Competitive foods, discrimination, and participation in the National School Lunch Program

Meals served through the National School Lunch Program (NSLP) must meet rigorous nutritional standards; however, barriers to student participation may limit the program's health and social equity benefits. Unsubsidized meals and food offerings competing with the NSLP offerings in school lunch environments may be lowering qualified student participation either directly or via identification of subsidized low-income students or stigmatization of the NSLP. We document a pilot intervention conducted in San Francisco in 2009 and 2010 that demonstrated gains in NSLP participation after removal of separate competitive à la carte lunch meal offerings. Our observations suggest the need for greater attention to the potential discriminatory effects of competitive foods and to the issue of stigma by school nutrition program administrators, researchers, regulators, and policymakers.     

Rural Disparities in the Distribution of Policies that Support Healthy Eating in US Secondary Schools

The distribution of food and nutrition policies and practices from 28 US states representing 6,732 secondary schools was evaluated using data from the 2008 School Health Profiles principal survey. School policies and practices evaluated were: availability of low-nutrient, energy-dense (LNED) snacks/drinks; use of healthy eating strategies; banning food marketing; availability of fruits and vegetables; and food package sizes. For each school, school-level demographic characteristics (percentage of students enrolled in free/reduced-price meals, minority enrollment, and geographic location) were also evaluated. Schools in small town/rural locations had significantly fewer policies that support healthy eating strategies and ban food marketing, and were less likely to serve fruits and vegetables at school celebrations, have fruits and vegetables available in vending or school stores, and limit serving-size packages. Schools serving the highest percentage of minority students consistently reported the same or better school food environments. However, schools serving the highest percentage of low-income students had varied results: vending and LNED vending policies were consistently better and fruit and vegetable availability–related policies were consistently worse. Disparities in the distribution of policies and practices that promote healthy school food environments seem most pronounced in small town/rural schools. The data also support the need for continued reinforcement and the potential for expansion of these efforts in urban and suburban areas and schools with highest minority enrollment.     

School-based physical fitness testing identifies large disparities in childhood overweight in Los Angeles

Few data are available on the epidemic of childhood overweight in local jurisdictions. To determine the prevalence and identify demographic and socioeconomic correlates of childhood overweight, we assessed height and weight data on 281,630 Los Angeles County, CA, public school students collected during school-based physical fitness testing in 2001. Overweight prevalence was 20.6% overall and varied by race/ethnicity: 25.2% among Latinos, 20.0% among Pacific Islanders, 19.4% among blacks, 17.6% among American Indians, 13.0% among whites, and 11.9% among Asians. By using multilevel analysis, we found that school-level percentage of students enrolled in free or reduced-price meal programs was independently associated with overweight, after controlling for school-level median household income and student-level demographic characteristics. When local overweight prevalence data are unavailable, percentage enrollment in free or reduced-price meal programs might be a useful indicator to identify schools where focused overweight prevention and control interventions are most needed.     

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.     

Elementary School Participation in the United States Department of Agriculture's Team Nutrition Program Is Associated With More Healthful School Lunches

ObjectiveTo assess school-level characteristics associated with Team Nutrition (TN) program participation, and compare the availability of food items in school lunches in participating vs nonparticipating schools.MethodsCross-sectional study with a nationally representative sample of 2,489 elementary schools in the United States. A mail-back survey was used to collect school administrator–reported annual data on availability of selected healthful and unhealthful lunch items between 2006-2007 and 2009-2010. Multivariate regression analyses was used to predict the availability of food items in school lunches based on TN participation.ResultsTeam Nutrition participation was higher among schools in the south, in rural areas, and in states with stronger nutrition policies. Program participation was higher in schools with mostly low-income students and where a dietitian was on staff. Participating schools were more likely to offer healthful items and less likely to serve unhealthful items during lunch.Conclusions and ImplicationsThe TN program has the potential to help schools offer healthier school meals.     

The association of the school food environment with dietary behaviors of young adolescents

OBJECTIVES: We examined the association between young adolescents' dietary behaviors and school vending machines, à la carte programs, and fried potatoes' being served at school lunch. METHODS: Using a cross-sectional study design, we measured à la carte availability and the number of school stores, vending machines, and amounts of fried potatoes served to students at school lunch in 16 schools. Grade 7 students (n = 598) completed 24-hour dietary recall interviews. RESULTS: A la carte availability was inversely associated with fruit and fruit/vegetable consumption and positively associated with total and saturated fat intake. Snack vending machines were negatively correlated with fruit consumption. Fried potatoes' being served at school lunch was positively associated with vegetable and fruit/vegetable intake. CONCLUSIONS: School-based programs that aim to promote healthy eating among youths should target school-level environmental factors.     

Ecological and socioeconomic correlates of fruit, juice, and vegetable consumption among African-American boys

BACKGROUND: Investigators have reported that the availability of foods in local grocery stores correlated with consumption when using large geopolitical units of analysis, e.g., zip codes. Associations across smaller geopolitical units, e.g., census tracts, have not been tested, nor has this work focused on restaurant availability, child consumption, or specific ethnic groups. METHODS: This study examined whether median family income and fruit, juice, and vegetable (FJV) availability in grocery stores, restaurants, and homes in 11 census tracts correlated with FJV consumption among 11- to 14-year-old African-American Boy Scouts. FJV consumption was measured in 90 scouts using two 24-h food recalls. Instruments were developed to measure the availability of FJV at area grocery stores, restaurants, and homes where troop members resided. RESULTS: Median household income (from 1990 census) was significantly correlated with restaurant fruit availability. Significant correlations were found between restaurant juice and vegetable availability and Boy Scout reported consumption of juice and vegetables. CONCLUSION: Census tract may be a useful unit when studying restaurant, but not grocery store, FJV availability. Within a census tract, restaurant FJV availability may be a significant target for community intervention and process evaluation.     

Increased School Breakfast Participation from Policy and Program Innovation: The Community Eligibility Provision and Breakfast after the Bell

School meals provide significant access to food and nutrition for children and adolescents, particularly through universal free meal mechanisms. Alongside added nutritional meal requirements under the Healthy, Hunger-Free Kids Act (2010), schools can utilize meal program and policy mechanisms such as the Community Eligibility Provision (CEP) and Breakfast after the Bell (BATB) to increase participation. This study examines longitudinal statewide school-level CEP and BATB adoption and estimates the impact on increased free and reduced-price (FRP) breakfast participation. We find that FRP breakfast participation increased for schools that utilize both CEP and BATB (14-percentage-point increase) and that CEP-participating schools are more likely to use BATB approaches such as breakfast in the classroom, grab-and-go carts, and second-chance breakfast. Additionally, using a conditional Difference-in-Differences (DiD) approach, we find that BATB adoption accounted for a 1.4-percentage-point increase in FRP school breakfasts served (p < 0.05). Study findings can inform policy and school official decision making around the policy and program mechanisms at their disposal to increase school meal participation and student nutrition.     

Associations among Food Security,School Meal Participation,and Students’ Diet Quality in the First School Nutrition and Meal Cost Study

The Healthy, Hunger-Free Kids Act of 2010 updated the nutrition standards in the National School Lunch and School Breakfast Programs (NSLP and SBP) and expanded universal free meals’ availability in low-income schools. Past studies have shown that school meals are an important resource for children in food-insecure households. This analysis used data from the School Nutrition and Meal Cost Study to classify students as food insecure (FI), marginally secure (MS), or food secure (FS). Diet quality from school and nonschool foods that students consumed was assessed using Healthy Eating Index (HEI)-2010 scores. Chi-squared and two-tailed t-tests were conducted to compare school meal participation, students’ energy intakes, and diet quality across food security groups. FI and MS students were significantly more likely to participate in NSLP than FS students (79%, 71%, and 49%, respectively). SBP participation followed a similar pattern but was lower (38% FI, 33% MS, and 16% FS). Compared to FS students, FI and MS students more likely attended schools offering SBP, universal free meals, or afterschool snacks and suppers. School meals contributed significantly more energy to FI and MS students’ diets than to FS students (22%, 20%, and 13%, respectively). All groups’ dietary intakes from school foods were of higher quality than non-school foods. These findings highlight the role of school meals in meeting the energy and diet quality needs of FI and MS students.     

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.     

The Costs of Food at Home and Away From Home and Consumption Patterns Among U.S. Adolescents

PurposeThis study examined the associations of prices of food at home groceries, prices of fast food away from home and the availability of food stores and restaurants with the number of days over the past week that adolescents consumed fruit and fruit juices, vegetables, meat, nonmeat protein, dairy, grains, and sweets.MethodsIndividual-level data on adolescents were drawn from the Child Development Supplement of the Panel Study of Income Dynamics combined at the zip code level with external economic contextual data. Multivariate regression analyses were used to estimate the associations between food consumption categories and the economic contextual factors. Regressions were also estimated by households' poverty status.ResultsFast food and food at home prices were not significantly associated with any of the food consumption categories in the full sample. However, among poor adolescents, higher fast food prices were associated with higher levels of nonmeat protein consumption. Food store outlet availability was found to have very small significant associations with some food consumption categories but no significant associations were found for restaurant outlets.ConclusionsFood away from home prices such as fast food prices and supermarket and grocery store availability were associated with some food consumption categories among low-income youths and related policies deserve further examination.     

Differences in Diet Quality between School Lunch Participants and Nonparticipants in the United States by Income and Race

Prior research has shown that participation in the United States’ National School Lunch Program (NSLP) is associated with consuming higher-quality lunches and diets overall, but little is known about differences by income and race/ethnicity. This analysis used 24 h dietary recall data from the School Nutrition and Meal Cost Study to examine how NSLP participation affects the diet quality of students in different income and racial/ethnic subgroups. Diet quality at lunch and over 24 h was assessed using the Healthy Eating Index (HEI)-2010, where higher scores indicate higher-quality intakes. HEI-2010 scores for NSLP participants and nonparticipants in each subgroup were estimated, and two-tailed t-tests were conducted to determine whether participant–nonparticipant differences in scores within each subgroup were statistically significant. NSLP participants’ lunches received significantly higher total HEI-2010 scores than those of nonparticipants for lower-income, higher-income, non-Hispanic White, and non-Hispanic Black students, suggesting that participating in the NSLP helps most students consume healthier lunches. These significantly higher total scores for participants’ lunch intakes persisted over 24 h for higher-income students and non-Hispanic White students but not for lower-income students or students of other races/ethnicities. For NSLP participants in all subgroups, the nutritional quality of their 24 h intakes was much lower than at lunch, suggesting that the positive influence of the NSLP on their overall diet quality was negatively influenced by foods consumed the rest of the day (outside of lunch).     

Childhood Obesity and Schools: Evidence From the National Survey of Children's Health

BACKGROUND: The international prevalence of childhood obesity and obesity-related diseases has received increasing attention. Applying data from the Centers for Disease Control and Prevention, we explore relationships between childhood obesity and school type, National School Lunch Program (NSLP) and School Breakfast Program (SBP) eligibility, membership in sports clubs and other sociodemographic, and household factors. METHODS: Nonlinear regression models with interaction terms were developed to investigate the effects of school type, physical activity, and NSLP/SBP, etc, on children's body mass index (BMI). Probit models then examine the probability of a child being overweight. RESULTS: Though clinically small, statistically significant effects on BMI were found for children from households eligible for the NSLP/SBP, attending public schools. They have a mean BMI value 0.401 higher than counterparts attending private schools (p < .05). If the child both attends public school and is eligible for the NSLP/SBP, then his or her BMI is 0.725 higher (p < .001). Children taking part in the NSLP or SBP have a 4.5% higher probability of being overweight (p < .001). CONCLUSIONS: Regardless of household socioeconomic status, children attending public schools have higher BMI than those attending private schools. Eligibility for free or reduced-cost lunch or breakfast programs at public schools is positively correlated with children's BMI. Children attending public schools are more likely to be overweight. In lower socioeconomic status households, school type does not have a significant effect on the probability of being overweight. Policy recommendations for factors to address childhood obesity are discussed.     

How the CATCH eat smart program helps implement the USDA regulations in school cafeterias.

This article describes the implementation of the U.S. Department of Agriculture's National School Lunch Program (NSLP) standards in school lunch menus in 56 intervention and 20 control schools from the Child and Adolescent Trial for Cardiovascular Health (CATCH) 5 years after the main trial, compared with 12 schools previously unexposed to CATCH. School food service personnel completed questionnaires to assess CATCH guideline implementation, demographic data, behavioral constructs, training, program material use, and participation in competing programs. Five days of menus and recipes were collected from school cafeteria staff, averaged, and compared to USDA School Meal Initiative (SMI) standards. Significant differences between intervention and unexposed schools were found for training and knowledge of CATCH and in mean percentage energy from fat and carbohydrates. Intervention schools most closely met USDA SMI recommendations for fat. Thus, the CATCH Eat Smart Program assisted school cafeterias in meeting USDA guidelines 5 years postimplementation.     

Fresh Fruit and Vegetable Program participation in elementary schools in the United States and availability of fruits and vegetables in school lunch meals

Dietary intake among children in the United States falls short of national recommendations. Schools can play an important role in improving children's preferences and food consumption patterns. The US Department of Agriculture's Fresh Fruit and Vegetable Program (FFVP) aims to improve children's nutrient intake patterns by offering fresh fruits and vegetables as snacks outside the reimbursable meals programs in elementary schools that serve large numbers of low-income children. Using a nationally representative sample of public elementary schools, this cross-sectional study investigated FFVP participation patterns among schools by demographic and school characteristics. Further, the study investigated the association between FFVP participation and availability of fresh fruits, salads, and vegetables at lunch as reported by school administrators and foodservice staff. Data collected via a mail-back survey from 620 public elementary schools participating in the National School Lunch Program during 2009-2010 were analyzed. Almost 70% of the FFVP-participating schools had a majority of students (>50%) eligible for free and reduced-cost meals. Participating in US Department of Agriculture Team Nutrition Program and having a registered dietitian or a nutritionist on staff were significantly associated with FFVP participation. Based on the results from logistic regression analyses schools participating in the FFVP were significantly more likely (odds ratio 2.07; 95% CI 1.12 to 3.53) to serve fresh fruit during lunch meals. Slightly >25% of public elementary schools across the United States participated in the FFVP, and participation was associated with healthier food availability in school lunches.     

The relationship between socioeconomic status, ethnicity, and cigarette smoking in urban adolescents

BACKGROUND: This study examined the relationship between community-level and school-level socioeconomic status indicators and current cigarette smoking among urban adolescents, and examined whether the socioeconomic status-cigarette smoking relationship was similar for African Americans and Whites. METHODS: Participants were 3,813 seventh-graders recruited in a large school system in the United States. Independent variables included median income and mean education within zip codes of participants' residence, percentage of participants receiving lunch at reduced or no cost at school level, and ethnicity. The dependent variable was current smoking status (never smoked vs smoking one or more cigarettes per month). RESULTS: Whites were significantly more likely than African Americans to smoke cigarettes. There was a main effect of education and lunch at reduced or no cost on cigarette smoking. Mean education by zip code was inversely associated with cigarette smoking, and lunch at reduced or no cost was directly associated with cigarette smoking. There was a significant interaction between income and ethnicity. Median income by zip code was directly associated with cigarette smoking among African Americans. CONCLUSIONS: Our findings suggest that smoking prevention efforts in this population should take both socioeconomic status and ethnicity into account.     

Factors associated with student participation in a school-based hepatitis B immunization program

This study examined the relationship between participation in a school-based hepatitis B immunization program and teacher attitudes toward school-based health care and student socioeconomic factors. A survey addressing teachers' attitudes was administered to all teachers participating in the program. Information regarding student participation in school lunch programs and scores on national standardized tests were collected. Of the 4,874 fifth-grade students targeted for the program, 3,483 (72%) consented to be vaccinated and 3,232 (93% of 3,483) received all three doses of vaccine. Socioeconomic factors were the most important predictors of student participation in this school-based immunization program. Participation was significantly lower among students in schools with a high proportion of students receiving free or reduced-price school lunch and with low test scores. The only teacher factor associated with student participation was whether the teacher had returned the questionnaire. Strategies to increase immunization coverage in school-based programs should target children of low socioeconomic status.     

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.