Reliability and Accuracy of Real-Time Visualization Techniques for Measuring School Cafeteria Tray Waste: Validating the Quarter-Waste Method

Fruit-Promoting Smarter Lunchrooms Interventions: Results From a Cluster RCT

INTRODUCTION

The Smarter Lunchrooms Movement was developed to provide schools with simple, low-cost solutions to encourage students to make healthier food choices at school. The objective of this study was to evaluate the impact of fruit-promoting Smarter Lunchroom interventions on middle school students' selection and consumption of fruits.

DESIGN

A 9-week cluster RCT was conducted using a pre-test/post-test control group design in upstate New York in February-April 2014.

SETTING/PARTICIPANTS

Ten middle schools (Grades 5-8) were recruited and randomized into a fruit intervention (n=4), vegetable intervention (n=3), or control group (n=3). This article focuses only on the fruit intervention and control groups.

INTERVENTION

The fruit intervention group made changes to the convenience, visibility, and attractiveness of fruit in their lunchrooms for a period of 6 weeks. The control group made no changes, and were offered Smarter Lunchrooms training post-intervention.

MAIN OUTCOME MEASURES

Selection and plate waste data were collected from February to April 2014, and analyzed in 2014-2015. Average selection, waste, and consumption of food items were computed, and the statistical differences between treatment and control groups were analyzed using t-test statistics and difference-in-difference analysis.

RESULTS

Fruit selection increased overall by 36% (p<0.001), and fruit consumption increased overall by 23% (p<0.017). Vegetable selection and consumption and white milk selection also increased significantly in the treatment schools (p<0.001), though were not significant overall.

CONCLUSIONS

The fruit intervention increased the selection and consumption of fruits overall, and increased the selection and consumption of vegetables and the selection of white milk in treatment schools. These findings provide evidence supporting the use of fruit-promoting Smarter Lunchrooms techniques in middle schools to increase the selection and consumption of healthy food items.

Design and Evaluation of a Training Protocol for a Photographic Method of Visual Estimation of Fruit and Vegetable Intake among Kindergarten Through Second-Grade Students

OBJECTIVE

To design a replicable training protocol for visual estimation of fruit and vegetable (FV) intake of kindergarten through second-grade students through digital photography of lunch trays that results in reliable data for FV served and consumed.

METHODS

Protocol development through literature and researcher input was followed by 3 laboratory-based trainings of 3 trainees. Lunchroom data collection sessions were done at 2 elementary schools for kindergarten through second-graders. Intraclass correlation coefficients (ICCs) were used.

RESULTS

By training 3, ICC was substantial for amount of FV served and consumed (0.86 and 0.95, respectively; P < .05). The ICC was moderate for percentage of fruits consumed (0.67; P = .06). In-school estimates for ICCs were all significant for amounts served at school 1 and percentage of FV consumed at both schools.

CONCLUSIONS AND IMPLICATIONS

The protocol resulted in reliable estimation of combined FV served and consumed using digital photography. The ability to estimate FV intake accurately will benefit intervention development and evaluation.

Younger Elementary School Students Waste More School Lunch Foods than Older Elementary School Students

BACKGROUND

Children may not receive nutritional benefits from school lunch meals if they do not eat the foods served.

OBJECTIVE

This study investigated whether there were differences in school lunch foods consumed and wasted by grade level of elementary school students.

DESIGN

In this cross-sectional study, anonymous meal observations were conducted after students selected their reimbursable school lunch meals in the cafeteria lunch line. The amounts of foods selected and consumed were recorded using the quarter waste method and food waste was calculated using the information recorded.

PARTICIPANTS/SETTING

During the spring of 2013, eight elementary schools (50% low income) enrolling children in kindergarten through grade 5 in one school district in the Houston, TX, area were selected by the Child Nutrition Director.

MAIN OUTCOME MEASURES

The amount of calories and foods consumed and the percentage wasted were assessed.

STATISTICAL ANALYSES PERFORMED

Analysis of covariance and post hoc analysis were used to examine food consumption and plate waste by grade level (kindergarten and grade 1 [K-Gr1], grades 2 and 3 [Gr2-3], and grades 4 and 5 [Gr4-5]), controlling for student sex and school-level free/reduced priced meal eligibility.

RESULTS

There were 568 nonrandom lunch meal observations of students included in the analyses. Approximately 48% of the observations were from boys; 50% were from low-income schools, and were evenly divided by grade. In general, students in K-Gr1 consumed fewer calories than both Gr2-3 and Gr4-5, and Gr2-3 students consumed significantly fewer calories than Gr4-5. K-Gr1 students also consumed less and wasted more total and red-orange vegetables, total/whole/refined grains, and total protein foods than the older students. Gr2-3 students wasted more calories and total grains than Gr4-5 students. K-Gr1 students wasted more fruit than Gr2-3 students.

CONCLUSIONS

Overall, younger students in elementary schools (K-Gr-1) consumed less of the foods they selected for their lunch meals, and wasted more than older elementary school students. Future studies should investigate why younger children wasted more food and potential strategies to reduce food waste by younger students.

Implementing Smarter Lunchrooms Makeovers in New York state middle schools: an initial process evaluation

BACKGROUND

This paper presents design and findings from the process evaluation of a randomized controlled trial (RCT) testing the effectiveness of Smarter Lunchrooms Movement (SLM) interventions to encourage consumption of either fruit, vegetables, or unflavored milk in middle school cafeterias (grades 6-8, typically children ages 10-14 years). Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework adapted for environmental interventions, the process evaluation monitored fidelity to SLM protocol, determined barriers and facilitators influencing fidelity, and identified the training and support needs of implementers.

METHODS

Under research team guidance, community partners (interventionists) assisted school food service staff (providers) with a six week implementation of protocol items in 13 public middle school cafeterias (two milk treatment, three vegetable treatment, four fruit treatment, and four control) in New York State during the 2013-2014 academic year. Process evaluation measures included semi-quantitative measures of implementation and maintenance (lunchroom audits) and qualitative data (environmental assessments and semi-structured interviews with school food service staff). Analyses identified challenges and opportunities for improving intervention delivery.

RESULTS

Approximately 75 % of enrolled students participated in school lunch programs and thus were exposed to the SLM intervention. Findings indicated potential contamination by other nutrition-related activities in the lunchroom and larger school environment may have affected the intervention impact. Modest implementation fidelity scores were observed for intervention treatments. Providers reported treatments were acceptable and feasible, however interventionists confirmed motivation and perceived effectiveness varied among schools. Post-intervention audits revealed limited maintenance of intervention protocols. Strategies to enhance buy-in and communication among providers and increased interventionist support are recommended.

CONCLUSIONS

RE-AIM was a valuable framework for this process evaluation. Results highlighted implementation barriers and facilitators, and findings will enhance interpretation of forthcoming outcome data. Results will inform future iterations of the SLM RCT and provide valuable insights for those designing environmental interventions in school cafeterias.

Head Start Wellness Policy Intervention in Hawaii: A Project of the Children's Healthy Living Program

BACKGROUND

The increased prevalence of childhood overweight and obesity across the United States and the Pacific has become a serious public health concern, with especially high prevalence among Native Hawaiian and Pacific Islander (NHPI) children. This study aimed to measure the effect of a Head Start (HS) policy intervention for childhood obesity prevention.

METHODS

Twenty-three HS classrooms located in Hawaii participated in the trial of a 7-month policy intervention with HS teachers. Classroom- and child-level outcome assessments were conducted, including: the Environment and Policy Assessment and Observations (EPAO) of the classroom environment; plate waste observations to assess child intake of fruit and vegetables; and child growth.

RESULTS

The intervention showed a positive and significant effect on classroom EPAO physical activity (PA) and EPAO total scores. Although mean BMI z-score (zBMI) increased at postintervention for both intervention (mean = 0.60; standard deviation [SD], 1.16; n = 114) and delayed-intervention groups (mean = 0.35; SD, 1.17; n = 132), change in zBMI was not significantly different between the groups (p = 0.50; p = 0.48).

CONCLUSIONS

These findings contribute evidence on the potential for HS wellness policy to improve the PA environment of HS classrooms. More research is needed to link these policy changes to other child outcomes.

Increased Fruit and Vegetable Intake among Older Adults Participating in Kentucky's Congregate Meal Site Program

The purpose of this study was to determine if the amount and variety of fruits and vegetables consumed increased among community-dwelling older adults participating in Kentucky's congregate meal site program following a series of five nutrition education lessons. A convenience sample of older adults attending senior centers (n=35), two intervention (n=19) and two control (n=16) centers, participated in this quasi-experimental pilot study. Following the intervention there was a significant increase in actual fruit and vegetable intake in the intervention group (p<0.05) as assessed by plate waste measurements of the congregate lunch meal. In addition, from pre- to post-intervention, a trend towards increased self-reported intake in the variety of fruit and vegetables was observed among the intervention group. As well, a significant increase in the number of days intervention participants self-reported consuming at least 4.5 cups of fruits and vegetables in the last seven days (2.44±2.09 days to 4.28±1.99 days (p=0.004)) was observed; and knowledge pertaining to phytochemicals increased (p<0.05). The phytochemical index (PI) score of the lunch meal, taking into account that the older adults consumption of meal components, including phytochemical-rich foods, was 26.9. Overall, study results indicated that a short theory-based nutrition education program offered to community-dwelling older adults was linked to an increase in fruit and vegetable consumption and phytochemical knowledge.

A plant to plate pilot: a cold-climate high school garden increased vegetable selection but also waste

AIM

Can high school gardens in cold climates influence vegetable intake in the absence of nutrition education?

METHODS

This study followed a before/after design where student tray-waste data were collected using the quarter-waste method. The study took place March-April 2012 in a high school in upstate New York. The subjects were 370 enrolled high school students that purchased lunch from the school cafeteria. Prior to the introduction of garden greens in the salad, salads were served as usual. On April 24, harvested greens were included in the salad, and changes in selection and plate waste were measured.

RESULTS

When the salad bar contained garden produce, the percentage of students selecting salad rose from 2% to 10% (p < 0.001), and on average, students ate two-thirds of the serving they took. Although waste increased relative to the control (from 5.56% to 33.33% per serving; p = 0.007), more students were consuming at least some salad.

CONCLUSION

This preliminary investigation suggests that school gardens increased selection and intake of school-raised produce. Although a third was not eaten, it is promising to see that still more produce was consumed compared to the past.

Energy Balance 4 Kids with Play: Results from a Two-Year Cluster-Randomized Trial

BACKGROUND

Identifying sustainable approaches to improving the physical activity (PA) and nutrition environments in schools is an important public health goal. This study examined the impact of Energy Balance for Kids with Play (EB4K with Play), a school-based intervention developed by the Academy of Nutrition and Dietetics Foundation and Playworks, on students' PA, dietary habits and knowledge, and weight status over 2 years.

METHODS

This cluster-randomized, controlled trial took place in four intervention and two control schools over 2 years (n=879; third- to fifth-grade students). PA (fourth and fifth grades only), dietary knowledge and behaviors, school policies, and BMI z-score were assessed at baseline (fall 2011), midpoint (spring 2012), and endpoint (fall 2012 for accelerometers; spring 2013 for all other outcomes).

RESULTS

At endpoint, there were no group differences in change in PA or dietary behaviors, although BMI z-score decreased overall by -0.07 (p=0.05). Students' dietary knowledge significantly increased, as did the amount of vegetables schools served. Post-hoc analyses stratified by grade revealed that, relative to control students, fourth-grade intervention students reduced school-day sedentary time by 15 minutes (p=0.023) and third-grade intervention students reduced BMI z-score by -0.2 (0.05; p<0.05). There were no significant differences for older students.

CONCLUSIONS

EB4K with Play, which leverages the existing infrastructure of two national programs, increases children's dietary knowledge and may improve weight status and decrease sedentary behaviors among younger children. Future iterations should examine programming specific for different age groups.

Validity and reliability of a simple, low-cost measure to quantify children's dietary intake in afterschool settings

BACKGROUND

Interest in evaluating and improving children's diets in afterschool settings has grown, necessitating the development of feasible yet valid measures for capturing children's intake in such settings.

OBJECTIVE

The purpose of this study was to test the criterion validity and cost of three unobtrusive visual estimation methods compared with a plate-weighing method: direct onsite observation using a 4-category rating scale and offsite rating of digital photographs taken onsite using 4- and 10-category scales.

DESIGN

Researchers observed and photographed 174 total snack meals consumed across 2 days at each program.

PARTICIPANTS/SETTING

Participants were 111 children in first through sixth grades attending four afterschool programs in Boston, MA, during December 2011.

STATISTICAL ANALYSIS

Visual estimates of consumption were compared to weighed estimates (the criterion measure) using intraclass correlations.

RESULTS

All three methods were highly correlated with the criterion measure, ranging from 0.92 to 0.94 for total calories consumed, 0.86 to 0.94 for consumption of prepackaged beverages, 0.90 to 0.93 for consumption of fruits/vegetables, and 0.92 to 0.96 for consumption of grains. For water, which was not preportioned, coefficients ranged from 0.47 to 0.52. The photographic methods also demonstrated excellent interrater reliability: 0.84 to 0.92 for the 4-point and 0.92 to 0.95 for the 10-point scale. The costs of the methods for estimating intake ranged from $0.62 per observation for the onsite direct visual method to $0.95 per observation for the criterion measure.

CONCLUSIONS

Feasible, inexpensive methods can validly and reliably measure children's dietary intake in afterschool settings. Improving precision in measures of children's dietary intake can reduce the likelihood of spurious or null findings in future studies.

Lunch, recess and nutrition: responding to time incentives in the cafeteria

OBJECTIVES

In this study, we evaluate if moving recess before lunch has an effect on the amount of fruits and vegetables elementary school students eat as part of their school-provided lunch.

METHODS

Participants were 1st-6th grade students from three schools that switched recess from after to before lunch and four similar schools that continued to hold recess after lunch. We collected data for an average of 14 days at each school (4 days during spring 2011, May 3 through June 1, 2011 and 9 days during fall 2011, September 19 through November 11, 2011). All of the schools were in Orem, UT. Data was collected for all students receiving a school lunch and was based on observational plate waste data.

RESULTS

We find that moving recess before lunch increased consumption of fruits and vegetables by 0.16 servings per child (a 54% increase) and increased the fraction of children eating at least one serving of fruits or vegetables by 10 percentage points (a 45% increase). In contrast, the schools in our control group actually experienced a small reduction in fruit and vegetable consumption during the same time period.

CONCLUSIONS

Our results show the benefits of holding recess before lunch and suggest that if more schools implement this policy, there would be significant increases in fruit and vegetable consumption among students who eat school lunch as part of the National School Lunch Program.

Impact of Fruit Smoothies on Adolescent Fruit Consumption at School

We examine the impact of serving fruit smoothies during school breakfast on fruit consumption among middle school and high school students. We draw on observational plate-waste data over a 10-week period during which fruit smoothies were introduced for breakfast at two Utah schools. Our total sample includes 2,760 student-day observations. We find that the fraction of students eating a full serving of whole fruit increased from 4.3% to 45.1%. As such, school districts should consider offering fruit smoothies as part of a set of interventions designed to increase fruit consumption at school.

Differential Improvements in Student Fruit and Vegetable Selection and Consumption in Response to the New National School Lunch Program Regulations: A Pilot Study

OBJECTIVE

To investigate changes in student food selection and consumption in response to the new National School Lunch Program meal patterns during fall 2011.

DESIGN

Eight elementary and four intermediate schools in one Houston area school district were matched on free/reduced-price meal eligibility and randomized into control or intervention conditions.

INTERVENTION

Both intervention and control school cafeterias served the same menu. The intervention school cafeterias posted the new meal pattern daily; students could select one fruit and two vegetable servings per reimbursable meal. Control school students could only select the previous meal pattern: a total of two fruit and vegetable servings per meal.

MAIN OUTCOME MEASURES

Students were observed during lunch: student sex and foods selected/consumed were recorded. Diet analysis software was used to calculate energy/food groups selected/consumed.

STATISTICAL ANALYSES PERFORMED

Cochran-Mantel-Haenszel χ² tests examined differences in the percent of students selecting each meal component by condition, controlling for sex, grade, and school free/reduced-price meal eligibility. Analysis of covariance assessed differences in amount of energy/food groups selected and consumed, and differences in percent of food groups consumed.

RESULTS

Observations were conducted for 1,149 elementary and 427 intermediate students. Compared with students in the control schools, significantly more intervention elementary and intermediate school students selected total (P<0.001, P<0.05) and starchy vegetables (P<0.001, P<0.01); more intervention intermediate school students selected fruit (P<0.001), legumes (P<0.05), and protein foods (P<0.01). There were significantly greater amounts of these foods selected and consumed, but no differences in the proportion of the foods consumed by condition. Fewer calories were consumed by elementary and intermediate school intervention students.

CONCLUSIONS

More intervention students selected fruit and vegetables at lunch and consumed them compared with control condition students. Future studies with larger and more diverse student populations are warranted.

Changes in foods selected and consumed after implementation of the new National School Lunch Program meal patterns in southeast Texas

OBJECTIVE

We compared elementary students' school lunches selected and consumed before (Spring, 2011) and after (Spring, 2013) implementation of the new National School Lunch Program meal patterns in the fall of 2012.

METHOD

Students in eight elementary schools in one Southeast Texas school district were observed during lunch: foods selected/consumed were recorded. The percentage of students who selected each food group was compared between years, as were the differences in consumption and the percent of food consumed by year, for students who selected the food group. All analyses controlled for student gender and grade and school free/reduced price meal status.

RESULTS

Observations were conducted for 472 (2011) and 573 (2013) students. Significantly more 2013 students selected fruit, 100% juice, total fruit + 100% juice, other vegetables, whole grains, protein foods and milk, but fewer selected starchy vegetables. For those students selecting them, significantly more total fruit + 100% juice and red orange vegetables, but significantly less other vegetables, legumes, and protein foods were consumed. There were no differences in waste of fruit, whole grains, or vegetables, with the exception of legumes. More legumes were wasted in 2013 than 2011.

CONCLUSION

The findings that students had similar consumption rates for fruit, whole grains, and most vegetables in this study are encouraging. Regular monitoring of student food selection and consumption at school is needed to assess whether the new meal patterns improve intake at school.

Early nutritional support and physiotherapy improved long-term self-sufficiency in acutely ill older patients

OBJECTIVE

An acute disease is regularly associated with inflammation, decreased food intake, and low physical activity; the consequence is loss of muscle mass. However, the restoration of muscle tissue is problematic, especially in older patients. Loss of muscle mass leads to further decrease of physical activity which leads, together with recurring disease, to the progressive muscle mass loss accompanied by loss of self-sufficiency. Early nutrition support and physical activity could reverse this situation. Therefore, the aim of this study was to determine whether an active approach based on early nutritional therapy and exercise would influence the development of sarcopenia and impaired self-sufficiency during acute illness.

METHODS

Two hundred patients >78 y were admitted to a hospital internal medicine department and participated in a prospective, randomized controlled study. The patients were randomized to a control group receiving standard treatment (n = 100) or to an intervention group (n = 100). The intervention consisted of nutritional supplements (600 kcal, 20 g/d protein) added to a standard diet and a simultaneous intensive rehabilitation program. The tolerance of supplements and their influence on spontaneous food intake, self-sufficiency, muscle strength, and body composition were evaluated during the study period. The patients were then regularly monitored for 1 y post-discharge.

RESULTS

The provision of nutritional supplements together with early rehabilitation led to increased total energy and protein intake while the intake of standard hospital food was not reduced. The loss of lean body mass and a decrease in self-sufficiency were apparent at discharge from the hospital and 3 mo thereafter in the control group. Nutritional supplementation and the rehabilitation program in the study group prevented these alterations. A positive effect of nutritional intervention and exercise during the hospital stay was apparent at 6 mo post-discharge.

CONCLUSIONS

The early nutritional intervention together with early rehabilitation preserves muscle mass and independence in ill older patients hospitalized because of acute disease.

Chocolate milk consequences: a pilot study evaluating the consequences of banning chocolate milk in school cafeterias

OBJECTIVES

Currently, 68.3% of the milk available in schools is flavored, with chocolate being the most popular (61.6% of all milk). If chocolate milk is removed from a school cafeteria, what will happen to overall milk selection and consumption?

METHODS

In a before-after study in 11 Oregon elementary schools, flavored milk-which will be referred to as chocolate milk-was banned from the cafeteria. Milk sales, school enrollment, and data for daily participation in the National School Lunch Program (NSLP) were compared year to date.

RESULTS

Total daily milk sales declined by 9.9% (p<0.01). Although white milk increased by 161.2 cartons per day (p<0.001), 29.4% of this milk was thrown away. Eliminating chocolate milk was also associated with 6.8% fewer students eating school lunches, and although other factors were also involved, this is consistent with the notion of psychological reactance.

CONCLUSIONS

Removing chocolate milk from school cafeterias may reduce calorie and sugar consumption, but it may also lead students to take less milk overall, drink less (waste more) of the white milk they do take, and no longer purchase school lunch. Food service managers need to carefully weigh the costs and benefits of eliminating chocolate milk and should consider alternative options that make white milk more convenient, attractive, and normal to choose.

Slim by design: serving healthy foods first in buffet lines improves overall meal selection

OBJECTIVE

Each day, tens of millions of restaurant goers, conference attendees, college students, military personnel, and school children serve themselves at buffets--many being all-you-can-eat buffets. Knowing how the food order at a buffet triggers what a person selects could be useful in guiding diners to make healthier selections.

METHOD

The breakfast food selections of 124 health conference attendees were tallied at two separate seven-item buffet lines (which included cheesy eggs, potatoes, bacon, cinnamon rolls, low-fat granola, low-fat yogurt, and fruit). The food order between the two lines was reversed (least healthy to most healthy, and vise-versa). Participants were randomly assigned to choose their meal from one line or the other, and researchers recorded what participants selected.

RESULTS

With buffet foods, the first ones seen are the ones most selected. Over 75% of diners selected the first food they saw, and the first three foods a person encountered in the buffet comprised 66% of all the foods they took. Serving the less healthy foods first led diners to take 31% more total food items (p<0.001). Indeed, diners in this line more frequently chose less healthy foods in combinations, such as cheesy eggs and bacon (r = 0.47; p<0.001) or cheesy eggs and fried potatoes (r= 0.37; p<0.001). This co-selection of healthier foods was less common.

CONCLUSIONS

Three words summarize these results: First foods most. What ends up on a buffet diner's plate is dramatically determined by the presentation order of food. Rearranging food order from healthiest to least healthy can nudge unknowing or even resistant diners toward a healthier meal, helping make them slim by design. Health-conscious diners, can proactively start at the healthier end of the line, and this same basic principle of "first foods most" may be relevant in other contexts - such as when serving or passing food at family dinners.