A Cafeteria Personnel Intervention to Improve the School Food Environment

School Nutrition Personnel Perceptions of School Salad Bars before and after COVID-19

Many schools have salad bars as a means to increase students' fruit and vegetable intake. School nutrition programs experienced drastic changes to the school food environment due to COVID-19. The aim of the current study was to understand cafeteria personnel's experiences related to salad bar implementation before the COVID-19 pandemic and in the current school environment to inform efforts to enhance salad bar sustainability. Seven elementary schools (N = 30 personnel) installed salad bars prior to COVID-19; three of these schools (n = 13 personnel) re-opened salad bars after COVID-19. Cafeteria personnel completed surveys assessing their experiences with salad bars at both time points. Satisfaction with salad bar implementation and training was high pre- and post-COVID-19. Most agreed that salad bars increased students' fruit and vegetable intake, yet had concerns about cleanliness and waste. Perceived job difficulty increased post-COVID-19 (p = 0.01), and satisfaction with student salad bar training decreased (p = 0.001). Additional staff support and greater student training were needed post-COVID-19. Overall, salad bars were viewed favorably; however, more challenges and lower satisfaction were reported following COVID-19. Increasing support for cafeteria personnel is needed for salad bar sustainability and improving the school food environment.

Policy, Systems, and Environmental Changes in Child Nutrition Programs: A Systematic Literature Review

The National School Lunch Program (NSLP) provides healthy food to millions of children annually. To promote increased lunch consumption, policy, systems, and environmental (PSE) change strategies are being implemented in child nutrition programs. An evaluation of the current evidence supporting PSE interventions in school nutrition programs is needed to facilitate evidence-based practices across the nation for programs. This systematic review aims to determine the quality and breadth of available evidence of the effectiveness of PSE strategies on the consumption and waste of fruits, vegetables, milk, and water in the NSLP. The inclusion criteria required studies to occur in a United States K-12 school setting, data collection after 2012, report consumption and waste findings for fruit, vegetable, milk, or water, and be an original research article. Articles included in the review are restricted to positive or neutral quality. Thirty studies are included, policy level (n = 4), systems level (n = 8), environmental level (n = 10), and multi-category (n = 8). Results from positively rated policy-level studies suggest that recess before lunch may increase milk consumption, whereas removing flavored milk may decrease consumption. System-level studies of offering vegetables first in isolation of other meal components and offering spiced vegetables compared with traditional preparations may increase vegetable consumption, and locally procuring produce may increase fruit and vegetable consumption. Environmental-level studies such as water promotion strategies such as placing cups near drinking fountains may increase water consumption. Improving the convenience, attractiveness, and palatability of fruits and vegetables may increase consumption. Future PSE research in child nutrition programs should incorporate implementation aides and metrics into their study designs to allow a better understanding of how to sustain interventions from the perspective of school nutrition professionals.

The Impact of Modifying Food Service Practices in Secondary Schools Providing a Routine Meal Service on Student's Food Behaviours, Health and Dining Experience: A Systematic Review and Meta-Analysis

The education sector is recognised as an ideal platform to promote good nutrition and decision making around food and eating. Examining adolescents in this setting is important because of the unique features of adolescence compared to younger childhood. This systematic review and meta-analysis examine interventions in secondary schools that provide a routine meal service and the impact on adolescents’ food behaviours, health and dining experience in this setting. The review was guided by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Checklist and Cochrane Handbook recommendations. Studies published in English searched in four databases and a hand search yielded 42 interventions in 35 studies. Risk of bias was assessed independently by two reviewers. Interventions were classified using the NOURISHING framework, and their impact analysed using meta-analysis, vote-counting synthesis or narrative summary. The meta-analysis showed an improvement in students selecting vegetables (odds ratio (OR): 1.39; 1.12 to 1.23; p = 0.002), fruit serves selected (mean difference (MD): 0.09; 0.09 to 0.09; p < 0.001) and consumed (MD: 0.10; 0.04 to 0.15; p < 0.001), and vegetable serves consumed (MD: 0.06; 0.01 to 0.10; p = 0.024). Vote-counting showed a positive impact for most interventions that measured selection (15 of 25; 41% to 77%; p = 0.002) and consumption (14 of 24; 39% to 76%; p = 0.013) of a meal component. Interventions that integrate improving menu quality, assess palatability, accessibility of healthier options, and student engagement can enhance success. These results should be interpreted with caution as most studies were not methodologically strong and at higher risk of bias. There is a need for higher quality pragmatic trials, strategies to build and measure sustained change, and evaluation of end-user attitudes and perceptions towards intervention components and implementation for greater insight into intervention success and future directions (PROSPERO registration: CRD42020167133).

Salad bars and energy intake in Virginia elementary schools with free meals

School salad bars are widely promoted as a means to increase adherence to National School Lunch Program (NSLP) nutrition mandates. Yet it is unknown how salad bars or fruit and vegetable (F&V) intake relates to energy intake within the NSLP, or if F&Vs displace energy from other sources. This relation is particularly important to understand among children from minoritized backgrounds, who are at high risk of obesity and food insecurity, and the most likely to be impacted by school food policies, given their reliance on school meals. This study purpose was to evaluate if school salad bars and F&V intake are associated with lower lunch energy intake. Energy intake in Virginia elementary schools with and without salad bars, and associations between F&V energy and other energy sources, were examined. Cross-sectional plate waste assessments were conducted in matched school pairs (3 with, 3 without salad bars; N = 1,102 students; >90% Black and Latinx; 100% free meals). Two-level hierarchical models assessed group differences in energy intake and the proportion of energy from each meal component. Mean total lunch energy intake was 304 ± 157 kcal (salad bar); 269 ± 152 kcal (no salad bar). Students in salad bar schools consumed more energy from vegetables (+11 kcal; P < .001). Energy intake patterns were inconsistent across pairs. F&V energy was not associated with non-F&V energy (F = 1.04, P = .31). Findings do not suggest that salad bars were associated with lower energy intake. Evidence was inconsistent regarding F&V displacement of other lunch calories. Further research regarding F&V, salad bars, and energy intake is needed.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

Training Preferences of School Food Service Staff Vary by Role in the School Nutrition Program

Professional development has been identified as a critical component for school nutrition professionals (SNPs) to successfully implement school meal standards in the United States. However, training needs may vary based on different factors. This study examined (1) the topics of highest priority for SNPs; (2) preferred learning methods; (3) where and when trainings should be conducted; and (4) whether responses differ according to important factors including position type, school locale (urban vs. rural), or job experience. Participants completed surveys that included questions on demographics and preferences for learning methods and training topics (n = 492). Descriptive statistics characterized survey responses. Chi square tests assessed differences in learning method and training topic preferences by participant role, locale, and job experience; Cramer's V assessed the strength of association for each chi square result. Qualitative responses to open-ended questions were analyzed using an inductive thematic analysis method. Nearly all training topic preferences were significantly different (p < 0.001 using Bonferroni method) when stratified by role. Significant differences were also observed for school locale and years of experience, but to a lesser degree. There was less variation in learning method preferences across staff role. Qualitative results (n = 93) identified three key themes related to training needs: role-specific trainings, innovative learning methods, and geographic access. The combination of quantitative and qualitative analysis indicate that professional development for SNPs should mostly be conducted in-person, be easily accessible, and include hands-on activities. Further, training should be tailored by job role and address situational barriers unique to the geographic area.

Using digital imagery to quantify students' added sugar intake at lunch in Title I schools with universal free meals

School meals are a major source of dietary intake for low-income students at high obesity risk. Associations between added sugar and obesity are well known, and the National School Lunch Program prohibits added sugar in fruit and juice; yet, no added sugar limits exist for other meal components. This study measured students' added sugar selection and consumption in school lunches and compared % of daily calories consumed from added sugar to the Dietary Guidelines for Americans (DGA) recommendations. In October 2016, this cross-sectional study was conducted in six Virginia Title I elementary schools (>90% racial/ethnic minorities; 100% free meals). Digital imagery plate waste methods assessed lunch consumption in N = 1155, 1st-5th graders. Added sugar (g, %kcal) in foods and beverages selected and consumed were quantified, and kcal of added sugar consumed was compared to DGA recommendations. Students consumed an average 6.6 g of added sugar from foods (grade differences; q = 0.0012), and 3.6 g of added sugar from beverages. Added sugar comprised ~10% of school lunch calories consumed from foods and ~35% of school lunch calories consumed from beverages. Added sugar in the total school lunch meal comprised ~2.5% of student's recommended daily calorie needs; thus, ~7.5% of daily calories from added sugar remained before students would have exceeded the DGA. Total added sugar consumption was within daily DGA recommendations. Findings contribute to previous reports that school-provided lunches are low in added sugar. Future research should examine added sugar consumed in school breakfast and lunch separately and combined.

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.