Impact of the new U.S. Department of Agriculture school meal standards on food selection, consumption, and waste

Daily Saturated Fat and Sodium Content of Elementary School Meals in a Large Sample of 128 Geographically Diverse School Systems in the United States

BACKGROUND

Despite federal regulations limiting saturated fat and sodium levels on a weekly average basis, daily nutrient content of school meals in the United States is not regulated, leading to potential large fluctuations and intake well in excess of dietary recommendations.

OBJECTIVE

To assess the daily prevalence of potential public elementary school meal combinations that were high in saturated fat and sodium (using cutoffs based on the US Department of Agriculture weekly average reimbursable meal thresholds), and to identify saturated fat and sodium thresholds for entrées to limit full meals exceeding those cutoffs.

DESIGN

Cross-sectional.

PARTICIPANTS AND SETTING

Four weeks of publicly available public elementary school (kindergarten through grade five) breakfast and lunch menus with associated nutrition data were collected from a national stratified random sample of 128 school districts during fall 2019.

MAIN OUTCOME MEASURES

Percent of meal combinations exceeding the saturated fat and Target 1 sodium thresholds were calculated, as well as thresholds for saturated fat and sodium levels in breakfast and lunch entrées.

STATISTICAL ANALYSES

Descriptive statistics and logistic regression were used to examine the odds of alignment with sodium and saturated fat US Department of Agriculture thresholds.

RESULTS

The prevalence of elementary breakfast and lunch meal combinations that were high in sodium was on average 11% and 12.4%, respectively, and for saturated fat was 10.6% and 34%, respectively. Entrées above certain thresholds (≥400 and ≥1,000 mg sodium and ≥4.5 and ≥6 g saturated fat for breakfast and lunch, respectively) had a higher odds of producing a reimbursable meal that was high in sodium and saturated fat.

CONCLUSIONS

There is widespread availability of high-saturated fat and sodium elementary school meal combinations on a daily basis. Daily thresholds, in addition to weekly nutrient thresholds, as well as limits on sodium and saturated fat for entrées, may therefore be needed to prevent daily excess intake of saturated fat and sodium among elementary students.

Interventions based on sensory-hedonic strategies and on nudging to facilitate vegetable and pulses consumption in the school environment

Childhood and adolescence shape lifelong taste preferences and dietary habits, making them crucial periods for promoting healthy and sustainable eating. As students consume up to half of their daily energy intake at school, school interventions can have a significant impact on promoting plant-based diets. Although the benefits of promoting plant-based diets on children's and adolescents' health and environmental sustainability are well established and various studies report promising effects of interventions based on sensory-hedonic strategies and on nudging in promoting vegetables and pulses in schools, a comprehensive collection of those reports is lacking. Therefore, this systematic review aims to collect published literature on the above interventions in schools that focus on promoting the consumption of vegetables and pulses to children and adolescents. Three databases-PubMed, Scopus, and Web of Science-were searched over all years until March 2022 using pre-specified terms. From the 10.488 studies identified, a total of 57 studies reporting sensory-hedonic (e.g., manipulating food sensory properties or their hedonic value) or nudging (e.g., changing the presentation) interventions targeting children and/or adolescents in schools and aiming at promoting vegetables and/or pulses were included. Overall, interventions based on sensory-hedonic strategies (either enhancing the perception of well-accepted flavor and texture or manipulating their hedonic value) and on nudging (through incentives and prompts) are effective in promoting vegetables and pulses. A gap in the literature was identified for interventions targeting adolescents and promoting pulses. Finally, multicomponent interventions, rather than using one strategy alone, could be more successful.

The Effects of Potato Presentation on Vegetable Intake in School-Aged Children: A Cross-Over Study

Vegetables are an essential component of a healthy dietary pattern in children; however, their consumption is often insufficient due to lack of preference. To address this, the influence of combining vegetables (mixed peas and carrots-MPACs) with potatoes, a generally liked food, on overall vegetable consumption among children aged 7-13 years was explored. The research involved a cross-over study design with 65 participants who completed five lunchtime meal conditions, each with different combinations of MPACs and potatoes versus a control (MPACs with a wheat roll). The meals were provided in a cafeteria setting, and plate waste was used to measure vegetable consumption. Anthropometric data and other variables were also measured. Notably, self-reported hunger did not significantly differ between conditions. Meal condition was a significant predictor of MPACs (F = 5.20; p = 0.0005), with MPAC consumption highest when combined with shaped potato faces in the same bowl (+8.77 g compared to serving MPACs and shaped potato faces in separate bowls) and lowest when combined with diced potatoes in the same bowl (-2.85 g compared to serving MPACs and diced potatoes in separate bowls). The overall model for MPAC consumption was influenced by age, height z-score, body fat percentage z-score, and condition (likelihood ratio = 49.1; p < 0.0001). Age had the strongest correlation with vegetable consumption (r = 0.38), followed by male gender, height z-score (r = 0.30), and body fat z-score (r = -0.15). The results highlight the positive impact of combining potatoes with vegetables in school meals, particularly when using shaped potato faces. These findings emphasize the potential of potatoes as a valuable vegetable option in promoting healthier eating habits among children. Additionally, future research could explore the impact of different potato combinations and investigate other factors influencing meal consumption in school settings.

Evaluation of health and economic effects of United States school meal standards consistent with the 2020-2025 dietary guidelines for Americans

BACKGROUND

The current school meal nutrition standards, established in 2010, are not fully aligned with the 2020-2025 Dietary Guideline for Americans (DGA). This study evaluates the potential short-term and long-term health and economic benefits of strengthening the school meal standards on added sugars, sodium, and whole grains to be aligned with current guidelines.

METHODS

We used comparative risk assessment frameworks based on nationally representative data incorporating current demographics, dietary habits, and risk factors of United States children aged 5-18 y from 3 cycles of the National Health and Nutrition Examination Survey (2013-2018). To estimate short-term impact, the model incorporated estimated dietary changes owing to potential new DGA-aligned school meal nutrition standards and the effect of these changes on childhood body mass index (in kg/m2) and blood pressure. To estimate long-term impact, the model further incorporated data on the sustainability of childhood dietary changes into adulthood, and on demographics and risk factors of United States adults, diet-disease associations, and disease-specific national mortality.

RESULTS

In a best-case scenario assuming full school compliance, implementing new DGA-aligned nutritional standards would lower elementary children's BMI by an average 0.14 (95% UI: 0.08-0.20) kg/m2 and systolic blood pressure by 0.13 (95% UI: 0.06-0.19) (95% mm Hg. Later in life, the new standards were estimated to prevent 10,600 [95% uncertainty interval (UI): 4820-16,800) annual deaths from cardiovascular disease (CVD), diabetes, and cancer in adulthood; and save 355,000 (95% UI: 175,000-538,000) disability-adjusted life years and $19.3 (95% UI: 9.35-30.3) B in direct and indirect medical costs each year. Accounting for plausible (incomplete) school compliance, implementation would save an estimated 9110 (95% UI: 2740-15,100) deaths, 302,000 (95% UI: 120,000-479,000) disability-adjusted life years, and $15.9 (95% UI: 4.54-27.2) B in healthcare-related costs per year in later adulthood.

CONCLUSIONS

Stronger school meal nutrition standards on added sugars, sodium, and whole grains aligned with the 2020-2025 DGA recommendations may improve diet, childhood health, and future adult burdens of CVD, diabetes, cancer, and associated economic costs.

School Nutrition Environment and Services: Policies and Practices That Promote Healthy Eating Among K-12 Students

BACKGROUND

Changes to policies at the federal, state, and local levels over the last decade have influenced the school nutrition environment and services.

METHODS

This systematic review includes an analysis of individual research articles and government reports published from 2010 to 2021 that examine interventions to improve the school nutrition environment and services and increase the availability, selection, and consumption of healthier foods and beverages in K-12 schools in the United States.

RESULTS

Nutrition standards for school meals and food outside of meals improved access to healthier options in school. Providing school nutrition professionals with professional development, improving the palatability of school meals, offering taste tests, pre-slicing fruit, providing recess before lunch, offering incentives for trying healthier options, and providing access to drinking water resulted in increased selection and consumption of healthier items. There were inconclusive or mixed findings for some intervention strategies including adequate seat time for meals.

CONCLUSIONS

Despite demonstrated improvements to school meal programs and competitive foods, more work is needed to change the selection and consumption of healthier options among K-12 students. Schools can use multiple interventions to improve the school nutrition environment and services and help students adopt food and beverage choices that support health.

Improving school lunch menus with multi-objective optimisation: nutrition, cost, consumption and environmental impacts

OBJECTIVE

To support school foods programmes by evaluating the relationship between nutritional quality, cost, student consumption and the environmental impacts of menus.

DESIGN

Using linear programming and data from previously served menu items, the relationships between the nutritional quality, cost, student consumption and the environmental impacts of lunch menus were investigated. Optimised lunch menus with the maximum potential student consumption and nutritional quality and lowest costs and environmental impacts were developed and compared with previously served menus (baseline).

SETTING

Boston Public Schools (BPS), Boston Massachusetts, USA.

PARTICIPANTS

Menu items served on the 2018-2019 BPS lunch menu (n 142).

RESULTS

Using single-objective models, trade-offs were observed between most interests, but the use of multi-objective models minimised these trade-offs. Compared with the current weekly menus offered, multi-objective models increased potential caloric intake by up to 27 % and Healthy Eating Index scores by up to 19 % and reduced costs and environmental impacts by up to 13 % and 71 %, respectively. Improvements were made by reducing the frequency of beef and cheese entrées and increasing the frequency of fish and legume entrées on weekly menus.

CONCLUSIONS

This work can be extrapolated to monthly menus to provide further direction for school districts, and the methods can be employed with different recipes and constraints. Future research should test the implementation of optimised menus in schools and consider the broader implications of implementation.

Improvements in School Food Offerings over Time: Variation by School Characteristics

The 2010 Healthy, Hunger-Free Kids Act (HHFKA) improved the nutritional quality of food served in schools. This longitudinal study examined school food offerings over time from school year 2010-11 to 2017-18 in public schools (n = 148) in four New Jersey cities. Six food indices were used to assess the number of healthy and unhealthy items offered as part of the National School Lunch Program (NSLP), in vending machines, and à la carte (i.e., competitive foods). Multilevel, multivariable linear regression with quadratic terms was used to model the trends over time. Interaction terms were added to examine whether the time trends varied by school-level factors, such as proportion of students eligible for free or reduced-price meals (FRPMs), race/ethnicity of enrolled students, and school level. Over the study period, healthy items offered in the NSLP increased (p < 0.001), while unhealthy items in the NSLP decreased (p < 0.001). Significantly different rates of declines in NSLP unhealthy offering were observed among schools at the two extremes of FRPM eligibility (p < 0.05). The trends for healthy and unhealthy foods offered in competitive foods showed significant non-linear trends, and differences were observed for school-level race/ethnicity, with worse outcomes for schools with majority Black student enrollment.

Food waste in primary schools: Evidence from peri-urban Viet Nam

Schools are a major source of food waste and an important setting for achieving dietary improvements. Few studies explore the links between food waste and nutrition. This study measured individual plate waste of about 1700 primary school children in peri-urban Viet Nam, adding to evidence on school food waste in low- and middle-income countries. We used survey data to explore whether food waste is associated with personal characteristics such as sex, knowledge and attitudes about nutritious foods. Qualitative interviews and focus groups with teachers, parents, food providers and children helped identify potential causes of food waste. The average student wasted 23% of the food served (approximately 85 g) during lunch, which roughly equates to 15.3 kg of food in a school year. Vegetables were wasted most: children left almost half of their portion unconsumed. Boys wasted less food than girls. Better knowledge and attitudes about fruits and vegetables are associated with less waste of these foods. A large portion was associated with a higher share of wasted food, suggesting the potential trade-off between efforts to cut food waste and efforts to increase consumption of nutritious foods. Students were dissatisfied with the quality of the dishes, especially vegetables were evaluated as undercooked, served too cold and too oily. To reduce food waste, it is critical for schools to prepare food in line with students' preferences. Food waste reduction could be treated as an intermediate step towards ultimate policy goals such as healthier food consumption.

Nutrition Effects of a Family-Centered Health Promotion Program for Mexican-Heritage Children in the Lower Rio Grande Valley of Texas

Systemic and social factors, like poverty and food insecurity, negatively influence fruit and vegetable (FV) intake and body mass index (BMI) among Latino/a children. Behavioral programs are needed to support children’s nutrition. This study examined program effects on FV intake and BMI outcomes for Mexican-heritage children (9–11 years). The program used a modified stepped-wedge design in the Lower Rio Grande Valley of Texas (2019 and 2020). Promotoras led experiential nutrition education sessions and collected height, weight, and instant skin carotenoid scores (biomarker for FV intake) at pre-test (baseline), post-test (6 weeks), and maintenance (3–4 months after post-test). Mean changes and group differences in skin carotenoid scores, BMI z-scores and percentiles were obtained from analyses of variance. Linear mixed-effects models were used to determine overall program effects. Mexican-heritage children were enrolled (n = 57 and 52.6% female). An overall decrease in skin carotenoid scores was observed at post-test (−15.1; 95% CI: −24.95, −5.33). While scores varied widely (range: 17–498), an increase of 14.8 ± 23.8 points occurred in one intervention group. Compared to the control period, greater reductions in BMI outcomes occurred during the program. These findings provide evidence for the use of strengths-based approaches in behavioral nutrition programs.

Nutrient Content and Compliance with Sodium Standards in Elementary School Meals in the United States Pre- and Post-COVID-19

Various federal policies have weakened school meal nutrition standards in the United States since the passage of the Healthy, Hunger-Free Kids Act in 2010, including temporary school meal nutrition waivers to promote post-COVID-19 pandemic recovery. This study used school menu and nutrient data from a nationally representative sample of 128 elementary school districts to examine differences in nutrients (average calories, total fat, saturated fat, sodium, total sugar, and fiber) and alignment with United States Department of Agriculture (USDA) sodium targets in 2019 (pre-pandemic) and in 2022 (post-pandemic). Data were analyzed using analysis of variance accounting for repeated measures within school districts, adjusting for geographic region and urbanicity. Small differences in the nutrient content for both breakfast and lunch were observed between 2019 and 2022. Most weeks met USDA sodium Target 1 for breakfast (≥95% of weeks) and Target 1 (≥96% of weeks) and Target 1A for lunch (≥92% of weeks) in both 2019 and 2022, although compliance decreased slightly when condiments were included. Additionally, meals provided on average 57 g of total sugar. Overall, many meals are already in alignment with lower sodium targets. Simple strategies, such as offering lower sodium condiments, can further reduce sodium in school meals. The total sugar levels observed highlight that the USDA should consider limits on added sugars in school meals.

Nutritional quality of lunch meals and plate waste in school lunch programme in Southern Thailand

Food waste globally affects food security and sustainability. There currently are few studies focusing on food waste in schools. The present study aimed to determine the meal quality and plate waste in school lunch programme in Thailand. This cross-sectional study was conducted in canteens of representing kindergarten and elementary schools in Southern Thailand within their real-life context. The assessment was carried out over five consecutive school days in July–August 2020 for each school, at which two types of menus, including rice with side dish and one-dish meal were served. Waste collection and quantification were conducted by selective aggregate weighing, according to the Food Loss and Waste Protocol. All lunch menus contained excess rice but insufficient meats, fruits, vegetables and eggs, regarding the national lunch standard. For each serving portion, 7–33 % rice, 9–22 % meats, 7–65 % vegetables, 1–19 % fruits and 3–14 % eggs were discarded. Plate waste from rice with side dish menus (10–29 %) was more than one-dish meals (7–17 %). By estimation, each kindergartener generated 71⋅4 g plate waste daily, accounting for the caloric and monetary values of 146 kcal and 0⋅16 US dollar. The amount of plate waste and the respective caloric and monetary losses were less obvious at the elementary school. Plate waste affected the adequacy of food intakes of schoolchildren from lunch meals. The data obtained from the present study will be useful for planning and implementation of school lunch programme in Thailand and countries with similar context.

Investigating the Impacts of Behavioural-Change Interventions and COVID-19 on the Food-Waste-Generation Behaviours of Catered Students in the UK and India

A food-waste initiative was conducted at two university canteens in the UK and India to examine food-waste attitudes and opportunities for food-waste reduction. Interventions were carried out to reduce food waste in both canteens. In the Indian canteen, postintervention data also included COVID-19-related changes, such as a change from self-service to table service, as well as reduced menu choices and an improved estimation of the number of students requiring meals. Surveys and focus groups were conducted with students to better understand their food-waste-related attitudes, while interviews were carried out with university staff to better understand food-waste management. The study in the UK university canteen found that introducing table cards, posters, and signs led to food-waste reductions of 13%. Meanwhile, the study in the Indian university canteen found that the interventions and COVID-19 impacts led to food-waste reductions of 50%. Concerning food-waste-related differences between the UK and India, culture and food preferences were key reasons for food waste in India, with 40.5% more participants in India stating that they wasted food because the ‘food didn’t taste good’. Students in India were more concerned about social issues and food poverty related to food waste, with around 9% more participants stating that the ‘food could be used by others’. Meanwhile, students in the UK were more bothered by the economic and environmental impacts of food waste, with around 31% more participants stating food waste is ‘a waste of money’, and is ‘bad for the environment’ when compared to India. Key opportunities for both countries included adopting food-sharing initiatives, informed menu choices, and meal planning, as well as student-led engagement projects.

Plate Waste in School Catering in Rezekne, Latvia

This research was conducted within the framework of a research project aimed at detecting patterns of plate waste and developing recommendations for improving catering in seven schools in Rezekne city (Latvia) by a combination of observation, physical weighing, semi-structured interview approaches and statistical analysis of variance (ANOVA). We identified plate waste (including wasted beverages), which remains after the lunch of schoolchildren in grades 1–7, examining a total of 7064 lunch samples. The originality of the research is due to the fact that a unified menu was designed for the field study, which ensured the same field study conditions in all the schools. The results of the research revealed that the average weight of plate waste per schoolchild reached 178 g, and the total weight of plate waste accounted for 28.75% of the total weight of food served. No significant differences in plate waste weight between various age groups and grades of schoolchildren were found, which was also confirmed by a one-way ANOVA test. An analysis of plate waste by food category showed that beverages accounted for the largest share of total plate waste (42.24%), followed by staple food (28.38%) and meat (11.77%). An analysis of plate waste shares of food served (%) by food category revealed a similar situation: the largest share of food served was made up of beverages (37.56%), followed by staple food (36.48%) and meat (28.77%). An analysis of the monetary value of food waste showed that the average cost of plate waste (excluding beverage) per schoolchild was EUR 0.236, which represented 16.6% of the national and municipal funding of EUR 1.42 per portion. Given the research results, the authors have concluded that in order to reduce the amount of plate waste generated by Rezekne city schools, school menus should be based not only on the requirements prescribed by relevant legal acts but also on cooking processes that meet the requirements of modern consumers (learners), e.g., by following trends in cooking practices in society to make the learners interested in consuming school food.

Online Pre-Order Systems for School Lunches: Insights from a Cross-Sectional Study in Primary Schools

Schools are increasingly using online pre-order systems for children to select school meals in advance. This study aimed to explore how children use and interact with these systems. Using a combination of direct observation and an online questionnaire, the operation of these systems in four UK primary schools was examined. This included how the menu options were displayed, how these were selected by children (4–11 years), and the interactions between children and others when making food selections. Where possible, most children pre-ordered their school lunch in the classroom, and differences in the food choice process among children were observed. These apparently related to children’s ages; older children (8–11 years) showed more independence when making food selections, whereas younger children were often supported by others. Most parents reported that their child was the decision maker when pre-ordering the school lunch, and the role of children in the selection of school lunches was evident. This may be accentuated by the online pre-order systems, and given the likely expansion of these systems in schools, there is an opportunity to implement interventions to influence children towards specific or different meal options from the school menu.

Implementation Leadership in School Nutrition: A Qualitative Study

OBJECTIVE

This paper identifies implementation leadership characteristics in the school nutrition setting and places findings in the context of implementation leadership literature.

METHODS

Fourteen interviews were conducted with school district leadership/staff in an urban school district. Modified grounded theory was employed.

RESULTS

Four themes emerged: (1) understanding of technical/operational intervention details; (2) ability to proactively develop and communicate plans; (3) supervisory oversight; and (4) intervention framing. Themes were consistent with 4 of the 5 dimensions comprising the Implementation Leadership Scale: knowledgeable, proactive, perseverant, and distributed leadership. The supportive domain was not a major finding. An additional domain, how leaders message the intervention to staff, was identified.

CONCLUSIONS AND IMPLICATIONS

Implementation leadership in school nutrition appears similar, but not identical, to leader behaviors present in the Implementation Leadership Scale. School nutrition leaders might consider involving staff early in implementation planning, incorporating technical expertise, and clearly communicating the intervention purpose to support successful implementation. Future research might explore the interplay between leadership and implementation outcomes.

Do Parental Perceptions of the Nutritional Quality of School Meals Reflect the Food Environment in Public Schools?

(1) Background: It is unknown whether parents’ perception of school meals, a determinant of student meal participation, align with the nutritional quality of meals served in schools. This study compares the healthfulness of foods offered in schools with parental perception of school meals at those same schools. (2) Method: Parents were asked to rate the healthfulness of school meals at their child’s school. Data on the types of foods offered were collected from public schools in four cities in New Jersey and matched with parent-reported data. Measures were developed to capture the presence of healthy and unhealthy items in the National School Lunch Program and the presence of a la carte offerings as well as vending machines. Multivariable analysis examined the association between parental perceptions of school meals and the school food measures after adjusting for covariates. (3) Results: Measures of the school food environment and parental perceptions were available for 890 pre-K to 12th grade students. No significant associations were observed between parental perceptions and food environment measures when examined one by one or in a comprehensive model. (4) Conclusions: Parents’ perception of the healthfulness of meals served do not align with the nutritional quality of foods offered at schools.

Prevalence and nutritional quality of free food and beverage acquisitions at school and work by SNAP status

BACKGROUND

The dual burden of poor diet quality and food insecurity makes free food-food acquired at no cost-a very important part of the nutrition safety net for low-income families. The goal of this study was to determine the national prevalence and nutritional quality of free food acquired separately in two settings: 1) by children at school; and 2) by employees at work; both stratified by participation in the Supplemental Nutrition Assistance Program (SNAP).

METHODS

Using National Household Food Acquisition and Purchase Survey data (2012; n = 4,826 U.S. households containing 5,382 employed adults and 3,338 school-aged children), we used survey-weighted proportions to describe free food acquisition and linear regression to compare the 2010 Healthy Eating Index (HEI-2010) for free/non-free food acquisition events (i.e., meals) by SNAP status. Analyses were conducted in 2019-2020.

RESULTS

SNAP households had more free acquisition events (29.6%) compared to non-SNAP households (<185% federal poverty level (FPL) = 22.3%; ≥185%FPL = 21.0%, p's<0.001). For SNAP-participant children, free acquisition events at school had a higher mean HEI-2010 compared to non-free acquisition events at school (50.3 vs. 43.8, p = 0.033) and free acquisition events by SNAP-non-participant children ≥185%FPL at school (50.3 vs. 38.0, p = 0.001). Free and non-free acquisition events at work had relatively low HEI-2010s, with no differences by SNAP status.

CONCLUSIONS

Over one fifth of all food acquisition events were free, but free food acquisitions at school and work were relatively unhealthy. For children participating in SNAP, free food acquired at school had higher nutritional quality. Improving the dietary quality of free foods could improve the health of families, especially those participating in SNAP.

Did School Meal Programs and SNAP Participation Improve Diet Quality of US Children from Low-Income Households: Evidence from NHANES 2013-2014?

Nutrition assistance programs such as school meals and the Supplemental Nutrition Assistance Program (SNAP) are designed to provide a safety net for the dietary intake of children from low-income families. However, compared with eligible non-participants, the relationship of diet quality with school meals only and school meals + SNAP is not well understood. The objectives of the study include: (1) To explore whether and to what extent nutrition assistance program participation (school meals only and school meals + SNAP) is related to diet quality; and (2) to examine the differences of diet quality between participating in school meals only, school meals + SNAP, or non-participation among American children. Children aged 5 to 18 years old from income eligible households who participated in the 2013-2014 National Health and Nutrition Examination Survey (NHANES) were included in this cross-sectional study (n = 1425). Diet quality was measured using the Healthy Eating Index (HEI)-2015 and its 13 subcomponents. A Rao-Scott Chi-square test, propensity scores approach, and Analysis of Covariance were performed. Covariates included age, sex, race/ethnicity, weight status, and family monthly poverty index. SAS survey procedures were used to incorporate the appropriate sample design weights. Participation in school meals + SNAP was not associated with higher diet quality compared to eligible non-participants or school meals-only participants. Participation in school meals + SNAP improved the intake of total dairy, but not added sugars or total vegetables compared to school meals only. Overall, school meal + SNAP participation did not significantly improve the overall diet quality of children in low-income households relative to comparable non-participants.

Strategies to Improve School Meal Consumption: A Systematic Review

School meals can play an integral role in improving children's diets and addressing health disparities. Initiatives and policies to increase consumption have the potential to ensure students benefit from the healthy school foods available. This systematic review evaluates studies examining initiatives, interventions, and policies to increase school meal consumption. Following PRISMA guidelines, this review was conducted using four databases and resulted in a total of 96 studies. The research evidence supports the following strategies to increase school meal consumption: (1) offering students more menu choices; (2) adapting recipes to improve the palatability and/or cultural appropriateness of foods; (3) providing pre-sliced fruits; (4) rewarding students who try fruits and vegetables; (5) enabling students to have sufficient time to eat with longer (~30 min) lunch periods; (6) having recess before lunch; and (7) limiting students' access to competitive foods during the school day. Research findings were mixed when examining the impact of nutrition education and/or offering taste tests to students, although multiple benefits for nutrition education outside the cafeteria were documented. There is some evidence that choice architecture (i.e., "Smarter Lunchroom") techniques increase the proportion of students who select targeted meal components; however, there is not evidence that these techniques alone increase consumption. There were limited studies of the impact of increasing portion sizes; serving vegetables before other meal components; and strengthening local district and/or school wellness policies, suggesting that further research is necessary. Additionally, longer-term studies are needed to understand the impact of policies that limit students' access to flavored milk. Several studies found increases in students' meal consumption following the Healthy Hunger-Free Kids Act (HHFKA) and concerns regarding an increase in food waste following the HHFKA were not supported. Overall, there are a range of effective strategies to increase school meal consumption that can be implemented by schools, districts, and policymakers at the local, state, and federal levels (PROSPERO registration: CRD42021244688).

Behavioral Economic Approaches to Childhood Obesity Prevention Nutrition Policies: A Social Ecological Perspective

Childhood obesity is a significant public health concern associated with the development of the leading causes of death. Dietary factors largely contribute to childhood obesity, but prevention interventions targeting these factors have reported relatively small effect sizes. One potential explanation for the ineffectiveness of prevention efforts is lack of theoretical grounding. Behavioral economic (BE) theory describes how people choose to allocate their resources and posits that some children place higher value on palatable foods (relative reinforcing value of food) and have difficulty delaying food rewards (delay discounting). These seemingly individual-level decision making processes are influenced by higher-level variables (e.g., environment/policy) as described by the social ecological model. The purpose of this manuscript is to provide a theoretical review of policy-level childhood obesity prevention nutrition initiatives informed by BE. We reviewed two policy-level approaches: (1) incentives-/price manipulation-based policies (e.g., sugary drink tax, SNAP pilot) and (2) healthful choices as defaults (Healthy Hunger Free Kids Act/National School Lunch Program, advertising regulations, default items). We review current literature as well as its limitations and future directions. Exploration of BE theory applications for nutrition policies may help to inform future theoretically grounded policy-level public health interventions.

School canteens and the food waste challenge: Which public initiatives can help?

Foodservice is estimated to produce 12% of the total food waste in Europe, and it is a major target for policies against food waste. The amount of food lost during foodservice operations has been assessed in the literature as a figure ranging from 10% to 41% of the quantity prepared in the kitchen, either as non-served food or as plate waste. In this paper, a systematization of the current initiatives against food waste in EU school foodservice is provided. This background is used as a base to discuss the results of a direct assessment of food waste conducted in 78 primary schools in Italy, where 28.6% of the food prepared was not consumed by the diners. Part of it was saved for reuse, while the rest was disposed and treated as organic waste or, to a lesser extent, as unsorted waste. The flows of food waste, represented by a Sankey diagram, show that some actions may be implemented in order to save more food from disposal; for example, implementing donation programmes for non-served food or using doggy bags to avoid the disposal of plate waste. A greater effort shall be put on preventive actions, aimed at avoiding the generation of food waste; in this sense regular monitoring at schools may act as a first preventive measure as it can increase the awareness of students, teachers and foodservice staff over the issue of food waste.

Food Waste in Schools: A Pre-/Post-test Study Design Examining the Impact of a Food Service Training Intervention to Reduce Food Waste

This study aimed to assess change in school-based food waste after training and implementing the Smarter Lunchrooms Movement (SLM) strategies with school food service workers. This non-controlled trial was implemented in a random sample of 15 elementary and middle schools in a Community Eligibility Program school district in the Northeast, the United States. Baseline and post-intervention food waste measurements were collected at two different time points in each school (n = 9258 total trays measured). Descriptive statistics, independent t-tests, and regression analyses were used to assess SLM strategies’ impact on changes in percent food waste. The mean number of strategies schools implemented consistently was 7.40 ± 6.97 SD, with a range of 0 to 28 consistent strategies. Independent t-tests revealed that at post-test, there was a significant (p < 0.001) percent reduction (7.0%) in total student food waste and for each food component: fruit (13.6%), vegetable (7.1%), and milk (4.3%). Overall, a training session on food waste and the SLM strategies with school-based food service workers reduced school food waste. However, the extent of the training and SLM strategies to reduce food waste varied on the basis of the consistency and type of strategies implemented.

Effects of Longer Seated Lunch Time on Food Consumption and Waste in Elementary and Middle School-age Children: A Randomized Clinical Trial

IMPORTANCE

Health experts recommend at least 20 minutes of seated lunch time for children, but no federal policy for lunch period duration exists in the United States. Additional strategies in the National School Lunch Program for mitigating food waste are needed to maintain the viability of the Healthy, Hunger-Free Kids Act.

OBJECTIVE

To assess the effect of a longer seated lunch time on food consumption and waste among elementary and middle school-age children.

DESIGN, SETTING, AND PARTICIPANTS

This randomized within-participant crossover trial was conducted from June 3 to June 28, 2019, for a total of 20 study days. All attendees of a summer camp held at the University of Illinois at Urbana-Champaign, were invited to participate in the study. Participants were elementary and middle school-age children and were provided every study day with lunch prepared according to the National School Lunch Program nutrition standards.

INTERVENTION

Five menus were served throughout the study. A 20-minute or 10-minute seated lunch condition was randomly assigned to each day within the 5 menus.

MAIN OUTCOMES AND MEASURES

The primary outcomes were food consumption, waste, and dietary intake, which were analyzed separately for each meal component (fruit, vegetable, entree [protein plus grain], beverage [both milk and water], and milk alone). Dietary intake was assessed for calories, fat, carbohydrates, fiber, protein, vitamin D, calcium, iron, and potassium. Participant behaviors were observed during the meal, including seated time as well as level of talking and phone use.

RESULTS

A total of 38 children with 241 lunch trays were observed. The 38 children had a mean (SD) age of 11.86 (1.23) years and 23 were female participants (61%); 30 had a non-Hispanic/non-Latino ethnicity (79%) and 23 were White individuals (61%). During 10 minutes of seated lunch time, participants consumed significantly less fruit (-11.3 percentage points; 95% CI, -18.1 to -4.5) and vegetables (-14.1 percentage points; 95% CI, -22.7 to -5.7) compared with 20 minutes of seated lunch time. Entree and beverage consumption and waste did not differ between the 10-minute and 20-minute seated lunch conditions. Participants also consumed significantly more and wasted significantly less calories (-22.03 kcal; 95% CI, -39.47 to -4.61 kcal), carbohydrates (-3.81 g; 95% CI, -6.20 to -1.42 g), dietary fiber (-0.51 g; 95% CI, -0.81 to -0.19 g), protein (-1.11 g; 95% CI, -2.17 to -0.04 g), iron (-0.20 mg; 95% CI, -0.38 to -0.02 mg), and potassium (-53.49 mg; 95% CI, -84.67 to -22.32 mg) during the 20-minute seated lunch condition.

CONCLUSIONS AND RELEVANCE

This study found that fruit and vegetable consumption increased in school-age children during a 20-minute seated lunch condition. This finding supports policies that require children to receive at least 20 minutes of seated lunch time; such policies could have favorable implications for children's dietary intake and food waste.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04191291.

Nutrient Intake During School Lunch in Title I Elementary Schools With Universal Free Meals

BACKGROUND

The National School Lunch Program (NSLP) provides >30 million meals to children daily; however, the specific nutrient composition of NSLP-selected and consumed meals for students from lower income and racial/ethnic minoritized backgrounds is unknown.

AIMS

To quantify the nutrients in school lunch selection and consumption among students participating in the NSLP and compare these values to nutrient recommendations.

METHOD

Students (1st-5th graders; 98.6% from racial/ethnic minoritized backgrounds; 92.5% NSLP participation) from six Title I elementary schools serving universal free meals participated. Digital images of students' lunch meal selection and consumption were obtained (n = 1,102 image pairs). Plate waste analyses quantified portions consumed. Nutrient composition of students' lunch selection and consumption were calculated and compared with the 2010 Healthy Hunger-Free Kids Act and 2009 Institute of Medicine recommendations.

RESULTS

Most lunches selected (59%-97%) met recommendations for all nutrients except for total calories (23%), vitamin C (46%), and dietary fiber (48%). Based on lunch consumption, most students' lunches met recommendations for sodium (98%), protein (55%), calories from fat (82%), and saturated fat (89%); however, few met recommendations for total calories (5%), calcium (8%), iron (11%), vitamin A (18%), vitamin C (16%), and fiber (7%).

DISCUSSION

Meals selected met most nutrient recommendations for the majority of children; yet overall consumption patterns reflect suboptimal nutrient intake.

CONCLUSION

Meals served under the NSLP policy mandates align with recommended nutrient patterns, highlighting the importance of maintaining these standards. Strategies to optimize children's intake of nutrient-rich portions of these meals are needed to optimize policy impact.

Impact Of The Healthy, Hunger-Free Kids Act On Obesity Trends

The Healthy, Hunger-Free Kids Act of 2010 strengthened nutrition standards for meals and beverages provided through the National School Lunch, Breakfast, and Smart Snacks Programs, affecting fifty million children daily at 99,000 schools. The legislation's impact on childhood obesity is unknown. We tested whether the legislation was associated with reductions in child obesity risk over time using an interrupted time series design for 2003-18 among 173,013 youth in the National Survey of Children's Health. We found no significant association between the legislation and childhood obesity trends overall. For children in poverty, however, the risk of obesity declined substantially each year after the act's implementation, translating to a 47 percent reduction in obesity prevalence in 2018 from what would have been expected without the legislation. These results suggest that the Healthy, Hunger-Free Kids Act's science-based nutritional standards should be maintained to support healthy growth, especially among children living in poverty.

Using the Veggie Meter in Elementary Schools to Objectively Measure Fruit and Vegetable Intake: A Pilot Study

Self-reported fruit and vegetable (FV) consumption in children has limitations that could be overcome with objective measures that are easy to implement. The Veggie Meter (VM) is a non-invasive portable device that measures skin carotenoid levels, a concentration biomarker of usual FV intake. While VM has been used to measure FV consumption in adults, few studies have explored its use in elementary school settings. Designing research studies using the VM with elementary school-age children requires an understanding of how well this device can be used in a school setting and of the distribution of VM scores in this population. We used VM to measure skin carotenoids in a diverse sample of 143 elementary school children who also answered commonly asked questions about consumption frequency of FV the previous day. Multivariable regression was used to assess the independent association of demographic variables with VM scores. VM scores were also compared with student-reported FV intake. There was a weak but statistically significant correlation between reported frequency of total vegetable consumption the previous day and observed VM scores (r = 0.174, p = 0.042). This study provides an example of the successful use of the VM in a school setting to collect an objective measure of FV intake and provides important description of data that can inform future studies.

Examining Nutrition and Food Waste Trade-offs Using an Obesity Prevention Context

Obesity and food waste are related issues, both exacerbated by an overabundance of food. Efforts to reduce food waste can have varying unintended, obesity-related consequences, which further underscores the need for a systems approach to food waste reduction. Yet, these 2 issues are rarely examined together. It is the authors' point of view that for nutrition educators and other public health practitioners to develop interventions that simultaneously address food waste and obesity, they need to understand how actions at the consumer-level may impact waste and its related food system consequences earlier in the supply chain.

Identifying the links between consumer food waste, nutrition, and environmental sustainability: a narrative review

Emerging research demonstrates unexpected relationships between food waste, nutrition, and environmental sustainability that should be considered when developing waste reduction strategies. In this narrative review, we synthesize these linkages and the evidence related to drivers of food waste and reduction strategies at the consumer level in the United States. Higher diet quality is associated with greater food waste, which results in significant quantities of wasted resources (e.g., energy, fertilizer) and greenhouse gas emissions. Food waste also represents waste of micronutrients that could otherwise theoretically fill nutritional gaps for millions of people. To make progress on these multiple fronts simultaneously, nutrition professionals must expand beyond their traditional purview, into more interdisciplinary arenas that make connections with food waste and environmental sustainability.

Enabling Food Environment in Kindergartens and Schools in Iran for Promoting Healthy Diet: Is It on the Right Track?

Enabling policies related to kindergarten and school food environments can be effective approaches in preventing childhood obesity. This study investigated policies and/or programs with direct or indirect effects on the food environment in kindergartens and schools in Iran. In this scoping review, we systematically searched PubMed, Scopus, and Web of science, as well as Iranian scientific search engines, including Scientific Information Database and Magiran from January 1990 to October 2020, to identify literature on policies/programs affecting the food environment in kindergartens and schools in Iran. A total of 30 studies and policy documents were included in this review relevant to eight policies/programs. These programs have helped to control food availability in schools, increase nutritional awareness, positively influence physical function and school performances, and reduce malnutrition in rural kindergartens. However, improving the food environment in schools and kindergartens requires proper revisions and local adaptation of many of these policies, strengthening of cross-sectoral collaborations, provision of necessary financial and human resources, and ensuring regular monitoring and evaluation. Reflecting on Iran's health policies and interventions provides insight into the progress achieved and challenges faced. Lessons can benefit the country itself, as well as other countries with similar contexts.

Universal School Meals and Associations with Student Participation, Attendance, Academic Performance, Diet Quality, Food Security, and Body Mass Index: A Systematic Review

The school environment plays an important role in children's diets and overall health, and policies for universal free school meals have the potential to contribute to positive child health outcomes. This systematic review evaluates studies examining the association between universal free school meals and students' school meal participation rates, diets, attendance, academic performance, and Body Mass Index (BMI), as well as school finances. The search was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). A search for studies published in economically developed countries published through December 2020 was performed in PubMed, Education Resources Information Center (ERIC), Thomson Reuters' Web of Science, and Academic Search Ultimate, followed by examining the references in the resultant literature. A total of 47 studies were identified and the Newcastle-Ottawa Scale (NOS) was applied to assess bias. Nearly all studies examining universal free school meals found positive associations with school meal participation. Most studies examining universal free school meals that included free lunch found positive associations with diet quality, food security, and academic performance; however, the findings of studies examining only universal free breakfast were mixed. Research findings were similarly mixed when examining attendance as an outcome. Concerns about adverse outcomes on student BMI were not supported by the literature; in fact, several studies detected a potentially protective effect of universal free school meals on BMI. Research examining the impact of universal free meals on school finances was limited, but suggest that lower-income school districts in the U.S. may have positive financial outcomes from participation in universal free school meal provisions. Additionally, providing free meals to students may be associated with improved household incomes, particularly among lower-income families with children. Further research is needed to examine the financial implications of universal free meals for both school districts and families. Overall, universal free school meals may have multiple benefits for students and countries should consider universal free school meal provisions with strong nutrition guidelines. (PROSPERO registration: CRD42020221782).

Alignment Of US School Lunches With The EAT-Lancet Healthy Reference Diet's Standards For Planetary Health

By feeding more than thirty million schoolchildren daily, the National School Lunch Program's food offerings substantially influence a contributing factor to climate change: US food production methods. Modifying school lunch nutrition standards could be a policy strategy to reduce climate change while promoting human health. To estimate how school lunches could be adjusted to encourage both outcomes, we compared the composition of school lunches with the EAT-Lancet Commission's healthy reference diet science-based benchmarks for reducing food system impacts on climate change. Analyzing more than 5,000 lunches served in the US during school year 2014-15, we found that they exceeded EAT-Lancet targets for dairy, fruit, refined grains, red meat, and starchy vegetables while containing insufficient whole grains, legumes, vegetables, and nuts. In addition, estimated food costs were higher for school lunches than for lunches meeting EAT-Lancet targets. Our findings suggest that redesigning school lunches could provide high-quality nutrition while benefiting the environment and reducing food costs.

The New school food standards and nutrition of school children: Direct and Indirect Effect Analysis

The Healthy, Hunger-Free Kids Act (HHFKA) of 2010 made sweeping changes to school nutritional standards. We estimate the impacts of shifts in school nutritional standards on dietary quality as well as dietary quantity of children's food intakes from school and away-from-school food sources. We find the average effect of consuming school food, rather than away-from-school food, on children's overall dietary quality significantly increased from the pre- to post-HHFKA implementation period. This effect was solely driven by substantial improvements in the dietary quality of foods acquired at school, mainly among older and higher-income children. Our indirect effect analysis indicated that children shifted towards consuming lower-quality diets at home in the post-HHFKA period, thereby partially offsetting the positive effects of the HHFKA on their overall dietary quality. Indirect impacts were primarily driven by a subset of children consuming more than a third of their daily calories from school food. Additionally, we find suggestive evidence of a modest decrease in daily calorie intake, particularly among older and higher-income children. Together, our findings imply that the HHFKA, despite its unintended negative indirect effects, led children to consume more-nutritious, less-energy-dense diets.

Parental Perceptions of the Nutritional Quality of School Meals and Student Meal Participation: Before and After the Healthy Hunger-Free Kids Act

OBJECTIVES

To examine (1) parental perceptions of school meals and (2) student meal participation before and after the implementation of the Healthy Hunger-Free Kids Act (HHFKA).

DESIGN

Data were collected from telephone surveys of 2 independent cross-sectional panels in New Jersey (2009-2010 and 2016-2017).

PARTICIPANTS

Households with children aged 7-18 years (pre-HHFKA: n = 1,027; post-HHFKA: n = 324).

MAIN OUTCOME MEASURES

Parental perception of school meals and parental reports of student participation in school meals.

ANALYSIS

Multivariable logistic regression models were developed to examine outcome variables. For school meal participation, nested models were analyzed first controlling for sociodemographic variables, followed by parental perception, and then the interaction between perception and time.

RESULTS

Parental perceptions of school meals did not change significantly after the HHFKA. At both time points, school meal participation rates were significantly higher for children of parents who perceived school meals as healthy compared with children whose parents perceived meals to be unhealthy (pre-HHFKA: 89.9% vs 75.1%, P < 0.001; post-HHFKA: 87.3% vs 64.9%, P = 0.02).

CONCLUSION AND IMPLICATIONS

Because higher perception of school meal quality is associated with higher participation, it is important for school food programs to inform parents about the improved nutritional quality of school meals.

Availability of Lower-Sodium School Lunches and the Association with Selection and Consumption among Elementary and Middle School Students

BACKGROUND

During 2010, the US Department of Agriculture updated the school meals standards, including three progressively decreasing sodium targets. The Target 1 standards went into effect in 2014, but during 2018, the US Department of Agriculture delayed the Target 2 standards until 2024 and eliminated the Target 3 standards citing concerns regarding the availability and acceptability of lower-sodium foods. In addition, there are currently no sugar standards, and it is unknown whether sugar is substituted for salt in lower-sodium school foods.

OBJECTIVE

To examine the availability, selection, and consumption of school lunches already in alignment with the Target 2 and 3 sodium levels and the association between sodium and sugar.

DESIGN

An observational cafeteria-based study conducted during fall 2018.

PARTICIPANTS AND SETTING

Students (n = 1985) in grades three through eight attending 13 elementary/kindergarten through eighth-grade schools in a large, urban school district in New England.

MAIN OUTCOME MEASURES

Availability, selection, and consumption were examined using plate waste methodology.

STATISTICAL ANALYSES PERFORMED

Mixed-model analysis of variance accounting for student demographic characteristics with schools/students as a random effect (students nested within schools) were used to examine differences in availability, selection, and consumption. Linear regression was used to examine the association between sodium and sugar in the school foods.

RESULTS

The majority of meals selected (87%) and consumed (98%) were already in alignment with the Target 2 standards. There were significant inverse associations between sodium levels and consumption; each 100-mg increase in sodium was associated with a decrease in consumption by 2% for entrées (P = 0.002) and 5% for vegetables (P = 0.01). When examining the association between sodium and sugar, each 10-mg reduction in sodium was associated with 1-g increase in sugar among entrées (P < 0.0001), whereas there was a significant positive association between sodium and sugar with vegetables and condiments.

CONCLUSIONS

This study provides some evidence that schools may already have the ability to provide lower-sodium meals that are acceptable to students, and therefore the recent rollbacks to the sodium standards may be unwarranted. Study findings suggest that the US Department of Agriculture should take under consideration policies that would limit added sugar for school meals as sugar may be substituted for salt.

The Theory of Planned Behavior and the USDA Summer Food Service Program

OBJECTIVE

Examine the impact of the Summer Food Service Program (SFSP) on the intentions to positively change fruit and vegetable consumption in a rural, low-income adolescent population using the Theory of Planned Behavior.

DESIGN

Quantitative data collected via a pre-post intervention survey to determine predictors of positive nutrition behaviors and changes in self-reported fruit and vegetable consumption.

SETTING

A mid-sized university.

PARTICIPANTS

Fifty-seven high school students. Participants were primarily female (n = 36) and white (n = 56).

INTERVENTION

Participants followed the standards of the SFSP for 5 weeks and were provided with mandatory and optional nutrition education sessions.

MAIN OUTCOME MEASURE

Intentions to change nutrition behaviors.

ANALYSIS

Multiple regression.

RESULTS

Paired-sample t test showed a significant increase in knowledge from pretest (mean [M] = 11.18, SD = 1.68) to posttest (M = 12.91, SD = 1.76); t[56] = -8.09, P < 0.001; (t[56] = -8.09, P < 0.001) and in self-reported fruit and vegetable intake from pretest (M = 13.96, SD = 4.23) to posttest (M = 16.80, SD = 5.42); (t[56] = -3.20, P = 0.002). Regression demonstrated that all constructs of the Theory of Planned Behavior were significant (F[4, 52] = 14.56, P < 0.001 with an R² of 0.53) for their effects on behavior intentions with perceived behavioral control being the most salient predictor.

CONCLUSIONS AND IMPLICATIONS

Opportunities for shaping adolescent nutrient intake and eating behaviors during enrollment in the SFSP exist. Reinforcing positive attitudes, subjective norms, and perceived behavioral control may help to increase nutrition behavioral intentions and nutrition behaviors.

The role of reducing food waste for resilient food systems

Food waste undermines long-term resilience of the global food system by aggravating ecosystem damage. The global community must therefore work to reduce the amount of food that gets wasted. However, we should be mindful of some potential conflicts between food waste reduction and food system resilience. Over-production and over-supply are a contributing cause of waste, yet they also provide resilience in the form of redundancy. In this paper, we examine individual interventions designed to minimise food waste by scoring their impact on different aspects of resilience. We find that there are strong synergistic elements and interventions that support short- and long-term resilience, such as improved storage, which reduces the need to provide a constant flow of 'surplus food' and replaces it with a stock of 'spare' food. Some interventions carry a risk of trade-offs due to possible losses of redundancy, and investment lock-in that may reduce the ability of farmers to adapt by changing what and where they farm. Trade-offs do not mean that those interventions should not be pursuit, but they should be recognised so that can be adequately addressed with complimentary actions. This review underlines the necessity of food-systems thinking and joined-up policy.

Meal Quality of Entrées That Can Be Sold as Competitive Foods in Schools and Potential Impact of the Proposed USDA Rollbacks

The Healthy, Hunger-Free Kids Act strengthened competitive food standards (i.e., Smart Snacks), but an exemption allows reimbursable meal entrées that do not meet Smart Snack standards to be sold as “competitive entrées” on the same day they are served in the reimbursable meal, and the following day. Proposed rollbacks would enable these competitive entrées to continue to be sold on a third day, increasing the availability of competitive foods exempt from Smart Snacks standards. This study compared the Healthy Eating Index (HEI) scores of potential competitive entrées alone versus full reimbursable school lunches, and examined the nutritional characteristics of potential competitive entrées. Data were from a national sample of 1108 schools from the School Nutrition and Meal Cost Study. Linear regression models, accounting for school-level and state and district policy characteristics, found that HEI scores of competitive entrées were an average of 30 points lower than HEI scores of reimbursable lunches, with greater differences in small and rural schools. Less than 1% of common potential competitive entrees met Smart Snack standards, primarily due to higher sodium and saturated fat levels. The proposed rollbacks are estimated to potentially add approximately 662 mg of sodium and 3 g of saturated fat over three days (1103 mg sodium and 5 g saturated fat over a week) on average relative to Smart Snacks limits. Instead of increasing opportunities to sell competitive entrées, their sales should be further limited.

Milk Consumption and Waste Across 5 Montana High School Lunch Programs

BACKGROUND

Few studies document milk selection and waste among high school lunch programs.

METHODS

This observational research assesses the types of milk selected and wasted among 5 Montana high school lunch programs. Over 6 days across the 2014-2015 school year, 3842 milk cartons were collected. Direct weighing was used to assess the ounces of milk wasted and consumed by milk type. Outcomes included the number of milks selected by type at each school, ounces of milk consumed and wasted on average per student. Descriptive and inferential statistics were used to assess demographics of school lunch participation, milk consumption and waste, and the amount of waste per type of milk.

RESULTS

Students were most likely (p < .05) to select fat-free flavored milk, followed by 1% plain milk, and fat-free plain milk. Fat-free flavored (mean = 0.86, SD = 0.55) was the least wasted, followed by fat-free plain (mean = 1.08 oz, SD = 1.55), and 1% plain (mean = 1.26 oz, SD = 1.02).

CONCLUSIONS

Across all milk options, milk waste was low. The findings indicate that high school students are more likely to select and consume greater amounts of, and waste less, fat-free flavored milk.

The addition of spices and herbs to vegetables in the National School Lunch Program increased vegetable intake at an urban, economically-underserved, and predominantly African-American high school

Vegetable intake is far below recommendations among African-American adolescents living in economically-underserved urban areas. While the National School Lunch Program (NSLP) helps overcome access barriers, vegetable intake remains challenging and novel interventions are required. A two-year, multi-phase, school-based intervention was conducted at an urban, economically-underserved, and predominantly African-American high school in Baltimore, Maryland to determine whether stakeholder-informed addition of spices and herbs to NSLP vegetables would increase intake. The stakeholder engagement phase included assessment of NSLP vegetable attitudes/preferences among 43 school stakeholders and subsequent student sensory testing. The second phase was conducted in the school cafeteria and consisted of eight weeks comparing student intake of typical vegetable recipes versus otherwise-identical recipes with spices and herbs. 4,570 student lunch plates were included in the vegetable intake comparison. Vegetable intake was measured by lunch tray plate waste. Willingness to try vegetables was assessed by the difference between plate waste and estimated mean vegetable served weight. Intake of typical vegetable recipes and vegetable recipes with spices and herbs was compared with student's t-test. Chi-square test was used to compare willingness to try vegetables. Total vegetable intake was 18.2% higher (8.22 grams per meal, p<0.0001) with spices and herbs than with typical recipes. There were no differences in trying vegetables with spices and herbs, although student-led advocacy was associated with increased trying vegetables with spices and herbs (78.8% with advocacy, 67.5% without advocacy, p<0.0001). The addition of spices and herbs to vegetables in the NSLP was feasible and associated with small increases in vegetable intake at an urban, economically-underserved, and predominantly African-American high school.

Variability in Dietary Quality of Elementary School Lunch Menus with Changes in National School Lunch Program Nutrition Standards

National School Lunch Program (NSLP) standards recently changed significantly. The Healthy, Hunger-Free Kids Act (HHFKA) presumably improved the dietary quality (DQ) of meals, whereas Child Nutrition Program (CNP) Flexibilities appear to decrease DQ. This variability has not been quantified. Our objective was to determine differences in DQ between elementary school lunch menus meeting NSLP standards: School Meal Initiative (SMI), HHFKA, CNP Flexibilities, and evidence-based best practices (BP). A base menu was portioned per NSLP standards and analyzed for nutrient content and DQ. Statistical analyses included 1-factor ANOVA, Kruskal-Wallis, and Dunnett's test. The BP menu had higher whole fruit and whole grain Healthy Eating Index scores than SMI (Ps < 0.0083). The BP and HHFKA menus had higher refined grain and added sugars scores than SMI (Ps < 0.0083). The SMI menu had lower total vegetable and saturated fat scores than all menus (Ps < 0.0083). This study informs policy toward improving standards, positively affecting child health and academic performance through higher-DQ lunches.

Acceptability and Feasibility of Best Practice School Lunches by Elementary School-Aged Children in a Serve Setting: A Randomized Crossover Trial

Background: National School Lunch Program (NSLP) standards have improved school lunch dietary quality (DQ), however, further improvements could be made. Acceptability and feasibility of higher DQ are potential barriers. Thus, the purpose is to compare acceptability and feasibility of best practice (BPSL, optimizing DQ) with typical school lunches (TSL, meeting minimum NSLP standards) served separately and concurrently. Methods: Forty elementary school-aged participants were recruited for a randomized crossover trial. Participants attended three meal conditions (MC) choosing one of two meal types—MC1) BPSL1/BPSL2, MC2) TSL1/TSL2, MC3) BPSL/TSL. Acceptability included taste test surveys, weighted plate waste assessments, and hunger scales. Feasibility included meal cost, time, and skill and equipment requirements. Results: There were no significant differences in total taste test score, average total plate waste, or change in hunger (ps > 0.017) before or after adjusting for covariates. TSL was selected significantly more often in MC3 (TSL = 83.3%, BPSL = 16.7%, p = 0.001). Meal cost (p = 0.783) and skill and equipment requirements were not significantly different between meal types. BPSL required significantly longer preparation time (TSL = 60 ± 25 min, BPSL = 267 ± 101 min, p = 0.026). Conclusions: Results indicate few differences in acceptability and feasibility between BPSL and TSL. This study could inform decision and policy-makers seeking to improve school lunch DQ and acceptance of higher DQ meals.

Effect of Removing Chocolate Milk on Milk and Nutrient Intake Among Urban Secondary School Students

INTRODUCTION

Schools across the United States have removed sweetened, flavored milk from cafeterias to reduce students' sugar consumption and improve their health. However, evidence on the impact of the removal is limited. We examined the effect of a policy that removed chocolate milk from secondary schools on students' milk consumption and estimated milk-related nutrient intake.

METHODS

We collected data on milk selection and consumption during 1 lunch period in 24 California public secondary schools pre-policy (N = 3,158 students in 2016) and post-policy (N = 2,966 students in 2018). Schools had a student population that was 38% Asian and 29% Latino, with 63% qualifying for free or reduced-price meals. We used linear mixed effects models to assess changes in milk selection and waste, and we estimated related changes in added sugars, calcium, protein, and vitamin D consumed from milk.

RESULTS

The proportion of students selecting milk declined 13.6%, from 89.5% pre-policy to 75.9% post-policy (95% CI for difference, 10.8% tο 16.4%), but the proportion of milk wasted remained stable (37.1% vs 39.3%; 95% CI for difference, -0.2% to 4.6%). Although average per-student milk consumption declined by less than 1 ounce per student (from 4.8 oz to 3.8 oz; 95% CI for difference, -1.1 oz to -0.7 oz), we observed no significant reductions in average per-student intake of calcium, protein, or vitamin D from milk. Estimated added sugars from milk declined significantly, by 3.1 grams per student (95% CI, -3.2 g to -2.9 g).

CONCLUSION

Removing chocolate milk modestly reduced student milk consumption without compromising average intake of key milk-related nutrients, and consumption of added sugars from milk declined significantly. Secondary schools should consider removing chocolate milk to support healthy beverage consumption.

The Impact of a Multi-Pronged Intervention on Students' Perceptions of School Lunch Quality and Convenience and Self-Reported Fruit and Vegetable Consumption

School lunch programs provide an opportunity to improve students' diets. We sought to determine the impact of a multifaceted intervention (cafeteria redesigns, increased points-of-sale and teacher education) on secondary students' perceptions of school-lunch quality and convenience and fruit and vegetable intake. Surveys (n = 12,827) from middle and high school students in 12 intervention and 11 control schools were analyzed. We investigated change in school-lunch perceptions and lunchtime and daily fruit and vegetable consumption from 2016 to 2018. Among 8th graders, perceptions that school lunch tastes good and that school lunch was enough to make students feel full increased 0.2 points (on a 5-point scale; p < 0.01) in intervention schools relative to control schools. Among 10th graders, lunchtime fruit and vegetable consumption increased 6% in intervention relative to control schools (p < 0.05 and p < 0.01 respectively). Daily fruit intake increased 0.1 cups/day in intervention relative to control schools among 9th graders (p < 0.01). This study provides important evidence on the limited effect of design approaches in the absence of meal changes. We observed only modest changes in school lunch perceptions and fruit and vegetable consumption that were not consistent across grades, suggesting that additional efforts are needed to improve school-lunch uptake.

Disparities in the Healthfulness of School Food Environments and the Nutritional Quality of School Lunches

The Healthy, Hunger-Free Kids Act (HHFKA), a public law in the United States passed in 2010, sought to improve the healthfulness of the school food environment by requiring updated nutrition standards for school meals and competitive foods. Studies conducted since the passage of the HHFKA indicate improvements in the food environment overall, but few studies have examined whether these improvements varied by the socioeconomic and racial/ethnic composition of students in schools. To better understand the extent of disparities in the school food environment after HHFKA, this paper examined differences in the healthfulness of school food environments and the nutritional quality of school lunches by the school poverty level and racial/ethnic composition of students using data from the School Nutrition and Meal Cost Study. Results from chi-square analyses showed lower proportions of high poverty, majority black, and majority Hispanic schools had access to competitive foods, while higher proportions of these schools had a school wellness policy in addition to a district wellness policy. The overall nutritional quality of school lunches, as measured by total Healthy Eating Index (HEI)-2010 scores, did not vary significantly across school types, although some HEI component scores did. From these findings, we concluded that there were disparities in the school food environment based on the socioeconomic and racial/ethnic composition of students in schools, but no significant disparities in the overall nutritional quality of school lunches were found.

Changes to dietary and health outcomes following implementation of the 2012 updated US Department of Agriculture school nutrition standards: analysis using National Health and Nutrition Examination Survey, 2005-2016

OBJECTIVE

In 2012, the US government overhauled school nutrition standards, but few studies have evaluated the effects of these standards at the national level. The current study examines the impact of the updated school nutrition standards on dietary and health outcomes of schoolchildren in a nationally representative data set.

DESIGN

Difference-in-differences. We compared weekday fruit and vegetable intake between students with daily school lunch participation and students without school lunch participation before and after implementation of updated school nutrition standards using a multivariable linear regression model. Secondary outcomes included weekday solid fat and added sugar (SoFAS) intake and overweight and obesity prevalence. We adjusted analyses for demographic and family socio-economic factors.

SETTING

USA.

PARTICIPANTS

K-12 students, aged 6-20 years (n 9172), from the National Health and Nutrition Examination Survey, 2005-2016.

RESULTS

Implementation of updated school nutrition standards was not associated with a change in weekday fruit and vegetable intake (β = 0·02 cups, 95 % CI -0·23, 0·26) for students with daily school lunch participation. However, implementation of the policy was associated with a 1·5 percentage point (95 % CI -3·0, -0·1) decline in weekday SoFAS intake and a 6·1 percentage point (95 % CI -12·1, -0·1) decline in overweight and obesity prevalence.

CONCLUSIONS

Changes to US school nutrition standards were associated with reductions in the consumption of SoFAS as well as a decrease in overweight and obesity in children who eat school lunch. However, we did not detect a change in weekday intake of fruits and vegetables associated with the policy change.

Changes in association between school foods and child and adolescent dietary quality during implementation of the Healthy, Hunger-Free Kids Act of 2010

PURPOSE

The purposes of the study were to estimate the effect of Healthy, Hunger-Free Kids Act of 2010 (HHFKA) implementation on dietary quality of all U.S. school-aged children and adolescents and examine whether those effects differed by the demographic group.

METHODS

We used survey regression on 2007-2016 National Health and Nutrition Examination Survey data to estimate the proportion of energy intake from school foods and the association between school food intake and dietary quality, before and after HHFKA passage/implementation. To account for demographic changes in the U.S. population over time, inverse probability weighting was used. The product of the proportion of energy from school foods and the association between school food intake and dietary quality estimated the effect of HHFKA implementation on dietary quality.

RESULTS

School food intake quantity remained stable during the study period. HHFKA implementation improved students' dietary quality by 4.3 Healthy Eating Index-2010 points (95% confidence interval: 2.5, 6.1) on days when school foods were eaten and by 1.3 Healthy Eating Index-2010 points (95% confidence interval: 0.73, 1.8) averaged over all days annually.

CONCLUSIONS

HHFKA implementation improved the total dietary quality of U.S. school students. U.S. students would benefit from eating school meals in the post-HHFKA era, and HHFKA regulations should not be relaxed.