Field Notes

Kids Are Tossing Mandated Fruits and Veggies at School

Less than a month before Congress was due to vote on whether to reauthorize a controversial program mandating healthier school lunches in September, a study confirmed the suspicions of school officials: Many students are putting the fruits and vegetables they’re now required to take straight into the trash, consuming fewer than they did before the law took effect.

The study, published online in Public Health Reports on August 25, is the first to use digital imaging to capture students’ lunch trays before and after they exited the lunch line.
It’s also one of the first to compare fruit and vegetable consumption before and after the controversial legislation—the Healthy, Hunger-Free Kids Act of 2010—was passed.

After passage of the legislation and the USDA mandates it put in place in 2012, the study found that students put more fruits and vegetables on their trays, as required, but consumed fewer of them and increased waste by approximately 56%.

“The basic question we wanted to explore was: ‘Does requiring a child to select a fruit or vegetable actually correspond with consumption?’” says Sarah Amin, PhD, MPH, a researcher in nutrition and food sciences at the University of Vermont and lead author on the study.
“The answer was clearly no,” she says. “It was heartbreaking to see so many students toss fruits like apples into the trash right after exiting the lunch line.”

Amin and her coauthors documented almost 500 tray observations over 10 visits to two elementary schools in the Northeast before implementation of the USDA guideline and almost twice as many observations afterwards. Forty percent to 60% of the students at the schools qualified for free or reduced lunch, a marker for low socioeconomic status.

The research team used a digital imaging method that they validated three years ago in the Journal of the Academy of Nutrition and Dietetics to measure consumption.

The new methodology, which involved visual estimations and calculations based on digital photographs of trays as students reached the cashier and again after they passed the food disposal area, was faster and more accurate than conventional methodologies that simply weighed food waste.

“The beauty of this method is that you have the data to store and code to indicate what was selected, what was consumed, and what was wasted as opposed to weighed plate waste, where everything needs to be done on site,” says Amin, who hopes to develop an online training tutorial that schools across the country can use to measure consumption and waste.

In an earlier study published in the Journal of Child Nutrition and Management, Amin and colleagues looked at what types of fruits and vegetables children selected before the new guideline. They found that children preferred processed fruits and vegetables such as the tomato paste on pizza or 100% fruit juice rather than whole varieties.

In addition to making sure those options are available, Amin and her colleagues offer the following additional strategies for increasing fruit and vegetable consumption in school lunch programs:

Cut up vegetables and serve them with dip or mix them in with other parts of the meal.
Slice fruits like oranges or apples, rather than serving them whole.
Adopt promising strategies targeting school settings such as Farm-to-School programs and school gardens, which can encourage fruit and vegetable consumption in addition to what the cafeteria is providing.
Put public health programs in place that encourage fruit and vegetable consumption at home, which could carry over to school.

Once schools have fully acclimated to the guidelines, Amin thinks consumption will increase, especially for students who entered as kindergarteners under the new guidelines in 2012 and know no other way. “An important message is that guidelines need to be supplemented with other strategies to enrich fruit and vegetable consumption.”

— Source: University of Vermont

Strong Physician Support Aids Patient Weight Loss

A review of survey data from more than 300 obese people who participated in a federally funded weight loss clinical trial found that although the overall weight loss rates were modest, those who rated their primary care doctor’s support as particularly helpful lost about twice as many pounds as those who did not.

In a report on the study by Johns Hopkins researchers, published in the August 21 issue of Patient Education and Counseling, the researchers said the findings could inform the development of weight loss programs that give primary care physicians a starring role.

Researchers have long known that high-quality patient-doctor relationships marked by empathy, good communication, collaboration, and trust are linked to better adherence to medication schedules, appointment-keeping, and other good outcomes, says Wendy L. Bennett, MD, MPH, an assistant professor of medicine at the Johns Hopkins University School of Medicine and a primary care physician at Johns Hopkins Bayview Medical Center. Previous studies also have shown, she says, that obese patients are more likely to report poor physician-patient relationships, with evidence of decreased respect and weight bias from providers.

To determine whether and what aspects of those relationships might influence weight loss efforts, Bennett and her colleagues reviewed information gathered by Johns Hopkins’ Practice-based Opportunities for Weight Reduction (POWER) trial, a two-year, randomized, controlled study funded by the federal government. During the trial, some obese patients worked to lose weight with the aid of health coaches while their primary care physicians supervised their efforts.

At the end of the trial, patients filled out surveys that asked, in part, about their relationships with their primary care physician, including questions about how often their providers explained things clearly, listened carefully, and showed respect, as well as how helpful their physicians’ involvement was in the trial. Of the 347 patients who filled out surveys, about 63% were female, about 40% were black, and all were obese, with BMIs of 36.3 on average. Each participant also had one of three cardiovascular disease risk factors: high blood pressure, high cholesterol, or diabetes.

Results of a review showed that nearly all of the 347 patient surveys reviewed for the study reported high-quality relationships with their physicians, with the overall relationship showing little effect on weight loss. However, those patients who gave their physicians the highest ratings on “helpfulness” during the trial lost an average of 11 pounds, compared with slightly more than five pounds for those who gave their physicians the lowest “helpfulness” ratings.

Current National Institutes of Health statistics suggest that more than one-third of adults in the United States are obese. Though Medicare and private insurance reimbursements are low or nonexistent for physician-guided weight loss interventions, Bennett says, the findings could spur new reimbursement models that provide for physician involvement and enable more team-based care models.

“This trial supports other evidence that providers are very important in their patients’ weight loss efforts,” Bennett says. Many current weight loss programs are commercially run, she adds, and patients often join these programs without their physician’s knowledge.
“Incorporating physicians into future programs might lead patients to more successful weight loss,” she says.

— Source: Johns Hopkins Medicine