To assess facility readiness and identify barriers to the facility-based management of childhood severe acute malnutrition (SAM) in public healthcare settings.

Qualitative methods were applied to assess readiness and identify different perspectives on barriers to the facility-based management of children with SAM. Data collection was done using in-depth interviews, key informant interviews, exit interviews and pre-tested observation tools.

Two tertiary care and four district hospitals in Rangpur and Sylhet Divisions of Bangladesh.

Healthcare professionals and caregivers of children with SAM.

Anthropometric tools, glucometer, medicines, F-75, F-100 and national guidelines for facility-based management of childhood SAM were found unavailable in some of the hospitals. Sitting and sleeping arrangements for the caregivers were absent in all of the chosen facilities. We identified a combination of health system and contextual barriers that inhibited the facility-based management of SAM. The health system barriers include inadequate manpower, rapid turnover of staff, increased workload, lack of training and lack of adherence to management protocol. The major facility barriers were insufficient space and unavailability of required equipment, medicines and foods for hospitalised children with SAM. The reluctance of caregivers to complete the treatment regimen, their insufficient knowledge regarding proper feeding, increased number of attendants and poverty of parents were the principal contextual barriers.

The study findings provide insights on barriers that are curbing the facility-based management of SAM and emphasise policy efforts to develop feasible interventions to reduce the barriers and ensure the preparedness of the facilities for effective service delivery.

Monitoring population salt intake is operationally and economically challenging. We explored whether a questionnaire assessment and a prediction of Na intake from spot-urine could replace or complement the recommended measurement of Na in 24-h urine (24-h U).

Compare the agreement of a Na-specific food record checklist (FRCL) and a late-afternoon spot-urine measurement (PM-spot) with 24-h U measurement in estimating Na intake at group level. Each participant’s use of these methods extended over 3 d. Agreement was assessed using mean (95 % CI) differences, linear regression models and Bland–Altman plots.

The validation study was part of a 1-year workplace intervention trial to lower salt intake in Switzerland.

Seventy women and 71 men, aged 21–61 years, completed three FRCL, and acceptable PM-spot and 24-h U samples at baseline (April–October 2015).

Mean Na intake estimates varied slightly across methods (3·5–3·9 g/d). Mean Na intake differences from 24-h U were 0·2 (95 % CI (0, 0·5)) g/d for FRCL and 0·4 (95 % CI (0·2, 0·6)) g/d for PM-spot. Linear regression models and Bland–Altmann plots more clearly depicted differences by sex and discretionary salt use.

Although 24-h U remains the best reference method for monitoring Na intake at the population level, PM-spot and FRCL might be more practical instruments for frequent, periodic Na intake assessments. Population-specific prediction models to estimate 24-h U could be developed and evaluated.

About one-third of under-five Filipino children are stunted, with significant socio-economic inequality. This study aims to quantify factors that explain the large gap in stunting between poor and non-poor Filipino children.

Using the 2015 Philippine National Nutrition Survey, we conducted a linear probability model to examine the determinants of child stunting and then an Oaxaca-Blinder decomposition to explain the factors contributing to the gap in stunting between poor and non-poor children.

Philippines.

1881 children aged 6–23 months participated in this study.

The overall stunting prevalence was 38·5 % with a significant gap between poor and non-poor (45·0 % v. 32·0 %). Maternal height, education and maternal nutrition status account for 26 %, 18 % and 17 % of stunting inequality, respectively. These are followed by quality of prenatal care (12 %), dietary diversity (12 %) and iron supplementation in children (5 %).

Maternal factors account for more than 50 % of the gap in child stunting in the Philippines. This signifies the critical role of maternal biological and socio-economic circumstances in improving the linear growth of children.

The aim of the study was to investigate the association between body roundness index (BRI) and all-cause mortality and cardiovascular mortality in general population.

A retrospective cohort study.

The status of cardiovascular mortality and all-cause mortality of participants were followed through 31 December 2015. Multivariate adjusted Cox restricted cubic spline regression models and Kaplan–Meier survival curves were used to evaluate the relationship between BRI and cardiovascular mortality and all-cause mortality.

A sample of 47 356 participants from the National Health and Nutrition Examination Surveys 1999–2014 with aged ≥18 years.

Mean age was 47 years and female were 49·9 %. During a median follow-up of 92 months, 4715 participants died from any cause, with 985 died of CVD. In multivariate adjusted Cox regression, compared with the lowest quartile of Body roundness index (BRI), the hazard ratios (HR) for all-cause mortality from other quartiles were 0·83, 95 % CI (0·75, 0·92), 0·73, 95 % CI (0·65, 0·81) and 0·80, 95 % CI (0·72, 0·89), respectively (Pfor trend < 0·05) and the HR for cardiovascular mortality from other quartiles were 0·79, 95 % CI (0·62, 1·00), 0·78, 95 % CI (0·62, 0·99) and 0·79, 95 % CI (0·62, 1·01), respectively (P for trend > 0·05). In the restricted cubic spline regression models, the relationship was showed U-shaped between BRI and all-cause mortality and cardiovascular mortality. In Kaplan–Meier survival curves, the lowest cumulative survival rate of cardiovascular mortality and all-cause mortality was recorded in the highest BRI quartile.

The U-shaped association between BRI and all-cause mortality and cardiovascular mortality in a large population-based cohort was observed.

To examine the association between childhood stunting and grade completion (as educational outcome) in South Africa.

Longitudinal study. Data were obtained using the National Income Dynamics Study over five waves (2008 to 2017). Children were tracked at wave 1 in 2008 until wave 5 in 2017 to determine their total years of schooling. We controlled for time-variant and time-varying confounding with a marginal structural model to estimate the associations between childhood stunting and subsequent grade completion.

Nationally representative study of South African households.

A total of 2629 children aged 2 and 3 years in 2008.

We observed a substantial decrease in the prevalence of stunting between wave 1 (28·2 %) and wave 4 (8·6 %). Our marginal structural model results suggest that childhood stunting was significantly associated with decreased odds (22 % less likely) of grade completion (OR = 0·78; 95 % CI: 0·40, 0·86; P = 0·015), while those who were only stunted during early childhood had a 29 % reduction in the odds of grade completion (OR = 0·71; 95 % CI: 0·51, 0·82; P = 0·020).

These findings underscore the fact that stunting is a significant predictor of academic achievement, whose effects might be long-lasting.

Neural tube defects (NTD) are potentially preventable by periconceptual folic acid supplementation. Women with obesity are at higher risk of NTD, therefore, are recommended a higher dose of 5 mg folic acid to mitigate this risk. The aim of this study was to evaluate maternal practice of folic acid supplementation amongst the antenatal population in relation to maternal obesity status.

Prospective observational study.

Women ≤18 weeks’ gestation at their first antenatal appointment attending University Maternity Hospital Limerick (Ireland) were recruited. Maternal height and weight were measured. Obesity was defined at a threshold of ≥30·0 kg/m2 and ≥27·5 kg/m2 when adjusting for ethnicity. A two-part questionnaire captured maternal characteristics and assessed supplementation compliance, commencement and dosage. Fisher’s exact test for independence analysed differences in variables. A P value of <0·05 was considered significant.

A total of 328 women participated over a duration of 6 weeks.

Mean gestational age was 12·4 ± 1·4 weeks and mean BMI 26·7 kg/m2 ± 5·2 kg/m2. 23·8 % (n 78) were classified as obese. 96·5 % (n 315) were taking folic acid and 95·7 % (n 314) supplemented daily. 30·2 % (n 99) commenced supplementation 12 weeks prior to conception. Overall, 57·9 % (n 190) of women met folic acid supplementation dose requirements. 89·1 % (n 55) of women with obesity did not. Women with obesity were less likely to meet the higher folic acid supplementation dose requirements (P =< 0·001).

Folic acid supplementation practices within this cohort were suboptimal to prevent their risk of NTD. This study showed inadequate compliance of folic acid supplementation, and inadequate dosage for women with obesity. Increased patient education and awareness are needed within the antenatal period of pregnancy to bring folic acid supplementation practices in line with best practice guidelines.

To evaluate the utility of three validated food responsiveness scales in measuring recall of, and responsiveness to, food marketing exposure on social media.

Cross-sectional survey among adolescents and adults who used the social media platform Twitch.tv (Twitch). Responsiveness to food marketing was self-reported as craving or purchasing any brands participants observed on Twitch. Participants completed three validated scales of food responsiveness: the revised 18-question Three Factor Eating Questionnaire (TFEQ), the external eating subscale of the Dutch Eating Behavior Questionnaire (DEBQ) and the External Food Cue Responsiveness (EFCR) scale. Adjusted linear regression models assessed the predictive ability of each scale on recall and responsiveness outcomes.

Online survey.

Five hundred and sixty-eight Twitch users (90·1 % male, 60·6 % White, 43·7 % aged 18–24, 25·9 % under 18).

In separate adjusted linear regression models, scores on the TFEQ were not related to any outcome, while DEBQ scores related to product cravings (OR: 1·10, 95 % CI 1·01, 1·19, P = 0·02). In contrast, scores on the EFCR scale were significantly associated with higher brand recall (incident rate ratio: 1·42, 95 % CI 1·20, 1·68, P < 0·001), product craving (OR: 3·93, 95 % CI 2·22, 7·17, P < 0·001) and purchasing behaviour (OR: 3·97, 95 % CI 1·99, 8·26, P < 0·001). A subset of three EFCR scale items related to influencer marketing were similarly associated with each outcome with greater precision in the point estimates than the overall EFCR.

The EFCR scale predicted recall of and responsiveness to food marketing via Twitch, suggesting its utility in monitoring the effects of food marketing on social media.

To examine Australian adolescents’ knowledge and beliefs regarding potential health consequences of soda and diet soda consumption and nutritional aspects of soda and explore associations with consumption.

A survey utilising a nationally representative sample (stratified two-stage probability design) assessed knowledge of nutritional contents and health consequences of soda, and beliefs regarding health risks of diet soda, and soda and diet drink consumption.

Australia.

9102 Australian school students (12–17 years) surveyed in 2018.

Adolescents had lower nutritional knowledge (sugar content (22·2 %), exercise equivalent (33·9 %), calories/kJ (3·1 %)) than general knowledge of health risks (87·4 %) and some health effects (71·7–75·6 % for tooth decay, weight gain and diabetes), with lower knowledge of heart disease (56·0 %) and cancer (19·3 %). Beliefs regarding health effects of diet soda were similar, albeit not as high. In general, female sex, older age and less disadvantage were associated with reporting health effects of soda and diet soda, and nutritional knowledge of soda (P < 0·001). Those reporting tooth decay, weight gain, heart disease and diabetes as health effects of soda and diet soda were lower consumers of soda and diet drinks (P < 0·001), as were those with higher nutritional knowledge (sugar content and exercise equivalent; P < 0·001).

This study highlights possible knowledge gaps regarding the health effects of soda and nutritional knowledge for public health intervention. When implementing such interventions, it is important to monitor the extent to which adolescents may consider diet drinks as an alternative beverage given varied beliefs about health consequences and evolving evidence.

This study seeks to empirically investigate how the changing eating habits affect health habits within three countries with entirely different cultures and diets to understand to what extent the pandemic may be responsible for these changes.

Specifically, a questionnaire was conducted in China, Portugal and Turkey in early 2021. A series of statistical analyses were performed to identify how changes in individuals’ eating habits have influenced their diets, considering the pandemic context and the varying cultural contexts where this research was performed.

A structured questionnaire form was developed and uploaded to an online platform with unique links for automatic distribution to respondents in each country. Data for the main survey were gathered between 3 January and 1 February 2021.

Using snowball sampling, the authors leveraged their social networks by asking friends and colleagues to distribute the survey to potentially interested individuals. This distribution was stratified accordingly to the distribution of the population. The authors ultimately collected 319 useable surveys from China, 351 from Portugal and 449 from Turkey.

The pandemic inspired healthier food habits, mostly because people have additional time to cook, shop differently for food and spend more money on groceries.

The study suggests that aside from cultural values and dietary habits, the available time and the fear of the pandemic most explained the new eating habits. Several implications are provided for researchers and overall society in these three countries.

In many countries, the provision of water in the early months of a baby’s life jeopardises exclusive breast-feeding (EBF). Using a behavioural theory, this study assessed the impact of a behaviour change intervention on mothers’ intention to act and, in turn, on the water provision in addition to breast milk to their infants under 6 months of age (IU6M) in two regions of Guinea.

A quasi-experimental design. Data on individual and environmental factors of the theoretical framework, sociodemographic and outcomes were collected using validated questionnaires before and after the intervention. The outcomes examined were the intention to provide water to IU6M, the provision of water and EBF. Path analyses were performed to investigate pathways by which psychosocial and environmental factors influenced the water provision in addition to breast milk.

Four health centres were assigned randomly to each study’s arm (one control/CG and one intervention group/IG per region).

The sample included 300 mothers of IU6M: 150 per group.

In IG, the proportion of mothers providing water decreased from 61 % to 29 % before and after the intervention (P < 0·001), while no difference was observed in CG (P = 0·097). The EBF rate increased in IG (from 24·0 % to 53·8 %, P < 0·001) as opposed to CG (36·7 % to 45·9 %, P = 0·107). An association (P < 0·001) between the intention and the behaviour was observed in both groups.

An intervention developed using a sound framework reduces the provision of water among IU6M and improves EBF.

To estimate the prevalence of online grocery shopping in a nationally representative sample and describe demographic correlates with online grocery shopping.

The Nielsen COVID-19 Shopper Behavior Survey was administered to a subset of Nielsen National Consumer Panel participants in July 2020. We used survey weighted-multivariable logistic regression to examine demographic correlates of having ever online grocery shopped.

Online survey.

18 598 Nielsen National Consumer Panel participants in the USA.

Thirty-nine percent of respondents had purchased groceries online, and among prior purchasers, 89 % indicated that they would continue to online grocery shop in the next month. Canned/packaged foods were the most shopped for grocery category online, followed by beverages, fresh foods and lastly frozen foods. In adjusted analyses, younger respondents (39 years or less) were more likely (47 %) to have ever shopped for groceries online than older age groups (40–54 years, 55–64 years and 65+ years) (29 %, 22 % and 23 %, respectively, all P < 0·001). Those with greater than a college degree were more likely to have ever grocery shopped online (45 %) than respondents with some college education (39 %) and with a high school education or less (32 %) (both P < 0·001). Having children, having a higher income and experiencing food insecurity, particularly among higher income food-insecure households, were also associated with a higher probability of prior online grocery shopping.

The COVID-19 pandemic accelerated the transition to online grocery shopping. Future research should explore the nutrition implications of online grocery shopping.

To examine associations of school food availability with student intake frequency and BMI, and whether the number of neighbourhood food outlets modifies these associations.

Baseline assessment of a nationally representative cohort study of US 10th graders. Students reported intake frequency of fruits and vegetables (FV), snacks and soda. BMI was calculated from measured height and weight. Administrators of seventy-two high schools reported the frequency of school availability of FV, snacks and soda. The number of food outlets within 1 km and 5 km were linked with geocoded school addresses. Data were analysed using adjusted linear and logistic mixed models with multiple imputation for missing data.

US 2009–2010.

Totally, 2263 US 10th graders from the Next Generation Health Study (NEXT).

Greater school FV availability was positively associated with student FV intake. Food outlets within 5 km of schools (but not 1 km) attenuated the association of school FV availability with student intake; this was no longer significant at schools with > 58 food outlets within 5 km. School food availability was not associated with student BMI or student snack or soda intake.

School food availability was associated with student intake of FV, but not with snacks, soda or BMI. Attenuation of the observed associations by the school neighbourhood food environment indicates a need to find ways to support healthy student eating behaviours in neighbourhoods with higher food outlet density.

Characterising meat consumption in Switzerland across socio-demographic, lifestyle and anthropometric groups.

Representative national data from the menuCH survey (two 24-hour dietary recalls, anthropometric measurements and a lifestyle questionnaire) were used to analyse the total average daily intake of meat and main meat categories. Energy-standardised average intake (g/1000 kcal) was calculated and its association with 12 socio-demographic, lifestyle and anthropometric variables was investigated using multivariable linear regression.

Switzerland.

Totally, 2057 participants aged 18–75 years.

Average total meat intake was 109 g/d, which included 43 g/d of processed meat, 37 g/d of red meat and 27 g/d of white meat. Energy-standardised meat intake was highest for men, the Italian-language region and the youngest age group (18–29 years). Regression results showed significantly lower total meat and red meat consumption (g/1000 kcal) for women than men. However, there were no sex-specific differences for white meat. Total meat and white meat consumption were positively associated with the 18–29 age group, compared with 30–44 years, non-Swiss compared with Swiss participants and one-parent families with children compared with couples without children. Consumption of all categories of meat showed positive associations for BMI > 25 kg/m2 compared with BMI 18·5–25 kg/m2 and for French- and Italian-language regions compared with German-language region.

The current study reveals that there are significant differences in the amounts and types of meat consumed in Switzerland, suggesting that evidence-based risks and benefits of these categories need to be emphasised more in meat consumption recommendations.

This study investigated associations between types and food sources of protein with overweight/obesity and underweight in Ethiopia.

We conducted a cross-sectional dietary survey using a non-quantitative FFQ. Linear regression models were used to assess associations between percentage energy intake from total, animal and plant protein and BMI. Logistic regression models were used to examine the associations of percentage energy intake from total, animal and plant protein and specific protein food sources with underweight and overweight/obesity.

Addis Ababa, Ethiopia.

1624 Ethiopian adults (992 women and 632 men) aged 18–49 years in selected households sampled using multi-stage random sampling from five sub-cities of Addis Ababa.

Of the surveyed adults, 31 % were overweight or obese. The majority of energy intake was from carbohydrate with only 3 % from animal protein. In multivariable-adjusted linear models, BMI was not associated with percentage energy from total, plant or animal protein. Total and animal protein intake were both associated with lower odds of overweight/obesity (OR per 1 % energy increment of total protein 0·92; 95 % CI: 0·86, 0·99; P = 0·02; OR per 1 % energy increment of animal protein 0·89; 95 % CI: 0·82, 0·96; P = 0·004) when substituted for carbohydrate and adjusted for socio-demographic covariates.

Increasing proportion of energy intake from total protein or animal protein in place of carbohydrate could be a strategy to address overweight and obesity in Addis Ababa; longitudinal studies are needed to further examine this potential association.

To identify determinants of egg consumption in infants and young children aged 6–23·9 months in Ethiopia.

Data used were from the cross-sectional baseline survey of an egg campaign in Ethiopia implemented by the Global Alliance for Improved Nutrition.

Children aged 6–23·9 months (n 453) were sampled. Data on socio-demographic characteristics, economic resources, caregiver’s behaviour, child health and feeding practices, and egg consumption in the last 7 d were collected using interviewer-administered questionnaires. Multivariable ordinal logistic regression was used to examine the association between explanatory variables and egg consumption in the last 7 d.

About half of children (53·4 %) did not consume eggs in the last 7 d. The odds of children consuming eggs were 4·33 (P < 0·002) times higher when their caregivers had some college education compared with no education. Wealth was positively (OR, 1·13, P = 0·029) and household food insecurity was negatively (OR, 0·96, P = 0·117) associated with child egg consumption. Purchasing eggs (OR, 9·73, P < 0·001) and caregiver’s positive behavioural determinants (OR, 1·37, P = 0·005) were associated with child egg consumption. The associations of socio-demographic characteristics and economic resources with egg consumption provide evidence of partial mediation through caregiver behaviour and child health.

About half of children aged 6–23·9 months consumed eggs. Availability of eggs in households, mainly through purchase, was strongly associated with egg consumption. Education of caregivers and household heads and economic resources were associated with egg consumption and may operate through caregiver behaviour.

To assess the relationship between market concentration and diversity, as indicators of market structure, and the healthiness of food and beverage sales across Europe.

Market share (MS) data per country were used to calculate market concentration, assessed by the four-firm concentration ratio and market diversity, and by the number of companies with ≥1 % MS and the number of companies uniquely present in one European country. The healthiness of food sales was assessed by applying the NOVA classification (level of processing). Simple and multiple linear regressions were performed to assess the relationship between market concentration, diversity and the healthiness of food and beverage sales.

The European single market.

The twenty-seven European single market member states for which Euromonitor sales data were available at the most fine-grained Euromonitor packaged food and non-alcoholic beverage product subcategory level.

Increased market concentration with a country and a product category fixed effect significantly predicted increased sales of ultra-processed packaged food products. There was insufficient data variability in the level of processing of non-alcoholic beverage product categories to formulate conclusions for non-alcoholic beverages. Increased market diversity in turn significantly predicted reduced country-level sales of ultra-processed products.

The results indicated a relationship between market structure and the healthiness of packed food products sold on the European market. However, more research with detailed nutritional data is warranted to document and quantify this interaction.

To examine the demographic and lifestyle characteristics related to the dietary inflammatory index (DII™) score and to evaluate the association between DII score and disability among older people in Japan.

Cross-sectional design. The DII score was calculated from nutrient intake information obtained from a FFQ. Disability was assessed using the Tokyo Metropolitan Institute of Gerontology Index of Competence questionnaire. Overall disability and disability in each component of everyday competence, that is, instrumental activities of daily living (IADL), intellectual activities and social participation, were assessed. Those with a deficit in one or more activities were defined as disabled.

Five non-urban areas in Japan.

A total of 1642 Japanese older people aged 65 years or older.

Women, residents of Oga-shi, and those with a higher education and greater frequency of shopping followed a more anti-inflammatory diet, while those living alone and residents of Minamiawaji-shi had higher dietary inflammation. A pro-inflammatory diet was associated with higher odds of overall disability and disability in each component of competence: overall disability, OR (95 % CI) = 1·26 (1·16, 1·36); IADL disability, OR (95 % CI) = 1·16 (1·07, 1·26); disability in intellectual activities, OR (95 % CI): 1·30 (1·20, 1·40); and disability in social participation, OR (95 % CI) = 1·20 (1·11, 1·29).

Sex, living alone, education, frequency of shopping and area of residence were shown to be determinants of DII score in Japanese older people. DII score was positively associated with disability.

To investigate perceptions of iTaukei Fijian women and men around diet and the ability to consume a healthy diet.

Six focus groups were conducted with women and men separately. Six to ten women and men participated in each group. Discussions were recorded, transcribed, translated and thematically analysed. Themes were mapped to an intersectionality framework to aid interpretation.

Four villages in Viti Levu, Fiji.

Twenty-two women and twenty-four men.

Seven overarching themes were identified, including generational changes in food behaviour, strong-gendered beliefs around food and food provision, cultural and religious obligations around food, the impact of environmental change on the ability to consume a healthy diet, perceptions of the importance of food, food preferences and knowledge. Participants across focus groups identified that it was the ‘duty’ of women to prepare food for their families. However, some women reflected on this responsibility being unbalanced with many women now in the formal workforce. Changes between generations in food preferences and practices were highlighted, with a perception that previous generations were healthier. Power dynamics and external factors, such as environmental changes, were identified by women and men as crucial influences on their ability to eat a healthy diet.

Embedded traditional perceptions of gendered roles related to nutrition were misaligned with other societal and environmental changes. Given factors other than gender, such as broader power dynamics and environmental factors were identified as influencing diet, viewing nutrition-related issues through an intersectional lens is important to inform equitable food policy in Fiji.

The double burden of malnutrition (DBM) has become an emerging public health issue in many low- and middle-income countries. This study aims to provide important evidence for the prevalence of different types of DBM at the national and subnational levels in Bangladesh.

The study utilised data from the latest Bangladesh Demographic and Health Survey (BDHS) 2017–2018. Multivariable logistic regression was performed to identify the sociodemographic factors associated with DBM.

Nationally representative cross-sectional survey.

8697 mothers aged 15 to 49 years with <5 children.

The overall prevalence of the DBM was approximately 21 %, where the prevalence of overweight mother (OWM) & stunted child/wasted child/underweight child (SC/WC/UWC) and underweight mother (UWM) & overweight child (OWC) was 13·35 % and 7·69 %, respectively, with a higher prevalence among urban households (OWM & SC/WC/UWC = 14·22 %; UWM & OWC = 10·58 %) in Bangladesh. High inequality was observed among UWM & OWC dyads, concentration index (CI) = -0·2998, while low level of inequality of DBM were observed for OWM & SC (CI = 0·0153), OWM & WC (CI = 0·1165) and OWM & UWC (CI = 0·0135) dyads. We observed that the age and educational status of the mother, number of children, fathers’ occupation, size and wealth index of the household, and administrative division were significantly associated with all types of DBM.

Health policymakers, concerned authorities and various stakeholders should stress the prevalence of DBM issues and take necessary actions aimed at identifying and addressing the DBM in Bangladesh.

The prevalence of obesity among pre-school-aged children in the USA remains unacceptably high. Here, we examine the impact of Healthy Caregivers-Healthy Children (HC2) Phase 2, a childcare centre (CCC)-based obesity prevention intervention on changes in the CCC nutrition and physical activity environment over 2 school years.

This was a cluster-randomised trial with twelve CCC receiving the HC2 intervention arm and twelve in the control arm. The primary outcome was change in the Environment and Policy Assessment and Observation (EPAO) tool over 2 school years (Fall 2015, Spring 2016 and Spring 2017). Changes in EPAO physical activity and nutrition score were analysed via a: (1) random effects mixed models and (2) mixed models to determine the effect of HC2 v. control.

The study was conducted in twenty-four CCC serving low-income, ethnically diverse families in Miami-Dade County.

Intervention CCC received (1) teachers/parents/children curriculum, (2) snack, beverage, physical activity, and screen time policies, and (3) menu modifications.

Two-year EPAO nutrition score changes in intervention CCC were almost twice that of control CCC. The EPAO physical activity environment scores only slightly improved in intervention CCC v. control CCC. Intervention CCC showed higher combined EPAO physical activity and nutrition scores compared to control CCC over the 2-year study period (β = 0·09, P = 0·05).

Obesity prevention programmes can have a positive impact on the CCC nutrition environment and can promote healthy weight in early childhood. CCC may need consistent support to improve the physical activity environment to ensure the policies remain intact.