Validation of the School Lunch Recall Questionnaire to Capture School Lunch Intake of Third- to Fifth-Grade Students

Packed School Lunch Food Consumption: A Childhood Plate Waste Nutrient Analysis

Packed school lunch consumption remains a sparsely studied aspect of childhood nutrition. Most American research focuses on in-school meals provided through the National School Lunch Program (NSLP). The wide variety of available in-home packed lunches are usually nutritionally inferior compared to the highly regulated in-school meals. The purpose of this study was to examine the consumption of home-packed lunches in a sample of elementary-grade children. Through weighing packed school lunches in a 3rd grade class, mean caloric intake was recorded at 67.3% (32.7% plate waste) of solid foods, while sugar-sweetened beverage intake reported a 94.6% intake. This study reported no significant consumption change in the macronutrient ratio. Intake showed significantly reduced levels of calories, sodium, cholesterol, and fiber from the home-packed lunches (p < 0.05). The packed school lunch consumption rates for this class were similar to those reported for the regulated in-school (hot) lunches. Calories, sodium, and cholesterol intake are within childhood meal recommendations. What is encouraging is that the children were not "filling up" on more processed foods at the expense of nutrient dense foods. Of concern is that these meals still fall short on several parameters, especially low fruit/vegetable intake and high simple sugar consumption. Overall, intake moved in a healthier direction compared to the meals packed from home.

Development of the PEA-PODS (Perceptions of the Environment and Patterns of Diet at School) Survey for Students

INTRODUCTION

Few instruments assess key outcomes of school-based obesity interventions, including student perceptions of school environments and school-specific dietary intake patterns. This study describes development of PEA-PODS (Perceptions of the Environment and Patterns of Diet at School), a 2-part survey to measure these outcomes.

METHODS

Part 1 (PEA) assessed student perceptions of policies, physical environment, and practices related to healthy eating and physical activity at school. Part 2 (PODS) assessed usual intake (ie, frequency, location obtained, and foods consumed) of breakfast and lunch. Foods consumed were presented by MyPlate categories (eg, Fruits, Grains). Students in grades 3, 6, and 9 participated in 2 phases: cognitive pre-testing (n = 10) and reliability/validation testing (n = 58). Both surveys were administered 1 week apart to assess test-retest reliability and 5-day food records validated PODS. Analyses included percent agreement (70% = acceptable), Pearson correlations, and Cronbach α.

RESULTS

Cognitive pre-testing provided feedback on content, length, and age-appropriateness. Percent agreements were acceptable for test-retest reliability of PEA (71%-96%). The final version included 34 items with Likert-type responses in 4 subscales (α ≥0.78). For PODS, agreement for breakfast and lunch location was ≥75% for both reliability and validation. For foods consumed at breakfast, reliability agreement ranged from 74% to 93%, and validation agreement from 68% to 91%. For foods consumed at lunch, agreement ranges were 76% to 95% and 73% to 88%, respectively.

CONCLUSION

Both parts of the instrument demonstrate acceptable reliability, and PODS demonstrates acceptable validity. This demonstrates appropriateness for assessing perceptions of the environment and usual dietary intake patterns for school-based obesity prevention initiatives.

Validation of a Questionnaire to Measure Fruits and Vegetables Selected and Consumed at School Lunch among Second- and Third-Grade Students

BACKGROUND

Interventions designed to encourage fruit and vegetable (F/V) consumption within schools are increasingly common. Thus, there is a need for valid, practical dietary assessment instruments to evaluate their effectiveness.

OBJECTIVE

The aim of this study was to examine the validity of a group-administered, paper-and-pencil questionnaire to assess F/V selection and consumption at school lunch relative to digital photography.

DESIGN

This was a five-phase, method-comparison study in which the questionnaire was iteratively modified between each phase.

PARTICIPANTS/SETTING

The study examined sets of questionnaires and photographs of lunch trays (n=1,213) collected on 44 days between May 2015 and June 2016 among second-grade students from three New York City schools (phases 1 to 4) and second- and third-grade students from 20 schools across eight states (phase 5).

MAIN OUTCOME MEASURES

Outcomes assessed were selection, amount eaten, preference, and intention to consume F/V.

STATISTICAL ANALYSES PERFORMED

Validity was assessed by percent agreement (categorized as "match, omission, or intrusion" for items on or off tray and "match, overestimation, or underestimation" for amount eaten), Spearman correlation coefficients, and intraclass correlation coefficients (ICC).

RESULTS

The total match rate for items on tray was substantial (phases 1 to 5: 83%, 84%, 92%, 93%, and 89%), with items more frequently intruded than omitted. For amounts eaten, the total match rates were moderate, but generally improved throughout the study (phases 1 to 5: 65%, 64%, 83%, 83%, and 76%), with overestimations more frequent than underestimations. There was good correspondence between methods in the estimates of amount eaten in a quantitative, cup equivalent amount (fruit ICC=0.61; vegetables ICC=0.64). Significant differences (α=.05) were not observed between second- and third-grade students, respectively, in the match rate for fruits (86% and 89%) or vegetable (89% and 86%) items on tray or fruit (69% and 73%) and vegetables (74% and 76%) amount eaten. Excellent correlations were observed between amount eaten and preference for fruit (r=0.91) and vegetables (r=0.93).

CONCLUSIONS

The questionnaire offers a feasible, valid instrument for assessing F/V selection and consumption among elementary students in schools participating in the National School Lunch Program. Additional research is recommended to test the instrument's sensitivity and to reproduce these findings using an alternative reference method, such as direct observations.

Validation of a Brief Questionnaire Against Direct Observation to Assess Adolescents' School Lunchtime Beverage Consumption

OBJECTIVE

Beverage consumption is an important determinant of youth health outcomes. Beverage interventions often occur in schools, yet no brief validated questionnaires exist to assess whether these efforts improve in-school beverage consumption. This study validated a brief questionnaire to assess beverage consumption during school lunch.

METHODS

Researchers observed middle school students' (n = 25) beverage consumption during school lunchtime using a standardized tool. After lunch, students completed questionnaires regarding their lunchtime beverage consumption. Kappa statistics compared self-reported with observed beverage consumption across 15 beverage categories.

RESULTS

Eight beverages showed at least fair agreement (kappa [κ] > 0.20) for both type and amount consumed, with most showing substantial agreement (κ > 0.60). One beverage had high raw agreement but κ < 0.20. Six beverages had too few ratings to compute κ's.

CONCLUSIONS AND IMPLICATIONS

This brief questionnaire was useful for assessing school lunchtime consumption of many beverages and provides a low-cost tool for evaluating school-based beverage interventions.

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.

Fourth-grade children's dietary reporting accuracy by meal component: Results from a validation study that manipulated retention interval and prompts

We examined reporting accuracy by meal component (beverage, bread, breakfast meat, combination entrée, condiment, dessert, entrée, fruit, vegetable) with validation-study data on 455 fourth-grade children (mean age = 9.92 ± 0.41 years) observed eating school meals and randomized to one of eight dietary recall conditions (two retention intervals [short, long] crossed with four prompts [forward, meal-name, open, reverse]). Accuracy category (match [observed and reported], omission [observed but unreported], intrusion [unobserved but reported]) was a polytomous nominal item response variable. We fit a multilevel cumulative logit model with item variables meal component and serving period (breakfast, lunch) and child variables retention interval, prompt and sex. Significant accuracy category predictors were meal component (p < 0.0003), retention interval (p < 0.0003), meal-component × serving-period (p < 0.0003) and meal-component × retention-interval (p = 0.001). The relationship of meal component and accuracy category was much stronger for lunch than breakfast. For lunch, beverages were matches more often, omissions much less often and intrusions more often than expected under independence; fruits and desserts were omissions more often. For the meal-component × retention-interval interaction, for the short retention interval, beverages were intrusions much more often but combination entrées and condiments were intrusions less often; for the long retention interval, beverages were matches more often and omissions less often but fruits were matches less often. Accuracy for each meal component appeared better with the short than long retention interval. For lunch and for the short retention interval, children's reporting was most accurate for entrée and combination entrée meal components, whereas it was least accurate for vegetable and fruit meal components. Results have implications for conclusions of studies and interventions assessed with dietary recalls obtained from children.

A Systematic Review of Methods to Assess Children's Diets in the School Context

To evaluate the impact of school-based nutrition interventions, accurate and reliable methods are needed to assess what children eat at school. The primary objective of this study was to systematically review methodological evidence on the relative accuracy and reliability of dietary assessment methods used in the school context. The secondary objective was to assess the frequency of methods and analytical approaches used in studies reporting in-school dietary outcomes. Three health databases were searched for full-text English-language studies. Twenty-two methodological studies were reviewed. For school meal recalls, the majority of studies (n = 8 of 12) reported poor accuracy when accuracy was measured by using frequencies of misreported foods. However, when energy report rates were used as a measure of accuracy, studies suggested that children were able to accurately report energy intake as a group. Results regarding the accuracy of food-frequency questionnaires (FFQs) and food records (FRs) were promising but limited to a single study each. Meal observations offered consistently good interrater reliability across all studies reviewed (n = 11). Studies reporting in-school dietary outcomes (n = 47) used a broad range of methods, but the most frequently used methods included weighed FRs (n = 12), school meal recalls (n = 10), meal observations by trained raters (n = 8), and estimated FRs (n = 7). The range of dietary components was greater among studies relying on school meal recalls and FRs than among studies using FFQs. Overall, few studies have measured the accuracy of dietary assessment methods in the school context. Understanding the methodological characteristics associated with dietary instruments is vital for improving the quality of the evidence used to inform and evaluate the impact of school-based nutrition policies and programs.

Fourth-Grade Children's Reporting Accuracy for Amounts Eaten at School-Provided Meals: Insight from a Reporting-Error-Sensitive Analytic Approach Applied to Validation Study Data

BACKGROUND

Validation studies that have directly assessed reporting accuracy for amounts eaten have provided results in various ways.

OBJECTIVE

To analyze amount categories of a reporting-error-sensitive approach for insight concerning reporting accuracy for amounts eaten.

DESIGN

For a cross-sectional validation study, children were observed eating school-provided breakfast and lunch, and randomized to one of eight 24-hour recall conditions (two retention intervals [short and long] crossed with four prompts [forward, meal name, open, and reverse]).

PARTICIPANTS/SETTING

Data collected during 3 school years (2011-2012 to 2013-2014) on 455 children from 10 schools (four districts) in a southern US state.

MAIN OUTCOME MEASURES

Items were classified as matches (observed and reported), omissions (observed but unreported), or intrusions (unobserved but reported). Within amount categories (matches [corresponding, overreported, and underreported], intrusions [overreported], and omissions [underreported]), item amounts were converted to kilocalories.

STATISTICAL ANALYSES PERFORMED

A multilevel model was fit with food-level explanatory variables (amount category and meal) and child-level explanatory variables (retention interval, prompt, sex, and race/ethnicity). To investigate inaccuracy differences, t tests on three contrasts were performed.

RESULTS

Inaccuracy differed by amount category (P<0.001; in order from largest to smallest: omission, intrusion, underreported match, and overreported match), meal (P=0.01; larger for breakfast), retention interval (P=0.003; larger for long), sex (P=0.004; larger for boys), race/ethnicity (P=0.045; largest for non-Hispanic whites), and amount category×meal interaction (P=0.046). Overreported amounts were larger for intrusions than overreported matches (P<0.0001). Underreported amounts were larger for omissions than underreported matches (P<0.0001). Overall underreported amounts (from omissions and underreported matches) exceeded overall overreported amounts (from intrusions and overreported matches) (P<0.003).

CONCLUSIONS

Amount categories provide a standard way to analyze validation study data on reporting accuracy for amounts eaten, and compare results across studies. Multilevel analytic models reflecting the data structure are recommended for inference. To enhance reporting accuracy for amounts eaten, focus on increasing reports of correct items, thereby yielding more matches with fewer intrusions and omissions.

Cardiovascular Health Promotion in Children: Challenges and Opportunities for 2020 and Beyond: A Scientific Statement From the American Heart Association

This document provides a pediatric-focused companion to "Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction: The American Heart Association's Strategic Impact Goal Through 2020 and Beyond," focused on cardiovascular health promotion and disease reduction in adults and children. The principles detailed in the document reflect the American Heart Association's new dynamic and proactive goal to promote cardiovascular health throughout the life course. The primary focus is on adult cardiovascular health and disease prevention, but critical to achievement of this goal is maintenance of ideal cardiovascular health from birth through childhood to young adulthood and beyond. Emphasis is placed on the fundamental principles and metrics that define cardiovascular health in children for the clinical or research setting, and a balanced and critical appraisal of the strengths and weaknesses of the cardiovascular health construct in children and adolescents is provided. Specifically, this document discusses 2 important factors: the promotion of ideal cardiovascular health in all children and the improvement of cardiovascular health metric scores in children currently classified as having poor or intermediate cardiovascular health. Other topics include the current status of cardiovascular health in US children, opportunities for the refinement of health metrics, improvement of health metric scores, and possibilities for promoting ideal cardiovascular health. Importantly, concerns about the suitability of using single thresholds to identify elevated cardiovascular risk throughout the childhood years and the limits of our current knowledge are noted, and suggestions for future directions and research are provided.

A Trial of the Efficacy and Cost of Water Delivery Systems in San Francisco Bay Area Middle Schools, 2013

INTRODUCTION

US legislation requires that schools offer free drinking water where meals are served. However, little information is available about what types of water delivery systems schools should install to meet such requirements. The study objective was to examine the efficacy and cost of 2 water delivery systems (water dispensers and bottleless water coolers) in increasing students' lunchtime intake of water in low-income middle schools.

METHODS

In 2013, twelve middle schools in the San Francisco Bay Area participated in a cluster randomized controlled trial in which they received 6 weeks of promotional activities, received provision of cups, and were assigned to 1 of 2 cafeteria water delivery systems: water dispensers or bottleless water coolers (or schools served as a control). Student surveys (n = 595) and observations examined the interventions' effect on students' beverage intake and staff surveys and public data assessed intervention cost.

RESULTS

Analysis occurred from 2013 through 2015. Mixed-effects logistic regression, accounting for clustering and adjustment for student sociodemographic characteristics, demonstrated a significant increase in the odds of students drinking water in schools with promotion plus water dispensers and cups (adjusted odds ratio = 3.1; 95% confidence interval, 1.4-6.7; P = .004) compared with schools with traditional drinking fountains and no cups or promotion. The cost of dispenser and bottleless water cooler programs was similar ($0.04 per student per day).

CONCLUSION

Instead of relying on traditional drinking fountains, schools should consider installing water sources, such as plastic dispensers with cups, as a low-cost, effective means for increasing students' water intake.

Association Between Student Purchases of Beverages During the School Commute and In-School Consumption of Sugar-Sweetened Beverages, San Francisco Bay Area, 2013

INTRODUCTION

Consumption of sugar-sweetened beverages (SSBs) such as sodas, fruit-flavored drinks, and sports drinks is a major contributor to childhood obesity. One strategy to reduce children's SSB consumption has been to restrict the sale of SSBs in schools. However, such policies may not sufficiently curb students' SSB intake, because students can obtain SSBs elsewhere, including from stores located on their school commute. Little is known about students' purchases of beverages during the school commute or about whether this purchasing behavior is related to in-school SSB consumption. The objective of this study was to describe where students from low-income, ethnically diverse communities obtain the SSBs they drink during school lunchtime and to examine whether students who purchase beverages while traveling to and from school are more likely to drink SSBs during school lunchtime.

METHODS

We analyzed survey data from a random sample of low-income, ethnically diverse middle school students (N = 597) who participated in a randomized controlled trial of a water promotion intervention. We used logistic regression analysis to examine the association between students' purchase of beverages during the school commute and their SSB consumption during school lunchtime.

RESULTS

One-fifth (20.4%) of students drank an SSB during lunch. Approximately 23% of SSBs were obtained during the school commute. Students who reported buying beverages during their school commute (50.1% of all students) were more likely to report drinking SSBs during lunch than students who reported that they do not buy beverages during the school commute (adjusted odds ratio 3.32, 95% confidence interval, 2.19-5.05, P < .001).

CONCLUSION

Students' purchase of beverages during the school commute was strongly associated with SSB consumption during school lunchtime. Interventions could benefit from focusing on retail environments (e.g., encouraging retailers to promote healthy beverages, posting beverage calorie information).

Effectiveness of Prompts on Fourth-Grade Children's Dietary Recall Accuracy Depends on Retention Interval and Varies by Gender

BACKGROUND

Dietary recall accuracy is related to retention interval (RI) (i.e., time between to-be-reported meals and the interview), and possibly to prompts. To the best of our knowledge, no study has evaluated their combined effect.

OBJECTIVE

The combined influence of RI and prompts on children's recall accuracy was investigated in this study. Two RIs [short (prior-24-h recall obtained in afternoon) and long (previous-day recall obtained in morning)] were crossed with 4 prompts [forward (distant-to-recent), meal-name (breakfast, lunch, etc.), open (no instructions), and reverse (recent-to-distant)], creating 8 conditions.

METHODS

Fourth-grade children (n = 480; 50% girls) were randomly selected from consenting children at 10 schools in 4 districts in a southern state during 3 school years (2011-2012, 2012-2013, and 2013-2014). Each child was observed eating school-provided breakfast and lunch, and interviewed one time under 1 of the 8 conditions. Condition assignment was constrained so that each had 60 children (30 girls). Accuracy measures were food-item omission and intrusion rates, and energy correspondence rate and inflation ratio. For each measure, linear models determined effects of RI, prompt, gender, and interactions (2-way, 3-way); race/ethnicity, school year, and district were control variables.

RESULTS

RI (P values < 0.015) and prompt (P values < 0.005) were significant for all 4 accuracy measures. RI × prompt (P values < 0.001) was significant for 3 accuracy measures (not intrusion rate). Prompt × gender (P = 0.005) was significant for omission rate. RI × prompt × gender was significant for intrusion rate and inflation ratio (P values < 0.001). For the short vs. long RI across prompts and genders, accuracy was better by 33-50% for each accuracy measure.

CONCLUSIONS

To obtain the most accurate recalls possible from children, studies should be designed to use a short rather than long RI. Prompts affect children's recall accuracy, although the effectiveness of different prompts depends on RI and varies by gender: at a short RI, the choice of prompts has little systematic effect on accuracy, whereas at a long RI, reverse prompts may elicit the most accurate recalls.

A validation study concerning the effects of interview content, retention interval, and grade on children's recall accuracy for dietary intake and/or physical activity

BACKGROUND

Practitioners and researchers are interested in assessing children's dietary intake and physical activity together to maximize resources and minimize subject burden.

OBJECTIVE

Our aim was to investigate differences in dietary and/or physical activity recall accuracy by content (diet only; physical activity only; diet and physical activity), retention interval (same-day recalls in the afternoon; previous-day recalls in the morning), and grade (third; fifth).

DESIGN

Children (n=144; 66% African American, 13% white, 12% Hispanic, 9% other; 50% girls) from four schools were randomly selected for interviews about one of three contents. Each content group was equally divided by retention interval, each equally divided by grade, each equally divided by sex. Information concerning diet and physical activity at school was validated with school-provided breakfast and lunch observations, and accelerometry, respectively. Dietary accuracy measures were food-item omission and intrusion rates, and kilocalorie correspondence rate and inflation ratio. Physical activity accuracy measures were absolute and arithmetic differences for moderate to vigorous physical activity minutes.

STATISTICAL ANALYSES PERFORMED

For each accuracy measure, linear models determined effects of content, retention interval, grade, and their two-way and three-way interactions; ethnicity and sex were control variables.

RESULTS

Content was significant within four interactions: intrusion rate (content×retention-interval×grade; P=0.0004), correspondence rate (content×grade; P=0.0004), inflation ratio (content×grade; P=0.0104), and arithmetic difference (content×retention-interval×grade; P=0.0070). Retention interval was significant for correspondence rate (P=0.0004), inflation ratio (P=0.0014), and three interactions: omission rate (retention-interval×grade; P=0.0095), intrusion rate, and arithmetic difference (both already mentioned). Grade was significant for absolute difference (P=0.0233) and five interactions mentioned. Content effects depended on other factors. Grade effects were mixed. Dietary accuracy was better with same-day than previous-day retention interval.

CONCLUSIONS

Results do not support integrating dietary intake and physical activity in children's recalls, but do support using shorter rather than longer retention intervals to yield more accurate dietary recalls. Additional validation studies need to clarify age effects and identify evidence-based practices to improve children's accuracy for recalling dietary intake and/or physical activity.

Determination of plate waste in primary school lunches by weighing and visual estimation methods: a validation study

The aim of this study was to validate the visual estimation method for aggregated plate waste of main dish at Portuguese primary school canteens. For this purpose plate waste at school lunch was measured for 505 individual servings, using weighing individual servings and plate waste and visual estimation method by a 6-point scale, as developed by Comstock et al. (1981). A high variability of initial serving weights was found with serving sizes ranging from 88.9 to 283.3g and with a coefficient of variation ranging from 5.5% to 24.7%. Mean plate waste was 27.5% according to the weighing method. There was a significant bias in the conversion of the visual waste estimations to actual waste, being overestimated by an average of 8.0 g (ranging from -12.9 g to 41.4 g). According to Bland and Altman plot, the mean difference between methods was of 8.0 g and the amplitude interval was 102.6g. The study showed that the visual estimation method is not as accurate as the weighing method in assessing nonselective aggregated plate waste at primary school canteens. Our findings are thus very important on considering plate waste assessment, since the wide variation on initial servings introduces a relevant bias when considering standard portions or a random sample of initial servings. Although, greater convenience, time-saving and the possibility to monitor plate waste of large groups, make the visual estimation method an important method to assess plate waste at school canteens, these results highlighted the need of portions standardization and control of initial servings to allow for its use.