Catherine Wright

Background: Human milk feeding and breastfeeding are the recommended standards for infant feeding. Nevertheless, breastfeeding rates in the United States remain below target levels, with disparities across racial, ethnic, and income groups. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) plays a substantial role in reducing these disparities by providing lactation support to individuals with low income. With ongoing WIC modernization efforts, there is an opportunity to create and optimize technology solutions responsive to WIC participants’ and staff’s needs to increase access to the program and its services. Objective: This study aimed to describe the development and pilot testing of Daily Drop, a gamified, low-bandwidth mobile app to provide human milk feeding education and support for WIC participants. Methods: Guided by the 5-stage model for comprehensive research on telehealth, Daily Drop underwent 3 stages: concept development, service design, and preimplementation. Using a mixed methods approach, the project team sought feedback from WIC leadership and staff at the state and local levels, state IT staff, and WIC participants at each stage. Suggestions from stages 1 and 2 were incorporated into the testable app before field testing (stage 3). During field testing, participants and staff completed surveys across multiple time points and qualitative interviews to evaluate the app’s feasibility, usability, and acceptability. Quantitative data were analyzed using descriptive statistics, and qualitative data were thematically analyzed. Results: Key feedback from WIC participants and staff included providing flexibility for a variety of human milk feeding approaches (stage 1); and providing easily accessible educational information throughout gameplay, diversifying progress tracking to emphasize knowledge growth and expertise development, and including supportive or affirming messages for users (stage 2). During field testing (stage 3), >67% of WIC participants agreed with 7 out of 12 acceptability, satisfaction, and usability questions about the app, reiterated in interviews where they highlighted the simplicity of the app and how it increased their confidence to feed human milk. However, barriers to app use included a lack of reminders and repetitive information for parents with previous human milk feeding experience. Similarly, for WIC staff, mean scores for acceptability and feasibility were 3.8 (SD 1.0) and 4.4 (SD 0.6), respectively (max 5) at the early phase, but these scores declined over time. Staff recommendations included providing further, in-depth training to increase their familiarity with the app and reporting, and integrating the reports into WIC’s management information system. Conclusions: The development of Daily Drop followed an agile development, co-design approach with the involvement of relevant key partners at all stages of development. Overall, Daily Drop was deemed acceptable, usable, and engaging by WIC participants and staff. Future research could focus on testing its effectiveness in improving human milk feeding behaviors and cost-effectiveness.

BACKGROUND Human milk feeding and breastfeeding are the recommended standards for infant feeding. Nevertheless, breastfeeding rates in the United States remain below target levels, with disparities across racial, ethnic, and income groups. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) plays a substantial role in reducing these disparities by providing lactation support to individuals with low income. With ongoing WIC modernization efforts, there is an opportunity to create and optimize technology solutions responsive to WIC participants’ and staff’s needs to increase access to the program and its services. OBJECTIVE This study aimed to describe the development and pilot testing of Daily Drop, a gamified, low-bandwidth mobile app to provide human milk feeding education and support for WIC participants. METHODS Guided by the 5-stage model for comprehensive research on telehealth, Daily Drop underwent 3 stages: concept development, service design, and preimplementation. Using a mixed methods approach, the project team sought feedback from WIC leadership and staff at the state and local levels, state IT staff, and WIC participants at each stage. Suggestions from stages 1 and 2 were incorporated into the testable app before field testing (stage 3). During field testing, participants and staff completed surveys across multiple time points and qualitative interviews to evaluate the app’s feasibility, usability, and acceptability. Quantitative data were analyzed using descriptive statistics, and qualitative data were thematically analyzed. RESULTS Key feedback from WIC participants and staff included providing flexibility for a variety of human milk feeding approaches (stage 1); and providing easily accessible educational information throughout gameplay, diversifying progress tracking to emphasize knowledge growth and expertise development, and including supportive or affirming messages for users (stage 2). During field testing (stage 3), >67% of WIC participants agreed with 7 out of 12 acceptability, satisfaction, and usability questions about the app, reiterated in interviews where they highlighted the simplicity of the app and how it increased their confidence to feed human milk. However, barriers to app use included a lack of reminders and repetitive information for parents with previous human milk feeding experience. Similarly, for WIC staff, mean scores for acceptability and feasibility were 3.8 (SD 1.0) and 4.4 (SD 0.6), respectively (max 5) at the early phase, but these scores declined over time. Staff recommendations included providing further, in-depth training to increase their familiarity with the app and reporting, and integrating the reports into WIC’s management information system. CONCLUSIONS The development of Daily Drop followed an agile development, co-design approach with the involvement of relevant key partners at all stages of development. Overall, Daily Drop was deemed acceptable, usable, and engaging by WIC participants and staff. Future research could focus on testing its effectiveness in improving human milk feeding behaviors and cost-effectiveness.

Nutrition plays an important role in proper physical and cognitive functioning. However, there is limited evidence on the relationship between overall diet, cognition, and academic success in children, particularly among low-income and diverse groups. The objective of this study was to examine the relationships between healthful versus less healthful food group intake, cognitive performance, and academic achievement in a diverse sample of schoolchildren. 868 urban schoolchildren (age 8 to 10 years) participated in the study. Intake of healthful (fruits, vegetables, unsweetened beverages) and less healthful (sweet and salty snacks, sugar-sweetened beverages) food groups was determined via a food frequency questionnaire. Digit Span and Stroop test scores were used to assess cognitive performance. Academic achievement was assessed via standardized test scores. Multiple Poisson and multiple linear regression were used to test the associations between diet and cognitive scores. Multiple ordered logistic regression was used to assess the associations between diet and academic achievement. Potential confounders (age, sex, body mass index (BMI) z-score, race/ethnicity, English language learner status, individualized education plan enrollment, physical activity, and parent education level) were tested for inclusion in all models. The sample included 868 children (56.7% girls; 33.2% non-Hispanic white, 26.2% Hispanic, 17.1% multiracial/other, 8.3% non-Hispanic black; 40.5% overweight/obese). The most frequently consumed foods were fruits and sweet snacks (1.9 and 1.6 servings per day, respectively). There were no statistically significant associations between diet and cognitive test scores. Greater intake of less healthful food groups (sweet snacks, salty snacks, and sweetened beverages) was associated with lower math (OR = 0.91, CI [0.84, 0.98], p = 0.014) and English standardized test scores (OR = 0.87, CI [0.80, 0.94, p = 0.001). Greater intake of sweet snacks and fruits was associated with lower English scores (OR = 0.72, 95% CI [0.59, 0.88] p = 0.001; and OR = 0.75, 95% CI [0.72, 0.94] p = 0.003, respectively). Consumption of less healthful food groups was associated with poorer academic achievement. Further research may shed light on unexpected associations between fruit consumption and achievement. Policies targeting multiple dietary components may positively influence child academic achievement and development.

Increasing children’s physical activity (PA) at school is critical to obesity prevention and health promotion. Implementing novel, low-cost PA programs offers potential to contribute to children’s in-school PA, particularly in resource-constrained schools. This evaluation describes implementation fidelity, reach, and dose of two PA programs in the Fueling Learning through Exercise (FLEX) Study. Thirteen diverse, low-income Massachusetts elementary schools were recruited and randomized to the 100 Mile Club walking/running program (n = 7) or CHALK/Just Move classroom activity break PA program (n = 6). Intervention programs were delivered across two school years. Surveys with program champions/teachers and children, in-session measurement of children’s PA by accelerometry (Actigraph GT3X) in a subset of schools, and key informant interviews were used to collect information on implementation, including fidelity, dose, reach, and sustainability, and to calculate an implementation score. Six CHALK/Just Move schools implemented the program in both years. Two schools randomized to 100 Mile Club did not implement at all, and only three schools implemented both years. Implementing schools had similar implementation scores (range = 0–3; 100 Mile Club = 2.0 vs. CHALK/Just Move = 1.9) but fidelity to core and enhanced elements differed between programs. In 100 Mile Club schools, dose of program delivered was greater than in CHALK/Just Move schools (34.9 vs. 19.7 min per week). Dose of PA received per session was also greater in 100 Mile Club schools (n = 55, 2 schools) compared with CHALK/Just Move schools (n = 160, 2 schools) (13.6 min vs. 2.7 min per session). A slightly higher proportion of eligible children participated in CHALK/Just Move compared to 100 Mile Club (54.0% vs. 31.2%). Both programs were well received by champions/teachers and students. Program implementation varied across programs and schools, and erosion in delivery was seen over the two years. However, among implementing schools, additional PA was delivered and received, and the programs were generally well-received. Although school resource issues remain barriers to implemention, this evaluation demonstrates that low-cost programs may enhance PA opportunities. Future research should evaluate how multiple programs can be implemented to increase children’s PA at school. ClinicalTrials.gov Identifier: NCT02810834 . Registered May 11, 2015.

BACKGROUND: A supportive school‐based physical activity environment (PAE) is integral to children's physical activity behaviors, but less understood is its association with academic achievement. We aimed to assess the association between PAE and academic performance and whether a stronger relationship exists in lower‐income schools (LIS) compared to middle‐income schools (MIS).METHODS: Schoolchildren (grades 3rd to 5th) were recruited from 17 Massachusetts public schools. Schools were classified based on geographic characteristics and free/reduced‐price lunch (FRPL) eligibility (LIS = 7, Median FRPL = 86%; MIS = 10, Median FRPL = 20%). PAE was measured using a 10‐item survey. Mixed‐effects logistic regression models were used to examine associations between PAE and scoring Advanced/Proficient on standardized Math and English Language Arts (ELA) tests.RESULTS: Demographic characteristics differed between LIS (N = 278, 5% non‐Hispanic white) and MIS (N = 297, 73% non‐Hispanic white). In LIS, PAE was associated with Math (odds ratio = 5.40, 95% CI = 2.52‐11.54 p < .001), but not ELA test scores (p > .05). There was no relationship between PAE and MIS test scores (p > .05). Schooltime moderate‐to‐vigorous physical activity was not associated with test scores (p > .05).CONCLUSIONS: A beneficial relationship exists between a high‐PAE and test scores among LIS children, suggesting that the PAE may be associated with a more supportive environment and may be more fundamentally important for lower‐income students.

Although there are several valid and reliable dietary screeners to measure child intake patterns, there is a paucity of brief assessment tools targeting under- and overconsumed foods. To compare the Fueling Learning through Exercise study (FLEX) dietary questionnaire, a screener designed to assess consumption patterns in third to fifth graders, to a validated dietary assessment tool. The FLEX dietary questionnaire was developed to assess fruit, vegetable, snack, and beverage consumption and was compared to the Block Kids Food Screener (BKFS). Correlations were analyzed using Pearson correlation coefficient. Agreement was assessed using Bland-Altman plots. The sample (n = 63) had mean age of 9.9 years (SD 0.7). Most participants were non-Hispanic white (70%) and eligible for free/reduced price lunch (57%). Correlations between food group categories were significant for all groups (P < .05) except fruits (r = 0.51) and sugar-sweetened beverages (SSBs) (r = 0.21). We found moderate-to-strong correlations between reported vegetable, salty snack, sweet snack, total beverage, milk, and fruit juice consumption (0.62, 0.59, 0.69, 0.47, 0.48, and 0.46, respectively). The FLEX screener reported systematically higher mean servings per day (0.24-1.1) compared to the BKFS (0.05-0.51). Based on these correlations, the FLEX dietary questionnaire performs similarly to a validated tool in assessing intake of under- and overconsumed food groups in a diverse third to fifth grade population. Overall serving size discrepancies are likely due to more relevant food items on the FLEX questionnaire and a more child-friendly format. This study highlights the need to update older diet screeners to reflect current child consumption patterns.

Physical activity (PA) is critical to preventing childhood obesity and contributes to children’s overall physical and cognitive health, yet fewer than half of all children achieve the recommended 60 min per day of moderate-to-vigorous physical activity (MVPA). Schools are an ideal setting to meeting PA guidelines, but competing demands and limited resources have impacted PA opportunities. The Fueling Learning through Exercise (FLEX) Study is a randomized controlled trial that will evaluate the impact of two innovative school-based PA programs on children’s MVPA, cognitive function, and academic outcomes. Twenty-four public elementary schools from low-income, ethnically diverse communities around Massachusetts were recruited and randomized to receive either 100 Mile Club® (walking/running program) or Just Move™ (classroom-based PA program) intervention, or control. Schoolchildren (grades 3–4, approximately 50 per school) were recruited to participate in evaluation. Primary outcome measures include PA via 7-day accelerometry (Actigraph GT3X+ and wGT3X-BT), cognitive assessments, and academic achievement via state standardized test scores. Additional measures include height and weight, surveys assessing psycho-social factors related to PA, and dietary intake. School-level surveys assess PA infrastructure and resources and intervention implementation. Data are collected at baseline, mid-point (5–6 months post-baseline), and post-intervention (approximately 1.5 years post-baseline). Demographic data were collected by parents/caregivers at baseline. Mixed-effect models will test the short- and long-term effects of both programs on minutes spent in MVPA, as well as secondary outcomes including cognitive and academic outcomes. The FLEX study will evaluate strategies for increasing children’s MVPA through two innovative, low-cost, school-based PA programs as well as their impact on children’s cognitive functioning and academic success. Demonstration of a relationship between school-based MVPA with neutral or improved, rather than diminished, academic outcomes in a naturalistic environment has the potential to positively influence investment in school PA programs and initiatives. ClinicalTrials.gov Identifier: NCT02810834 . Registered May 11, 2015. (Retrospectively registered)