Lunchbox contents of Australian school children: room for improvement

OBJECTIVE: In light of the increasing prevalence of obesity in children and the potential of schools as a setting for intervention, we aimed to identify the main foods and beverages consumed at primary school and to determine differences in consumption patterns between children who used the school canteen and those who did not. DESIGN: Cross-sectional survey of school foods in 1681 5-12 y old children, 2003-2004. SETTING: Barwon South-Western region of Victoria, Australia. RESULTS: The school food provided an average (+/-s.e.m.) of 3087+/-26 kJ. Bread was the most frequently consumed food and contributed 20% of total energy at school, biscuits 13%, fruit 10%, muesli/fruit bars 8%, packaged snacks 7%, and fruit juice/cordial 6%. About 10% of children used the school canteen and these children obtained more total energy and more energy from cakes, fast foods and soft drink than noncanteen users (P<0.001). In all, 68% of children had fruit in their lunchboxes, however, over 90% of children had energy-dense, micronutrient-poor snacks ('junk food'). CONCLUSIONS: Fruit intake in primary schools seems reasonably high but could be targeted for further increase as part of promoting a healthy diet. Of concern, however, are the excessive amounts of energy-dense foods in school lunchboxes. These should be considered a priority for health promotion efforts along with reducing the consumption of sweetened drinks. These measures are urgently needed to improve the school-based diets of Australian children and attempt to curb the increasing prevalence of childhood obesity.     

What are the key food groups to target for preventing obesity and improving nutrition in schools?

OBJECTIVE: To determine differences in the contribution of foods and beverages to energy consumed in and out of school, and to compare consumption patterns between school canteen users and noncanteen users. DESIGN: Cross-sectional National Nutrition Survey, 1995. SETTING: Australia. SUBJECTS ON SCHOOL DAYS: A total of 1656 children aged 5-15 y who had weekday 24-h dietary recall data. RESULTS: An average of 37% of total energy intake was consumed at school. Energy-dense foods and beverages such as fat spreads, packaged snacks, biscuits and fruit/cordial drinks made a greater contribution to energy intake at school compared to out of school (P< or =0.01). Fast foods and soft drinks contributed 11 and 3% of total energy intake; however, these food groups were mostly consumed out of school. Fruit intake was low and consumption was greater in school. In all, 14% of children purchased food from the canteen and they obtained more energy from fast food, packaged snacks, desserts, milk and confectionary (P< or =0.05) than noncanteen users. CONCLUSIONS:: Energy-dense foods and beverages are over-represented in the Australian school environment. To help prevent obesity and improve nutrition in schools, biscuits, snack bars and fruit/cordial drinks brought from home and fast food, packaged snacks, and confectionary sold at canteens should be replaced with fruit and water.     

Food consumption and nutrient intake in a sample of Italian secondary school students: results from the INRAN-RM-2001 food survey

The present study was designed to estimate the average food and nutrient intake in a sample of Italian students living in the District of Rome. In the school year 1999-2000 all students belonging to the first, second or third year of nine randomly selected secondary public schools were contacted for filling in a food frequency questionnaire (3982 subjects). The next year, 233 of them (125 males and 108 females), randomly extracted, participated in a detailed food survey. Food intake was assessed on the basis of 12 (four consecutive days in three different periods) 24-h dietary records. The average daily intakes of fruit (107 +/- 100 g/day), vegetables (186 +/- 74 g/day) and legumes (16 +/- 29 g/day) were lower than recommended. The percentage of energy intake from fat (39%) and that from saturated fats (12%) were high. On the other hand, the percentage of energy intake from carbohydrates was low (45%) even if that from sugar (14%) was rather high. The students' diet was characterized by low intakes of fibre (16 +/- 6 g/day) and calcium (710 +/- 247 mg/day) in both males and females. Iron intakes were lower than 12 mg/day in a very high percentage of females (80%), suggesting that iron deficiency may be present in this population group. Results indicate that the diet of these students is both unbalanced in terms of macronutrients and deficient for some micronutrients, suggesting the need for intervention.     

Changes in a middle school food environment affect food behavior and food choices

Increasing rates of obesity among children ages 12 to 19 years have led to recommendations to alter the school food environment. The purpose of this study was to determine whether there are associations between an altered school food environment and food choices of middle school students both in and outside of school. In a midsized western city, two of six middle schools allowed only bottled water in vending machines, only milk and fruit on à la carte menus, and offered a seasonal fruit and vegetable bar. Three years after the intervention was initiated, seventh- and eighth-grade students attending the two intervention schools and four control middle schools were surveyed about their food choices. A total of 2,292 surveys were completed. Self-reported frequency of consumption for nine food groups in the survey was low; consumption was higher outside than in school. Boys consumed more milk than girls although girls consumed more fruits and vegetables. Significant socioeconomic differences existed. Compared with students who paid the full lunch fee, students qualifying for free and reduced-price meals consumed more milk and juice in schools but less outside school; more candy and energy drinks in school; and more sweet drinks, candy, pastries, and energy drinks outside school. Students in intervention schools were 24% more likely to consume milk outside school, 27% less likely to consume juice in school, and 56% less likely to consume sweet pastries in school. There were no differences in fruit and vegetable consumption reported by children in control and intervention schools. Overall, there was a positive association between a modified school food environment and student food behavior in and outside school. Policies related to the school food environment are an important strategy to address the obesity epidemic in our country.     

Reliability of the School Food Checklist for in-school audits and photograph analysis of children's packed lunches

Background:  Assessment of children's diets is problematic, typically relying on error-prone parent or child recall or reporting, or resource intensive direct observation. The School Food Checklist (SFC) is an objective instrument comprising of 20 food and beverage categories designed to measure the foods contained in children's packed lunches. The present study aimed to assess intra-rater and inter-rater reliability of each of the food and beverage categories of the SFC for both in-school audits and photograph analysis of children's school lunches.
Methods:  Participants comprised 176 children aged 5–8 years from five primary schools in Northern Metropolitan Melbourne. The SFC was used to measure the foods contained in children's packed lunches in the school setting and using photographs. Photograph analysis was conducted by the auditors 2–3 months after completion of in-school audits.
Results:  Both intra-rater [intra-class correlation coefficient (ICC) = 0.78–1] and inter-rater (ICC = 0.50–0.95) reliability analysis indicated strong agreement for in-school auditing. With the exception of the food category titled 'leftovers', there was strong intra-rater reliability for auditors' live audits and their analysis of photographs [ICC = 0.57–0.98 (Auditor 1); ICC = 0.72–0.90 (Auditor 2)], and strong inter-rater reliability for photograph analysis (ICC = 0.68–0.92).
Conclusions:  The SFC is a reliable method of measuring the foods and beverages contained in children's packed lunches when used in the school setting or for photograph analysis. This finding has broad implications, particularly for the use of photograph analysis, because this approach offers a convenient and cost effective method of measuring what food and beverages children bring to school in home packed lunches.     

Water incorporated into a food but not served with a food decreases energy intake in lean women.

BACKGROUND: Previous research showed that decreasing the energy density (kJ/g) of foods by adding water to them can lead to reductions in energy intake. Few studies have examined how water consumed as a beverage affects food intake. OBJECTIVE: This study examined the effects of water, both served with a food and incorporated into a food, on satiety. DESIGN: In a within-subjects design, 24 lean women consumed breakfast, lunch, and dinner in our laboratory 1 d/wk for 4 wk. Subjects received 1 of 3 isoenergetic (1128 kJ) preloads 17 min before lunch on 3 d and no preload on 1 d. The preloads consisted of 1) chicken rice casserole, 2) chicken rice casserole served with a glass of water (356 g), and 3) chicken rice soup. The soup contained the same ingredients (type and amount) as the casserole that was served with water. RESULTS: Decreasing the energy density of and increasing the volume of the preload by adding water to it significantly increased fullness and reduced hunger and subsequent energy intake at lunch. The equivalent amount of water served as a beverage with a food did not affect satiety. Energy intake at lunch was 1209 +/- 125 kJ after the soup compared with 1657 +/- 148 and 1639 +/- 148 kJ after the casserole with and without water, respectively. Subjects did not compensate at dinner for this reduction in lunch intake. CONCLUSION: Consuming foods with a high water content more effectively reduced subsequent energy intake than did drinking water with food.     

Development and evaluation of the school cafeteria nutrition assessment measures

BACKGROUND: Foods provided in schools represent a substantial portion of US children's dietary intake; however, the school food environment has proven difficult to describe due to the lack of comprehensive, standardized, and validated measures. METHODS: As part of the Arkansas Act 1220 evaluation project, we developed the School Cafeteria Nutrition Assessment (SCNA) measures to assess food availability in public school cafeterias (n = 113). The SCNA provides a measure to evaluate monthly school lunch menus and to observe foods offered in school cafeterias during the lunch period. These measures provide information on the availability of fruit, vegetables, grains (whole or white), chips (reduced fat or regular), side dishes, main dishes, beverages, à la carte selections, and desserts, as well as information on healthier preparation of these items. Using independent raters, the inter‐rater reliability of the measure was determined among a subsample of these schools (n = 32). RESULTS: All food categories assessed, with the exception of the side dish and chip categories, had inter‐rater reliability rates of 0.79 or greater, regardless of school type. The SCNA scores encompassed the majority of the possible scores, indicating the ability for the measures to differentiate between school cafeterias in the availability of healthier options. CONCLUSION: These measures allow comprehensive, rapid measurement of school cafeteria food availability with high inter‐rater reliability for public health and school health professionals, communities, and school personnel. These measures have the potential to contribute to school health efforts to evaluate cafeteria offerings and/or the impact of policy changes regarding school foods.     

Resources for a healthy diet: school meals

School meals have changed during the last decades. The traditional service style with on-site food preparation has shifted towards catering delivery services. Vending machines, school cafeterias and other ways of food distribution are widely used in many schools, particularly in secondary schools. From a health promotion approach, the quality and quantity of food and beverages consumed while in school have an enormous potential impact on the health and well-being of young people. Most children spend a significant part of their lives in school. Additionally, school meals supply 30-35 % of daily energy intake and provide an important contribution to nutrient intake. School life is a critical period in the acquisition and practice of healthy behaviours. Environmental interventions in schools, to increase availability and access to healthy foods such as fruit and vegetables, have proved to be effective. School meals should make high-quality foods available which allow nutrient requirements to be met, consistent with dietary guidelines and offering a positive nutritional experience. School meals should be part of the educational process in the life of the school.     

Dietary energy density determined by eight calculation methods in a nationally representative United States population

Dietary energy density [kcal/g (kJ/g)] influences energy intake under controlled laboratory conditions. Little is known about the energy density of the diets of free-living persons. Because energy density investigations are a relatively new endeavor, there are neither standard calculation methods nor published nationally representative values. This paper examines the calculation of energy density based on systematic exclusion of beverage categories, presents data on variability, and compares values by sex, age, and race/ethnicity in a representative sample of U.S. adults. Mean daily dietary energy density values for adults (aged >19 y) were calculated using two 24-h recalls from the Continuing Survey of Food Intakes by Individuals 1994-1996 based on food, food and liquid meal replacements, food and alcohol, food and juice, food and milk, food and juice and milk, food and energy-containing beverages, and food and all beverages. Energy density varied by calculation method, ranging from 0.94 to 1.85 kcal/g (3.93-7.74 kJ/g). Intraindividual-to-interindividual CV ratios were highest for the food and energy-containing beverages calculation. Men reported diets with a higher energy density than women for all calculation methods (P < 0.0001). There were differences by race/ethnicity and an inverse linear trend for age. These data indicate that beverage inclusion schemes should be clearly defined when reporting energy density values. In epidemiologic studies, calculations based on food and all beverages and food and energy-containing beverages may diminish associations with outcome variables. These nationally representative data, which provide an important frame of reference for other studies, indicate that dietary energy density differs by sex, age, and race/ethnicity.     

Non-Hispanic white and Hispanic elementary school children's self-regulation of energy intake

BACKGROUND: Preschool-aged children consistently self-regulate energy intake by adjusting food intake to reflect the energy density of the diet. However, only select adults demonstrate self-regulation skills related to energy density cues. OBJECTIVE: The objective was to examine the developmental characteristics of non-Hispanic white and Hispanic children's self-regulation of energy intake and to determine whether individual differences in the precision of food intake regulation were related to the children's anthropometric measures. DESIGN: Three hundred forty-two 5-12-y-old children were recruited from 2 schools, one school that enrolled predominantly non-Hispanic white children (n = 148) and another school in a Hispanic neighborhood (n = 194). The children ate 2-part meals, which consisted of a preload and a main meal. The preloads were fruit-flavored drinks that were either high (625 kJ) or low (12.5 kJ) in energy density. The children's food intake at the meal was measured and energy intake was estimated. An eating Compensation Index (COMPX) score, which reflected the children's ability to regulate energy intake, was used to predict the children's adiposity. RESULTS: Both non-Hispanic white and Hispanic children showed evidence of incomplete compensation, with a mean (+/-SEM) COMPX score of 48.6 +/- 6.4%. No significant ethnicity or sex differences in the children's overall COMPX scores were observed; however, the children's COMPX scores decreased with age (P < 0.05). Maternal body mass index was the best predictor of the children's weight status. CONCLUSION: Children aged 5-12 y show individual variation in their responsiveness to energy density cues; the responsiveness declines with increasing age.     

Patterns of food use and nutrient intake of obese and non-obese Hualapai Indian women of Arizona

To document patterns of food use and nutrient intake associated with obesity in Native American women, a sample of 14 obese and 14 non-obese free-living Hualapai Indian women living in northwest Arizona was studied. Patterns of food use were determined through long-term observation, dietary histories, and 24-hour dietary recalls. Dietary intake was determined through 24-hour dietary recalls over 7 consecutive days. Patterns of food acquisition, selection, and preparation were similar for obese and non-obese Hualapai women. The diets of both groups were dominated by nonalcoholic beverages, potatoes, beans, white wheat flour, and canned goods. Wild and locally cultivated foods were not eaten on a regular basis. The diets of both the obese and non-obese women were high in energy (pooled mean +/- standard deviation [SD] = 2,602 +/- 766 kcal/day) and carbohydrates (pooled mean +/- SD = 333.4 +/- 95.6 gm/day), moderate in protein (pooled mean +/- SD = 77.8 +/- 20.9 gm/day) and fat (pooled mean +/- SD = 101.1 +/- 25.4 gm/day), and low in crude fiber (pooled mean +/- SD = 4.7 +/- 2.0 gm/day). The study indicates that significantly (p less than .001) higher energy intakes of the obese women can be attributed to their greater consumption of nonalcoholic and alcoholic beverages.     

Energy density of the diet, food volume and energy intake by age and sex in a healthy population.

OBJECTIVE: To assess the changes in energy intake (EI), food intake volume (FV) and energy density (ED) related to age and gender in a population in the Mediterranean area of Spain, and to determine the different role of FV and ED on the consecution of the adequate EI throughout lifespan. SUBJECTS: One thousand and eighty-eight individuals (1-65 y) randomly selected from the population census. DESIGN: Cross-sectional study in which food intake was quantified by 24 h dietary recall, three non-consecutive days. Height and weight measurements were taken in 885 individuals. RESULTS: EI, FV and ED increased progressively (P < 0.001) between 1-2 y and 10-12 y of age in both sexes. At 1-2 y the EI is 5.8+/-1.5 MJ/d, FV 1195+/-275 g/d and ED 4.8+/-0.9 kJ/g. Between 1-2 and 3-4 y, coinciding with an EI that increased up to 7.2+/-1.5 MJ/d, there was an increase in ED up to 6.1+/-0.8 kJ/g (P < 0.001), while the FV did not vary significantly. At the start of puberty, between 7-9 and 10-12 y, when the EI increased to 9.7+/-0.9 MJ/d (P < 0.001) in males, the ED rose to 7.1+/-0.9 kJ/g (P < 0.001) while the FV did not vary significantly. At this age, a significant difference between the genders was observed in the EI (P = 0.04), and in the ED (P = 0.02) but not, as yet, in the FV. During adulthood, a significant trend towards decrease (P < 0.001 in both sexes) was observed in EI and ED. However, FV decreased significantly only in females. CONCLUSIONS: The changes in energy intake that were observed with respect to age and gender were accommodated-for by changes in the ED of the diet rather than by variations in food volume intake. Autoregulation of the ED of the diet, sufficient for energy intake requirement changes, appears to be an essential human capacity for efficient nutrition.     

Intervention with traditional food as a major source of energy, protein, iron, vitamin C and vitamin A for rural Dalit mothers and young children in Andhra Pradesh, South India

Intakes of energy, protein, iron and vitamin A in India are usually reported as inadequate. Recognizing that traditional food systems are sustainable, high in species variety, and have rich nutrient sources, we compared dietary intakes and nutrient sources of Dalit mothers and their children living in villages with and without an intervention based on improved access to the traditional Dalit food system. 24-hour recalls were conducted with Dalit mothers and their children aged 6-39 months during summer and rainy seasons in 2003. We found that mothers from intervention villages had significantly higher intakes of energy (mean +/- SD: 12,197 +/- 3,515 kJ vs. 11,172 +/- 3,352 kJ; p =0.02) and protein (77.5 +/- 25.1 g vs. 71.1 +/- 25.2 g; p =0.05) in summer, and higher intakes of energy (11,168 +/- 3,335 kJ vs. 10,168 +/- 3,730 kJ; p = 0.04), protein (68.9 +/- 22.6 g vs. 60.4 +/- 23.8 g; p <0.01) and iron (15.8 +/- 6.6 mg vs. 13.7 +/- 9.1 mg; p <0.01) during rainy season. There were no differences in children's intakes between intervention and control villages. In mothers, sorghum contributed 29% of energy, 33% of protein and 53% of iron, and green leafy vegetables contributed 21% of vitamin C and 38% of vitamin A. Our results indicate that traditional food such as sorghum, pulses and green leafy vegetables are major sources of energy, protein, iron, vitamin C and vitamin A, and that mothers from villages with the traditional food intervention had higher intakes of energy, protein and iron.     

Nutritional intake from food sources of high school football athletes

Male high school football athletes served as subjects (no. = 134; age = 15.0 +/- 1.2 years, range = 12 to 18 years; weight = 67.7 +/- 13.9 kg) (mean +/- standard deviation) in a dietary survey project to characterize nutritional intake from food sources. Dietary intake data were collected using the recall method for 1 weekday during the summer when athletes participated in unsupervised, informal conditioning. Subjects were grouped by age as junior high (JR-HI: 12 to 14 years) or senior high (SR-HI: 15 to 18 years) students. Absolute mean energy and nutrient intakes, except for vitamin A, were statistically greater for SR-HI relative to JR-HI (p less than .02). These findings are consistent with age-related growth on nutritional intake. Mean nutritional intakes from food sources for SR-HI met or exceeded the RDAs. For JR-HI, mean intakes met or exceeded the RDAs except for energy (94% RDA) and zinc (87% RDA). Mean intakes exceeded those of a representative sample of same-age boys in the larger American population.     

Does the consumption of caloric and non-caloric beverages with a meal affect energy intake?

Beverages are frequently consumed with meals, but their influence on meal energy intake is not understood. We hypothesized that differences in the energy, nutrient content, and sensory properties of beverages consumed with a meal would affect intake. Forty-four women ate lunch in the laboratory once a week for 6 weeks. Lunch was consumed ad libitum, and was served with one of five beverages that were consumed in full, or no beverage. The beverages were 360 g of water, diet cola, regular cola, orange juice, and 1% milk. Results showed an effect of beverage type on meal intake (p<0.0001). Energy intake did not differ among the non-caloric and no-beverage conditions. Similarly, energy intake from lunch (including beverage) did not differ among the caloric beverage conditions. When a caloric beverage (156 kcal; 653 kJ) was consumed with the meal, energy intake was 104+/-16 kcal (435+/-67 kJ) greater than when a non-caloric beverage or no beverage was consumed. Subjects' ratings of fullness after lunch did not differ among the beverage conditions, but were lower for the no-beverage condition. These results show that when caloric beverages are consumed with a meal they add to energy intake from food, without significantly affecting satiety ratings.     

Development and Validation of a Beverage and Snack Questionnaire for Use in Evaluation of School Nutrition Policies

School nutrition policies limiting access to sweetened beverages, candy, and salty snacks have the potential to improve the health of children. To effectively evaluate policy success, appropriate and validated dietary assessment instruments are needed. The objective of this study was to develop and validate a beverage and snack questionnaire suitable for use among young adolescents. A new 19-item Beverage and Snack Questionnaire (BSQ) was administered to middle school students on two occasions, 2 weeks apart, to measure test-retest reliability. The questionnaire inquired about frequency of consumption, both at school and away from school, of soft drinks, salty snacks, sweets, milk, and fruits and vegetables. Students also completed 4-day food records. To assess validity, food-record data were compared with BSQ data. Forty-six students of diverse backgrounds from metropolitan Seattle, WA, participated in this study. Participants answered the BSQ during class time and completed the food record at home. Pearson correlation coefficients assessed test-retest reliability and validity. Using frequency per week data, the test-retest reliability coefficients were r=0.85 for fruits and vegetables consumed at school and r=0.74 and r=0.72 for beverages and sweets/snacks, respectively, consumed at school. Correlations ranged from r=0.73 to 0.77 for foods consumed outside of school. Compared with the criterion food record, validity coefficients were very good: r=0.69 to 0.71 for foods consumed at school and r=0.63 to 0.70 for foods consumed away from school. The validity coefficients for the 19 individual food items ranged from r=0.56 to 0.87. This easy-to-administer 19-item questionnaire captures data on sugar-sweetened beverages, salty snacks, sweets, milk, and fruit and vegetables as well as a more lengthy and expensive food record does. The BSQ can be used by nutrition researchers and practitioners to accurately evaluate student consumption of foods that are the focus of school nutrition policies.     

Gender differences in food and energy intake among adult villagers in northwestern Bangladesh: a food frequency questionnaire survey

This study aimed to elucidate gender differences in dietary intake of rural Bangladeshi adults. A food frequency questionnaire (FFQ) survey using 15 food/dish items, together with anthropometric measurements, was conducted for 230 adults and adolescents (95 males and 135 females). To estimate the portion sizes of these foods/dishes, the samples consumed by 25 subjects were weighed. The FFQ revealed that rice was eaten two to three times (or more) per day by 98% of the subjects, providing nearly 60% of energy for both sexes. Puri (fried bread), meats, eggs, pulses, milk, fresh vegetables, fruits, tea with milk and sugar, and soft drinks were consumed more frequently by males. Males' larger portion sizes of rice, fish dish, potato dish, and vegetable dish resulted in larger daily energy intake per body weight in males (235 +/- 41 kJ/kg) than in females (161 +/- 28 kJ/kg). Despite males' larger energy intake, the proportion of chronically energy deficient persons (<18.5 kg/m2 in body mass index) was similar between males (35.8%) and females (37.8%), attributing to males' larger energy expenditure. Females' less-frequent consumption of nutritious foods and smaller energy intake were considered vulnerable to micronutrient deficiency.     

Increasing the volume of a food by incorporating air affects satiety in men

BACKGROUND: Previous research indicated that increasing the volume of food by adding water can lead to reductions in energy intake. However, the addition of water affects not only the volume but also the energy density (kJ/g) of foods. No studies have examined the effect of volume independent of energy density on intake. OBJECTIVE: We examined the effect of food volume independent of energy density on satiety. DESIGN: In a within-subjects design, 28 lean men consumed breakfast, lunch, and dinner in the laboratory 1 d/wk for 4 wk. On 3 d, participants received a preload 30 min before lunch and on 1 d no preload was served. Preloads consisted of isoenergetic (2088 kJ), yogurt-based milk shakes that varied in volume (300, 450, and 600 mL) as a result of the incorporation of different amounts of air. Preloads contained identical ingredients and weighed the same. RESULTS: The volume of the milk shake significantly affected energy intake at lunch (P < 0.04) such that intake was 12% lower after the 600-mL preload (2966 +/- 247 kJ) than after the 300-mL preload (3368 +/- 197 kJ). Subjects also reported greater reductions in hunger and greater increases in fullness after consumption of both the 450- and 600-mL preloads than after the 300-mL preload. CONCLUSIONS: Changing the volume of a preload by incorporating air affected energy intake. Thus, the volume of a preload independent of its energy density can influence satiety.