Food sales outlets, food availability, and the extent of nutrition policy implementation in schools in British Columbia

BACKGROUND: The purpose of this study was to determine the number and types of different food sales outlets, the types of foods offered for sale in all school food outlets, and the extent of nutrition policy implementation in schools in British Columbia. We also directly measured the number and types of snack foods available for sale in each vending machine at each school. METHODS: Based on a thorough literature review and guided by an expert panel of nutritionists, we developed an instrument to measure the quantity and types of foods offered for sale in vending machines, the types of food for sale in all school food outlets, and the extent of nutrition policy development. RESULTS: The survey response rate was approximately 70%. Approximately 60% of surveyed schools had a permanent food sales outlet. Snack and beverage vending machines were most common in secondary schools, while tuck shops and food-based fundraisers were more common in elementary schools. While few snack vending machines were present in elementary schools, tuck shops stocked items commonly found in snack machines. Approximately 25% of schools had a formal group responsible for nutrition. These schools were more likely to have nutrition policies in place. CONCLUSION: "Junk" foods were widely available in elementary, middle, and secondary schools through a variety of outlets. Although snack machines are virtually absent in elementary schools, tuck shops and school fundraisers sell foods usually found in snack machines, largely cancelling the positive effect of the absence of snack machines in these schools. Schools with a group responsible for nutrition appear to have a positive impact on nutrition policy implementation.     

The Impact of the Availability of School Vending Machines on Eating Behavior during Lunch: The Youth Physical Activity and Nutrition Survey

Childhood obesity is a major public health concern and is associated with substantial morbidities. Access to less-healthy foods might facilitate dietary behaviors that contribute to obesity. However, less-healthy foods are usually available in school vending machines. This cross-sectional study examined the prevalence of students buying snacks or beverages from school vending machines instead of buying school lunch and predictors of this behavior. Analyses were based on the 2003 Florida Youth Physical Activity and Nutrition Survey using a representative sample of 4,322 students in grades six through eight in 73 Florida public middle schools. Analyses included χ² tests and logistic regression. The outcome measure was buying a snack or beverage from vending machines 2 or more days during the previous 5 days instead of buying lunch. The survey response rate was 72%. Eighteen percent of respondents reported purchasing a snack or beverage from a vending machine 2 or more days during the previous 5 school days instead of buying school lunch. Although healthier options were available, the most commonly purchased vending machine items were chips, pretzels/crackers, candy bars, soda, and sport drinks. More students chose snacks or beverages instead of lunch in schools where beverage vending machines were also available than did students in schools where beverage vending machines were unavailable: 19% and 7%, respectively (P≤0.05). The strongest risk factor for buying snacks or beverages from vending machines instead of buying school lunch was availability of beverage vending machines in schools (adjusted odds ratio=3.5; 95% confidence interval, 2.2 to 5.7). Other statistically significant risk factors were smoking, non-Hispanic black race/ethnicity, Hispanic ethnicity, and older age. Although healthier choices were available, the most common choices were the less-healthy foods. Schools should consider developing policies to reduce the availability of less-healthy choices in vending machines and to reduce access to beverage vending machines.     

Parental attitudes towards soft drink vending machines in high schools

Soft drink vending machines are available in 98% of US high schools. However, few data are available about parents' opinions regarding the availability of soft drink vending machines in schools. Six focus groups with 33 parents at three suburban high schools were conducted to describe the perspectives of parents regarding soft drink vending machines in their children's high school. Parents viewed the issue of soft drink vending machines as a matter of their children's personal choice more than as an issue of a healthful school environment. However, parents were unaware of many important details about the soft drink vending machines in their children's school, such as the number and location of machines, hours of operation, types of beverages available, or whether the school had contracts with soft drink companies. Parents need more information about the number of soft drink vending machines at their children's school, the beverages available, the revenue generated by soft drink vending machine sales, and the terms of any contracts between the school and soft drink companies.     

Are school vending machines loaded with calories and fat: an assessment of 106 middle and high schools

BACKGROUND: The purpose of this study was to describe the extent to which vending offerings in 106 schools in the St. Paul‐Minneapolis, Minnesota metropolitan area, met criteria for types of beverages, fat, and calories based on selected criteria offered by the Institute of Medicine. METHODS: Schools where youth participants were attending for the 2006–2007 school year were identified and invited to participate in the study (n = 143); 81% of schools (n = 116) agreed to participate. RESULTS: Of the 116 schools, 106 had vending machines. Across schools with vending machines (n = 106), 5085 food and 8442 beverage items were offered. Overall, only 18% of beverage items met criteria for calories and type of beverage; significantly more items in public schools met the criteria as compared to private schools (19% vs 12%; p < .01). This difference was also significant for high schools as compared to middle schools (18% vs 22%; p < .01). For food items, 41% met calorie criteria, 45% met fat criteria, and 22% met both fat and calorie criteria. Significantly more food items met both criteria in public than private schools (22% vs 18%; p = .01), while high schools (22%) and middle schools (21%) were similar. A very small proportion of foods (<5%) would have met the full criteria suggested by the Institute of Medicine for competitive foods. CONCLUSION: Overall, foods and beverages offered in vending machines continue to be high in fat and calories. Public schools are doing a slightly better job of providing healthy foods as compared to private schools.     

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.     

School and district wellness councils and availability of low-nutrient, energy-dense vending fare in Minnesota middle and high schools

The Child Nutrition and WIC Reauthorization Act of 2004 required school districts participating in the federal school meals program to establish by the start of the 2006-2007 school year policies that included nutrition guidelines for all foods sold on school campus during the school day and policy development involving key stakeholders. For many schools, policy development was done by wellness councils. This study examined the association between having a wellness council and availability of low-nutrient, energy-dense foods/beverages in school vending machines following enactment of the federal legislation. In 2006-2007, Minnesota middle (n=35) and high (n=54) school principals reported whether their school and district had a wellness council. Trained research staff observed foods/beverages in vending machines accessible to students. Low-nutrient, energy-dense foods/beverages (snacks >3 g fat or >200 calories/serving, and soda, fruit/sport drinks and reduced-fat/whole milk) were grouped into seven categories (eg, high-fat baked goods) and a food score was calculated. Higher scores indicated more low-nutrient, energy-dense vending fare. Multivariate linear regression, adjusted for school characteristics, was used to examine associations between scores and a three-category council variable (district-only; district and school; no council). Among schools, 53% had district-only councils, 38% district and school councils, and 9% had no council. Schools with both a district and school council had a significantly lower mean food score than schools without councils (P=0.03). The potential of wellness councils to impact availability of low-nutrient, energy-dense vending fare is promising. There may be an added benefit to having both a school and district council.     

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.     

Factors affecting sugar-sweetened beverage availability in competitive venues of US secondary schools

BACKGROUND: This study explores sugar‐sweetened beverage (SSB) availability in US secondary school competitive venues during the first 3 years following the school wellness policy requirement (2007‐2009). Furthermore, analyses examine associations with school policy and SSB availability. METHODS: Analyses use questionnaire data from 757 middle and 762 high schools in the nationally representative Youth, Education, and Society study to examine soda and non‐soda SSB availability associations with school policy including (1) beverage bottling contracts and related incentives, (2) individuals/organizations responsible for decisions regarding beverages available in vending machines, and (3) school wellness policies and nutrition guidelines. RESULTS: Non‐soda SSBs made up the majority of SSBs in both middle and high schools. Soda was especially likely to be found in vending machines; non‐soda SSBs were widely available across competitive venues. Access to soda decreased significantly over time; however, non‐soda SSB access did not show a similar decrease. School policy allowing beverage supplier contractual involvement (bottling contract incentives and beverage supplier “say” in vending machine beverage choices) was related to increased SSB access. However, the existence of developed nutritional guidelines was associated with lower SSB availability. CONCLUSIONS: Students had high access to SSBs across competitive school venues, with non‐soda SSBs making up the majority of SSB beverage options. Efforts to reduce access to SSBs in US secondary schools should include a focus on reducing both soda and non‐soda SSBs, reducing beverage supplier involvement in school beverage choices, and encouraging the development of targeted nutritional guidelines for all competitive venues.     

Food environment in secondary schools: a la carte,vending machines,and food policies and practices

OBJECTIVES: This study described the food environment in 20 Minnesota secondary schools. METHODS: Data were collected on school food policies and the availability and nutritional content of foods in school à la carte (ALC) areas and vending machines (VMs). RESULTS: Approximately 36% and 35% of foods in ALC areas and in VMs, respectively, met the lower-fat criterion (< or = 5.5 fat grams/serving). The chips/crackers category constituted the largest share of ALC foods (11.5%). The median number of VMs per school was 12 (4 soft drink, 2 snack, 5 other). Few school food policies were reported. CONCLUSIONS: The availability of healthful foods and beverages in schools as well as school food policies that foster healthful food choices among students needs greater attention.     

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.     

The association between state bans on soda only and adolescent substitution with other sugar-sweetened beverages: a cross-sectional study

Background

Across the United States, many states have actively banned the sale of soda in high schools, and evidence suggests that students’ in-school access to soda has declined as a result. However, schools may be substituting soda with other sugar-sweetened beverages (SSBs), and national trends indicate that adolescents are consuming more sports drinks and energy drinks. This study examined whether students consumed more non-soda SSBs in states that banned the sale of soda in school.

Methods

Student data on consumption of various SSBs and in-school access to vending machines that sold SSBs were obtained from the National Youth Physical Activity and Nutrition Study (NYPANS), conducted in 2010. Student data were linked to state laws regarding the sale of soda in school in 2010. Students were cross-classified based on their access to vending machines and whether their state banned soda in school, creating 4 comparison groups. Zero-inflated negative binomial models were used to compare these 4 groups with respect to students’ self-reported consumption of diet soda, sports drinks, energy drinks, coffee/tea, or other SSBs. Students who had access to vending machines in a state that did not ban soda were the reference group. Models were adjusted for race/ethnicity, sex, grade, home food access, state median income, and U.S. Census region.

Results

Students consumed more servings of sports drinks, energy drinks, coffee/tea, and other SSBs if they resided in a state that banned soda in school but attended a school with vending machines that sold other SSBs. Similar results were observed where schools did not have vending machines but the state allowed soda to be sold in school. Intake was generally not elevated where both states and schools limited SSB availability – i.e., states banned soda and schools did not have SSB vending machines.

Conclusion

State laws that ban soda but allow other SSBs may lead students to substitute other non-soda SSBs. Additional longitudinal research is needed to confirm this. Elevated SSB intake was not observed when both states and schools took steps to remove SSBs from school.

     

Public health strategies for dietary change: schools and workplaces

Environmental intervention represents an effective strategy to promote the purchase and consumption of healthful foods in community-based settings. Three such studies promoted the consumption of healthier snacks and lower-fat foods at worksites and at schools. The first study examined lower prices and point-of-purchase promotion on sales of lower-fat snacks in vending machines in 12 worksites and 12 secondary schools. Price reductions of 10%, 25% and 50% on lower-fat snacks resulted in an increase in sales of 9%, 39% and 93%, respectively, as compared to usual-price conditions. The second study examined the impact of a 50% price reduction on the consumption of fresh fruit and baby carrots in 2 secondary school cafeterias. In the third study, 20 secondary schools were randomly assigned to either an environmental intervention or a control group for a 2-y period. The intervention increased the availability of lower-fat foods and implemented student-based promotions. School-based environmental interventions to increase availability and promotion of lower-fat foods and healthier snacks can increase purchase of these foods among adolescents.     

School vending machine use and fast-food restaurant use are associated with sugar-sweetened beverage intake in youth

OBJECTIVE: To examine associations between use of school vending machines and fast-food restaurants and youth intake of sugar-sweetened beverages. DESIGN: A cross-sectional observational study. SUBJECTS/SETTING: From a group randomized obesity intervention, we analyzed baseline data from 1,474 students in 10 Massachusetts middle schools with vending machines that sold soda and/or other sweetened drinks. MAIN OUTCOME MEASURES: Daily sugar-sweetened beverage consumption (regular soda, fruit drinks, and iced tea), purchases from school vending machines, and visits to fast-food restaurants in the preceding 7 days were estimated by self-report. STATISTICAL ANALYSES PERFORMED: Chi(2) and nonparametric tests were performed on unadjusted data; multivariable models adjusted for sex, grade, body mass index, and race/ethnicity, and accounted for clustering within schools. RESULTS: Among 646 students who reported using school vending machines, 456 (71%) reported purchasing sugar-sweetened beverages. Overall, 977 students (66%) reported eating at a fast-food restaurant. Sugar-sweetened beverage intakes averaged 1.2 servings per day. In adjusted models, relative to no vending machine purchases, servings per day increased by 0.21 for one to three purchases per week (P=0.0057), and 0.71 with four or more purchases (P<0.0001). Relative to no fast-food restaurant visits, sugar-sweetened beverage servings per day increased by 0.13 with one visit per week (P=0.07), 0.49 with two to three visits (P=0.0013), and by 1.64 with four or more visits (P=0.0016). CONCLUSIONS: Among students who use school vending machines, more report buying sugar-sweetened beverages than any other product category examined. Both school vending machine and fast-food restaurant use are associated with overall sugar-sweetened beverage intake. Reduction in added dietary sugars may be attainable by reducing use of these sources or changing product availability.     

Managing Sales of Beverages in Schools to Preserve Profits and Improve Children's Nutrition Intake in 15 Mississippi Schools

School environments that provide consistent and reliable nutrition information promote the development of healthful eating in children. High-energy, nutrient-poor beverages offered for sale to children during the school day compete with healthful choices. The primary objective of this prospective, quasiexperimental study was to encourage children to choose more healthful beverages during the school day without adversely affecting the profits realized from vending sales. Fifteen of 18 schools completed voluntary changes to beverage sales practices during the school day between August 2005 and May 2006. Twelve of 15 schools reported increased profits from the previous year (2004-2005) while offering more healthful beverage choices at discounted prices. Units of carbonated soft drinks sold declined when sports drinks, 100% fruit juice, and water were made available in their place. Passive marketing in the form of vending machine fronts, attractive pricing with a nominal 10% to 25% discount, and changing the types and proportions of beverages offered encouraged children to make more healthful choices. Local school administrators were receptive to making changes to beverage sales when local needs were incorporated into the study design. Profit information from this study informed state legislators and the Mississippi State Board of Education in the development and adoption of statewide snack and beverage vending guidelines. Registered dietitians serve as advocates to foster these collaborative efforts, inform key decision makers, and work in their local communities to develop and promote healthful practices in K-12 school settings.     

Food Environment in Secondary Schools: À La Carte, Vending Machines, and Food Policies and Practices

Objectives. This study described the food environment in 20 Minnesota secondary schools.

Methods. Data were collected on school food policies and the availability and nutritional content of foods in school à la carte (ALC) areas and vending machines (VMs).

Results. Approximately 36% and 35% of foods in ALC areas and in VMs, respectively, met the lower-fat criterion (≤ 5.5 fat grams/serving). The chips/crackers category constituted the largest share of ALC foods (11.5%). The median number of VMs per school was 12 (4 soft drink, 2 snack, 5 other). Few school food policies were reported.

Conclusions. The availability of healthful foods and beverages in schools as well as school food policies that foster healthful food choices among students needs greater attention.

     

Improvements in middle school student dietary intake after implementation of the Texas Public School Nutrition Policy

Objectives. We assessed the effect of the Texas Public School Nutrition Policy on middle school student lunchtime food consumption.Methods. Three years of lunch food records were collected from middle school students in southeast Texas: baseline (2001–2002), after local district changes (2002–2003), and 1 year after implementation of the Texas Public School Nutrition Policy (2005–2006). Students recorded amount and source of foods and beverages they consumed. Analysis of variance and covariance and nonparametric tests were used to compare intake after the policy change with intake during the 2 previous years.Results. After implementation of the nutrition policy, student lunch consumption of vegetables, milk, and several nutrients increased (protein, fiber, vitamins A and C, calcium, and sodium), and consumption of less desirable items (sweetened beverages, snack chips) decreased, as did percentage of energy from fat. Most of the desired nutrients and foods (vegetables and milk) were obtained from the National School Lunch Program meal. Fewer sweetened beverages, candy, chips, and dessert foods were purchased and consumed, but more of these items were brought from home and purchased from the snack bar.Conclusions. Overall, state school nutrition policies can improve the healthfulness of foods consumed by students at lunch.Public health efforts to reduce the increasing rates of childhood obesity1 have recently focused on school food environments.2 Although regulations exist for National School Lunch Program (NSLP) meals, there are no federal rules for competitive foods sold elsewhere in the school such as in snack bars and vending machines, except for foods of minimal nutritional value (e.g., soda).3 This has become an issue because the school environment influences dietary behavior.4 For example, middle school students with access to snack bar and a la carte foods consumed more sweetened beverages and french fries, and fewer fruit and vegetables compared with elementary school students without snack bars.5^,6 The number of snack vending machines was negatively related to daily fruit consumption among middle school youth.7 In high schools where soft drink machines were turned off during lunch, students purchased fewer soft drinks compared with students in schools where these machines were on during lunch.8 Improving types and portion sizes of foods available in school snack bars and a la carte could reduce the source of kilojoules available for student purchase and possibly improve energy balance.9States, school districts, and individual schools have enacted laws and policies regarding foods and beverages available in school food environments.10 The beverage industry also developed a voluntary beverage vending policy for schools.11 Such changes are controversial, and barriers to improving school food environments exist. These include the revenue generated from vending and snack bar and a la carte sales,12 school staff, student and parent attitudes toward types of foods expected in schools,13 and the concern that limiting access to these foods at school will not improve overall student dietary intake.14 Critics suggest that if these items are not available in schools, students will compensate by increasing consumption of desired foods in out-of-school environments.14Few data exist for the effect of policy changes on actual food consumption by students at school. One recent study documented significant improvements in food consumption by Texas middle school students (more milk, calcium, and vitamin A; fewer sweetened beverages) after a local school district enacted a snack bar food policy change.15 Consumption of chips purchased from the snack bar declined, but consumption of chips from vending machines increased, because the school administration, which was responsible for vending machines, made no changes. These results suggest that all school food sources have to make similar changes to favorably influence consumption.The Texas Public School Nutrition Policy, an unfunded mandate to promote a healthy school environment for Texas students, was implemented statewide in the fall of 2004. The guidelines apply to all school food sources, including vending machines.16 For middle schools, the policy restricts the portion sizes of high-fat and sugar snacks (limits vary by food group), sweetened beverages (≤ 12 oz), and the fat content of all foods served (≤ 28 grams of fat per serving no more than 2 times per week). It also sets limits on the frequency of serving high-fat vegetables such as french fries (3 oz per serving no more than 3 times per week). We report the results of a naturalistic study that assessed the effect of the Texas Public School Nutrition Policy on lunch consumption of middle school students in southeast Texas. Student lunch consumption data for 2 previous years were available for comparison.15     

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.