Fresh Fruit and Vegetable Program participation in elementary schools in the United States and availability of fruits and vegetables in school lunch meals

The impact of primary school nutrition policy on the school food environment: a systematic review

School nutrition policies that aim to address unhealthy diets have been introduced in many countries. This systematic review aimed to synthesize the international literature to determine the impact (overall and by socioeconomic position [SEP]) of primary school nutrition policies on the availability of foods and beverages in schools. Seven databases were searched using keywords and medical subject headings related to nutrition policies and schools. Studies that reported on the impact of implemented school nutrition policies on food and beverage availability within primary schools were included. Eighteen studies (reported across 20 papers) were included. Fifteen of the included studies reported some positive impacts of policies, including increased availability of healthier foods and decreased availability of less healthy foods. Five studies focused specifically on schools in low-income communities and a further three specifically compared schools by SEP, with mixed findings. Two studies reported on factors influencing policy implementation, reporting a lack of financial resources as a barrier to schools offering a wider selection of healthy foods and additional school resources as increasing the likelihood of offering healthy foods. School nutrition policies appear to be effective at improving the healthiness of foods and beverages available at schools. Furthermore, the results suggest that well-implemented school nutrition policies that improve the healthiness of foods available are unlikely to exacerbate the socioeconomic gradient of poor nutrition. However, the number of studies that reported results by SEP limits drawing strong conclusions regarding equity impacts and we strongly recommend further studies analyze their findings according to SEP.

School Fruit and Vegetables Scheme: Characteristics of Its Implementation in the European Union from 2009/10 to 2016/17

The “School Fruit and Vegetables Scheme” (SFVS) was proposed in 2009/10 as a strategy to support the consumption of Fruit and Vegetables (FV), decrease rates of obesity, improve agricultural income, stabilize markets, and ensure the current and future supply of these foods. However, there is little information about how it was carried out in the EU. Given the potential of the SFVS to support healthier, more sustainable food systems, the objective of this study was to identify the characteristics of SFVS implementation from 2009/10 to 2016/17 in the EU. A longitudinal, observational, and retrospective study was carried out based on secondary data. A total of 186 annual reports of the Member States (MS) participating in the SFVS from 2009/10 to 2016/17 were consulted: European and national budget, funds used from the EU, participating schools and students, duration of the SFVS, FV offered, and application of sustainability criteria, expenditure per student, days of the week, the quantity of FV offered per student and other indicators were calculated. The majority of MS participated in the SFVS during the study period with a heterogeneous implementation pattern in terms of funds used, coverage, duration, quantity (totals and by portion), and cost of FV distributed per student. The sustainability criteria for the FV distribution were also not applied uniformly in all the MS. Establishing minimum recommendations for SFVS implementation are recommended to maximize the benefits of the SFVS. The results may be useful for planning new strategies to help address and improve current health and environmental problems.

Identification and Evaluation of Tools Utilised for Measuring Food Provision in Childcare Centres and Primary Schools: A Systematic Review

BACKGROUND

Children aged 2-11 years spend significant hours per week in early childhood education and care (ECEC) and primary schools. Whilst considered important environments to influence children's food intake, there is heterogeneity in the tools utilised to assess food provision in these settings. This systematic review aimed to identify and evaluate tools used to measure food provision in ECEC and primary schools.

METHODS

The Preferred Reporting Items for Systematic Reviews (PRISMA) was followed. Publications (2003-2020) that implemented, validated, or developed measurement tools to assess food provision within ECEC or primary schools were included. Two reviewers extracted and evaluated studies, cross checked by a third reviewer and verified by all authors. The Academy of Nutrition and Dietetics Quality Criteria Checklist (QCC) was used to critically appraise each study.

RESULTS

Eighty-two studies were included in the review. Seven measurement tools were identified, namely, Menu review; Observation; Weighed food protocol; Questionnaire/survey; Digital photography; Quick menu audit; and Web-based menu assessment. An evidence-based evaluation was conducted for each tool.

CONCLUSIONS

The weighed food protocol was found to be the most popular and accurate measurement tool to assess individual-level intake. Future research is recommended to develop and validate a tool to assess service-level food provision.

School Nutrition Director Perceptions of Flexible Regulations for School Nutrition Programs in One Southeastern State

BACKGROUND

Schools are a promising site for influencing the dietary intake of children and adolescents. The US Department of Agriculture recently released flexibilities to requirements for whole-grains, sodium, and low-fat milk in schools who demonstrated difficulty meeting nutrition standards for school meal programs. The support of School Nutrition Directors (SNDs) is vital to the success of school food environment changes; however, few studies have explored SNDs perceptions to changes in nutrition standards.

METHODS

Experiences and perspectives toward nutrition standards of 10 SNDs, and their satisfaction with flexibilities for whole-grains, sodium, and low-fat milk were explored using a semi-structured interview. Responses were analyzed using an inductive approach with thematic analysis.

RESULTS

Three broad categories emerged challenges with the Healthy, Hunger-Free Kids Act, food preferences and acceptability, and support and representation. A greater need for internal and external support, assistance in equipment and staff, procurement of foods compliant with regulations and acceptable to students, and more input on federal decisions and policies were perceived as important.

CONCLUSIONS

Results provide critical insight into the implementation of nutrition standards. Future research and changes to school nutrition programs should consider these challenges as they strive to meet the needs of this important population.

Salad Bars and Fruit and Vegetable Intake in Title I Elementary Schools

Objective

Despite widespread support for salad bars as a means to increase fruit and vegetable (F&V) intake within the National School Lunch Program (NSLP), empirical support for their use is limited. This cross-sectional study examined associations between salad bar access and F&V selection and consumption in Title I elementary schools in Virginia serving universal free meals.

Methods

Three matched pairs of schools (3 with salad bars; 3 without [control]) were randomly selected. Digital imagery plate waste methods assessed F&V selection, waste, and consumption. N = 1559 trays (N = 760 salad bar; N = 799 control) from 1^st-5^th grade students were analyzed (92.5% NSLP participation; 98.6% racial/ethnic minority).

Results

Salad bar usage varied widely (8.2%-63.8%). Different patterns of F&V selection and consumption were observed across pairs. Vegetable selection was higher in one salad bar school (+43.6g; q < .001) and vegetable consumption higher in 2 salad bar schools (+15.3g [q = .005]; +8.3g [q = .022]), compared with matched controls. Students in 2 salad bar schools selected more fruit than controls (+30.2g and +18g; qs < .001), yet fruit consumption differed across all 3 pairs.

Conclusions

Salad bar access might facilitate children's vegetable intake. Inconsistent results across school pairs suggest that school food environment factors other than salad bar access influenced F&V consumption.

Snacking in nutrition and health

Many studies suggest that distributing energy and nutrient intake across 4-5 eating occasions/day (rather than across three standard meals) could favourably affect human health. The inclusion of 1-2 snacks in the daily pattern alleviates the potential digestive and metabolic overload caused by fewer heavier meals and might contribute to meet recommendations for food groups (e.g. fruits, dairy) and nutrients like fibre and vitamins. The snack composition should be evaluated taking into account the whole day's diet. In early and late ages, and for specific population groups, snacking may need to follow particular characteristics in order to be optimal, both in terms of composition and timing. This document, which is the result of a collaboration of experts across several fields of research, intends to provide a review of the current scientific literature on meal frequency and health, highlighting the beneficial effects of correct snack consumption across the human lifespan.

Soda, salad, and socioeconomic status: Findings from the Seattle Obesity Study (SOS)

Background

Documenting geographic disparities in dietary behaviors can help inform public health interventions at the local level.

Objective

To study and visualize socioeconomic gradient in soda and salad consumption using a geo-localized measure of socioeconomic status in contrast to more traditional measures.

Methods

Geo-localized dietary intake data came from the Seattle Obesity Study I, a population-based sample of King County adults (n=1099). Socio-demographic data and soda and salad consumption frequencies (times/week) were obtained by 20-min telephone survey. Food frequency questionnaire (FFQ) data were used to construct Healthy Eating Index (HEI) scores. Individual residential property values obtained from the King County tax assessor. Multivariable linear regressions examined socioeconomic gradient in the frequency of soda and salad consumption by residential property values, the primary independent variable, in comparison to annual household incomes and educational attainment, with adjustment for age, gender, and race/ethnicity. Geographic disparities in soda and salad consumption by property value metric were illustrated at the census block level using modeled predicted marginal means.

Results

Among all three socioeconomic indicators (income, education and residential property values), residential property values captured strongest gradient in soda and salad consumption. Higher quintiles of residential property values were associated with lower soda and higher salad consumption. Respondents living in the highest quintile of property values −1.04 fewer sodas per week (95% CI= −1.87, −0.21) and 0.89 more salads per week (95% CI= 0.36, 1.42), adjusting for sociodemographic covariates. Residential property values illustrated geographic disparities in soda and salad consumption at the census-block level.

Conclusion

Geo-localized disparities in food consumption patterns by neighborhood can inform current discourse on the socioeconomic determinants of health, while providing a useful tool for targeted interventions at the local level.

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Soda (inverse) and salad (positive) consumption show gradients with socioeconomic status (SES).

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Place-based measures of SES and property values, allow for high resolution mapping of diet measures.

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Provides new tools for spatial, nutritional epidemiology analyses.

Impact of Nutrition Education on the Compliance with Model Food Ration in 231 Preschools, Poland: Results of Eating Healthy, Growing Healthy Program

To ensure the adequate supply of nutrients, a model food ration (MFR) should be used for planning the menu. The purpose of the study was to determine the effects of the nutrition education program on the compliance with MFR in 231 preschools. The average supply of food products (per child/day) with reference to the MFR was examined on the baseline and 3 to 6 months after education on the basis of 10-day menus and daily inventory reports (4620 in total). According to the recommendations, preschool should implement 70⁻75% of the recommended daily intake standards. Examined menus had too high content of meat and meat products, whereas vegetables, milk and fermented milk beverages, cottage cheese and eggs were served in scarce. Education significantly reduced the amount of meat (47.7 vs. 44.5 g), processed meat (16.2 vs. 14.4 g), sugar and sweets (15.9 vs. 14.4 g) and increased the amount of cereals, groats, rice (17.7 vs. 18.5 g), vegetables (164.3 vs. 170.8 g), milk and fermented milk beverages (200.3 vs. 209.5 g) but the compliance with the MFR remained poor. The evaluation of menus stressed the need for further modifying their composition. Education can positively affect the quality of nutrition; however, introduction of the legal nutritional regulations should be recommended.

School-Level Practices and Perceptions Associated With Salad Bars in Schools

BACKGROUND

Salad bars are placed in schools to promote fruit and vegetable consumption among students. This study assessed differences in school nutrition practices and perceptions in schools with and without salad bars.

METHODS

Cross-sectional surveys were completed by school nutrition managers (N = 648) in Arizona schools participating in the National School Lunch Program during 2013-2014. Mixed general estimating equation binomial regressions assessed factors related to having a salad bar after mutually adjusting for clustering within districts, school level, free/reduced rate, and respondents' time in current position.

RESULTS

On average, 61% of schools reported having a salad bar. After adjustment, school nutrition managers were significantly more likely to report having a salad bar if they served lunch by grade level (vs mixed grades), had a full-service kitchen, and their personal perception of salad bars was positive; schools were less likely to have a salad bar if menu and food service decisions were made at the school level.

CONCLUSIONS

Several school-level nutrition practices and perceptions were associated with having a salad bar in schools. Enhancement of these factors may facilitate having salad bars in schools.

Fresh Fruit and Vegetable Program and Requests for Fruits and Vegetables Outside School Settings

BACKGROUND

Consumption of fruits and vegetables (F/V) among elementary school-aged children remains inadequate, especially among low-income children. The US Department of Agriculture's Fresh Fruit and Vegetable Program (FFVP) provides F/V as snacks to children during the school day, outside of school meals. School-based initiatives are successful in changing behaviors in school settings; however, their influence on behaviors outside of schools needs investigation.

OBJECTIVE

To examine whether FFVP participation is associated with F/V requests at stores, self-efficacy to ask for and choose F/V at home, and F/V consumption.

DESIGN

Cross-sectional study.

PARTICIPANT/SETTING

Fourth graders in six classrooms (n=296) from three urban, low-income school districts in Phoenix, AZ, were surveyed during 2015; one FFVP and one non-FFVP school from each district that were similar in school size, percent free/reduced-price meal eligibility, and race/ethnicity of enrolled students were selected.

MAIN OUTCOME MEASURES

Children's self-reported F/V requests during shopping, their self-efficacy to ask for and choose F/V at home, and F/V consumption on the previous day (non-FFVP school day) were measured using questions adapted from validated surveys.

STATISTICAL ANALYSIS

Multivariable mixed-effect regression models, adjusting for clustering of students within classes and classes within schools were explored.

RESULTS

In models adjusting for individual-level factors (ie, age and sex) only, several significant positive associations were observed between school FFVP participation and healthier F/V outcomes. After additionally adjusting for school-level factors (ie, total enrollment and % Hispanic/Latino students) significant associations were observed between school FFVP participation and more requests for vegetables during shopping (P<0.001), higher scores on self-efficacy to choose vegetables at home (P=0.004), stronger preferences for vegetables (P<0.001), and more frequent consumption of fruit (P=0.006).

CONCLUSIONS

School FFVP participation was associated with more requests for vegetables during shopping and higher self-efficacy to make healthy choices at home, suggesting the influence of the FFVP may extend beyond the school day.

Association between childhood socioeconomic status and fruit and vegetable intake among older Japanese: The JAGES 2010 study

Fruit and vegetable intake (FVI) contributes to the prevention of non-communicable diseases. Although food preference is considered to be determined early in life, few studies have investigated the association between childhood socioeconomic status (SES) and FVI in older age. Because a school lunch program was initiated in Japan after World War II, we were able in this study to examine this association in an older Japanese population. We used data from a population of physically and cognitively independent adults aged 65years or older who were living independently in the community and were recruited from 27 municipalities in the Japan Gerontological Evaluation Study 2010 project (August 2010-January 2012). Three categories of childhood SES (low, middle, and high) and current FVI were evaluated via a self-reported questionnaire. Poisson regression was used to investigate the association between childhood SES and FVI in 19,920 individuals. After adjustment for age and sex, older people with low childhood SES were 1.36 times more likely (95% CI 1.23-1.52) to have poor FVI than those with high childhood SES. In the fully adjusted model, the significant association disappeared. Further age-stratified analysis revealed a positive association between childhood SES and FVI among people aged 70-76years who were partially exposed to the school lunch program, but not among people aged 65-69years old who were fully exposed to the program. In conclusion, social policy such as school lunches targeting children with low SES could help improve FVI in old age.

Prevalence and Implementation Practices of School Salad Bars Across Grade Levels

PURPOSE

To assess the prevalence of school salad bars in Arizona and to describe common practices of salad bar use among school nutrition managers across grade level.

DESIGN

Cross-sectional web-based surveys.

PARTICIPANTS

School nutrition managers from elementary, middle, high, and K-12 schools (N = 648).

MEASURES

Prevalence of salad bars; implementation practices such as years with salad bar, salad bar type, location, monitor, and reimbursement practices; and food-related components of salad bars including frequency of items, popular items, and sources of food.

ANALYSIS

Descriptive analyses were conducted including Fisher exact test, analysis of variance, and the Kruskal-Wallis test comparing practices across grade level (elementary, middle, high, and K-12 schools).

RESULTS

Overall, 61.1% of respondents had a salad bar; there were significant differences in the prevalence across grade level: elementary, middle, high, and K-12 schools had prevalence of 67.3%, 75.0%, 45.5%, and 51.1%, respectively ( P < .001). We observed significant differences in the implementation and food-related components of salad bars across grade levels including type, salad bar location, sources of food, and frequency of serving cut vegetables.

CONCLUSION

This study provides insights on the prevalence of salad bars and is the first to report on implementation practices of school salad bars. These results may also guide the development of interventions for nutrition educators to use for the promotion fruit and vegetable consumption via school salad bars.

Best practices for using natural experiments to evaluate retail food and beverage policies and interventions

Policy and programmatic change in the food retail setting, including excise taxes on beverages with added-caloric sweeteners, new supermarkets in food deserts, and voluntary corporate pledges, often require the use of natural experimental evaluation for impact evaluation when randomized controlled trials are not possible. Although natural experimental studies in the food retail setting provide important opportunities to test how nonrandomized interventions affect behavioral and health outcomes, researchers face several key challenges to maintaining strong internal and external validity when conducting these studies. Broadly, these challenges include 1) study design and analysis; 2) selection of participants, selection of measures, and obtainment of data; and 3) real-world considerations. This article addresses these challenges and different approaches to meeting them. Case studies are used to illustrate these approaches and to highlight advantages and disadvantages of each approach. If the trade-offs required to address these challenges are carefully considered, thoughtful natural experimental evaluations can minimize bias and provide critical information about the impacts of food retail interventions to a variety of stakeholders, including the affected population, policymakers, and food retailers.

Fruit and Vegetable Preferences and Identification by Kindergarteners through 2nd-Graders With or Without the US Department of Agriculture Fresh Fruit and Vegetable Program

OBJECTIVE

The US Department of Agriculture Fresh Fruit and Vegetable Program (FFVP) allows schools to increase fruit and vegetable (FV) exposure by distributing FV as snacks. The objective of this study was to compare kindergarten through second (K-2nd)-graders who were exposed or not to FFVP for preferences and identification.

DESIGN, SETTING, PARTICIPANTS

The FV Preference Survey for K-2nd-graders contained 12 fruits and 12 vegetables, a 3-Likert scale (liked it, okay, don't like it), and an I don't know option. Data were collected from K-2nd-graders at 2 elementary schools near Chicago, IL (n = 435, FFVP school, n = 235 with 12 teachers; non-FFVP school, n = 200 with 10 teachers).

MAIN OUTCOME MEASURE(S)

Mean preference scores.

ANALYSIS

Chi-square, Mann-Whitney U, and multiple linear regression analyses compared school data (P < .05).

RESULTS

There were significant differences in mean preference scores, with higher fruit scores at the FFVP school (1.8 ± 0.6) than at the non-FFVP school (1.7 ± 0.6). In contrast, there was a higher vegetable score for the non-FFVP school (1.3 ± 0.9) than for the FFVP school (1.2 ± 0.9). The school variable had weak impact on fruit ranking (multivariate coefficient = 0.01; P < .05). For fruits and vegetables and combined, there were fewer I don't know responses in the FFVP (χ² = 149.080; P < .01).

CONCLUSIONS AND IMPLICATIONS

At the FFVP school, fewer I don't know responses suggested better FV identification. Non-FFVP students had higher vegetable preferences than did FFVP students. Tasting a variety of FV may help with identifying FV, but more research is needed to determine the impact on preferences.

School Nurses' Experiences and Perceptions of Healthy Eating School Environments

School nurses provide health promotion and health services within schools, as healthy children have a greater potential for optimal learning. One of the school nurses' role is in encouraging healthy eating and increasing the availability of fruits and vegetables in the school. The purpose of this study was to explore and describe school nurses' perceptions of their role in promoting increased fruit and vegetable consumption in the school setting. One avenue to increased availability of fruits and vegetables in schools is Farm to School programs mandated by the Federal government to improve the health of school children. School nurses are optimally positioned to work with Farm to School programs to promote healthy eating. A secondary aim was to explore school nurses' knowledge, experiences and/or perceptions of the Farm to School program to promote fruit and vegetable consumption in the school setting. Three themes emerged from the focus groups: If There Were More of Me, I Could Do More; Food Environment in Schools; School Nurses Promote Health. School nurses reported that they addressed health issues more broadly in their roles as educator, collaborator, advocate and modeling healthy behaviors. Most of the participants knew of Farm to School programs, but only two school nurses worked in schools that participated in the program. Consequently, the participants reported having little or no experiences with the Farm to School programs.

Factors associated with the implementation of a vegetable and fruit program in a population of Australian elementary schools

Implementation of vegetable and fruit programs in schools is less than optimal. This study aimed to identify, using a theoretical framework, factors associated with implementation of a school vegetable and fruit program; that provides a time in class for children to consume a piece of vegetable or fruit they have brought from home. Three hundred and three randomly selected school principals across the state of New South Wales, Australia responded to a 25-min telephone survey. Principals were asked if their school had implemented a vegetable and fruit program, and which of 12 factors from Damschroder's consolidated framework for implementation research had facilitated or impeded implementation. Multiple logistic regression models examined the association between such factors and program implementation. Seventy-eight percent of schools had a vegetable and fruit program. Schools were significantly more likely to implement the program if the principal believed that: the program was effective (OR = 2.97; P < 0.02); they had sufficient resources to implement the program (OR = 4.22; P < 0.0001); the program would not be difficult to implement (OR = 10.16; P< 0.0001) and that the program was as important as other school priorities (OR = 2.45; P < 0.02). Realizing the intended benefits of vegetable and fruit programs requires widespread implementation by schools. Consideration of principal beliefs about the program effectiveness, resources, difficultly and relative importance in program implementation strategies appear key to increasing program implementation.

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.

The Impact of Crunchy Wednesdays on Happy Meal Fruit Orders: Analysis of Sales Data in France, 2009-2013

OBJECTIVE

Beginning in September, 2010, all McDonald's restaurants in France offered free fruit with every Happy Meal sold on the first Wednesday of the month. Sales data were used to determine the impact of free fruit promotion on the proportion of regular Happy Meal fruit desserts sold.

METHODS

Trend analyses examined the proportion of fruit desserts for 2009-2013. Analyses also compared fruit orders on Crunchy Wednesdays with other weekdays.

RESULTS

Happy Meal fruit desserts rose from 14.5% in 2010 to 18.0% in 2011 and to 19.4% in 2013 (P < .001). More Happy Meal fruit desserts were ordered on Crunchy Wednesdays compared with other weekdays (P < .001). Orders of cherry tomato sides and water as a beverage on Crunchy Wednesdays were unaffected.

CONCLUSIONS AND IMPLICATIONS

Based on sales transactions data across multiple years, this study provides evidence of the long-term effectiveness of menu promotions aimed at increasing children's consumption of vegetables and fruit.

Gains Made By Walmart's Healthier Food Initiative Mirror Preexisting Trends

Healthier food initiatives conducted by national food retailers may offer opportunities to improve the nutritional profile of food purchases. Using a longitudinal data set of packaged food purchases made by US households, we examined the effect of a healthier food initiative officially launched by Walmart in 2011. From 2000 to 2013, household-level purchases of packaged foods at Walmart showed major declines in energy, sodium, and total sugar density, as well as in quantities of sugary beverages, grain-based desserts, snacks, and candy. These trends in packaged food purchases were more pronounced than similar concurrent trends seen at other major food retailers. However, the declines seen at Walmart after the initiative's official implementation did not exceed what would have been expected had pre-implementation trends continued, and therefore they cannot be attributed to the initiative. These results suggest that food retailer-based initiatives that purportedly create a healthier food environment may not suffice to improve the nutritional profile of food purchases. More systemic shifts in consumers' characteristics and preferences may be needed.

USDA Fresh Fruit and Vegetable Program Is More Effective in Town and Rural Schools Than Those in More Populated Communities

BACKGROUND

We attempted to determine effects of the United States Department of Agriculture (USDA) Fresh Fruit and Vegetable Program (FFVP) on variety and frequency of fruit and vegetable intake by students in schools from different locales.

METHODS

Data were derived from the 2011-2012 Indiana FFVP Student Survey completed by 4229 fourth-sixth graders. Effects were studied within 2 groups, 39 city and suburb schools, and 12 town and rural schools. Differences in students' responses over time to 2 items measuring variety and 10 items measuring fruit and vegetable intake frequency were determined with multilevel regression models.

RESULTS

Town and rural students were 1.2 times more likely to eat different kinds of fruit (p = .04) and vegetables (p = .01) daily, and increased fruit (+1.0 time/day; p < .01) and vegetable intake frequency (+0.5 times/day; p = .03). City and suburb students increased fruit intake frequency (∼0.8 times/day; p < .01) but not vegetable intake frequency or daily variety (p > .05).

CONCLUSIONS

FFVP improved fruit and vegetable eating behaviors in the "town and rural" group, but was only partially effective in the "city and suburb" group. Strategies to implement FFVP may need to differ depending on school locale.

Dietary and economic effects of eliminating shortfall in fruit intake on nutrient intakes and diet cost

Background

Children in the United States do not consume the recommended amounts of fruit. The economic and dietary consequences of meeting the shortfall in fruit consumption have not been evaluated.

Methods

Analyses were based on a nationally representative sample of 4–18 year-old children (n = 2,647) from the 2009–2010 National Health and Nutrition Examination Survey (NHANES). The shortfall in total fruit consumption for each child was estimated based on the USDA MyPlate recommendations. The potential impact of filling the shortfall in total fruit consumption was projected with whole fruit alone (WF model) or a combination of 100 % fruit juice and whole fruit (FJ + WF model). Juice consumption was capped using American Academy of Pediatrics (AAP) standards. The USDA national food prices database was used to estimate the cost of meeting the dietary recommendations for fruit. Selected nutrient and mineral intakes, as well as daily diet cost were estimated after eliminating the shortfall in fruit consumption.

Results

Among all children, vitamin C (+22.8 mg [95 % CI 21.4, 24.1] in the WF model and +48.1 mg [95 % CI 45.2, 51.1] in the FJ + WF model) and potassium intakes (+203 mg [95 % CI 190, 215] in WF and +263 mg [95 % CI 248, 280] in FJ + WF) were increased in both models. The FJ + WF model resulted in a marginal increase in dietary fiber (e.g., a relative change less than 10 %), while the WF model resulted in a meaningful increase in dietary fiber (e.g., a relative change greater than 10 %; +2.2 g [95 % CI 2.1, 2.3]). Conversely, the WF model resulted in only a marginal increase in calcium, while the FJ + WF model resulted in a meaningful increase in calcium (+85 mg [95 % CI 79, 89]). Calories were increased in all models (+4.5 % [95 % CI 4.1, 4.9 %] for FJ + WF and +3.5 % [95 % CI 3.2, 3.7 %] for WF). Meeting the fruit shortfall with whole fruit alone increased estimated diet costs by 9.9 % (+$0.44/d [95 % CI 0.42, 0.47]), while the fruit juice/whole fruit combination increased diet costs by 5.2 % (+$0.23/d [95 % CI 0.22, 0.25]).

Conclusions

Meeting fruit consumption guidelines without a substantial increase in diet costs may be a challenge. Combining whole fruit with 100 % fruit juice capped at AAP standards may be one approach to meeting fruit recommendations within cost constraints. Identifying approaches to increasing whole fruit consumption in as cost-neutral a fashion as possible should be a priority.

Student feedback to improve the United States Department of Agriculture Fresh Fruit and Vegetable Program

BACKGROUND/OBJECTIVES

Fruit and vegetable consumption of children in the United States falls below recommendations. The U.S. Department of Agriculture Fresh Fruit and Vegetable Program (FFVP) is a national free-fruit and vegetable school distribution program designed to address this problem. This permanent, legislated program provides funding to qualified elementary schools for provision of additional fruit and vegetables outside of school meals. The objective of this study was to understand children's perceptions of FFVP after the intervention and formulate recommendations that may improve success of the intervention.

SUBJECTS/METHODS

Secondary data were obtained from 5,265 4^th-6^th graders at 51 randomly-selected FFVP intervention schools in Indiana. Anonymous questionnaires were completed late in the 2011-2012 academic year. Multilevel logistic regressions were used to determine associations between students' perceptions of program effects (4 close-ended items) and their preference toward the program. Content analysis was applied to a single open-ended item for program comments.

RESULTS

Over 47% of students reported greater intake of fruit and vegetables due to FFVP, and over 66% reported liking the program. Student-reported program effects were positively associated with preference for the program (P < 0.01). Themes that emerged during analysis of 3,811 comments, included, students liked: the opportunity to try different kinds of fruit and vegetables, types and flavors of fruits served, and benefits of eating fruit. Fewer students liked the types of vegetables and their benefits. A small group disliked the program citing poor flavor of vegetables and quality of fruits. Important suggestions for the program include serving more dipping sauces for vegetables, cooking vegetables, and providing a greater variety of produce.

CONCLUSIONS

The degree that students liked FFVP may predict the program's effects on fruit and vegetable intake. FFVP may become more acceptable to students by incorporating their suggestions. Program planners should consider these options for achieving program goals.

The School Food Environment and Obesity Prevention: Progress Over the Last Decade

The school food environment-including when and where children obtain food and the types of options available during the school day-plays an important role in children's consumption patterns. Thus, childhood obesity prevention efforts often focus on altering the school food environment as a mechanism for improving student dietary intake. This review examines the role school food programs and policies play in improving children's diet, weight, and health. Overall, research suggests that significant improvements have been made in school nutrition policies and programs. Due to the recent program changes made as a result of the 2010 Healthy, Hunger-Free Kids Act, an emphasis was placed on research conducted over the past decade and especially on the evaluation of foods and beverages served and sold since implementation of this national law. This review also examines remaining gaps in the literature and opportunities for further improvements in school food programs and policies.

Worksite Health Program Promoting Changes in Eating Behavior and Health Attitudes

Background. The aim of the present study was to evaluate the effectiveness of a worksite multicomponent health promotion intervention on eating behavior and attitudes, changes in body weight, and readiness to make eating behavior changes among workers over a 12-month intervention period. Method. A total of 3,095 workers of a logistic company participated in a quasi-experimental comparison group study design. The intervention group received a multicomponent health training. Two of the main elements of the multicomponent intervention were physical exercise training and nutrition counseling/training. During the pilot year, participants completed a survey at baseline and again after 12 months to assess physical activity–, health-, and diet-related factors. Results. Results showed that participants’ body weight did not significantly decrease in the intervention group. Mean weight loss in the intervention groups was 0.5 kg (body mass index = 0.1 kg/m2). Eating behaviors in the intervention group improved more than in the comparison group. Some positive intervention effects were observed for the cognitive factors (e.g., changes in eating attitudes). Baseline readiness to change eating behavior was significantly improved over time. Conclusions. We demonstrated initial results of a long-term multicomponent worksite health promotion program with regard to changes in body weight, eating behavior, and attitudes. This evaluation of a 12-month pilot study suggests that a worksite health promotion program may lead to improvements in nutritional health behaviors for a number of workers. An investigation of long-term effects of this multicomponent intervention is strongly recommended.

A comparison of fruits, vegetables, sugar-sweetened beverages, and desserts in the packed lunches of elementary school children

BACKGROUND

An estimated 40% of children bring a packed lunch to school. These lunches are not required to meet nutrition standards. The aim of this study was to compare differences in the nutritional quality of elementary packed lunches by the presence or absence of sugar-sweetened beverages (SSB), desserts, and fruits and vegetables (FVs).

METHODS

Observational data for prekindergarten and kindergarten packed lunches were collected from three schools in rural Virginia for 5 consecutive school days and analyzed for macro- and micronutrients and by the presence or absence of food and beverage items.

RESULTS

Of the 561 packed lunch observations collected, 41.7% contained no FV, 41.2% contained an SSB, and 61.1% contained a dessert. The nutrient profile of packed lunches with at least one fruit or vegetable had significantly higher levels of carbohydrate, fiber, sugar, vitamin A, and vitamin C. Packed lunches containing an SSB had significantly higher levels of sugar and vitamin C and significantly lower levels of protein, fiber, vitamin A, calcium, and iron. Packed lunches containing a dessert had significantly higher levels of energy, carbohydrate, fat, saturated fat, sodium, sugar, vitamin C, and iron and significantly lower levels of vitamin A.

CONCLUSIONS

Additional research is needed to fully understand parent and child motivations for packing lunches and the decision processes that influence the inclusion of food items. The development of packed lunch interventions, encouragement of National School Lunch Program participation, or enactment of school policies to increase the nutritional value of packed lunches is warranted.

Rural adults' perspectives on school food in a North Carolina county

INTRODUCTION

To address alarming rates of youth obesity, multiple stakeholder perspectives must be understood and considered when developing nutrition interventions. The purpose of this qualitative study was to examine adults' perceptions of school food in rural North Carolina and their opinions about potential changes to encourage students to eat more fruits and vegetables in school meals.

METHODS

We conducted semistructured key informant interviews by telephone from February through March 2013 to determine adult opinions regarding elementary school food and child health. Participants included parents, teachers, school administrators, and a cafeteria staff member. Interview transcripts were thematically analyzed using Dedoose qualitative analysis software.

RESULTS

Four themes emerged from key informant interviews regarding school meals and increasing fruit and vegetable consumption: 1) schools are an appropriate place for nutritious food, 2) current school food is bland and unappealing, 3) school cafeterias can use simple strategies to increase fruit and vegetable intake, and 4) federal school meal guidelines are perceived as barriers to increased fruit and vegetable intake during school meals.

CONCLUSION

Study findings suggest that training and support for cafeteria staff on healthy food preparation and presentation are critical and that there should be a "meeting in the middle" between child appeal and health. Nutritious and appealing school food options may have the potential to greatly increase fruit and vegetable consumption in rural elementary schools in North Carolina.

Nutritional comparison of packed and school lunches in pre-kindergarten and kindergarten children following the implementation of the 2012-2013 National School Lunch Program standards

OBJECTIVE

Approximately 40% of children bring a packed lunch to school. Little is known about the quality of these lunches. This study examined the nutritional quality of packed lunches compared with school lunches for pre-kindergarten and kindergarten children after the implementation of 2012-2013 National School Lunch Program standards.

METHODS

The researchers collected observational data for packed and school lunches from 3 schools in rural Virginia for 5 consecutive school days and analyzed them for macro and micro nutrients.

RESULTS

Of the 1,314 observations collected; 42.8% were packed lunches (n = 562) and 57.2% were school lunches (n = 752). Energy, fat, saturated fat, sugar, vitamin C, and iron were significantly higher whereas protein, sodium, fiber, vitamin A, and calcium were significantly lower for packed lunches than school lunches.

CONCLUSIONS AND IMPLICATIONS

Packed lunches were of less nutritional quality than school lunches. Additional research is needed to explore factors related to choosing packed over school lunches.

Position of the Academy of Nutrition and Dietetics: nutrition guidance for healthy children ages 2 to 11 years

It is the position of the Academy of Nutrition and Dietetics that children ages 2 to 11 years should achieve optimal physical and cognitive development, maintain healthy weights, enjoy food, and reduce the risk of chronic disease through appropriate eating habits and participation in regular physical activity. Rapid increases in the prevalence of childhood obesity during the 1980s and 1990s focused attention on young children's overconsumption of energy-dense, nutrient-poor foods and beverages and lack of physical activity. While recent data suggest a stabilization of obesity rates, several public health concerns remain. These include the most effective ways to promote healthy weights, the number of children living in food insecurity, the under-consumption of key nutrients, and the early development of diet-related risks for chronic diseases, such as cardiovascular disease, type 2 diabetes, cancer, obesity, and osteoporosis. This Position Paper reviews what children 2 to 11 years old in the United States are reportedly eating, explores trends in food and nutrient intakes, and examines the impact of federal nutrition programs on child nutrition. Current dietary recommendations and guidelines for physical activity are also discussed. The roles of parents and caregivers in influencing the development of life-long healthy eating behaviors are highlighted. The Academy of Nutrition and Dietetics works with other allied health and food industry professionals to translate dietary recommendations and guidelines into positive, practical health messages. Specific recommendations and sources of science-based nutrition messages to improve the nutritional well-being of children are provided for food and nutrition practitioners.

Free school fruit: can an extra piece of fruit every school day contribute to the prevention of future weight gain? A cluster randomized trial

Background

Several school fruit programs are initiated with the aim to improve diet and thereby contribute to reduce the prevalence of overweight. To date, no published studies have demonstrated that school fruit schemes do prevent overweight.

Objective

The aim of the present study was to assess if increased consumption of fruits and vegetables, due to free school fruit, have an impact on future weight status.

Design

An intervention study including 10- to 12-year-old children from nine schools in two Norwegian counties (Hedmark and Telemark) participating in the Norwegian School Fruit Program for free during the school year 2001/2002 and children from 29 control schools. Follow-up studies were performed in 2005 and 2009. The cohort includes 1950 pupils (984 boys, 966 girls) at baseline, 1,602 participants in 2005 and 320 participants in the 2009 survey, of which 282 also had participated in 2005.

Results

In 2005, there was no significant difference between the free fruit group and the control group regarding weight status, Body mass index, or perceived weight status. In 2009, a significant difference in prevalence of overweight was observed (15% vs. 25%, p=0.04). In the crude logistic analysis, the OR for being overweight was 0.52 (95% CI: 0.28–0.97) for the intervention group compared to controls. When adjusting for school, sex, grade level and parental education, the association was no longer statistically significant.

Conclusions

These results indicate that free school fruit might contribute to prevent future excessive weight gain. However, the study results are limited by low participation rate.

Energy balance for kids with play: design and implementation of a multi-component school-based obesity prevention program

BACKGROUND

Improving nutrition and physical activity behaviors associated with childhood obesity are significant national public health goals. Energy Balance for Kids with Play (EB4K with Play), developed through a partnership between the Academy of Nutrition and Dietetics Foundation and Playworks, is a multi-component school-based intervention designed to address youth's nutrition and physical activity behaviors. This article describes the EB4K with Play intervention and evaluation study and presents the baseline data.

METHODS

The evaluation is a 2-year cluster-randomized design targeting third- to fifth-grade students enrolled in a low-income, urban school district in northern California. Six schools were recruited to participate. Four were randomized to the intervention group and two into a control group. Baseline student-level data pertaining to nutrition, physical activity, fitness, and BMI were collected in the fall of 2011. The EB4K with Play program, which includes direct-to-student nutrition and physical activity interventions, a school wellness component, and parent/community partner outreach components, began immediately after baseline data collection.

RESULTS

An ethnically diverse sample of students (n=844) was recruited to participate in the study. Baseline data showed a higher percent of eligibility for free and reduced-price school lunch and higher rates of obesity/overweight than the California state averages. Fitness levels and levels of moderate-to-vigorous physical activity were comparable to state averages.

CONCLUSIONS

End-point data will be collected after 2 years of the intervention. The findings from this study should help guide future efforts to design effective intervention programs to support the prevention of pediatric obesity.

Turning point for US diets? Recessionary effects or behavioral shifts in foods purchased and consumed

BACKGROUND

In the past decade, the United States has seen declining energy intakes and plateauing obesity levels.

OBJECTIVE

We examined whether these observed trends suggest a longer-term shift in dietary and health behavior that is independent of adverse economic conditions.

DESIGN

We used nationally representative cross-sectional surveys on intake and longitudinal household food purchase data along with random-effects models to address this question. Data included individuals in NHANES 2003-2004 to 2009-2010 (children: n = 13,422; adults: n = 10,791) and households from the 2000-2011 Nielsen Homescan Panel (households with children: n = 57,298; households with adults only: n = 108,932).

RESULTS

In both data sets, we showed that children decreased their calories the most. Even after we controlled for important socioeconomic factors, caloric purchases fell significantly from 2003 to 2011 (P < 0.001), particularly for households with children. The Great Recession was associated with small increases in caloric purchases, in which a 1-percentage point increase in unemployment in the local market was associated with a 1.6-4.1-kcal · capita⁻¹ · d⁻¹ (P < 0.001) increase in total calories purchased. Results also indicated shifts in caloric purchases were driven more by declines in caloric purchases from beverages than food.

CONCLUSIONS

US consumers have exhibited changes in intake and purchasing behavior since 2003 that were independent from changing economic conditions linked with the Great Recession or food prices. Public health efforts in the past decade may have contributed to this trend.

Increasing Fruit and Vegetable Consumption among Schoolchildren: Efforts in Middle-Income Countries

Background

To reverse the trend of rising child obesity rates in many middle-income countries, recommendations include increasing fruit and vegetable consumption. Schools can positively impact children's eating behavior, and multicomponent interventions that include the curriculum, school food environments, and parental involvement are most effective.

Objective

To find out how fruits and vegetables feature in the dietary guidelines provided to schools, what specific schemes are available for providing these foods, the extent to which nutrition education is included in the curriculum, and how vegetables and fruits are procured in primary schools.

Methods

In 2008, a survey questionnaire previously validated and revised was sent electronically to national program managers and focal points for school feeding programs in 58 middle-income countries. The rationale was to obtain information relevant to the entire country from these key informants. The survey response rate was 46%. The information provided by 22 respondents in 18 countries was included in the current study. On average, respondents answered 88% of the questions analyzed in this paper. Of the respondents, 73% worked for the national authority responsible for school food programs, with 45% at the program coordinator or director level.

Results

Few countries have any special fruit and vegetable schemes; implementation constraints include cost and lack of storage facilities. Although 11 of 18 countries have both nutrient-based guidelines and school food guidelines for meals, fruits and vegetables are often not adequately specified.

Conclusions

In some countries, nutrition education, special activities, school gardens, and parental participation are used to promote fruits and vegetables. Specific schemes are needed in some, together with school food guidelines that include fruits and vegetables.