconomic status (SES) and emerging obesity in Thailand, and ascertain if an inverse relationship between SES and obesity has appeared.

Methods

The data derived from 87 134 individuals (54% female; median age, 29 years) in a national cohort of distance-learning Open University students aged 15–87 years and living throughout Thailand. We calculated adjusted odds ratios for associations of SES with obesity (body mass index, ≥25) across 3 age groups by sex, after controlling for marital status, age, and urbanization.

Results

Obesity increased with age and was more prevalent among males than females (22.7% vs 9.9%); more females were underweight (21.8% vs 6.2%). Annual income was 2000 to 3000 US dollars for most participants. High SES, defined by education, income, household assets, and housing type, associated strongly with obesity—positively for males and inversely for females—especially for participants younger than 40 years. The OR for obesity associated with income was as high as 1.54 for males and as low as 0.68 for females (P for trend <0.001).

Conclusions

Our national Thai cohort has passed a tipping point and assumed a pattern seen in developed countries, ie, an inverse association between SES and obesity in females. We expect the overall population of Thailand to follow this pattern, as education spreads and incomes rise. A public health problem of underweight females could emerge. Recognition of these patterns is important for programs combating obesity. Many middle income countries are undergoing similar transitions.Key words: body mass index, weight, obesity, socioeconomic status, Thailand     

Elevated Blood Lead Levels Among Fire Assay Workers and Their Children in Alaska, 2010–2011

In October 2010, an employee at Facility A in Alaska that performs fire assay analysis, an industrial technique that uses lead-containing flux to obtain metals from pulverized rocks, was reported to the Alaska Section of Epidemiology (SOE) with an elevated blood lead level (BLL) ≥10 micrograms per deciliter (μg/dL). The SOE initiated an investigation; investigators interviewed employees, offered blood lead screening to employees and their families, and observed a visit to the industrial facility by the Alaska Occupational Safety and Health Section (AKOSH). Among the 15 employees with known work responsibilities, 12 had an elevated BLL at least once from October 2010 through February 2011. Of these 12 employees, 10 reported working in the fire assay room. Four children of employees had BLLs ≥5 μg/dL. Employees working in Facility A''s fire assay room were likely exposed to lead at work and could have brought lead home. AKOSH inspectors reported that they could not share their consultative report with SOE investigators because of the confidentiality requirements of a federal regulation, which hampered Alaska SOE investigators from fully characterizing the lead exposure standards.Occupational lead exposure continues to threaten workers'' health.^1–3 In the United States, the Occupational Safety and Health Administration (OSHA) prescribes standards for permissible exposure limits for lead in the workplace and specifies that a blood lead level (BLL) of 40 micrograms per deciliter (μg/dL) triggers more frequent (i.e., every two months rather than every six months) blood lead testing. OSHA standards require that workers with a BLL ≥60 μg/dL, or an average BLL for the last three tests or all tests during the previous six months (whichever is longer) of ≥50 μg/dL, be removed from the lead exposure area, unless the most recent test indicated a BLL ≤40 μg/dL.⁴ However, research has increased concern regarding lead toxicity at lower doses and has supported a reevaluation of the level at which BLLs can be considered safe.⁵ The National Institute for Occupational Safety and Health (NIOSH) defines an elevated BLL in an adult as ≥10 μg/dL.⁶ In addition to adverse impacts on the health of the workers themselves, children of lead-exposed workers have disproportionately higher BLLs when compared with other children.^7–9Elevated BLLs among adults are associated with muscle and joint pain, reproductive problems, and neurologic symptoms, including memory loss.¹⁰ Negative health effects have been observed among adults with only modestly elevated BLLs,^11–13 with increased odds of an ill effect occurring at levels as low as 1.6–2.4 μg/dL.¹¹ Among children, elevated BLLs can result in devastating health effects, including brain and nervous system damage, slow growth, and hearing problems.¹⁰ Research indicates that there is no safe level of lead among children.¹⁴ Despite considerable data on the deleterious health effects of lead regarding both children and adults, harmful occupational exposures that are inadequately controlled continue to put workers and their families at risk. A BLL of ≥5 μg/dL is the reference level that the Advisory Committee on Childhood Lead Poisoning Prevention has recommended to identify children with elevated BLLs.¹⁴ Elevated BLLs ≥10 μg/dL for children and adults are reportable in Alaska under Alaska Administrative Code 27.014.¹⁵     

Declining Trends and Widening Disparities in Overweight and Obesity Prevalence Among Massachusetts Public School Districts, 2009–2014

Objectives. We evaluated the overall and sociodemographic disparities in trends in prevalence of childhood overweight and obesity in Massachusetts public school districts between 2009 and 2014.Methods. In 2009, Massachusetts mandated annual screening of body mass index for students in grades 1, 4, 7, and 10. This was part of the statewide Mass in Motion prevention programs. We assessed trends in the prevalence of overweight and obesity between 2009 and 2014 by district, gender, grade, and district income.Results. From 2009 to 2014, prevalence decreased 3.0 percentage points (from 34.3% to 31.3%) statewide. The 2014 district-level rates ranged from 13.9% to 54.5% (median = 31.2%). When stratified by grade, the decreasing trends were significant only for grades 1 and 4. Although rates of districts with a median household income greater than $37 000 improved notably, rates of the poorest remain unchanged and were approximately 40%.Conclusions. Although overall prevalence began to decrease, the geographic and socioeconomic disparities in childhood obesity are widening and remain a public health challenge in Massachusetts. Special efforts should be made to address the needs of socioeconomically disadvantaged districts and to narrow the disparities in childhood obesity.Childhood obesity has been associated with chronic diseases such as hypertension, cardiovascular disease earlier in life,1–4 asthma, and sleep apnea.2,3,5 Many of these health risks continue well into adulthood, contributing to the higher risks for multiple chronic diseases, all-cause mortality, and premature death.4–8 Although a few studies have reported limited success in childhood obesity control,8,9 reducing the prevalence of overweight and obesity among children and adolescents remains a critically important public health endeavor in the United States.In response to growing concerns over childhood obesity, in 2003, the American Academy of Pediatrics released a policy statement advising that body mass index (BMI) be routinely assessed and tracked over time.10 In 2005, the Institute of Medicine recommended that all school systems develop a BMI measurement program and track their students annually. The Institute of Medicine also called on the federal government to create guidance documents for the development of these state programs.11 Since then, 20 states have developed BMI screening or body composition assessment programs.12In April 2009, the Massachusetts Public Health Council unanimously approved the state’s first BMI screening regulations as a key component of the state’s Mass in Motion initiative. Mass in Motion programs use community-based environmental approaches to promote healthy eating and active living at home, at work, and in communities throughout the state. The goal is to prevent overweight and obesity in all segments of the population.The state’s BMI screening regulation requires all public school districts to measure students’ height and weight, by the school nurse or other trained staff, of all students in grades 1, 4, 7, and 10 annually and report aggregate data to the Massachusetts Department of Public Health (MDPH). Before the 2013–2014 school year, the results of the screening were directly and confidentially communicated to the parents or guardians of each student. Starting in 2013–2014, notifications to parents were no longer required, although they could be done at the discretion of the local school district.Using the data collected between the 2008–2009 and 2013–2014 school years, we assessed the overall and district-level variations in trends in the prevalence of childhood overweight and obesity. These data were used to inform the state’s future efforts on prevention of childhood overweight and obesity. Furthermore, we examined the trends in childhood overweight and obesity by district-level income to inform the state’s efforts to reduce disparities in childhood obesity.