Food and Beverage Environment Analysis and Monitoring System: A Reliability Study in the School Food and Beverage Environment

States and school districts around the country are developing policies that set nutrition standards for competitive foods and beverages sold outside of the US Department of Agriculture's reimbursable school lunch program. However, few tools exist for monitoring the implementation of these new policies. The objective of this research was to develop a computerized assessment tool, the Food and Beverage Environment Analysis and Monitoring System (FoodBEAMS),^? to collect data on the competitive school food environment and to test the inter-rater reliability of the tool among research and nonresearch professionals. FoodBEAMS was used to collect data in spring 2007 on the competitive foods and beverages sold in 21 California high schools. Adherence of the foods and beverages to California's competitive food and beverage nutrition policies for schools (Senate Bills 12 and 965) was determined using the data collected by both research and nonresearch professionals. The inter-rater reliability between the data collectors was assessed using the intraclass correlation coefficient. Researcher vs researcher and researcher vs nonresearcher inter-rater reliability was high for both foods and beverages, with intraclass correlation coefficients ranging from .972 to .987. Results of this study provide evidence that FoodBEAMS is a promising tool for assessing and monitoring adherence to nutrition standards for competitive foods sold on school campuses and can be used reliably by both research and nonresearch professionals.     

Competitive foods and beverages available for purchase in secondary schools--selected sites, United States, 2006

Schools are in a unique position to help improve youth dietary behaviors and prevent and reduce obesity. In most schools, foods and beverages are made available to students through the U.S. Department of Agriculture (USDA) school meal programs and the sale of competitive foods, which are any foods and beverages sold at a school separately from the USDA school meal programs. Foods and beverages sold through the USDA school meal programs must meet federal nutrition requirements. Competitive foods are not subject to any federal nutrition standards unless they are sold inside the food service area during mealtimes. A 2007 Institute of Medicine (IOM) report concluded that schools should limit the availability of less nutritious competitive foods or include more nutritious foods and beverages if they make competitive foods available. To identify the types of competitive foods and beverages available for purchase from vending machines or at school stores, canteens, or snack bars, CDC analyzed data from the 2006 School Health Profiles for public secondary schools in 36 states and 12 large urban school districts. CDC also compared 2004 and 2006 data among 24 states and nine large urban school districts. This report summarizes the results of these analyses, which indicated that, from 2004 to 2006, the median percentage of secondary schools across states allowing students to purchase chocolate candy and salty snacks that are not low in fat decreased; however, in 2006, secondary schools still offered less nutritious foods and beverages that compete with school meals. School and public health officials should work together with families to provide foods and beverages at school that follow the IOM recommendations.     

Association between Nutrition Policies and Student Body Mass Index

In response to concerns about childhood obesity, many US states have implemented policies to limit the sale of unhealthy foods and beverages (e.g., snacks, desserts, and sugary drinks) sold in competition with school meal programs (i.e., competitive foods) in order to improve the nutritional environment of schools and support student health. This study measured state-level competitive food and beverage policies that require foods and beverages sold in à la carte lines, vending machines, and school stores to meet strong nutrition standards and tested the hypothesis that students living in states with stronger laws would have lower body mass index (BMI)-for-age percentiles. BMI data from a national sample of 1625 students attending 284 schools from the School Nutrition and Meal Cost Study were linked to state laws coded as part of the National Wellness Policy Study. A survey-adjusted linear regression model accounting for student and school-level characteristics showed that stronger state nutrition policies were associated with lower student BMI scores (coefficient: −0.06, 95% CI: −0.12, −0.00). Additional models indicated that stronger state policies were significantly associated with fewer unhealthy foods and beverages available in schools. These findings suggest that strong regulations on competitive foods and beverages may lead to improvements in the nutritional quality of the school environment and student BMI. Thus, current federal standards regulating snacks in US schools (i.e., Smart Snacks) are an important element of a comprehensive strategy to improve the school nutrition environment and reduce rates of childhood obesity.     

Assessment of Food Quality in School Canteens: A Comparative Quantitative Study between Primary and Secondary Schools in Malaysia

Schools are an important food environment to cultivate and promote healthy food choices and practices among children and adolescents. The aim of the present study was to assess the type and quality of food and beverages sold in school canteens in public primary and secondary schools in Kelantan, Malaysia. Eligible schools were randomly selected from the list of all schools and detailed information of all food and beverage items sold in the school canteens were collected during school days. Food and beverages were classified based on food groups derived from the Malaysian Food Dietary Guideline and the Recommended Foods for Healthy Cafeteria Guideline. An assessment of the traffic-light nutrition food-labelling system of the total sugar content in all pre-packaged foods was also undertaken. A total of 568 food items were identified, with secondary school canteens selling a greater proportion of food items than the primary schools (55.5% vs. 44.5%). In terms of the main food groups, grains and cereal products represented the largest food group served (33–36%), followed by beverages (21–25%) and confectionary and sweet foods (12–13%). In contrast, the vegetable and fruit group represented the smallest proportion of food items sold (1–3%). Comparisons between primary and secondary schools showed a similar trend and pattern of food types and quality of foods sold, except for animal-based foods. A greater percentage of food items in this category was found among secondary schools (12.1%) versus primary schools (6.7%). When total sugar content of all pre-packaged foods was quantified based on the traffic-light nutrition-labelling system, almost one-third of foods and beverages were classified as high (29.1%). Confectionary (19.1%) and flavoured milk and fruit drinks (10.0%) both exceeded the recommended sugar levels of >22.5 g per 100 g and >11.25 mL per 100 m L, respectively. Only one of these packaged foods and beverages (0.9%) was classified as a healthy food choice. About a quarter of the food items available in school canteens were classified as prohibited based on a new revised list of prohibited food and beverage items. These findings indicate that, despite the Guidelines, a large number of unhealthy food items are being sold in school canteens. Hence, interventions such as sustainable healthy school canteen menus should be implemented to promote healthy food choices amongst school-aged children.     

Alliance for a Healthier Generation's Competitive Beverage and Food Guidelines: Do Elementary School Administrators Know About Them and Do They Report Implementing Them?

BACKGROUND: The availability of competitive foods in schools is a modifiable factor in efforts to prevent childhood obesity. The Alliance for a Healthier Generation launched the Healthy Schools Program in 2006 to encourage schools to create healthier food environments, including the adoption of nutritional guidelines for competitive beverages and foods. This study examines nationwide awareness and implementation of the guidelines in US public elementary schools. METHODS: Data were collected from a nationally representative sample of elementary schools using mail-back surveys in 2006-2007, 2007-2008, 2008-2009, and 2009-2010. RESULTS: From 2006-2007 to 2009-2010, awareness of the Alliance's beverage guidelines increased from 35.0% to 51.8% among school administrators (p < .01); awareness of the food guidelines increased from 29.4% to 40.2% (p < .01). By 2009-2010, almost one third of the schools that sold competitive beverages and foods reported having implemented or being in the process of implementing the guidelines. Implementation was higher among schools from Southern states. Schools with a majority of Black or Latino students were less likely to implement the guidelines. CONCLUSIONS: Awareness and implementation of the Alliance's beverage and food guidelines has significantly increased since the 2006-2007 school year, indicating successful diffusion of the guidelines. However, many administrators at schools who sold competitive products were not aware of the guidelines, indicating a need for continued efforts. In addition, lower implementation among schools serving minority students suggests that the Alliance's targeted efforts to provide intensive technical assistance to such schools is warranted and necessary.     

Increases in support structures for healthy eating especially in low decile schools in New Zealand

Objective : To compare two surveys conducted in 2007 and 2009, of the food and nutrition environment in New Zealand primary schools. Methods : A sample of primary schools was asked about foods and beverages provided or sold to students or used for fundraising, and nutrition‐related policies and procedures. Comparisons were made between school decile groups and between years. Results: Of primary schools selling food or beverages, 34% sold ‘everyday’ items once or more a day (39% in 2007) and 25% sold ‘occasional’ items once or more a day (36% in 2007). Two‐thirds of schools sold food or beverages for fundraising, generally once a term or less. About half the schools had written policies about food (increased from 2007). Conclusion: There have been some improvements in the food and nutrition environment, with primary schools from lower deciles more likely to be making changes. Implications: The reduction in funding for nutrition‐related programs in primary schools may hinder the sustainability of the changes seen, especially in low decile schools.     

Nutrition services and foods and beverages available at school: results from the School Health Policies and Programs Study 2006

BACKGROUND: Schools are in a unique position to promote healthy dietary behaviors and help ensure appropriate nutrient intake. This article describes the characteristics of both school nutrition services and the foods and beverages sold outside of the school meals program in the United States, including state- and district-level policies and school practices. METHODS: The Centers for Disease Control and Prevention conducts the School Health Policies and Programs Study every 6 years. In 2006, computer-assisted telephone interviews or self-administered mail questionnaires were completed by state education agency personnel in all 50 states plus the District of Columbia and among a nationally representative sample of school districts (n=445). Computer-assisted personal interviews were conducted with personnel in a nationally representative sample of elementary, middle, and high schools (n=944). RESULTS: Few states required schools to restrict the availability of deep-fried foods, to prohibit the sale of foods that have low nutrient density in certain venues, or to make healthful beverages available when beverages were offered. While many schools sold healthful foods and beverages outside of the school nutrition services program, many also sold items high in fat, sodium, and added sugars. CONCLUSIONS: Nutrition services program practices in many schools continue to need improvement. Districts and schools should implement more food preparation practices that reduce the total fat, saturated fat, sodium, and added sugar content of school meals. In addition, opportunities to eat and drink at school should be used to encourage greater daily consumption of fruits, vegetables, whole grains, and nonfat or low-fat dairy products.     

Environmental influences on energy balance-related behaviors: A dual-process view

Background  

Federal nutritional guidelines apply to school foods provided through the national school lunch and breakfast programs, but few federal regulations apply to other foods and drinks sold in schools (labeled "competitive foods"), which are often high in calories, fat and sugar. Competitive food policies among school districts are increasingly viewed as an important modifiable factor in the school nutrition environment, particularly to address rising rates of childhood overweight. Congress passed legislation in 2004 requiring all school districts to develop a Wellness Policy that includes nutrition guidelines for competitive foods starting in 2006–2007. In addition, the Institute of Medicine (IOM) recently published recommendations for schools to address childhood obesity.     

Position of the American Dietetic Association: local support for nutrition integrity in schools

It is the position of the American Dietetic Association that the schools and the community have a shared responsibility to provide all students with access to high-quality foods and school-based nutrition services as an integral part of the total education program. Educational goals, including the nutrition goals of the National School Lunch Program and the School Breakfast Program, should be supported and extended through school district wellness policies that create overall school environments that promote access to healthful school meals and physical activity and provide learning experiences that enable students to develop lifelong healthful eating habits. The National School Lunch and School Breakfast Programs are an important source of nutrients for school-age children, and especially for those of low-income status. The American Dietetic Association was actively involved in the 2004 reauthorization of these programs, ensuring access through continued funding, promoting nutrition education and physical activity to combat overweight and prevent chronic disease, and promoting local wellness policies. The standards established for school meal programs result in school meals that provide nutrients that meet dietary guidelines, but standards do not apply to foods and beverages served and sold outside of the school meal. Labeled as competitive foods by the US Department of Agriculture, there is a growing concern that standards should be applied to food in the entire school environment. Legislation has mandated that all school districts that participate in the US Department of Agriculture's Child Nutrition Program develop and implement a local wellness policy by the school year 2006-2007. Resources are available to assist in the development of wellness policies, and dietetics professionals can assist schools in developing policies that meet nutrition integrity standards.     

District Wellness Policy Nutrition Standards Are Associated with Healthier District Food Procurement Practices in the United States

Food procurement policies often exist to require that schools purchase foods with specific nutrient standards. Such policies are increasingly being used with the hope of improving access to healthier foods and beverages. Local wellness policies, required in any school district that participates in Federal Child Nutrition Programs, often contain specific nutrition standards that detail what can be sold to students during the school day. This study investigated the extent to which nutrition standards in wellness policies may be associated with healthier nutrition standards in district-level purchasing specifications. Cross-sectional data from the 2014–2015 school year for 490 school food authorities from 46 states and the District of Columbia were collected as part of the School Nutrition and Meal Cost Study and the National Wellness Policy Study. Survey-adjusted multivariable logistic regression models were computed to examine the association between district wellness policy nutrition standards and corresponding district food purchasing specifications. Results show that having a district wellness policy with corresponding nutrition standards and being in a rural area were associated with district food purchasing specifications for specific nutrients. These findings contribute to the literature to suggest that having a wellness policy with detailed nutrition standards may help to increase access to healthier foods and beverages.     

Competitive foods and beverages available for purchase in secondary schools--selected sites, United States, 2004

The percentage of overweight youths aged 12-19 years in the United States more than tripled from 5% during 1976-1980 to 16% during 1999-2002. Overweight youths are at increased risk for cardiovascular consequences and other serious physical and psychosocial health problems. Because most youths are enrolled in school, the school nutrition environment is integral to any strategy to improve dietary behavior and reduce overweight among youths. In most schools, the nutrition environment has two components: the U.S. Department of Agriculture (USDA) school meals program and the sale of competitive foods. USDA defines competitive foods as those foods and beverages, regardless of nutritional value, sold at a school separate from the USDA school meals program. To identify the types of competitive foods and beverages available for purchase from school vending machines or at school stores, canteens, or snack bars, CDC analyzed data from the 2004 School Health Profiles for public secondary schools in 27 states and 11 large urban school districts. This report summarizes the results of that analysis, which indicated that, in 2004, the majority of secondary schools (median across states: 89.5%; median across large urban school districts: 81.5%) allowed students to purchase snack foods or beverages from vending machines or at the school store, canteen, or snack bar. In addition, the percentage of schools offering certain types of snack foods and beverages varied across states and large urban school districts. Although the majority of schools offered some nutritious foods and beverages in these settings, the majority of schools also offered less nutritious choices. Educators, families, and school and public health officials should work together to provide school nutrition environments that will help improve dietary behavior and reduce overweight among youths.     

The effect of nutrient-based standards on competitive foods in 3 schools: potential savings in kilocalories and grams of fat

BACKGROUND: The study investigated how nutrient standards affected the number of kilocalories and grams of fat and saturated fat in competitive foods offered and sold in 3 high schools. METHODS: The study is a quasi‐experimental design with 3 schools serving as the units of assignment and analysis. The effect of the nutrient standards was measured by the change in kilocalories and grams of fat and saturated fat in offerings and purchases of competitive foods pre‐ and postimplementation of the standards. A paired sample t‐test was used to compare kilocalories and grams of fat and saturated fat pre‐ and postimplementation of nutrition standards. RESULTS: After the implementation of the nutrition standards, students in 3 high schools purchased significantly smaller numbers of kilocalories and grams of fat and saturated fat, during the postpolicy school year of 2007‐2008 than during the prepolicy school year of 2004‐2005. CONCLUSION: Using nutrient standards to guide the selection of competitive foods offered in school cafeterias may positively affect intake of kilocalories, total grams of fat, and total saturated fat of those foods. The quantitative assessment is novel and demonstrates the reduction in kilocalories and fat in both the competitive food offerings and purchases as a result of nutrient standards.     

Impact of Connecticut Legislation Incentivizing Elimination of Unhealthy Competitive Foods on National School Lunch Program Participation

Objectives. We analyzed the impact of Connecticut legislation incentivizing voluntary school district–level elimination of unhealthy competitive foods on National School Lunch Program (NSLP) participation.Methods. We analyzed data on free, reduced, and paid participation in the NSLP from 904 schools within 154 Connecticut school districts from the 2004–2005 to the 2009–2010 school year, resulting in 5064 observations of annual school-level meal participation. We used multilevel regression modeling techniques to estimate the impact of the state competitive food legislation on the count of NSLP lunches served per student in each school.Results. Overall, the state statute was associated with an increase in school lunch participation. We observed increases between 7% and 23% for middle- and high-school meal programs, and a slight decrease of 2.5% for the elementary school free meal eligibility category, leading to an estimated revenue increase of roughly $30 000 for an average school district per school year.Conclusions. This study provides support for national implementation of proposed rigorous competitive food standards that can improve the health of students while supporting local school district finances.Federal meal programs in the United States serve more than 30 million students every day, providing an unparalleled opportunity to improve the diet of the nation’s youths.1 Recent changes to school meal program regulations will substantially improve the nutritional quality of meals that have already succeeded at preventing childhood nutritional deficiencies in the United States.2–4 Public health efforts to reduce childhood obesity rates and improve diet quality in the United States have increasingly focused on improving the food environment in schools.5–7The sale of foods in schools outside the school meal programs, known as competitive foods, has been consistently linked with unhealthy diet and, in some but not all studies,8 with increased risk of obesity.9 Energy-dense, nutrient-poor competitive foods and beverages are widely available in US schools and are regularly consumed by children.10–13 A number of local school district and statewide policy changes reducing or eliminating the sale of unhealthy competitive food and beverages at school have been shown to improve dietary outcomes, including reduced sugar-sweetened beverage consumption and increased consumption of fruits and vegetables.14–16 Sanchez-Vaznaugh et al. reported that removing unhealthy competitive foods may be linked to a lower incidence of overweight in children in California.17 Taber et al. reported findings based on the Early Childhood Longitudinal Study–Kindergarten showing that adolescents in states with strong competitive food standards from 2003 to 2006 gained 0.44 body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) units less than adolescents in states without such standards.18Despite the success of some state and local policies, national policy efforts have so far failed to sufficiently address the negative impact of the sale of unhealthy competitive foods on children’s health. The Child Nutrition and WIC Reauthorization Act of 2004 required all school districts participating in the National School Lunch Program (NSLP) to develop wellness policies that include nutrition guidelines for all foods available at schools by the 2006–2007 school year.19 However, the legislation did not require districts to implement specific competitive food policies.5 A review of a nationally representative sample of wellness policies and related regulations from 2006–2007 up to 2008–2009 found that, although some districts have implemented strong policies, in general, rules governing competitive food sales were weak or nonexistent.20In response to concerns about the role of both the school meal programs and competitive foods in addressing the obesity epidemic, Congress passed The Healthy, Hunger-Free Kids Act of 2010.21 The act required the US Department of Agriculture (USDA) to update the nutrition standards for the NSLP and the School Breakfast Program while providing a performance-based increase in reimbursement rate for lunches. The bill also for the first time gave the USDA authority to set nutrition standards for competitive foods sold throughout the school day.21 Congress instructed the USDA to develop nutrition standards for competitive foods that align with the current Dietary Guidelines for Americans22 while giving consideration to practical application of the standards. The USDA is currently developing competitive food standards with the goal of releasing final regulations in 2013.Reactions to the USDA’s revised nutrition standards for the school meal program suggest that the USDA may face strong opposition to nutritionally rigorous competitive food standards.23,24 In addition to objections raised by food industry associations, the School Nutrition Association, which represents school food service professionals, commented to the USDA that improving the health quality of the school meals may reduce participation in the program if students instead purchase competitive foods or bring food from outside school.25However, creating rigorous new competitive food nutrition standards could support simultaneous implementation of improved meal program standards by removing unhealthy yet attractive alternatives to the meal program from school environments. A number of studies have found that reducing availability of unhealthy competitive foods results in increased meal program participation and limited impact on overall food service revenue.26,27 On the basis of a systematic review that identified 7 studies that assessed the relationship between nutrition standards and school revenue, Wharton et al. concluded that fears of net negative financial impacts of improved nutrition standards are unfounded and that increased participation in NSLP may compensate for lost revenue from lower competitive food sales.27 However, because there is a relatively limited evidence base, additional evidence showing that implementing stronger competitive food standards across a broad range of schools can increase school meal participation would support ongoing USDA efforts to implement rigorous national competitive food and school meal nutrition standards.Since 2006, Connecticut’s Healthy Food Certification (HFC) has offered school districts in the state a monetary incentive to comply with stringent competitive food nutrition standards that are updated annually.28 The standards, which are based on the Dietary Guidelines for Americans, apply to all foods sold at school at all times. Exceptions can be granted by local school boards for food sold during events held outside the regular school day. Districts must annually file compliance forms with the Connecticut State Department of Education (CSDE), which reviews nutrition information for all foods sold in each district and conducts site visits in selected participating districts to ensure compliance. Districts that choose to comply with the voluntary standards are paid an additional 10 cents per lunch by the state, based on the total number of reimbursable lunches (paid, free, and reduced) served in the district in the previous school year. Previous research based on the program’s first year of implementation found that districts participating in HFC substantially reduced the availability of unhealthy competitive food and increased paid school meal participation in middle schools.29This study extends the initial evaluation of the program, and analyzes the impact of district participation in HFC on student participation in free, reduced, and paid lunches by using statewide school meal participation data from the 2004–2005 to 2009–2010 school years. It was hypothesized that district participation in HFC is positively related to student participation in the NSLP.     

Schoolchildren's Consumption of Competitive Foods and Beverages,Excluding à la Carte*

BACKGROUND: Competitive foods/beverages are those in school vending machines, school stores, snack bars, special sales, and items sold à la carte in the school cafeteria that compete with United States Department of Agriculture (USDA) meal program offerings. Grouping à la carte items with less nutritious items allowed in less regulated venues may obfuscate analysis of the school competitive food environment. Excluding à la carte items from competitive foods, the objectives were to: (1) assess competitive food use by gender, ethnicity, eligibility for free or reduced-price meals, and participation in school meals programs, (2) determine differences between grade levels in energy intakes obtained from food sources, (3) determine the nutrient intake derived from competitive foods for students who consumed them, and (4) determine energy-adjusted differences in 24-hour nutrient intakes of protein, calcium, iron, and other selected nutrients between competitive food consumer and nonconsumers. METHODS: Competitive foods/beverages use, excluding à la carte items, was examined using the third School Nutrition Dietary Assessment Study (SNDA III), a nationally representative sample of 2309 schoolchildren in grades 1 to 12. Mean nutrient intakes were adjusted for energy intake and other covariates, and differences between consumers and nonconsumers of competitive items were determined using analysis of variance and sudaan . RESULTS: Excluding à la carte items, 22% of schoolchildren consumed competitive items in a representative school day and use was highest in high school. Consumers of competitive items other than à la carte had significantly higher mean energy, sugar intakes, and lower sodium, dietary fiber, B vitamins, and iron intakes than nonconsumers. CONCLUSIONS: Use of competitive foods/beverages, excluding à la carte, was detrimental to children's diet quality.     

Association between state school nutrition laws and subsequent child obesity

Many states have enacted laws to improve school nutrition. We tested whether stronger state nutrition laws are associated with subsequently decreased obesity. We conducted a retrospective national multi-year panel data study (analyzed 2014–2016 at the Children's Hospital of Philadelphia). The predictors were 2010 laws regarding 9 nutrition categories from the Classification of Laws Associated with School Students, which grades the strength of state laws (none, weak, or strong). The outcome was weight status (healthy weight, overweight, or obese) in elementary, middle, and high school from the 2011/2012 National Survey of Children's Health. We tested the association between the strength of laws and weight using multinomial logistic regression. To further evaluate our main results, we conducted state-level longitudinal analyses testing the association between competitive food and beverage laws on the change in obesity from 2003–2011. In main analyses of 40,177 children ages 10–17 years, we found strong state laws restricting the sale of competitive food and beverages in elementary school (OR: 0.68; 95% CI: 0.48, 0.96) and strong advertising laws across all grades (OR: 0.63; 95% CI: 0.46, 0.86) were associated with reduced odds of obesity. In longitudinal analyses, states with strong competitive food and beverage laws from 2003–2010 had small but significant decreases in obesity, compared to states with no laws. Although further research is needed to determine the causal effect of these laws, this study suggests that strong state laws limiting the sale and advertising of unhealthy foods and beverages in schools are associated with decreased obesity rates.     

Impact of portion-size control for school a la carte items: changes in kilocalories and macronutrients purchased by middle school students

We assessed the impact of a pilot middle school a la carte intervention on food and beverage purchases, kilocalories, fat, carbohydrate, and protein sold per student, and nutrient density of the foods sold. A la carte sales were obtained from six middle schools in three states for 1 baseline week and daily during the 6-week intervention. Intervention goals included reducing sizes of sweetened beverages and chips, and increasing the availability of water and reduced-fat/baked chips. Nutrients sold per day were computed and weekly nutrient means per student and per number of items sold were calculated and compared between baseline and week 6. Five schools achieved all goals at 6 weeks. Four schools showed increases in the percentage of kilocalories from protein and decreases in the amount of sweetened beverages sold; five showed substantial increases in water sales. Changes in regular chips varied by school. There were significant changes in energy density of foods sold. School foodservice changes in middle school snack bar/a la carte lines can be implemented and can lead to a reduction in the caloric density of foods purchased.     

Lessons Learned From Evaluations of California's Statewide School Nutrition Standards

Objectives. We assessed the impact of legislation that established nutrition standards for foods and beverages that compete with reimbursable school meals in California.Methods. We used documentation of available foods and beverages, sales accounts, and surveys of and interviews with students and food service workers to conduct 3 studies measuring pre- and postlegislation food and beverage availability, sales, and student consumption at 99 schools.Results. Availability of nutrition standard–compliant foods and beverages increased. Availability of noncompliant items decreased, with the biggest reductions in sodas and other sweetened beverages, regular chips, and candy. At-school consumption of some noncompliant foods dropped; at-home consumption of selected noncompliant foods did not increase. Food and beverage sales decreased at most venues, and food service à la carte revenue losses were usually offset by increased meal program participation. Increased food service expenditures outpaced revenue increases.Conclusions. Regulation of competitive foods improved school food environments and student nutritional intake. Improvements were modest, partly because many compliant items are fat- and sugar-modified products of low nutritional value. Additional policies and actions are needed to achieve more substantive improvements in school nutrition environments and student nutrition and health.The current obesity epidemic in the United States has been associated with environmental factors such as the proliferation of unhealthy foods in schools and neighborhoods, as well as promotion of unhealthy foods in media environments.^1–4 An effective way to support children in being active and eating healthfully is to change institutional practices within schools by improving physical education and the nutritional value and quality of foods served.^5,6Schools participating in the federally reimbursed National School Lunch Program and School Breakfast Program serve meals that must meet federal nutrition guidelines. However, foods that are not part of the meal programs are only subject to minimal federal regulation, and these “competitive” foods have become increasingly widespread in schools over the last 40 years.⁷ Sold throughout schools in vending machines, school stores, snack bars, and at fundraisers, competitive foods and beverages are of lower nutritional quality and are typically high in added sugars, salt, and fat. Common examples of competitive foods include soft drinks and other sweetened beverages, potato chips, candy, cookies, and pastries.^8–11In an effort to combat childhood obesity, state and local policymakers have recently begun to regulate competitive school food offerings by enacting stricter school nutrition standards.¹² These efforts were reinforced by provisions in the Child Nutrition and WIC Reauthorization Act of 2004, which required school districts receiving federal meal program funding to enact wellness policies—including guidelines for all foods and beverages served—by the 2006–2007 school year.¹³The wellness policies of 92 out of 100 large school districts polled by the School Nutrition Association in 2007 included nutrition standards limiting times or offerings of competitive foods and beverages in school à la carte services, stores, and vending machines.¹⁴ Although the effects of state and local regulations of competitive foods are only beginning to be evaluated,¹⁵ emerging evidence suggests that school policies that decrease access to competitive foods of limited nutritional value are associated with less frequent student consumption of these foods during the school day.^16,17In California, Senate Bill 12 (SB 12), which applied nutrition standards to competitive foods sold in K–12 schools, took effect in July 2007. The law imposed the following limits on foods in secondary schools¹⁸:Individually sold snacks must contain no more than:

• 35% of calories from fat (with some exceptions, such as legumes, nuts, and eggs);
• 10% of calories from saturated fat (excluding eggs and cheese);
• 35% sugar by weight (excluding fruits and vegetables); and
• a total of 250 calories.

Individually sold entrées must contain no more than 36% of calories from fat and 400 calories per entrée.At elementary schools, the only competitive foods allowed are individually sold portions of nuts, nut butters, seeds, eggs, cheese packaged for individual sale, fruit, vegetables that have not been deep-fried, legumes, and dairy or whole-grain foods that meet the nutrient limits described previously and contain no more than 175 calories.A second law, SB 965, limited the competitive beverages that could be offered during the school day.¹⁸ The limits went into full effect in July 2007 for elementary and middle schools; at high schools, 50% of beverages had to comply by July 2007, and 100% of beverages had to comply by July 2009. The law limits competitive beverages to the following:

• fruit-based and vegetable-based drinks that are at least 50% fruit juice without added sweeteners;
• drinking water without added sweeteners;
• milk products and nondairy milks that have no more than 2% fat and 28 g of total sugars per 8 oz; and
• electrolyte replacement beverages with no caffeine and no more than 42 g of added sweetener per 20 oz (not allowed at elementary schools).

Three studies—the Healthy Eating, Active Communities study (HEAC), the High School Study (HSS), and the School Wellness Study (SWS), all conducted by the authors of this article, assessed different aspects of the implementation and impact of California''s school nutrition standards in diverse settings (

Are Nutrition Standards for Beverages in Schools Associated with Healthier Beverage Intakes among Adolescents in the US?

Under the U.S. Department of Agriculture’s Smart Snacks in School standards, beverages sold in schools are restricted to water, flavored or unflavored non-fat milk or unflavored low-fat milk (and milk alternatives), and 100% fruit and vegetable juices; and, at the high school level, diet (≤10 kcal), low-calorie (≤60 kcal), and caffeinated beverages may also be sold. Using data from the School Nutrition and Meal Cost Study, this study examined whether secondary school student beverage consumption was associated with school-level à la carte and vending machine beverage availability, controlling for district, school, and student characteristics. On average, most beverages sold in middle schools (84.54%) and high schools (74.11%) were Smart Snacks compliant; while 24.06 percent of middle school students and 14.64 percent of high school students reported consuming non-compliant beverages, including non-compliant milk, fruit drinks, and sports or energy drinks. School beverage availability was not related to consumption among middle school students; however, high school students were less likely to consume non-compliant beverages when enrolled in schools that sold a higher proportion of compliant beverages (Range: OR = 0.97–0.98, 95% CI = 0.95, 1.00). Findings from this study build upon prior research illustrating the role that schools can play in influencing student dietary intake.     

Evaluating the Impact of a Connecticut Program to Reduce Availability of Unhealthy Competitive Food in Schools

BACKGROUND: This article seeks to inform state and local school food policies by evaluating the impact of Connecticut's Healthy Food Certification (HFC), a program which provides monetary incentives to school districts that choose to implement state nutrition standards for all foods sold to students outside reimbursable school meals. METHODS: Food service directors from all school districts participating in the National School Lunch Program (NSLP) (N = 151) in Connecticut were surveyed about the availability of competitive foods before and after the 2006-2007 implementation of HFC. Food categories were coded as healthy or unhealthy based on whether they met the Connecticut Nutrition Standards. Data on NSLP participation were provided by the State Department of Education. Changes in NSLP participation and availability of unhealthy competitive foods in elementary, middle, and high schools were compared pre- and post-HFC across districts participating (n = 74) versus not participating (n = 77) in HFC. RESULTS: On average, all districts in Connecticut reduced the availability of unhealthy competitive foods, with a significantly greater reduction among HFC districts. Average NSLP participation also increased across the state. Participating in HFC was associated with significantly greater NSLP participation for paid meals in middle school; however, implementing HFC did not increase overall NSLP participation beyond the statewide upward trend. CONCLUSION: The 2006–2007 school year was marked by a significant decrease in unhealthy competitive foods and an increase in NSLP participation across the state. Participation in Connecticut's voluntary HFC further reduced the availability of unhealthy competitive foods in local school districts, and had either a positive or neutral effect on NSLP participation.