THE EFFECT OF A FAMILY-BASED DIETARY INTERVENTION ON DIETARY FIBER DENSITY IN CHILDREN AGES 6-11

Background: Fiber intake has been shown to be higher in normal weight children compared to overweight and obese children. However, the effect of family-based interventions have been inconclusive. Objective: To determine if a family-based weight management intervention, which has been successful at lowering BMI Z-score, has an effect on energy adjusted dietary fiber intake and other markers of dietary quality. Methods: Sixty-six children ages 6-11 and their guardians participated in a 16 week nutrition and physical activity intervention. Guardians and children completed a food frequency questionnaire (FFQ) during the first and last sessions. The FFQ provided information about fiber, macronutrients and micronutrients. Results: Children increased fiber from 8.65±2.00g/1000kcal to 9.48±2.26g/1000kcal (p<0.001). Energy decreased from 2122.77±506.13kcals to 1889.86±425.58kcals (p<0.001).BMI Z-score decreased from 2.06±0.40 to 1.99±0.40 (p=0.003). Iron decreased from 15.18±4.06mg to 13.92±3.85mg (p=0.014), sodium decreased from 2638.38±677.93mg to 2330.14±521.85mg (p<0.001), and saturated fat decreased from 10.34±1.64% to 9.96±1.69%. Conclusion: The intervention was associated with an increase in fiber density and a reduction in energy intake, which was reflected in a decrease in BMI Z-score, without compromising micronutrient intake.


Background
In the United States obesity affects 17.7% of children ages 6 to 11 (1). Obesity can lead to the development of health problems in children including hyperinsulimia, high blood pressure, high cholesterol, asthma, and metabolic syndrome (2,3). Dietary factors have been implicated in the development of obesity and health problems in children. For example, dietary fiber intake is significantly higher in normal weight compared to overweight and obese children, but in general children's fiber intake is below recommendations (4)(5)(6). Besides fiber, children are not consuming adequate amounts of calcium, vitamin D, iron, and potassium and are consuming excess sodium, saturated fat, and added sugar (7).
A review of clinical, school, and family-based interventions assessed BMI and BMI z-score to determine if the interventions were successful at decreasing obesity risk (8). Of 24 clinical-based interventions that assessed BMI, 21 recorded a decrease, and of 21 that assessed BMI z-score 18 recorded a decrease (8). Outcomes were not as favorable for school-based interventions; 6 out of 16 found a decrease in BMI and 4 out of 6 observed a decrease in BMI z-score (8). With family-based interventions, 16 out of 17 observed a decrease in BMI and 6 out of 7 reported a decrease in BMI z-score (8). The review concluded that family-based interventions had similar success in decreasing BMI and BMI z-score as clinical-based interventions (8).
Three of the family-based intervention studies have not only assessed weight but also dietary components, including dietary fiber (9)(10)(11). However, the effect of these interventions have been inconclusive. Two studies have seen no changes in dietary fiber intake, and one study found an increase in dietary fiber intake (9)(10)(11).
Adequate dietary fiber intake is important as it has been shown to help with healthy weight maintenance (12)(13)(14). The physiological basis for the effect of fiber on energy balance regulation include three possible mechanisms. The first is through reduction in eating rate, which has been associated with a reduction in energy intake (12).
The second mechanism is related to energy lost in fecal matter (13). Isaksson et al. (13) found that more energy is lost in high-fiber rye diets than in low-fiber wheat diets. The final mechanism is substitution, high-fiber nutrient dense foods displace energy dense foods (14). One study found subjects consuming a high-fiber low calorie breakfast consumed the same amount of energy at lunch as a low-fiber high calorie breakfast group, resulting a net reduction in energy intake in the high-fiber group compared to the low-fiber group (14). In conclusion, increasing dietary fiber may be useful for maintaining a healthy body weight.
Fiber is primarily found in healthful foods such as fruits, vegetables, and whole grains. Thus fiber could be considered a marker of dietary quality (15). A healthful diet also provides adequate micronutrients, such as vitamin D, calcium, iron, and potassium, which are often low in the diets of children (7). A healthful diet should also be low in sodium, and saturated fat, which are often high in the diets of children (7). In addition, according to NHANES 2005-2008 data, individuals consuming lower amounts of calcium and vitamin D had higher rates of adiposity (16). Consuming low amounts of calcium and vitamin D can also lead to lower bone mineral density, low intakes of iron is related to poor cognitive function, excessive intake of sodium and inadequate potassium intake can lead to hypertension, and high intakes of saturated fat can lead to dyslipidemia and cardiovascular disease (17)(18)(19)(20)(21).
The purpose of this study was to determine if the family-based intervention program South County Food Fitness and Fun (SCFFF), which had been found to reduce BMI z-score in overweight and obese children over two years (22), was associated with an improvement in the density of dietary fiber intake and an improvement in dietary quality assessed by vitamin D, calcium, iron, potassium, sodium, and saturated fat.

D. Methodology
This study was a descriptive secondary analysis focusing on dietary changes (grams of fiber intake per 1000 kilocalories, intake of energy, calcium, vitamin D, potassium, sodium, and saturated fat) from baseline to post SCFFF assessments. In addition, anthropometrics including BMI z-score was assessed to determine if the program was successful in the prevention of excess weight gain. The study was approved by the University of Rhode Island Internal Review Board. All participating parents signed consent forms and all children signed assent forms.

Sample
SCFFF participants were eligible for the study if the child was between the ages of 6-11, had a BMI ≥85th percentile for age, at least one parent/guardian could attend, were referred by a physician, and had no medical condition requiring a specialized diet.
The children resided in the South County region of Rhode Island. There was a total of 106 who signed consent and assent forms to participate in the intervention between whole grains, choosing healthier fats, animal and plant based sources of protein, the energy sodium, fat, and sugar in fat and processed foods, the importance of dairy, and family meals, healthy snacks vs. treats, and decreasing sugar sweetened beverages.

Dietary Assessment
The  (24,25). Recommend intakes used for assessment were based on the Committee of the Dietary Guidelines for Americans and the National Academy of Science (26,27).

Anthropometric Measurements
Height and weight was obtained using a TANITA Corporation balance-beam physician's scale and stadiometer (model 08110136, Tokyo, Japan). The same pediatrician measured height and weight at the first and last session. The child's date of birth and gender were recorded during measurements. BMI z-score was computed using The Children's Hospital of Philadelphia Pediatric Z-score calculator, which is based on the Center for Disease Control (CDC) growth charts (28,29).

Analysis
All variables were assessed to determine if the data were normally distributed.
Baseline dietary data was compared between non-completers (n=18) and completers of the second FFQ (n=66) using independent t-tests. The primary outcome analysis was a multivariate repeated measures Analysis of Variance assessing within subject changes between baseline and post intervention in fiber(g/1,000 kcal), energy intake (kcal) percentage of energy from saturated fat, calcium(mg), iron(mg), potassium(mg), sodium(mg), and vitamin D(mcg). Significant multivariate analyses were followed by univariate analyses were conducted to determine changes between baseline and post intervention for each variable. Because of the reduction in sample size for added sugar, a second analysis including added sugar was conducted using the same procedure. A multivariate repeated measures Analysis of Variance was also conducted on exploratory variables related to fruit, vegetable and whole grain intake (carotene (IU), folic acid (mcg), vitamin E (mg), vitamin C (mg), vitamin B 6 (mg), phosphorus (mg), magnesium (mg), folate (mcg), and vitamin A (IU)). Significant multivariate analysis was followed by univariate analyses to determine changes between baseline and post for each variable.
A probability value of p<0.05 was utilized for the above analyses. Analysis of the children meeting recommendations was performed using paired t-tests with the Bonferroni procedure to correct alpha, thus p<0.003 was determined to be significant.
Analysis of covariance was used to determine if gender and age affected outcomes. All data was analyzed using IBM SPSS Statistics Version 20 (IBM Corporation, Armonk, NY).

Results
The average age of participants was 8.6±1.3 years and they attended 90% of the classes on average. More participants were female (62.1%) than were male (37.9%).
Height and weight increased from baseline to post, while BMI z-score decreased (p=0.003) indicating the program was successful for weight management. Information on anthropometrics can be found in No other differences between completers and non-completers were found.
There were no changes in calcium, vitamin D, and potassium between baseline and post.
This data can be found in Table 2 F=1.85 (9,57) ; p=0.08). Descriptive data are available in Table 3.
Looking at dietary adequacy as percentage of recommendations at baseline, fiber, potassium and vitamin E were below recommendations, sodium and saturated fat were above recommendations and added sugar met recommendations. The proportion of recommendations increased for fiber density (p<0.05). Sodium (p<0.05), and vitamin E (p=0.05) decreased from baseline to post. Results are displayed in Table 4.

Macronutrient Intake
Protein, as a percent of energy, increased (p<0.001) and fat, as a percent of energy, decreased (p=0.016) between baseline and post while carbohydrates did not change. Despite changes, macronutrients were in recommended ranges at both baseline and post intervention. Results are in Table 5.

Discussion
Children completing this family-based program decreased weight gain velocity, determined by BMI z-score, over 2 years (22). This study also found a significant decrease in BMI z-score from baseline to post, without affecting normal height and weight gain expected in children. This decrease in BMI z-score coincided with a decrease in energy intake. Despite the change in energy intake, children increased fiber density, decreased sodium and saturated fat, and maintained diet quality for calcium, vitamin D, iron, and potassium.
Children in this study were not meeting recommendations for fiber (14g/1000kcal) at baseline or post, however, they significantly increased intake by 0.84g/1000kcal to 9.5g/1000kcal (7). This increase is greater than previous studies. Of the 3 family-based intervention studies that looked at fiber intake two reported no change in intake (9,10). Program Obesity Zero (POZ), a non-randomized study of children ages 6-10, reported an increase in fiber of 0.20g/1000kcal (11). However, there was a difference in dietary assessment as SCFFF used FFQ while POZ used two 24-hour recalls (11).
Although children in SCFFF were only consuming 67.8% of recommended fiber at the end of the study, previous research in a large sample of children found a decrease in fiber density of about 3g/1000kcal was associated with a 21% increase in adiposity (5).
Therefore, even though the increase in fiber density was small, it is possible that it contributed to the successful weight regulation observed in this study, though future research needs to be conducted.
Most other family-based studies have assessed dietary quality based on servings of food groups or types of foods (9,11,30). This study was one of the few that assessed micronutrients. Sodium, saturated fat, and added sugar decreased, consistent with Dietary Guideline recommendations, indicating an improvement in quality (7). Other child intervention studies have not seen similar decreases in sodium, saturated fat and added sugar (9)(10)(11)31). The decrease in sodium and added sugar may be associated with a reduction in processed and convenience foods as well as sugar sweetened beverages, which are energy dense and may contribute to weight gain (32,33).
Participants in this study were meeting the recommendations for macronutrients and micronutrients, except for fiber, potassium, and vitamin E, both at baseline and follow-up (26,27). However, children were consuming higher amounts of dietary fiber, potassium, and vitamin E (4.8g/1000kcal, 1909mg, and 3.5mg respectively) than the national average (34). It may be beneficial for future intervention programs for overweight children to emphasize more the importance of increasing fruits, vegetables, whole grains, legumes, nuts and seeds which contain fiber, potassium, and vitamin E (35).
There are a few limitations to this study. The first is the FFQ is validated in children ages 9-18 self-completing the questionnaire (36). For this study, parents of children ages 6-11 complete the questionnaire, with the assistance of their children (36).
The FFQ also assessed intake over the period of one year, but the time between the two assessments was only 4 months. However, FFQ instruments in general tend to be more representative of the previous month than the previous 12 months (37). Significant changes were observed in this study demonstrating the FFQ was sensitive to change over this period. Another limitation is that FFQs may overestimate fiber, vitamin C, calcium, and iron while under estimating saturated fat (38). The questionnaires were completed in the presence of the study instructors which could bias results (39). The FFQ also did not quantify food groups which limits comparison with other studies. However, reporting on micronutrients allows us to assess overall diet quality which is a strength of this study (15). This study also lacked a control group; therefore, even though there were changes seen during the intervention, it isn't possible to determine if there were outside factors that were causing the changes. Changes in physical activity were not assessed, and may be another explanation for the decrease in BMI z-score. Another limitation is that added sugar was not available for the first year, but we found a significant reduction in a multivariate analysis of the subsample. Finally, there was no follow-up dietary data at the 1 year or 2 year follow-up to assess maintenance of dietary changes, though the decrease in BMI z-score at two years suggests that healthful changes have continued (22).
This successful family-based intervention was able to increase dietary fiber intake and retain diet quality while decreasing energy intake and BMI z-score. This study indicates that family-based interventions may be useful in helping combat childhood obesity without sacrificing dietary quality. Further research is needed to determine if dietary changes are retained over long term and if increasing fiber intake will effect BMI z-score in the long term in overweight and obese children.

Conflicts of Interest
The authors of the study have worked closely with the South County Food Fitness and Fun program and one author received support from the program.      Both environmental and genetic factors can play a role in the development of childhood obesity, which can lead to a variety of health problems in children (40)(41)(42)(43)(44)(45)(46)(47)(48)(49). Adequate dietary fiber intake has been shown to reduce obesity risk (4)(5)(6). A healthful diet provides enough Vitamin D, calcium, iron and potassium, but should be low in sodium, saturated fat, and added sugars (7). These nutrients have been shown to be inadequate in children (7). Few studies have shown a change in fiber density intake during community-based weight management interventions for children or have looked at micronutrient distributions (9)(10)(11). This review will discuss the cause and effects of obesity in children, the effects of fiber intake on weight, micronutrient adequacy of children, and the effects of interventions on weight, fiber intake and diet quality in children.

Obesity
About 31.8% of all children ages 2-19 years old were overweight and obese in 2012, and 17.7% of 6-11 years olds were classified as obese (1). Obesity in children has been related to environmental and genetic factors. Environmental factors related to obesity include family dynamics, the type and amount of food outlets available, and screen time (40)(41)(42)(43)(44)(45)(46). Genetic factors have also been shown to play a role in obesity.
Satiety mechanisms like the hormone leptin have been shown to effect obesity genetically (49). Obesity in children can lead to hyperinsulimia, high blood pressure, high cholesterol, asthma, and metabolic syndrome (2,3). Children who are obese are more likely to be obese adults and if overweight during childhood, obesity in adulthood is likely to be more severe (50).  old with a randomly selected twin from the Twin Early Development Study. The researchers genotyped (SNPs and selected those that were associated with increase obesity risk and from here assign a genetic predisposition score (PRS). They measured adiposity by BMI SD score (similar to BMI Z-score) and waist circumference SD score.

Causes of Obesity
In addition, they also measured satiety responsiveness by a 6-item version of the  (48). Environmental factors currently explain more of the variance in obesity than specific genetic markers (48).

Consequences of Obesity
It is important to focus on decreasing obesity in children due to the adverse effects of obesity on health. Studies have indicated higher fat mass in children can lead to elevated blood pressure, diabetes, non-alcoholic fatty liver disease, metabolic syndrome, and asthma in children. Fat mass was determined using a Dual-energy X-ray absorptiometry. Blood samples were obtained after a 12 hour fast and were analyzed for triglycerides, total cholesterol, highdensity lipoprotein cholesterol, low-density lipoprotein cholesterol, insulin and glucose.
Blood pressure was measured using an electronic device validated in pediatric populations. Ultrasound was used to determine SCAT and AFLD and MS was determined by the World Health Organization standards. Both genders had a high prevalence of MS. High SCAT was associated with elevated blood pressure. IAAT was positively associated with dyslipidemia and NAFLD. Although SCAT or IAAT were not associated with hyperinsulima, NAFLD was positively associated with hyperinsulima. In addition IAAT was more closely associated with MS and NAFLD than SCAT. The study found that both IAAT and SCAT were associated with higher undesirable outcomes such as elevated blood pressure, dyslipedmia, and NAFLD. This is similar to findings in adults, that a higher body fat mass is associated with MS and NAFLD. Adiposity was measured using BMI, height and weight were taken without shoes and age and sex specific percentiles were used to determine cutoff points for overweight and obesity. The OR for wheeze in relation to overweight and obesity was 1.14 (95% CI: 0.98-1.33), and 1.67 (5% CI: 1.25-2.21) respectively (3). Those who reported a dry cough at night and were woken with a tightness in the chest were more often obese. Also wheeze was associated with exercise in those who were overweight and obese. There was a lower FEV1/FVC in relation with overweight and obesity (3). There was no association of rhinitis with overweight and obesity. Eczema was only associated with obesity in affluent areas. These results indicate that overweight and obesity are associated with asthmatic symptoms and airway obstruction.
Obesity can cause increased health problems. Studies show that elevated blood pressure, non-alcoholic fatty liver disease, and asthma symptoms are more common in children with excess body weight (2,3). As overweight and obese children are more likely to be overweight and obese adults these adverse health outcomes are likely to continue and progress (50). Helping to prevent or reverse obesity in children could reduce health risks in adulthood.

Mechanism of Fiber in relation to Obesity
Adequate dietary fiber intake has been shown to reduce or maintain an individual's body weight, and a higher intake of fiber has been associated with lower body weight after controlling for energy intake (4-6). The physiological basis for the effect of fiber on energy balance regulation include several possible mechanisms. These mechanisms include eating rate, lower absorption of energy, and the displacement of higher calorie foods (12)(13)(14).
Viskaal-van Dongen et al. (12) analyzed eating rate using common foods. The 24 subjects were both men and women ages 18-35 with a normal BMI (18.5-25kg/m 2 ) who were restrained eaters and were in good physical and mental health. Subjects performed 7 test sessions that each lasted 30 minutes at lunch time. They fasted for 3 hours before the start of the session. Each session was broken into two parts. In the first part they were given 50g of the food and instructed to eat at a normal rate without pausing between bites or sips and then stop after the last bite. In the second part they were given about 2 times a large portion size, which differed per food, and were instructed to consume until completely full. Results showed that eating rate ranged even within food groups of similar viscosity. Eating rate of solids ranged from 4.2 ± 3.7g/min to 128 ± 73g/min, while semi solid foods ranged from 50 ± 36g/min to 229 ± 247g/min and for liquid foods it ranged from 305g/min to 631g/min (12). Fiber content of foods was inversely associated with eating rate indicating that higher fiber foods had a lower eating rate (β = -0.087, p=0.022, R2 = 0.52) (12).
Isaksson et al. (13) measured the difference between a high fiber rye diet and low fiber wheat diet on energy and macronutrients lost in ileal secretions in ileostomy subjects. Ten subjects, primarily men (8) who had a proctocolectomy, due to ulcerative colitis, at least 8 years prior were assessed. Each subject consumed a low fiber wheat diet for two weeks and then a high fiber rye diet for two weeks, under two conditions, either seven small meals or three larker meals per day. Each subjected consumed both diets and both conditions in a cross-over design. On day 3 of each diet/consumption pair (low fiber/seven meals, low fiber/three meals, high fiber/seven meals, low fiber/three meals) ileal secretions were measured, bomb calorimetry was used to determine energy content of excretions as well as the proportions of macronutrients. There was no differences 7 meal per day or 3 meal per day conditions so results were combined. The high fiber rye diet provided more protein, dietary fiber, total dry matter, and ash than the low fiber wheat group, but energy content was the same. In the high fiber rye diet, higher amounts of gross energy, macronutrients, ash, and total dry matter were excreted compared to the low fiber wheat diet (13). This study showed that the gross energy excretion increased from 1.4MJ/24 hours during the low fiber wheat diet to 2.4MJ/24 hour in the high fiber rye group (p<0.001). Research suggests that a higher fiber diet was associated with a decrease the amount of energy absorbed by the body regardless of energy intake (13).
Hamedani et al. (14) studied 32 health males and females between the ages of 20-26 years, with a BMI between 20.5 and 24.5kg/m 2 . In a crossover design, subjects consumed either a high fiber cereal or a low fiber cereal that were similar in weight and volume, but different in energy content. Meals were consumed between 8 and 11 am, after a 10-12 hour fast, with a standardized meal the night before. The study's subjects were instructed to consume the breakfast meal within 10 minutes. A second meal was provided 180 minutes from the first meal, consisting of 500mL of water and ad libitum pizza. Subjects were instructed to eat until comfortably full. There were no differences in the amount of food consumed at lunch time. Because high-fiber food was lower in calories, total energy intake from both meals was lower in the high fiber group (p=0.01) (14). The high fiber group felt "fuller" immediately after breakfast compared to the low fiber group (70.0±3.3 and 64.3±2.6, respectively; p=0.008) (14).
These studies provide information behind the fiber mechanisms that regulate weight. Fiber can reduce eating rate, reduce energy absorption, and reduce total caloric intake in mostly healthy subjects (12)(13)(14).

Fiber Intake in Children
Studies conducted in children have shown that children consuming higher fiber diets have a lower weight status than those consuming a lower fiber diet (5,6). These weight differences have sometimes been found without differences in energy intake and whether or not children were meeting the recommended dietary intake of fiber.
Balthazar and Oliveira (6) found that lower body weight was associated with higher intake of fiber when adjusting for energy intake. Researchers compared the differences in dietary composition and meal patterns between obese and normal weight children. The study consisted of 83 children ages 7-11 that were either obese( ≥95 th percentile for age and sex specific BMI) or normal weight (BMI value between the 5 th and 85 th percentile). Food intake for both groups was determined using two non- There was no significant difference in calcium intake between the two groups, but neither group consumed the Adequate Intake (AI), primarily related to inadequate consumption of dairy products (6). The normal weight group consumed 678.6±295.9 milligrams and the obese group consumed 613.8±295.3 milligrams (p=0.320). The authors concluded that a low intake of dietary fiber was associated with the risk of obesity.

Davis et al. (5) observed an inverse relationship between dietary fiber intake and
visceral adiposity in overweight Latino youth. There were 85 subjects, ages 8-13 years old with a BMI of ≥85 th percentile. Weight was measured using a beam scale, while height was measured using a wall mounted stadiometer. Body fat was determined using dual-energy X-ray absorpitometry and body mass was calculated from height and weight.
Dietary intake was assessed using two 24-hour diet recalls and then NDS-R was utilized to analyze intake of dietary variables including dietary fiber, total sugars, and added sugar. Results showed that decreases in dietary fiber (g/100kcal) and insoluble fiber (g/1000kcal) were associated with a higher visceral adipose tissue using partial correlation (r=-0.27; p=0.02 and r=-0.27, p=0.03 respectively) (5). Energy, protein, fat, and sugar variables were not associated with any changes in adiposity (5) This indicates that those consuming a higher fiber diet reduce their risk of overweight and obesity. The benefits of fiber intake seen here is also regardless of not meeting the 14g/1000kcal recommendation (7,27).
Dietary fiber has been shown to help with weight regulation. Studies have indicated that higher fiber diets can decrease eating rate, increase energy fecal excretion, and displace higher calorie, low fiber foods in the diet (12)(13)(14). Studies have also found that fiber intake helps reduce adiposity risk in children. Children who consume a higher fiber density are less at risk to be overweight or obese (4)(5)(6).

Dietary Inadequacies
According to the Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2015, children are not consuming adequate amounts of calcium, potassium, iron, Vitamin D and fiber and consuming excess sodium, saturated fat, and added sugar (7). Dietary fiber has been previously reviewed. Consuming inadequate amounts of calcium, potassium, and Vitamin D and excess amounts of sodium, saturated fat, and added sugar can also cause adverse health outcomes (7).
Consuming inadequate amounts of some nutrients can lead to adverse health effects. Low amounts of calcium and Vitamin D in the diet, especially in growing children, is associated with low bone mineral density (17,18). Excess intake of sodium combined with a low intake of potassium are associated with high blood pressure (19).
Excess saturated fat is associated with high cholesterol which is associated with coronary artery disease and insulin insensitivity (20,52). Diets high in added sugar are associated with excessive energy intake, elevated triglycerides, increased blood pressure, and cardiovascular disease (53,54).

Calcium
Calcium has had a positive impact on bone health, specifically bone mineral density. Cvijetic et al. (18) conducted a study on 18 adopted and 17 biological children who were around 14 years of age. Diet assessment to analyze calcium intake was done using a food frequency questionnaire during a personal interview. Bone mineral density was measured using a Dual x-ray absorptiometry. For adopted children calcium was the most significant predictor of bone mineral density in the spine (10.8%), femur (17.0%), and radius (66.1%, p<0.001) (18). In biological children calcium was also the greatest predictor of bone mineral density in the radius (54.5%, p<0.001) (18). This study shows that calcium is associated with bone mineral density in children.

Vitamin D
Vitamin D is necessary for calcium absorption. Tis is also important for bone health. A study by Pekkinen et al. (17) analyzed Vitamin D status and its association with intake and bone health. One-hundred and ninety-five Finnish children who were ages 7-19 years participated. A FFQ and 3-day food record was used to assess Vitamin D intake and Vitamin D serum levels were assessed. Dual x-ray absorptiometry was used to determine bone mineral content and bone area. There was a positive correlation between Vitamin D intake and serum levels (r=0.217, p = 0.003) (17). Vitamin D was also positively associated with bone mineral density z-scores in the lumbar spine, total hip,  (19). There was also an association with the sodium-to-potassium ratio, with an increase of 0.5 units leading to an increase of 1.05mmHq (95% CI: 0.12-1.98) (19). For diastolic pressure, for every increase in potassium by 1,000mg/day there was a decrease of 0.75 mmHg (95% CI: 0.22-1.28), while sodium had no effect (19). This study indicated that helps lower blood pressure while sodium is associated with an increase in systolic blood pressure.

Saturated Fat
Masquio et al. (20)   were not taking any medications contraindicated by the study. Diet was assessed using two 24 hour dietary recalls. Blood pressure, blood lipids, and percent body fat were taken, along with physical activity status. There was a significant positive correlation between sugar and diastolic blood pressure (β=0.0206, p=0.0462) (54). Added sugars were also positively associated with triglycerides (β=0.1090, p=0.0206) with total body fat contributing to the model (p=0.0104) (53). However systolic blood pressure and other lipid values did not have any association with added sugar. This study indicates that added sugar can raise two components, diastolic blood pressure and triglycerides, of this disease.  Participants received: individual counseling with the child and at least one parent, a 3hour family 'healthy cooking' workshop, and a school-based intervention with child sessions totaling 6-hours and parent sessions totaling 3-hours. Height, weight, and waist circumference were measured using standardized procedures and dietary intake was assessed using two 24-hour recalls (one at baseline and another at 6-months). BMI-forage percentile (p<0.001), and waist circumference (p<0.001) were significantly lower between baseline and follow-up and there was a significant increase in fiber intake from 16.7 grams to 19.2 grams (p=0.005) (11). There were no differences in energy intake. In conclusion, this study demonstrated the effectiveness of a multi-component comprehensive approach to reducing overweight and obesity (11). However, this study was school-based in contrast to SCFFF which is community based and only looked at macronutrients and energy intake and didn't look at micronutrient or total dietary quality intake.

Reference Intakes for Nutrients
Cohen et al. (9) focused on improving diet, physical activity level, and weight status of rural children based on the successful model by the Shape-Up Somerville study (55). The Shape-Up Somerville study was a non-randomized control trial of 3 communities (55). Children in grades 1-3 were recruited, and interventions within the community were developed to increase the child's everyday physical activities (55). The intervention led to decrease in BMI z-score for at least 2 years after the study concluded (55 hemoglobin A1c, quality of life, and physical activity level were also assessed. Intervention schools had a higher intake of fruit consumption (138 g vs 122g, p=0.0016) and water intake (438g vs 429g, p=0.008) at follow-up than control (31). There were no significant differences in fiber or energy, macronutrients, grains, vegetables, legumes, sweets, sweetened beverages, and high-or low-fat milk consumption between groups.
Results of interventions on weight and fiber intake have been mixed. There has been either a slight increase or no change in total fiber (9)(10)(11)31). Because most successful interventions have been associated with a reduction in energy intake, it is necessary to look energy adjusted fiber density.

Conclusion
This literature review has demonstrated that fiber intake is related to a reduced risk of obesity in children. Due to high prevalence of overweight and obesity in children, and the adverse health effects of this excess body weight, it is important to focus on ways to help prevent obesity by making appropriate dietary changes (1). Two out of the three interventions in children, that reported on dietary fiber, had a positive impact on their dietary fiber intake (9,11). However, it is clear that additional research assessing fiber density and micronutrient intake in a community-based weight management intervention is needed. This review also found that children are not consuming adequate amounts of calcium, vitamin D, iron and potassium, but are consuming excess amounts of sodium, and saturated fat, (7). Though interventions assessing micronutrient intake are limited.
The purpose of this study is to examine changes in dietary quality based on fiber intake as well as, calcium, vitamin D, iron, potassium, sodium and saturated fat.

V.
Challenge for Next Meeting: Have participants take home a blank myplate sheet and choose one meal they had during the week to draw in and color on the blank sheet. Stress the importance of trying to set up that meal according to Myplate guidelines VI.
Materials Needed: 1. Dry Erase Board with markers and eraser 2. Journals/notebooks (10)(11)(12) 3. Pens and Pencils 4. My Pyramid Game Show materials: game instructions, two or three sets of paddles with the letters A, B, or C on them. 5. Blank Myplate coloring sheets 6. Prizes -Color photo/picture of grain field -Samples of unprocessed grains -Plastic food models of grain foods -Collection of various grains to be used in the Grain Art Activity (rice, oatmeal, barley, quinoa…) -Blank sheets of paper for kids to draw fields on, printer paper will work but a sturdier paper will work better if available. -Washable paint, paint brushes, glue
Audiencechildren ages 7 -10 II. Objectives: 1. Participants will learn how eating foods from the fruit group is important in helping to keep their bodies healthy and free from illness. 2. Participants will be introduced to and get to try different kinds of fruit. III. i. White and redthe heart and blood ii. Yellow and Orangethe eyes and skin iii. Greenthe bones and muscles iv. Purplethe brain (and memory) As they discuss what colored vegetables help which parts of the body stay healthy, have them name two or three different vegetables of that color. 5 I. Audiencechildren ages 7 -10 II.
Objectives: 1. Participants will learn how eating foods from the meats and beans group is important for building strong muscles and strong bodies. 2. Participants will become familiar with different types of beans. III.
Discussion Topics: 1. Review challenge from the last meeting, ask participants if any of their vegetables have begun to sprout. 2. Ask the participants if they think it's important for us to eat meat and poultry. 3. Explain that the meat and beans group is represented by the protein group on MyPlate. 4. Explain that foods from the meats and beans group are important because they give us the building blocks of our muscles. Have the participants name two different foods from the protein group. 5. Tell them that nuts and beans are also part of the protein group but instead of coming from animals, these foods come from plants, and explain why choosing beans and nuts is important. 6. Ask the participants to give examples of different kinds of foods they eat from the protein group. 7. Have the participants think of some creative ways to have foods from the protein group as a snack. IV.
Activity: Name That Bean! 1. The objective of this game is to set up a relay race. To set up the game, divide the beans and names of the beans into two groups. Each group should be comprised of the same number and type of beans. 2. On one side of the room, place the bags of beans on the ground (in two groups). On the other side of the room, place the name of the beans in a scattered pile (in two groups) 3. Divide the participants in two groups. Line one team up behind the first group of bean names, and the other team behind the other group of bean names 4. Have the first participant in line pick up a name of the bean, run over to the bagged beans, and guess which bean belongs to the name they have. 5. The participant should place the bean name next to the bean, and run back to the line to tag the next participant in line. Continue until all of the bagged beans have names next to them. 6. At the end, give participants a chance to work as a team and change any answers they think may be wrong. 7. Count up how many each team got correct, showing the participants which bean goes with which name as you count. Team with most correct, wins. V.
Challenge for the Next Meeting: Ask the participants to cut out pictures of foods in the protein group over the week. Have them build their own "Strong Man" or "Strong Woman" by pasting the pictures to the muscle man or muscle woman outline provided to them in class. Have them bring their strong person in to the next meeting to show their classmates how many foods they could find. Tell participants to provide at least three pictures found in the protein group that are not meat. VI.
Objectives: 1. Participants will learn how calcium helps bones and bodies grow.
2. Participants will learn that dairy foods are a good source of calcium and that yogurt and milk are the best sources.
III. Challenge for the Next Meeting: Have participants create an advertisement that illustrates the concept of having 4 servings of dairy a day. The advertisement can be cut out pictures from magazines, the computer, or something that they have drawn themselves. VI.
Materials Needed: -Journals/notebooks/pens/pencils -MyPlate poster -Plastic food models of various dairy foods -8-10 different kinds of yogurt for the tasting, Dixie cups, spoons -'Calcium, it's in your bones' materials: plastic bags with different amounts of flour in each bag that represents calcium in the bones of different age groups.
Objectives: 1. Participants will learn why fat and oils are needed by the body.
2. Participants will learn how too much fat and oils in foods can be harmful to their bodies. III.
Discussion Topics: 1. Review challenge from the last meeting. Have participants discuss if they ate breakfast everyday, and how they felt after eating breakfast/if they had skipped breakfast. 2. Ask the participants if they can tell you the difference between a snack and a treat. 3. Together, have the participants come up with some healthy snack ideas as well as actual snacks that they have tried. 4. Explain why snacks are important for everyone, but especially for growing participants. Snacks give extra opportunities to get healthy foods into the body to help participants grow the best they can. They also help keep them from becoming too hungry in between meals. 5. Discuss why treats should only be had on special occasions and ask the participants to name examples of treats and of what might be a special occasion. IV.
Activity: The Snack vs. Treat Relay 1. Break the kids into two groups 2. Give each group the same number of boxes/ wrappers. The boxes and wrappers are examples of common 'snacks' and 'treats'. 3. Set up the 'treat' and 'snack' bins a short distance away, opposite of the two teams. 4. Have the kids line up, and as it is their turn, pick up a box or wrapper.
They will then run down to the bins and determine if the box or wrapper they have is a 'snack' or 'treat'. They will then place the box or wrapper in the appropriate bin, and run back to tag their next team member who will repeat. 5. Whichever team gets the most correct, wins. If it is a tie, the fastest team wins. 6. As you are counting out how many each team got correct, discuss the reasons that each box/wrapper is considered a treat or a snack. V.
Materials Needed: -Journals/notebooks/pens/pencils -MyPlate poster -Four small buckets or baskets, two labeled with "Snack" and two labeled with "Treat" -Snack and treat paper food models -First place prizes, second place prizes Lesson # 10 -Make it count with Meal Time (Week 12) I. Audiencechildren ages 7 -10 II.
Objectives: 1. Participants will learn how meal time can be a great time to learn about themselves as well as each other.
1. Go over challenge from the last meeting. 2. Ask the participants to name the two most important beverages they think they should be drinking every day. 3. Have the participants explain why having too much juice and soda isn't the best for their bodies. 4. Discuss the difference between a beverage that is 10% juice and a beverage that is 100% juice. 5. Explain that both soda and juice have a lot of sugar in them but that juice is the healthier choice of the two. However, emphasize that participants of their age group should only be drinking one to two cups of juice a day because that's all they need. 6. Discuss alternatives to drinking soda and juice when their "daily allowance" has run out. IV. Activity 1: "How much sugar?" 1. Show them various empty bottles of beverages. 2. Have them guess from most to least amount of sugar in the beverages. Ask them to line them up from least to most amount of sugar content. 3. Next, groups of two will tape together the amount of sugar for various beverages. They can pick their favorite beverage. They have to look at the amount of sugar in beverage (check serving size) and divide by 4 for one packet or 1 teaspoon of sugar. They might need help with the math. 4. Then they will show the amount of sugar of their beverage to the other groups and ask them to comment. 5. You will also have bags of sugar (not packs of sugar) for each empty bottle to show them more clearly. V.
Materials Needed: -Dry Erase Board with markers and eraser -Journals/notebooks -Pens and Pencils -MyPlate poster -10% juice and 100% juice containers -Materials for "How much sugar?" activity: five to eight empty juice/soda bottles, sugar packets, tape -Incentive prizes  (34) When comparing the data to the NHANES 2011-2012 dietary intakes of children 6-11 all nutrients consumed by the study group were higher aside from Vitamin E at both baseline and post and iron at post (34). Even though iron consumption was less than the national average (13.91 vs 14.3mg) at post, they were still getting 156.52% of the RDA (10mg) (34). Though potassium was only meeting about 75% of requirements with participants consuming 3000mg this was greater than the national average of 2280mg (34). The intervention may benefit with incorporating more target information on increasing these two nutrients along with potassium as they seem to be nutrients of