RESEARCH
Current Research
School Food Environments and Practices Affect
Dietary Behaviors of US Public School Children
RONETTE R. BRIEFEL, DrPH, RD; MARY KAY CREPINSEK, MS, RD; CHARLOTTE CABILI, MS, MPH; ANDER WILSON; PHILIP M. GLEASON, PhD
ABSTRACT
Background Changes to school food environments and
practices that lead to improved dietary behavior are a
powerful strategy to reverse the childhood obesity epidemic.
Objectives To estimate the effects of school food environments and practices, characterized by access to competitive foods and beverages, school lunches, and nutrition
promotion, on children’s consumption of sugar-sweetened
beverages, low-nutrient energy-dense foods, and fruits/
vegetables at school.
Design Cross-sectional study using data from the third
School Nutrition Dietary Assessment Study, a nationally
representative sample of public school districts, schools,
and children in school year 2004-2005. Data from school
principals and foodservice directors, school menu analysis, and on-site observations were used to characterize
school food environments and practices. Dietary intake
was assessed using 24-hour recalls.
Subjects/setting The sample consists of 287 schools and
2,314 children in grades one through 12.
Statistical analyses performed Ordinary least squares regression was used to identify the association between school
food environments and practices (within elementary,
middle, and high schools) and dietary outcomes, controlling for other school and child/family characteristics.
Results Sugar-sweetened beverages obtained at school
contributed a daily mean of 29 kcal in middle school
children and 46 kcal in high school children across all
R. R. Briefel is a senior fellow and C. Cabili is a nutrition research analyst, Mathematica Policy Research, Inc,
Washington, DC. M. K. Crepinsek is a senior researcher
and A. Wilson is a senior program analyst, Mathematica Policy Research, Inc, Cambridge, MA. P. M.
Gleason is a senior fellow, Mathematica Policy Research, Inc, Geneva, NY.
STATEMENT OF CONFLICT OF INTEREST: See
page S105.
Address correspondence to: Ronette R. Briefel, DrPH,
RD, Mathematica Policy Research, Inc, 600 Maryland
Ave, Ste 550, Washington, DC 20024-2512. E-mail:
rbriefel@mathematica-mpr.com
Address reprint requests to: Jackie Allen, Mathematica Policy Research, Inc, PO Box 2393, Princeton,
NJ 08543-2393. E-mail: jallen@mathematica-mpr.com
Copyright © 2009 by the American Dietetic
Association.
0002-8223/09/10902-1009$36.00/0
doi: 10.1016/j.jada.2008.10.059
© 2009 by the American Dietetic Association
school children. Attending a school without stores or
snack bars was estimated to reduce sugar-sweetened beverage consumption by 22 kcal per school day in middle
school children (P⬍0.01) and by 28 kcal in high school
children (P⬍0.01). The lack of a pouring rights contract in
a school reduced sugar-sweetened beverage consumption
by 16 kcal (P⬍0.05), and no à la carte offerings in a school
reduced consumption by 52 kcal (P⬍0.001) in middle
school children. The most effective practices for reducing
energy from low-energy, energy-dense foods were characteristics of the school meal program; not offering french
fries reduced low-nutrient, energy-dense foods consumption by 43 kcal in elementary school children (P⬍0.01)
and sugar-sweetened beverage consumption by 41 kcal in
high school children (P⬍0.001).
Conclusions To improve children’s diet and reduce obesity
continued changes to school food environments and practices are essential. Removing sugar-sweetened beverages
from school food stores and snack bars, improving à la
carte choices, and reducing the frequency of offering
french fries merit testing as strategies to reduce energy
from low-nutrient, energy-dense foods at school.
J Am Diet Assoc. 2009;109:S91-S107.
T
wenty-five million American children are overweight
or obese (1-3). What has properly been termed an
epidemic costs up to $14 billion annually in direct
health care treatment and poses significant risks for children’s physical health and psychosocial well-being (1-6).
Nearly one out of three school-aged children in the United
States is overweight or obese, and is thus predisposed to
the associated negative health consequences, such as
type 2 diabetes and coronary heart disease, later in life
(2,3,7,8). Low-income and minority children are at increased risk (4,9,10).
Most children do not meet recommendations for dietary
intake or physical activity, two behaviors closely associated with the risk of obesity (2,11,12). Environmental and
policy changes that lead to improved dietary and physical
activity behavior are a powerful strategy to reverse the
obesity epidemic. In its action plan for the prevention of
childhood obesity, the Institute of Medicine (IOM) concluded that schools should be a primary setting for such
changes (2). The rationale is clear: At school, children
spend a significant amount of their time; consume, on
average, 35% of their daily food intake; and expend up to
50% of their daily energy (2,13).
The Child Nutrition and WIC Reauthorization Act of
2004 (14) requires that local education agencies address
childhood obesity by developing wellness policies that
include nutrition guidelines “for all foods available on
Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION
S91
each school campus.” As a result of the 2004 legislation
and a 2005 IOM report on childhood obesity, many state
and local policymakers launched efforts to promote
changes in school food environments and practices
(1,2,6,15-17). However, little scientific evidence is available for policymakers as to whether such policies are
effective, and, if they are, which ones have the greatest
potential to affect dietary behavior or weight and thus
curb childhood obesity among school-aged children.
Environmental and policy changes
that lead to improved dietary and
physical activity behavior are a
powerful strategy to reverse the
obesity epidemic.
One area receiving attention as a means to improve the
school food environment involves competitive foods—
foods that are available in schools but are not part of US
Department of Agriculture (USDA) school meals. These
include foods and beverages sold in schools through vending machines, à la carte purchase in cafeteria lines,
school stores, and snack bars. Other sources include foods
used in fundraising and other school activities, or provided by teachers (2,18). Such foods are usually lownutrient and energy-dense and are often influenced by
contracts between schools and food and beverage companies (2,16,18). Many middle and high schools generate
substantial revenue from the sale of competitive foods
and use the funds to support their foodservice program or
school activities (19). Other school food environment factors include characteristics of meals offered through
USDA-sponsored meal programs, school nutrition education and other activities to promote healthful eating and
wellness, and whether the school has an open campus
policy that allows children to leave campus for lunch.
Despite the lack of evidence as to the most effective
school food environments and practices to curb childhood
obesity, strong evidence does exist linking children’s particular dietary behaviors to risk of overweight. Scientific
reviews and meta-analysis of the evidence relating consumption of sugar-sweetened beverages to risk of overweight in children and adolescents found that the larger
and more rigorous (eg, prospective design) studies support the connection between intake of sugar-sweetened
beverages and body mass index or overweight among
children (20,21). In addition, an increase in soda consumption from age 9 to 19 years was associated with a
reduced consumption of milk and the lowest increase in
calcium intake (22,23). Consumption of low-nutrient, energy-dense foods and fried foods is adversely associated
with body mass index, weight, intake of energy, and consumption of fruits and vegetables among older children and
adolescents (2,24-26). In 2005 Anderson and Butcher (27)
estimated that the increase in the availability of junk foods
(ie, foods high in energy and low in nutrients) in schools
accounted for one fifth of the increase in body mass index
observed in adolescents during the past 10 years.
The evidence for a relationship between consumption of
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February 2009 Suppl 1 Volume 109 Number 2
fruits and vegetables and body weight indicates a modest
effect of intake on protecting against increased adiposity
in children and stronger evidence for fruits alone or for
fruits and vegetables combined than for vegetables alone
(28). No association has been found between consumption
of 100% fruit juice and childhood overweight, except for a
few studies that found a connection between very large
amounts of total juice or apple juice and overweight
(29,30). School intervention studies and cross-sectional
analyses have shown mixed results with respect to fruit
and vegetable consumption and overweight among children (31,32).
This study examined associations between characteristics of the school food environments and practices and
child dietary behavior using data from the third School
Nutrition Dietary Assessment Study (SNDA-III), a nationally representative, cross-sectional sample of public
school districts, schools, and children conducted during
school year 2004-2005. SNDA-III was designed to assess
the USDA school meal programs, their contribution to
students’ food and nutrient intakes, and related characteristics of school food environments and practices (33).
This analysis uses SNDA-III data on school food environments and practices (gathered from surveys of principals
and school foodservice managers, from on-site observations, and from school lunch menus) to determine if
school food environments and practices are associated
with children’s dietary behaviors related to the maintenance of healthful weight.
The school food environments and practices in any
given school can be influenced by a variety of community
and school-level characteristics (eg, public education finance systems, food availability and marketing, and cultural norms), and children’s dietary behaviors and weight
are influenced by many factors other than the school food
environments and practices (eg, family income and parental views on diet). Figure 1 presents a conceptual
model that shows the school domains and levels of influence that are included in our analysis. We focused on
dietary outcomes that have been shown to be related to
children’s weight status or that could be hypothetically
linked to the presence or absence of school food environments and practices: consumption of sugar-sweetened
beverages, low-nutrient, energy-dense foods, and fruits
and vegetables (2,20,22-24,26,34,35). Our research hypothesis was that more healthful school food environments and practices, characterized by limited access to
competitive foods, more healthful school lunches, and
promotion of healthful eating, would be associated with
children consuming less energy from sugar-sweetened
beverages and low-nutrient, energy-dense items and
more fruits and vegetables. Because school food environments and practices influence most directly what happens at school, we focused on children’s intakes from
items obtained and consumed at school.
METHODS
Study Design and Sample
During spring 2005, SNDA-III collected data from a nationally representative, cross-sectional sample of US public
schools participating in the National School Lunch Program
(NSLP). The study’s multistage sampling approach first
Figure 1. Conceptual framework of school food environment and practices and children’s diet. aLNED⫽low-nutrient, energy-dense. bUSDA⫽US
Department of Agriculture.
sampled school districts from USDA’s seven geographic regions. Approximately three schools were selected from each
school district, including an elementary, a middle, and a
high school, if possible. Random subsamples of these schools
and students within these schools were then selected for
on-site data collection. The final samples of 287 schools (in
94 districts) with child-level dietary recall data and 2,314
children in grades one through 12 (children aged 6 to 18
years) are the basis for this analysis.
SNDA-III data indicate that 54% of children are nonHispanic white, 17% non-Hispanic African American,
22% Hispanic, and 7% other race/ethnicity (33). About
42% of children are certified to receive a free or reducedprice school lunch; 62% participated in the NSLP and
18% in the School Breakfast Program (33). Additional
details about the study design and sample have been
published elsewhere (33,36).
All data collection instruments and procedures were
reviewed and approved by the USDA Food and Nutrition
Service, the 2004 Education Information Advisory Committee of the Council of Chief State School Officers, and
the Office of Management and Budget. In addition, the
study worked with any institutional review process a
school district required. Data analyses were approved by
an independent institutional review board (Public/Private Ventures, Philadelphia, PA).
Data on School Food Environments and Practices
To characterize school food environments and practices,
we used data obtained from several sources: questionnaires administered to school food authority directors
(directors of the school districts’ nutrition programs),
school principals, and school foodservice managers; onsite observer checklists of foods and beverages offered à la
carte during school meals or in vending machines; and
detailed 5-day school menus recorded by school foodservice managers and coded to assess the types and quantities of food served to children as part of USDA reimbursable school lunches.
Based on the questionnaire, checklist, and menu data,
we created 20 binary variables that indicated the presence of a healthful school food policy, practice, or environmental characteristic and grouped them into three
domains: wellness policies and nutrition promotion practices of the district or school, competitive foods and beverages and related school practices, and characteristics of
USDA lunches offered and practices related to school
meals. Table 1 contains the list of specific variables in
each of the three domains.
Wellness policies and nutrition promotion practices were
based on four variables. Principals were asked whether or
not they had a state or local wellness policy, if their school
had a nutrition and/or health advisory council, and whether
or not nutrition education was provided in every grade.
Foodservice managers were asked if they made information
available on the nutrient content of school meals.
Competitive foods and beverages are those available
through vending machines, à la carte sales, fundraising
activities of school organizations, and snack bars/school
stores. Information on a school’s pouring rights contracts,
which establish a particular sole-source vendor for beverages in the school, was collected from both the principal
and the school food authority director. Both data sources
were used because each contained some missing data on
pouring rights contracts. For 171 schools that had missing data on this item in the principal survey, data were
used from the school food authority director survey. For
76 schools, data were available from both sources but
were not consistent; these schools were classified as having a pouring rights contract if either source indicated
there was a contract.
On-site observations conducted in SNDA-III were used
to classify vending machines as to whether they were
located on school grounds and/or in the foodservice area.
On-site study staff used checklists to record types of
items sold in vending machines or à la carte in the cafeteria during lunch. Low-nutrient, energy-dense foods and
beverages include the following categories: sugar-sweet-
February 2009 ● Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION
S93
Table 1. Proportion of elementary, middle, and high school children exposed to school food environments and practices in school year
2004-2005a
Children
Environment/practices variable
Elementary school
(nⴝ732)
Middle school
(nⴝ787)
High school
(nⴝ795)
All
(nⴝ2,314)
P value
4™™™™™™™™™™™™™™™™™ %⫾standard error ™™™™™™™™™™™™™™™™™3
Wellness policies and nutrition promotion practices of
district or school
Has school wellness policyb
Has nutrition/health advisory councilb
Provides nutrient content for USDAc mealsd
Has nutrition education in every gradeb
Availability of competitivee foods and beverages and
related school practices
No pouring rights contractbf
No items offered from brand-name restaurantsf
No store or snack bars selling foods or beveragesb
No fundraising activities selling sweet or salty snacksb
No à la carte foods or beverages except skim/1% milkg
Has à la carte, but no low-nutrient, energy-dense foods
or beveragesg
No vending machinesbg
Has vending, but not in food service areabg
Has vending, but no low-nutrient, energy-dense foods or
beveragesg
Characteristics of USDA lunches offered and related
school practices
Uses government fruit and vegetable programgh
Has nutrient requirements for food purchasingf
Whole and 2% milk not offereddi
Fresh fruit/raw vegetables offered dailydi
French fries not offereddi
Dessert not offereddi
Average meal has ⱕ30% of energy from fatdi
44.4⫾6.2
21.3⫾4.8
60.1⫾6.5
74.4⫾5.4
48.4⫾6.3
15.9⫾3.7
56.4⫾6.4
72.8⫾5.2
38.7⫾7.4
29.5⫾5.6
60.0⫾6.6
23.6⫾5.5
43.6⫾4.5
22.6⫾3.3
59.3⫾4.5
59.3⫾3.5
0.127
0.023
0.569
⬍0.001
43.1⫾6.3
66.9⫾6.3
93.7⫾2.9
47.2⫾6.3
23.6⫾4.9
35.4⫾6.7
65.0⫾6.6
84.1⫾4.3
35.5⫾5.5
6.4⫾2.8
16.3⫾4.3
64.4⫾7.0
46.6⫾6.6
21.9⫾5.5
5.1⫾2.5
33.7⫾4.6
65.8⫾5.8
78.0⫾3.5
37.7⫾4.1
14.7⫾2.9
0.017
0.715
⬍0.001
0.006
0.001
28.9⫾6.0
75.6⫾5.4
16.6⫾4.9
3.5⫾1.9
8.5⫾3.3
47.8⫾5.6
4.4⫾2.1
1.6⫾1.5
44.8⫾6.3
16.6⫾3.3
40.3⫾3.5
31.2⫾3.8
0.001
⬍0.001
0.008
17.1⫾5.1
18.8⫾4.6
7.0⫾3.3
14.4⫾2.9
0.363
49.8⫾6.2
46.7⫾6.3
46.6⫾6.2
47.8⫾6.3
30.7⫾6.1
20.8⫾4.4
32.9⫾6.1
62.2⫾6.5
64.3⫾6.1
36.6⫾6.1
58.6⫾6.5
17.5⫾5.8
24.4⫾5.4
14.2⫾4.2
66.3⫾5.9
69.0⫾6.0
39.5⫾6.6
72.8⫾5.4
19.7⫾6.3
27.6⫾6.1
17.3⫾4.9
57.1⫾5.7
56.8⫾5.9
42.5⫾5.4
57.3⫾4.6
24.8⫾4.2
23.5⫾3.6
24.6⫾4.1
0.695
0.131
0.694
0.158
0.313
0.994
0.120
a
Data are from the third School Nutrition Dietary Assessment Study, including Principal Interview, School Food Service Manager Interview, School Food Authority Director Interview,
On-site Observer Checklists, and School Menus, school year 2004-2005. Tabulations are weighted to be nationally representative of children in public National School Lunch Program
schools. Sample sizes are unweighted.
b
Information obtained from the school principal.
c
USDA⫽US Department of Agriculture.
d
Information obtained from the school foodservice manager.
e
Competitive foods refers to foods available at school that are not part of the USDA reimbursable school meal. They include foods from the following five sources: school stores, school
snack bars, fundraising activities, vending machines, and à la carte sales in the school cafeteria.
f
Information obtained from the School Food Authority director at the school district level.
g
Obtained from on-site observer checklists and analysis of foods and beverages recorded on the checklists.
h
Used Department of Defense’s Fresh Fruit and Vegetable Program or state’s Farm to School Program.
i
Information obtained from the analysis of school lunch menus offered.
ened beverages (eg, carbonated soft drinks, fruit-flavored
juice drinks, lemonades, sweetened teas, and “energy” or
“sports” drinks), chips (eg, regular, not lower-/reducedfat), cookies, ice cream, cake-type desserts, muffins (eg,
regular, not lower-fat), pastries, donuts, crispy rice
bars, candy, energy bars, fruit snacks, and french fries/
similar potato products.
School Lunch Characteristics
Seven variables were used to characterize the healthfulness of a school lunch. Five were based on menu survey
data; two on information from the school food authority
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February 2009 Suppl 1 Volume 109 Number 2
director: whether or not the school district participated in
the Department of Defense’s Fresh Fruit and Vegetable
Program or the state’s Farm to School Program, or had
nutrient requirements for food purchasing. The first four
menu variables were how many days out of five that
schools offered fresh produce, french fries or similar potato products, dessert, and 2% or whole milk. The fifth
menu variable was whether the percent of energy from
fat in the average lunch was below 30%; which was determined by analyzing data on the foods and portions
offered during the 5-day menu survey period. We conducted nutrient analysis of menus using USDA’s Survey
Net coding system (version 3.14, 2004, USDA Agricultural Research Service, Beltsville, MD) (37).
Data on Dietary Behaviors
Food and nutrient consumption for this analysis was
based on a single 24-hour dietary recall collected using
the USDA Automated Multiple Pass Method software
(version 2.3, 2003, USDA Agricultural Research Service,
Beltsville, MD) and processed with the Survey Net coding
system and Food and Nutrient Database for Dietary
Studies (version 1.0, 2004, and version 3.14, 2004, USDA
Agricultural Research Service, Beltsville, MD) (37,38).
Children’s intakes were analyzed using two categories:
foods and beverages consumed at school (regardless of
where the items were obtained), and those both consumed
and obtained or purchased at school. All foods and beverages reported by school children (or with the assistance of
parents, for children in elementary school) were recorded.
This analysis focuses on children’s consumption of sugarsweetened beverages and low-nutrient, energy-dense
solid foods classified into five categories: baked goods,
including muffins and desserts; candy (all types); dairybased desserts; french fries/similar potato products; and
chips/salty snacks (eg, potato chips, corn chips, popcorn,
not lowered/reduced fat). Low-nutrient, energy-dense
solid foods were summed to calculate energy from all
low-nutrient, energy-dense foods obtained and consumed
at school. The percentage of children reporting any lownutrient, energy-dense item in a subcategory and the
total energy from all items within reporting categories
were calculated.
The intake of fruit and vegetable cup equivalents was
estimated by matching the foods reported on the 24-hour
dietary recall to the MyPyramid database (39). For reference, 1 c raw or cooked vegetables, 1 c fruit, 1⁄2 c dried
fruit, and 1 c 100% fruit juice each count as 1-c equivalent
of fruit or vegetables. Vegetables included legumes and
vegetables contained in entrées.
Analytic Methods
To examine whether or not school food environments and
practices were associated with children’s dietary outcomes at school, binary and multivariate analyses were
conducted. Because many school policies, practices, and
characteristics operate simultaneously in the school environment, the relative importance of the three major
domains (Figure 1), as well as the individual policies or
practices within each, were of primary interest (Table 1).
A series of binary analyses was first conducted to compare the school food consumption of children with the
school food practice or food environment characteristic
(the exposed group) to the consumption of those without
it (the unexposed group). These analyses were useful in
determining the characteristics of school food environments and practices that might be most influential to
children’s “at school” consumption of particular foods considered more or less healthful.
Next, the variables shown in Table 1 were used to
create a score for each of the three school domains (40). A
higher score was associated with policies or practices
denoting a more healthful school food environment. For
the domain reflecting promotion of wellness/nutrition,
each of the four individual practices or policies within
that domain—if present in a school— contributed a value
of 1 to the wellness/nutrition promotion score for that
school, resulting in a maximum score of 4. Each of the
seven individual school lunch characteristics—if present
in the school—also contributed a value of 1, resulting in a
maximum score of 7. For the competitive foods domain,
four of the individual practices (eg, no pouring rights, no
brand-name restaurant foods, no school store or snack
bar, and no fundraising activities involving the sale of
salty or sweet snacks) potentially contributed a 1 to the
score. We assigned equal weights to the presence or absence of the practices or school menu characteristics, with
the exception of two competitive food individual practices:
vending and à la carte. To account for the multidimensionality of these practices a score of 0 to 2 was created
based on the presence, location, and low-nutrient, energydense food content. Information on location and hours of
operation of vending machines in schools was used to
create five mutually exclusive groups and assign a vending subscore as follows: 2 (no vending machines on the
school campus), 1.5 (vending machines present but not in
the cafeteria and not containing low-nutrient, energydense items), 1 (vending in the cafeteria but not containing low-nutrient, energy-dense items), 0.5 (vending outside the cafeteria but some low-nutrient, energy-dense
items), and 0 (vending machines in the cafeteria). An à la
carte subscore was created in a parallel manner: 2 (no à
la carte items except skim/1% milk), 1 (à la carte, but no
low-nutrient, energy-dense items), and 0 (à la carte with
low-nutrient, energy-dense items). The maximum competitive food practices domain score was 8 points.
Statistical Methods
Descriptive analysis was conducted to estimate the prevalence of individual school food policies and practices by
school type and boys’ and girls’ consumption of beverages,
low-nutrient, energy-dense foods, and fruits and vegetables. Multivariate analysis was conducted to identify the
relationship between school food environments and practices (within elementary, middle, and high schools) and
dietary outcomes while controlling for other school and
child/family characteristics. All statistical procedures
were completed using Statistical Analysis Software
(SAS) (version 9.1, 2004, SAS Institute, Cary, NC) and
SUDAAN (release 9, 2005, Research Triangle Institute,
Research Triangle Park, NC), incorporating appropriate
sampling weights and design effects. The statistical significance of differences in dietary intake between children
in schools with a specific practice and children in schools
without the practice was assessed by t test. Differences
were determined to be statistically significant at P⬍0.05.
Ordinary least squares regression was used to identify
independent predictors of school consumption of sugarsweetened beverages, low-nutrient, energy-dense foods,
and fruits and vegetables. Because dietary patterns and
school food practices varied across school types, separate
regressions were conducted for elementary, middle, and
high school children. Because wellness policies pertain to
access to particular food items on school campuses, the
analyses focused on sugar-sweetened beverages; low-nutrient, energy-dense foods; and fruits and vegetables obtained and consumed at school as the dependent variable.
February 2009 ● Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION
S95
Table 2. Proportion of public elementary, middle, and high school children reporting meals and snacks at school during school year 2004-2005a
Children
Eating occasion
Elementary school
(nⴝ732)
Middle school
(nⴝ789)
High school
(nⴝ795)
All
(nⴝ2,314)
4™™™™™™™™™™™™™™™™™™™™™™™™™™ %⫾standard error ™™™™™™™™™™™™™™™™™™™™™™™™™3
Proportion reporting eating at school
Anytime
Breakfastb
Lunchb
Snacksbc
No. eating occasions at school
No. snacks at school
98.2⫾0.73
94.9⫾1.10
89.5⫾1.31
95.0⫾0.60
27.0⫾3.06
18.3⫾1.69
18.9⫾1.71
22.9⫾1.76
97.1⫾0.79
91.2⫾1.62
79.4⫾2.29
90.7⫾0.87
44.6⫾3.31
29.2⫾2.80
41.0⫾2.24
40.4⫾1.90
4™™™™™™™™™™™™™™™™™™™™™™™™ mean⫾standard error ™™™™™™™™™™™™™™™™™™™™™™™™3
1.8⫾0.06
1.5⫾0.05
1.6⫾0.05
1.7⫾0.03
0.6⫾0.05
0.4⫾0.04
0.6⫾0.04
0.5⫾0.03
a
Data are from the third School Nutrition Dietary Assessment Study, 24-hour Dietary Recall Interview, school year 2004-2005. Tabulations are weighted to be nationally representative
of children in public National School Lunch Program schools. Sample sizes are unweighted.
b
Defined by child or respondent in the 24-hour dietary recall interview.
c
Includes eating occasions reported by the child (or respondent) as a snack or a drink.
Realizing that foods and beverages obtained from nonschool sources also contribute to children’s dietary behavior at school, the proportion consuming these items at
school is also reported, but the rest of this article focuses
on the obtained and consumed at school analyses.
With a large number of potential policies and practices
to examine in the multivariate analysis, a two-step procedure was used to study the effects of the individual
policies and practices. First, a model that included just
the three index scores without individual policies and
practices was estimated, and P values were evaluated at
the P⬍0.10 level after adjusting for multiple comparisons
for the three domains using the Benjamini-Hochberg approach (41). The purpose of this set of models was to
determine if the variables within a particular domain
significantly influenced the dietary outcomes. If the estimated effect of a particular domain score was significant,
we concluded that there was sufficient evidence of an
effect to look more closely at the individual policies and
practices within that domain. This was an arbitrary
value based on binary analysis showing that some food
practices produced a positive or a negative effect on the
dietary outcomes depending on the school type (ie, elementary, middle, or high school) or subgroup (eg, sex and
race/ethnicity). Thus, in the second stage of estimation,
the domain score that had been significant in the first
stage was replaced with the individual policies and practices that contributed to the score.
After estimating the effects of these practices on dietary outcomes, a final set of models was created to explore the role of variables that potentially mediate the
relationship between school food environments and practices and dietary behavior. These variables included
whether or not the child participated in the School Breakfast Program or NSLP or skipped lunch on the day of the
24-hour dietary recall. If these variables play an important mediating role, then their inclusion in the model
should reduce the estimated effect of the individual practices whose effect they are mediating.
Other independent variables in the model included
school, household/family, and child characteristics. School
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February 2009 Suppl 1 Volume 109 Number 2
characteristics included region; urbanicity; proportion of
children eligible for free and reduced-price meals; enrollment (size); and, for high schools, whether there was an
open campus policy. Information on schools’ urbanicity,
enrollment, and proportion of children eligible for free or
reduced-price school meals was based on data from the
National Center for Education Statistics’ Common Core
of Data for the 2004-2005 school year (42,43). Household/
family characteristics included language spoken at home,
household income in five categories, family structure and
parental employment, highest parent education level,
food security, number of children, and weekly frequency
of family dinners. Child characteristics included demographics (eg, age, sex, race/ethnicity) and factors that
might affect diet (eg, skipping breakfast; food allergies;
being on a weight loss diet; and parent’s view of child
being a picky eater and being more or less active, and
eating more or less, than other children of the same age).
RESULTS
In spring 2005, about 44% of public school children attended schools with a wellness policy, although substantially fewer attended schools with a nutrition or health
advisory council (Table 1). About three fourths of elementary and middle school children attended schools that
provided nutrition education in every grade, compared
with one fourth of high school children. As they move
from elementary to secondary school, children have increasing access to competitive foods and beverages
through pouring rights contracts, à la carte offerings,
school stores and snack bars, and fundraising activities.
For example, more than 90% of elementary school children attended schools with either no vending machine or
a vending machine not in the foodservice area, compared
with less than half of high school children. In contrast,
there were no significant differences in the proportion of
children in elementary, middle, and high schools attending schools with more healthful school lunch characteristics or school meal policies, such as not offering whole or
Table 3. Consumption of selected low-nutrient, energy-dense (LNED) foods and sugar-sweetened beverages (SSBs) at school among public
elementary, middle, and high school childrena
Children
Percentage
consuming at
school
Percentage obtaining
and consuming at
school
4™™™™™™™™™ %⫾standard error ™™™™™™™™™3
Elementary school (nⴝ732)
SSBs
All LNED solid foodse
Baked goods/desserts
Dairy-based desserts
Candy
French fries
Chips/salty snacks
Middle school (nⴝ787)
SSBs
All LNED solid foodse
Baked goods/desserts
Dairy-based desserts
Candy
French fries
Chips/salty snacks
High school (nⴝ795)
SSBs
All LNED solid foodse
Baked goods/desserts
Dairy-based desserts
Candy
French fries
Chips/salty snacks
All (nⴝ2,314)
SSBs
All LNED solid foodse
Baked goods/desserts
Dairy-based desserts
Candy
French fries
Chips/salty snacks
Energy from LNED Items Obtained and
Consumed at School (in kcal)
Among all
childrenb
Among consumers of
specific LNED categoryc
4™™™™™™™™™ mean⫾standard error ™™™™™™
3
16.9⫾1.88
63.5⫾3.05
30.3⫾3.36
9.1⫾2.09
12.8⫾1.53
17.5⫾3.09
19.4⫾1.81
3.1⫾0.91d
43.7⫾3.44
21.1⫾3.13
7.7⫾1.95
4.9⫾1.25
15.7⫾3.13
5.5⫾1.15
3⫾1.0
77⫾7.5
38⫾5.8
11⫾2.9
4⫾1.6d
16⫾3.4
8⫾2.0
100⫾11.6d
176⫾9.8
178⫾11.1
142⫾10.2
89⫾27.2d
102⫾9.6
151⫾18.1
32.1⫾2.45
60.4⫾2.28
22.7⫾1.87
4.0⫾0.79
16.2⫾1.81
19.3⫾3.38
20.4⫾1.75
21.3⫾2.84
45.0⫾2.99
17.6⫾1.87
3.3⫾0.74
4.8⫾0.97
18.9⫾3.32
11.0⫾1.69
29⫾4.0
86⫾8.1
29⫾4.1
6⫾1.4
8⫾2.5d
26⫾4.9
18⫾2.8
136⫾8.7
191⫾11.1
164⫾16.5
179⫾14.4
161⫾34.7d
136⫾10.6
163⫾9.2
35.8⫾2.72
61.2⫾2.06
21.7⫾1.67
1.9⫾0.68d
24.6⫾2.15
19.7⫾2.65
17.4⫾1.73
27.1⫾2.77
46.1⫾2.44
16.9⫾1.70
1.5⫾0.65d
9.5⫾1.23
18.8⫾2.55
11.4⫾1.46
46⫾5.2
111⫾9.0
39⫾5.7
2⫾0.9d
20⫾3.0
31⫾4.6
19⫾2.4
170⫾9.5
241⫾11.9
230⫾20.5
128⫾8.5
212⫾20.2
166⫾11.0
165⫾8.0
25.5⫾1.55
62.2⫾1.92
26.3⫾1.84
5.9⫾1.16
16.9⫾1.26
18.5⫾2.09
19.0⫾1.17
13.8⫾1.47
44.7⫾2.16
19.2⫾1.70
5.0⫾1.08
6.2⫾0.79
17.2⫾2.05
8.4⫾0.92
21⫾2.4
89⫾5.3
36⫾3.5
7⫾1.7
10⫾1.4
22⫾2.6
13⫾1.5
152⫾6.5
199⫾7.0
189⫾9.9
145⫾7.9
155⫾16.8
130⫾7.1
160⫾7.2
a
Data are from the third School Nutrition Dietary Assessment Study, 24-hour Dietary Recall Interview, school year 2004-2005. Tabulations are weighted to be nationally representative
of children in public National School Lunch Program schools. Sample sizes are unweighted.
b
All children includes those who did not consume any of the specific LNED items obtained at school.
c
Consumers are defined as children who reported consuming at least one of the specific LNED items in each category listed.
d
Indicates a statistic that is potentially unreliable due to a small sample size and/or a coefficient of variation ⬎30%.
e
Sum of the LNED food categories are listed separately.
2% milk, not offering french fries, or using government
fruit and vegetable programs.
Meals and Snacks at School
On a typical school day, children consumed 35% of daily
energy at school (13), and consumed and obtained 26% of
daily energy at school (and up to 47% of daily energy for
school meal participants, data not shown). Table 2 shows
the proportion of children reporting eating breakfast,
lunch, and/or snacks at school (note that breakfast and
lunch here are not just reimbursable meals, but any
breakfast or lunch reported by the child). Nearly all chil-
dren (95%) reported eating at least one meal or snack at
school, usually lunch (91%). About one fourth of children
(23%) reported eating breakfast at school, and 40% reported consuming a snack. Child snacking patterns at
school did not vary significantly across school types.
Sugar-Sweetened Beverage Consumption at School
Consumption of soft drinks and other sugar-sweetened
beverages at school ranged from 17% of children in elementary school to 32% in middle school and 36% in high
school (Table 3). Among children who consumed sugarsweetened beverages at school, those in elementary
February 2009 ● Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION
S97
Figure 2. Sources of soft drinks and other sugar-sweetened beverages consumed at school. aObtained from sources other than school or home
(eg, store, fast-food restaurant, friend, or preschool/after school).
school were much more likely to bring these drinks from
home (67% of consumers) compared to 29% and 18% of
middle and high school consumers, respectively (Figure
2). Secondary-school children were most likely to obtain
sugar-sweetened beverages from a school source, less
likely to obtain them from home, and least likely to obtain
them from other sources such as fast-food restaurants,
stores outside school, or friends.
We focused most analysis on items obtained and consumed at school. The percentage of children consuming
sugar-sweetened beverages obtained from school sources
increased nearly 10-fold from elementary to high school
(Table 3). On average, sugar-sweetened beverages obtained from school contributed 46⫾5 kcal to high school
children’s diets during the school day and were most
commonly consumed for lunch (data not shown). Among
consumers of sweetened beverages obtained from school,
these drinks accounted for an average of 100 kcal in
elementary school, increasing to 170 kcal in high school,
which indicates that some older children either consume
larger portions of sugar-sweetened beverages and/or consume them more than once during the school day.
Consumption of Low-Nutrient, Energy-Dense Solid Foods at School
Nearly two thirds (62%) of all public school children consumed some type of low-nutrient, energy-dense food at
school, and the majority of these items were obtained
from school; 45% of all children consumed at least one
low-nutrient, energy-dense item obtained from school
(Table 3). Baked goods/desserts, dairy-based desserts,
and french fries were obtained primarily from school, but
chips/salty snacks and candy tended to be brought to
school from home or from other nonschool sources. This
pattern was consistent for elementary, middle, and high
school children.
Among all children, low-nutrient, energy-dense foods
obtained and consumed at school contributed 89 kcal to
daily school intake. For those who obtained and consumed low-nutrient, energy-dense foods at school, intake
from these foods averaged 199 kcal and ranged from 176
kcal among elementary school children to 241 kcal among
high school children. Across all school types, more than
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February 2009 Suppl 1 Volume 109 Number 2
half of energy from low-nutrient, energy-dense food items
at school came from baked goods/desserts and french fries
combined. Among consumers of particular types of lownutrient, energy-dense items obtained from school, leading energy contributors were baked goods/desserts in elementary school (178 kcal) and high school (230 kcal);
french fries obtained from school contributed 130 kcal. On
average, consumers ate 1.3 low-nutrient, energy-dense
solid foods from school (data not shown). Progressing
from elementary school to high school, candy became a
more important source of energy from low-nutrient, energy-dense food sources and dairy-based desserts a less
important one overall. Most low-nutrient, energy-dense
foods were consumed at lunch, although baked goods/
desserts at breakfast were popular in elementary school,
as was candy at snacks across all school types (data not
shown).
Consumption of Fruits and Vegetables at School
About half of all school children (54%) reported consuming some amount of any fruit or vegetable obtained at
school, an average of 0.5 MyPyramid cup equivalents per
day in elementary school, declining to 0.3 c in secondary
schools (Table 4). Solid fruit was more commonly obtained and consumed at school than 100% fruit juice in
elementary school only. Consumption in school of solid
fruits, 100% fruit juices, and vegetables declined as
school level increased. French fries represented a large
portion of the total vegetables consumed at school, especially in high school.
School Food Environments and Practices and Sugar-Sweetened
Beverage Consumption
Table 5 shows the regression results examining the relationship between school food environments and practices
and intake of sugar-sweetened beverages obtained and
consumed at school, separately for elementary, middle,
and high school children. Among middle school and high
school children, school food environments and practices
limiting the sale of competitive foods were related to
reduced intake of energy from sugar-sweetened bever-
Table 4. Consumption of fruits and vegetables at school among US public school elementary, middle, and high school childrena
Children
Elementary school (nⴝ732)
All fruits and vegetables
All fruit
Solid fruit
100% fruit juice
All vegetablesd
All vegetables except french fries
Middle school (nⴝ787)
All fruits and vegetables
All fruit
Solid fruit
100% fruit juice
All vegetablesd
All vegetables except french fries
High school (nⴝ795)
All fruits and vegetables
All fruit
Solid fruit
100% fruit juice
All vegetablesd
All vegetables except french fries
All (nⴝ2,314)
All fruits and vegetables
All fruit
Solid fruit
100% fruit juice
All vegetablesd
All vegetables except french fries
Percentage
consuming
at school
Percentage obtaining
and consuming at
school
Cup Equivalentsb from Fruits and
Vegetables Obtained and Consumed at
School
Among all
children
Among fruit and
vegetable consumersc
4™™™™™™™™ %⫾standard error ™™™™™™™™3
4™™™™™™ mean⫾standard error ™™™™™™™3
76.5⫾2.44
60.4⫾2.50
47.8⫾2.68
25.1⫾3.10
45.6⫾3.43
31.6⫾3.02
63.2⫾3.09
47.7⫾3.23
36.9⫾2.89
20.2⫾3.07
41.0⫾3.52
27.9⫾3.04
0.5⫾0.04
0.3⫾0.03
0.2⫾0.02
0.1⫾0.02
0.2⫾0.02
0.1⫾0.02
1.8⫾0.08
1.3⫾0.05
1.1⫾0.03
1.1⫾0.04
1.2⫾0.04
1.2⫾0.04
57.4⫾3.24
31.3⫾2.64
19.5⫾2.44
14.6⫾1.97
38.2⫾3.52
21.0⫾2.11
49.8⫾3.61
23.7⫾2.19
12.3⫾1.55
13.0⫾1.99
35.9⫾3.73
19.1⫾2.25
0.3⫾0.03
0.2⫾0.02
0.1⫾0.01
0.1⫾0.02
0.2⫾0.02
0.1⫾0.01
1.3⫾0.04
1.2⫾0.04
1.1⫾0.05
1.1⫾0.03
1.1⫾0.03
1.1⫾0.02
50.3⫾2.61
27.3⫾1.88
17.0⫾1.56
14.2⫾2.10
34.8⫾3.34
16.7⫾2.68
41.2⫾2.93
19.9⫾2.18
10.2⫾1.52
13.2⫾1.92
31.2⫾3.22
13.8⫾2.57
0.3⫾0.03
0.2⫾0.02
0.1⫾0.01
0.1⫾0.02
0.1⫾0.02
0.1⫾0.02
1.4⫾0.05
1.2⫾0.04
1.1⫾0.07
1.0⫾0.03
1.1⫾0.03
1.1⫾0.04
64.9⫾1.66
44.8⫾1.67
33.1⫾1.75
19.8⫾1.86
41.0⫾2.24
25.1⫾1.66
54.1⫾2.03
34.7⫾2.00
24.1⫾1.81
16.7⫾1.81
37.1⫾2.24
22.0⫾1.70
0.4⫾0.02
0.3⫾0.02
0.1⫾0.01
0.1⫾0.01
0.2⫾0.01
0.1⫾0.01
1.6⫾0.05
1.3⫾0.03
1.1⫾0.02
1.1⫾0.02
1.2⫾0.02
1.2⫾0.03
a
Data are from the third School Nutrition Dietary Assessment Study, 24-hour Dietary Recall Interview, school year 2004-2005. Tabulations are weighted to be nationally representative
of children in public National School Lunch Program schools. Sample sizes are unweighted.
b
As defined by MyPyramid Equivalents database (39).
c
Consumers are defined as children who reported consuming at least one of the specific fruits and/or vegetables in each category listed.
d
Includes french fries and similar potato products.
ages obtained at school (see Table 5). Attending a school
without stores or snack bars selling foods or beverages
was estimated to reduce sugar-sweetened beverage consumption at school by 22 kcal per school day among
middle school children (P⬍0.01) and by 28 kcal per school
day among high school children (P⬍0.01). Attending a
middle school with no pouring rights contract was estimated to reduce child consumption of sweetened beverages by 16 kcal per school day (P⬍0.05) or, with à la carte
but no low-nutrient, energy-dense items, by 26 kcal per
school day, or with no à la carte, by 52 kcal (P⬍0.001).
Restricting access to vending machines was not related to
intake of sweetened beverages at the middle school level.
At high schools, no vending machine (ie, a score of 2)
was associated with 40 kcal fewer per day of sweetened
beverages, although this effect did not quite achieve statistical significance (P⫽0.07). None of the three policy
domains were significantly related to consumption of
sugar-sweetened beverages obtained at school among elementary school children. School lunch characteristics
were significantly associated with high school children’s
sweetened beverage intake (eg, not offering french fries
was associated with 41 kcal fewer per day, and using a
government fruit and vegetable program, with 21 kcal
fewer per day).
The estimated effects of control variables in the model
varied by school type. High school children who were
female (P⬍0.001) or had special dietary needs or food
allergies (P⬍0.05, data not shown) were less likely to
consume sweetened beverages obtained at school,
whereas non-Hispanic African-American children were
more likely to do so (P⬍0.01). Being non-Hispanic African
American was associated with a 42 kcal higher daily
school intake of sweetened beverages in high school. High
school children who were rated by their parents as much
more physically active than their peers were less likely to
February 2009 ● Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION
S99
Table 5. Estimated effect of school food environment characteristics and practices on sugar-sweetened beverages obtained and consumed by
elementary, middle, and high school children, while at school (in kilocalories)a
Elementary school
(nⴝ732)
Middle school
(nⴝ787)
High school
(nⴝ795)
4™™™™™™™ coefficient estimate⫾standard error ™™™™™™™3
⫺5⫾6.6
56⫾57.4
195⫾60.8**
Intercept
Wellness policies and nutrition promotion practicesb
Has a nutrition or health advisory council
Has a wellness policy addressing student nutrition and physical activity
Information is available on nutrient content of USDAd reimbursable meals
Has nutrition education in every grade
1⫾0.7
⫺5⫾3.6
8⫾3.9c*
20⫾6.2**
12⫾7.8
⫺9⫾8.6
16⫾8.0
Competitive foods and related school-district practicesb
No pouring rights contract
No store or snack bar selling foods or beverages
No fundraising activities selling sweet or salty snacks
Vending machine scoree
À la carte scoref
No foods offered from a national or regional brand-name or chain restaurant
⫺1⫾0.6
⫺6⫾1.9c**
⫺16⫾6.1*
⫺22⫾6.7**
10⫾5.3
⫺1⫾4.4
⫺26⫾4.9***
6⫾6.1
⫺7⫾2.9c*
⫺11⫾10.9
⫺28⫾10.1**
11⫾10.2
⫺20⫾11.1
⫺1⫾7.7
9⫾6.9
School-lunch characteristics and related school-meal practicesb
High-fat milk not offered
Fresh fruit and raw vegetables offered daily
French fries not offered
Dessert not offered
Average meal contains ⱕ30% of energy from fat
Uses government fruit and vegetable programg
Has nutrient requirements as part of its food purchasing specifications
No open-campus (high school only)
⫺1⫾0.5
⫺4⫾2.4
⫺11⫾3.5c*
⫺12⫾9.4
10⫾10.9
⫺41⫾9.8***
19⫾10.2
⫺18⫾8.4*
⫺21⫾8.6*
⫺23⫾8.1**
15⫾5.9*
Sociodemographic characteristics
Female (male excluded)
Race/ethnicity (non-Hispanic white excluded)
Hispanic
Non-Hispanic African American
Other race/ethnicity
Mean of dependent variable
R2
NAh
NA
⫺1⫾1.2
⫺5⫾5.2
⫺24⫾6.1***
2⫾1.2
3⫾3.0
⫺3⫾1.8
3.1
0.095
⫺5⫾8.5
6⫾8.7
⫺13⫾7.7
29.0
0.146
3⫾10.4
42⫾14.7**
⫺5⫾9.5
46.3
0.181
a
Based on data from the third School Nutrition Dietary Assessment Study, 24-hour Dietary Recall Interview, Student Interview, Parent Interview, Principal Interview, School Food Service
Manager Interview, School Food Authority Director Interview, On-site Observer Checklists, and School Menus, school year 2004-2005. Tabulations are weighted to be nationally
representative of children in public National School Lunch Program schools. Sample sizes are unweighted. Coefficient estimates were derived from the regression model that included
the full set of child, family, and school control variables.
b
Individual practice estimates are not displayed if the policy domain score did not reach significance in the preliminary model after adjustment for multiple comparisons using the
Benjamini-Hochberg procedure (41).
c
Policy domain score from the preliminary model.
d
USDA⫽US Department of Agriculture.
e
A higher score indicates more healthful, meaning no vending or no low-nutrient, energy-dense items sold in vending machines.
f
A higher score indicates more healthful, meaning no à la carte offered or no low-nutrient, energy-dense items sold à la carte except skim/1% milk.
g
Used Department of Defense’s Fresh Fruit and Vegetable Program or state’s Farm to School Program.
h
NA⫽not applicable.
*Estimated coefficient significantly different from zero at 0.05 level, based on two-tailed test.
**Estimated coefficient significantly different from zero at 0.01 level, based on two-tailed test.
***Estimated coefficient significantly different from zero at 0.001 level, based on two-tailed test.
consume sugar-sweetened beverages than peers who
were rated equally physically active (P⬍0.01, data not
shown).
We added three potentially mediating variables in a
separate set of models. When School Breakfast Program and NSLP participation, along with lunch skipping, were added to the model, the magnitude of the
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February 2009 Suppl 1 Volume 109 Number 2
estimated effects of competitive food practices and
school lunch characteristics on intake of sugar-sweetened beverages remained the same. Skipping lunch
was associated with 24 kcal fewer from sugar-sweetened beverages obtained and consumed at school
among high school children (P⬍0.05, data not shown).
Because we did not examine foods and beverages con-
Table 6. Estimated effect of school food environment characteristics and practices on low-nutrient, energy-dense foods obtained and consumed
by elementary, middle, and high school children, while at school (in kilocalories)ab
Elementary school
(nⴝ732)
Middle school
(nⴝ787)
High school
(nⴝ795)
Intercept
4™™™™™™™ coefficient estimate⫾standard error ™™™™™™™3
⫺20⫾71.9
135⫾102.7
105⫾115.6
Wellness policies and nutrition promotion practicesc
Competitive foods and related school district practicesc
No pouring rights contract
No store or snack bar selling foods or beverages
No fundraising activities selling sweet or salty snacks
Vending machine scoree
À la carte scoref
No foods offered from a national or regional brand-name or chain restaurant
⫺0.3⫾7.74
12⫾4.2d*
29⫾13.0*
41⫾19.9*
18⫾14.9
20⫾8.7*
6⫾10.1
⫺26⫾14.5
School-lunch characteristics and related school-meal practicesc
High-fat milk not offered
Fresh fruit and raw vegetables offered daily
French fries not offered
Dessert not offered
Average meal contains ⱕ30% of energy from fat
Uses government fruit and vegetable programg
Has nutrient requirements as part of its food-purchasing specifications
No open-campus (high school only)
⫺12⫾4.6d*
32⫾19.7
⫺36⫾16.4*
⫺43⫾14.0**
⫺12⫾17.4
⫺28⫾15.8
⫺3⫾12.2
5⫾14.0
NAh
Sociodemographic characteristics
Female (male excluded)
Race/ethnicity (non-Hispanic white excluded)
Hispanic
Non-Hispanic African American
Other race/ethnicity
Mean of dependent variable
R2
⫺9⫾9.7
⫺3⫾6.2
7⫾5.4
NA
7⫾10.8
⫺6⫾6.6
⫺13⫾8.0
⫺11⫾18.6
4⫾10.2
⫺9⫾11.3
⫺46⫾14.7**
⫺19⫾13.9
⫺8⫾21.0
3⫾24.4
77.0
0.137
⫺11⫾24.1
⫺6⫾21.0
⫺21⫾21.1
86.1
0.094
47⫾21.9*
70⫾29.4*
34⫾28.3
110.9
0.125
a
Based on data from the third School Nutrition Dietary Assessment Study, 24-hour Dietary Recall Interview, Student Interview, Parent Interview, Principal Interview, School Food Service
Manager Interview, School Food Authority Director Interview, On-site Observer Checklists, School Menus, school year 2004-2005. Tabulations are weighted to be nationally representative
of children in public National School Lunch Program schools. Sample sizes are unweighted. Coefficient estimates presented in each column were derived from the regression model
that included the full set of child, family, and school control variables.
b
Low-nutrient, energy-dense foods include baked goods/desserts (not reduced-/low-fat), dairy-based desserts, candy, fried potatoes, and chips/salty snacks (not reduced-/low-fat).
c
Individual practice estimates are not displayed if the policy domain score did not reach significance in the preliminary model after adjustment for multiple comparisons using the
Benjamini-Hochberg procedure (41).
d
Policy domain score from the preliminary model.
e
A higher score indicates more healthful, meaning no vending or no low-nutrient, energy dense items sold in vending machines.
f
A higher score indicates more healthful, meaning no à la carte offered or no low-nutrient, energy-dense items sold à la carte except skim/1% milk.
g
Used Department of Defense’s Fresh Fruit and Vegetable Program or state’s Farm to School Program.
h
NA⫽not applicable.
*Estimated coefficient significantly different from zero at 0.05 level, based on two-tailed test.
**Estimated coefficient significantly different from zero at 0.01 level, based on two-tailed test.
sumed outside school, we did not estimate the effects of
school meal participation on total intake of beverages
(or low-nutrient, energy-dense foods or fruit and vegetables).
School Food Environments and Practices and Low-Nutrient,
Energy-Dense Solid Food Consumption
Among elementary school children, more healthful school
lunch characteristics and related meal practices were
associated with reduced consumption of low-nutrient, energy-dense foods obtained at school (Table 6). Attending
an elementary school that did not offer french fries (or
similar potato products) at least once weekly was estimated to reduce low-nutrient, energy-dense food consumption by 43 kcal per school day among elementary
school children (P⬍0.01). In elementary schools that offered daily fresh fruit or raw vegetables, children consumed 36 kcal less of low-nutrient, energy-dense foods
(P⬍0.05), after controlling for other factors.
In elementary school, three competitive food practices
were associated with more energy per school day from
low-nutrient, energy-dense items: no vending machines
(40 kcal, P⬍0.05) or vending in cafeteria but no low-
February 2009 ● Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION
S101
nutrient, energy-dense items (20 kcal, P⬍0.05); no pouring rights contracts (29 kcal, P⬍0.05); and no snack bars
or stores (41 kcal, P⬍0.05). This finding may suggest that
the lack of access to competitive foods in elementary
schools leads children to bring such items to school or
that these schools may differ in other ways not captured
in our model.
By contrast, competitive food practices were not significantly associated with energy intake from all low-nutrient, energy-dense solid foods obtained in middle school or
in high school. Holding other practices and control factors
constant, in high school, being female was associated
with 46 kcal fewer from low-nutrient, energy-dense foods
(P⬍0.01), whereas being Hispanic or non-Hispanic African American was associated with 47 and 70 kcal more
from low-nutrient, energy-dense foods, respectively, than
for non-Hispanic whites (P⬍0.05). The magnitude of the
estimated effects of other practices on low-nutrient, energy-dense food consumption remained the same when
School Breakfast Program and NSLP participation and
skipping lunch were added to the model. School meal
participation was significantly associated with more energy from low-nutrient, energy-dense foods—in high
school, 73 kcal more for school breakfast participation
(P⬍0.01) and 61 kcal more for school lunch participation
(P⬍0.001); in middle school, 38 kcal more for school
breakfast participation (P⬍0.05) but no difference for
school lunch participation (data not shown). Skipping
lunch was associated with 61 kcal fewer from low-nutrient, energy-dense foods in middle school (P⬍0.01) but not
in high school.
School Food Environments and Practices and Fruit and
Vegetable Consumption
Multivariate analyses revealed few significant relationships between school food environments and practices
and fruit and vegetables obtained and consumed at
school. Regressions were run for total fruits and vegetables and each of the subcategories shown in Table 4.
Because total consumption of fruits and vegetables obtained from school is low and declines from an average of
0.5-c equivalents in elementary school to 0.3-c equivalents in high school, consumption of any subcategory was
even lower. The most relevant findings were for solid
fruits and total vegetables excluding french fries, shown
in Table 7. Consumption of vegetables (excluding french
fries) in elementary schools was significantly and positively associated with offering fresh fruits and vegetables
daily and not offering french fries (P⬍0.05). The effects
were small, 0.08-c equivalents, but roughly equivalent to
three fourths of the total consumption obtained at school.
Results for middle schools suggest that offering no lownutrient, energy-dense foods à la carte was positively related to vegetable intake (excluding french fries). The effect
is small (0.12-c equivalents, P⬍0.05), but large in comparison to the mean of 0.1-c equivalent. In high schools, not
having an open campus policy was estimated to increase
in-school consumption of vegetables (excluding french fries)
by 0.06-c equivalents (P⬍0.001).
Results of multivariate regressions show small but significant associations between some categories of fruits
and vegetables obtained and consumed at school and
school food environment characteristics and practices
S102
February 2009 Suppl 1 Volume 109 Number 2
when controlling for school and child characteristics and
school meal program participation (P⬍0.05, data not
shown). Two competitive food policies in elementary
schools were positively associated with the number of
100% fruit juice– cup equivalents: not having a store or
snack bar and no à la carte items (0.2-c equivalents each,
P⬍0.05, data not shown). NSLP participation showed
significant positive associations with the consumption of
solid fruit obtained from school (0.2-c equivalents in elementary school and 0.1-c equivalents in high school) and
with vegetables excluding fried potatoes obtained from
school (0.1-c equivalents across school types, P⬍0.001,
data not shown).
DISCUSSION
The 2004 Child Nutrition and WIC Reauthorization Act
requires that, by school year 2006-2007, local school wellness policies include goals for nutrition education, physical activity, and other school-based activities, including
nutrition guidelines, for all foods available on campus
during the school day (14). The timing of these requirements, and the extent to which they have been incorporated since 2004, varies across local school districts.
Greves and Rivara (44) found that none of the largest
school districts in each state had addressed all the legislated recommendations in 2004-2005. Data from SNDAIII were collected during spring 2005, when local school
districts were still transitioning toward addressing all
the requirements of the 2004 legislation. Thus, these
national findings are an important benchmark for tracking progress in implementing school wellness policies.
The data can also be used to estimate the potential effects
of further changes in school food environments and practices on children’s consumption patterns at school and
their overall diet, with the caveat that the estimates are
based on cross-sectional rather than longitudinal data measuring changes in both school practices and child diet.
Implications of School Food Environments and Practices for
School Consumption of Sugar-Sweetened Beverages and
Low-Nutrient, Energy-Dense Foods
Previous nutrition research on the role of school food
policies in childhood obesity has found that increased
access to competitive foods and beverages is associated
with increased consumption of these items and that consuming sugar-sweetened beverages is associated with
consuming fattier foods (1,20,21,29,35,45-49). However,
many of these studies have been based on small or nonrepresentative samples and have not controlled for the
full range of school characteristics, foodservice practices,
and other policies or child characteristics that could affect
child consumption at school. Our SNDA-III findings on a
nationally representative sample of public schools and
children and a wide range of school food practices provide
a richer picture of school food environments and practices
and their effects on children’ consumption of healthful
and less healthful foods and beverages on school campuses in the United States.
Our research demonstrates that school food practices
that limit the availability of competitive beverages, specifically no pouring rights contracts and not selling low-
Table 7. Estimated effect of school food environment characteristics and practices on the mean number of fruits and vegetables (cup
equivalents) obtained and consumed by elementary, middle, and high school children, while at schoolab
Elementary School (nⴝ732)
Vegetables
excluding fried
potatoes
Solid fruit
Solid fruit
Intercept
Wellness policies and nutrition
promotion practicesc
Has a nutrition or health advisory council
Has a wellness policy addressing student
nutrition and physical activity
Information is available on nutrient content
of USDAe reimbursable meals
Has nutrition education in every grade
Competitive foods and related
school-district practicesc
No pouring rights contract
No store or snack bar selling foods or
beverages
No fund-raising activities selling sweet or
salty snacks
Vending machine scoref
À la carte scoreg
No foods offered from a national or
regional brand-name or chain restaurant
Vegetables
excluding fried
potatoes
High School (nⴝ795)
Solid fruit
Vegetables
excluding fried
potatoes
4™™™™™™™™™™™™™™™™™™™™™™™™™™™™ coefficient estimate⫾standard error ™™™™™™™™™™™™™™™™™™™™™™™™™™3
0.17⫾0.206
⫺0.07⫾0.092
⫺0.17⫾0.222 ⫺0.03⫾0.201
0.04⫾0.181
0.15⫾0.175
⫺0.04⫾0.015d*
0.06⫾0.045
⫺0.01⫾0.010
0.01⫾0.014 ⫺0.01⫾0.013
⫺0.002⫾0.013
⫺0.002⫾0.009
⫺0.01⫾0.035
⫺0.12⫾0.033***
⫺0.10⫾0.040*
0.04⫾0.010d*** ⫺0.01⫾0.007
⫺0.04⫾0.036
0.001⫾0.008
⫺0.003⫾0.056
0.02⫾0.008d**
0.01⫾0.026
0.02⫾0.009d* ⫺0.02⫾0.007d**
0.06⫾0.043
⫺0.02⫾0.033
0.01⫾0.029
0.05⫾0.029
⫺0.07⫾0.037
⫺0.06⫾0.032
0.05⫾0.029
0.03⫾0.029
0.01⫾0.026
⫺0.02⫾0.029
⫺0.03⫾0.023
⫺0.05⫾0.034
0.03⫾0.029
0.08⫾0.024**
⫺0.02⫾0.024
0.03⫾0.022
0.06⫾0.028*
0.07⫾0.037
0.04⫾0.022
0.01⫾0.022
0.02⫾0.022
0.02⫾0.009
⫺0.01⫾0.011
0.01⫾0.008
School-lunch characteristics and related
school-meal practicesc
0.02⫾0.011d*
High-fat milk not offered
0.06⫾0.047
Fresh fruit and raw vegetables offered daily
0.09⫾0.047
French fries not offered
0.02⫾0.030
Dessert not offered
0.11⫾0.041**
Average meal contains ⱕ30% of energy
from fat
⫺0.02⫾0.039
Uses government fruit and vegetableh
program
0.05⫾0.031
Has nutrient requirements as part of its
food-purchasing specifications
⫺0.04⫾0.034
No open-campus (high school only)
NAi
Sociodemographic characteristics
Female (male excluded)
Race/ethnicity (non-Hispanic white
excluded)
Hispanic
Non-Hispanic African American
Other race/ethnicity
Mean of dependent variable
R2
Middle School (nⴝ787)
0.03⫾0.008d* ⫺0.01⫾0.010
⫺0.01⫾0.024
0.08⫾0.030*
0.07⫾0.028*
⫺0.02⫾0.025
0.01⫾0.029
0.02⫾0.024
0.04⫾0.025
NA
NA
NA
0.03⫾0.028
0.06⫾0.016***
⫺0.001⫾0.030
0.02⫾0.018
0.02⫾0.026 ⫺0.02⫾0.022
0.01⫾0.020
⫺0.003⫾0.019
0.04⫾0.046
0.05⫾0.049
⫺0.01⫾0.036
0.20
0.150
⫺0.01⫾0.031
0.05⫾0.039
0.001⫾0.035
0.11
0.149
⫺0.01⫾0.028 ⫺0.02⫾0.029
⫺0.04⫾0.035 0.003⫾0.036
⫺0.07⫾0.028
0.01⫾0.060
0.09
0.09
0.089
0.102
0.09⫾0.051
0.05⫾0.041
⫺0.01⫾0.032
0.08
0.092
⫺0.02⫾0.029
0.05⫾0.038
⫺0.01⫾0.027
0.06
0.155
a
Based on data from the third School Nutrition Dietary Assessment Study, 24-hour Dietary Recall Interview, Student Interview, Parent Interview, Principal Interview, School Food Service
Manager Interview, School Food Authority Director Interview, On-site Observer Checklists, and School Menus, school year 2004-2005. Tabulations are weighted to be nationally
representative of children in public National School Lunch Program schools. Sample sizes are unweighted. Coefficient estimates presented in each column were derived from the
regression model that included the full set of child, family and school control variables.
b
As defined by MyPyramid Equivalents database (39).
c
Individual practice estimates are not displayed if the policy domain score did not reach significance in the preliminary model after adjustment for multiple comparisons using the
Benjamini-Hochberg procedure (41).
d
Policy domain score from the preliminary model.
e
USDA⫽US Department of Agriculture.
f
A higher score indicates more healthful, meaning no vending or no low-nutrient, energy-dense items sold in vending machines.
g
A higher score indicates more healthful, meaning no à la carte offered or no low-nutrient, energy-dense items sold à la carte except 1%/skim milk.
h
Information obtained from the School Food Authority director at the school district level.
i
NA⫽not applicable.
*Estimated coefficient significantly different from zero at 0.05 level, based on two-tailed test.
**Estimated coefficient significantly different from zero at 0.01 level, based on two-tailed test.
***Estimated coefficient significantly different from zero at 0.001 level, based on two-tailed test.
February 2009 ● Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION
S103
nutrient, energy-dense foods or beverages in school stores
or à la carte, were associated with children consuming
less energy from sugar-sweetened beverages at secondary schools. Energy from low-nutrient, energy-dense
foods was more closely associated with school meal characteristics and child demographics than with having a
school wellness policy or competitive food practices. This
is not surprising, because foods such as higher-fat muffins and baked goods and french fries are available in
school meals or à la carte. In high schools, females consumed less energy from low-nutrient, energy-dense food
items from school sources, and non-Hispanic African
Americans and Hispanics consumed more.
School food practices related to reducing the intake of
sugar-sweetened beverages included those associated
with the availability of sugar-sweetened beverages as
well as of competitive foods. Based on multivariate regression analyses controlling for school, family, and child
characteristics and school meal participation, school
practices significantly associated with lower consumption
of soda/sweetened beverages included serving french fries
less than once per week in high school (or none) and
having no pouring rights contracts in middle school, as
well as not selling à la carte items except milk in middle
school. Being in a middle or high school with practices
limiting access to competitive foods (no school stores or
snack bars, no à la carte, and/or no pouring rights contracts) was estimated to reduce in-school energy from
sugar-sweetened beverages by roughly 16 to 90 kcal per
school day (90 kcal for all three practices among middle
school children). During the course of a 38-week school
year, this would translate to 3,040 to 17,100 kcal, on
average, across secondary school children. At a population level, this can be significant and in line with the
levels achieved in school interventions to reduce overweight (2,31,35,50,51).
A switch from sugar-sweetened beverages to bottled
water or diet soda could have dramatic effects on reducing energy consumption at school and reducing longerterm risk of obesity (assuming other eating behaviors
outside school do not change to compensate for such improvements). In May 2006 the American Beverage Association and three leading beverage companies (PepsiCo
[PepsiCo, Inc, Purchase, NY], Coca-Cola [The Coca-Cola
Co, Atlanta, GA], and Dr Pepper Snapple Group, Inc
[Plano, TX]) agreed to adopt specific guidelines— developed by the Alliance for a Healthier Generation, the
American Heart Association, and the Clinton Foundation—for beverages in schools (52). Under the implementation plan, nondiet soft drinks are to be removed and
only bottled water, diet soda, low-fat milk, 100% juice,
and low-energy teas and drinks are to be offered (52).
SNDA-III analysis provides an important baseline
(spring 2005) before these guidelines are fully implemented by school year 2009-2010.
At the same time, the estimates presented here pertain
to foods and beverages consumed and obtained at school.
If policies or practices such as restricting access to competitive foods reduce children’s consumption of sugarsweetened beverages obtained in school, children might
compensate by disproportionately obtaining such beverages outside school, and the effects of the policies on
energy intake from these beverages could thus be dimin-
S104
February 2009 Suppl 1 Volume 109 Number 2
ished or eliminated. Although our findings reveal that
school food environments and practices are powerful influences in reducing consumption of sugar-sweetened
beverages in school, the results showed that other factors
contribute to such consumption when access to these
beverages at school is limited. Elementary schools have an
overall more healthful school food environment and reduced
access to competitive foods on school grounds (43), but some
elementary school children compensate by bringing sugarsweetened beverages from home. This finding provides evidence for the importance of parental education and nutrition education in elementary school, when behaviors are
less established.
We also found that while competitive food practices
were significantly associated with the consumption of
sugar-sweetened beverages in school, these practices did
not lead to any reduction in the energy consumed from all
low-nutrient, energy-dense foods. Instead, the most effective school food practices for reducing low-nutrient, energy-dense foods seemed to be characteristics of the school
meal program itself, such as offering fresh fruit and vegetables daily and not offering french fries.
Implications of School Food Environments and Practices on
Fruit and Vegetable Consumption
A number of studies conducted in school settings have
examined interventions designed to increase fruit and
vegetable consumption in multiple ways: by offering free
fresh fruits and vegetables, by providing variety through
salad bars, by improving the quality and variety of fresh
produce or fruits and vegetables offered in school meals,
by providing nutrition education to children and families,
and by making point-of-purchase or foodservice changes
(50,51,53). Promising results from a study of seven interventions suggest that promoting fruit and vegetables
through the school environment led to a moderate increase in fruit and vegetable intake among children (51),
averaging 0.45 servings at the child level. When exploring the relationship between school food environments
and practices and the consumption of fruits and vegetables in this study, we found that, on average, children
consume slightly less than 1-c equivalent of fruits and
vegetables obtained at school—a small total, of which
french fries are a large proportion.
Our findings also show that school food environments
and practices and children’s choices of foods and beverages on campuses are associated, but that there is no
consistent pattern across younger and older children in
the relationship between school food environments and
practices and fruit and vegetable consumption. Moreover,
health-promoting practices that are significantly associated with increased consumption of fruits and vegetables
appear to have small effects in terms of cup equivalents,
likely because of the small number of fruit and vegetable
daily cup equivalents children consume in school. Offering fresh fruits and vegetables daily in school lunches
was associated with consumption of vegetables other
than fried potatoes among elementary school children.
Participation in school lunch contributes to fruit and vegetable intake; however, about half of all children did not
consume any fruit, 100% fruit juice, or vegetable during
the school day. Our results suggest that not offering low-
nutrient, energy-dense foods à la carte or in vending
machines in secondary schools has the potential to increase fruit consumption. Improving fresh fruit and vegetable consumption at school, or reducing the dropoff that
occurs in middle school, warrants continued emphasis
and attention.
Efforts to address these concerns are ongoing. The IOM
report, Nutrition Standards for Healthy Schools: Leading
the Way Toward Healthier Youth (54), concluded that
opportunities for competitive foods should be limited and
that federally reimbursable school meals should be the
main source of nutrition in schools. An IOM ad hoc expert
committee is reviewing the content of the school meals in
consideration of children’s dietary needs and recommending revisions to the NSLP and School Breakfast Program
meal pattern and nutrient standard requirements (55).
The committee’s report, expected in 2009, is intended to
provide, for School Breakfast Program and NSLP meal
patterns and standards, practical recommendations that
reflect current nutrition science, foster healthful eating
habits, and safeguard children’s health.
Relevance of Findings by Race/Ethnicity and Socioeconomic Status
A 2008 article by Finkelstein and colleagues (43) on the
distribution of school food environments and practices
and school meal characteristics found little variation by
the racial/ethnic or socioeconomic composition of the
schools; school food environments and practices were
most healthful in elementary schools and declined in
middle schools and even further in high schools. Controlling for school food environments and practices and other
factors, we observed some differences in school-day consumption across racial/ethnic groups, but few by household income level. Hispanic and non-Hispanic AfricanAmerican high school children consumed more energy
from low-nutrient, energy-dense foods than their nonHispanic white counterparts, which suggests that reducing access to candy, chips, and other junk foods could
benefit minority groups at high risk of obesity. Consumption of soft drinks and other sugar-sweetened beverages was
common among all ages and racial/ethnic groups and increased with age; non-Hispanic African-American high
school children consumed significantly more energy from
sugar-sweetened beverages than other racial/ethnic groups.
These findings support the need for continued nutrition
education and health promotion activities for minority children.
CONCLUSIONS
SNDA-III data provide a comprehensive view of school
food environments and practices in US public schools
during school year 2004-2005. Considering school wellness policies and health promotion practices and school
meal characteristics, we found that practices about competitive foods were most important in terms of the “empty
calories” consumed from sugar-sweetened beverages obtained on campuses in middle and high schools. These
findings provide support for School Wellness Policies in
all school levels to not allow sugar-sweetened beverages
in school stores, snack bars, and vending machines and to
reduce the frequency of french fries in school lunch or à la
carte to less than once per week or none. Improvements
in policies on competitive beverages whereby schools
would offer only healthful choices such as low-fat milks,
100% juices, and bottled water have the potential to reduce energy intake and body weight during the school
year, holding other dietary factors and physical activity
levels constant. Continued changes to school food environments and practices, as well as nutrition education for
children and parents, are essential. Food and nutrition
professionals, including school foodservice managers, are
key professionals to work with local school districts and
families to improve the wellness policies and healthfulness of school food environments.
This study also found that children’s homes were significant sources of sugar-sweetened beverages consumed
at school, especially in elementary school. Although
changes in school food policies can reduce access to sugarsweetened beverages at school and possibly daily intake
of such items, improvements in home and away consumption (eg, at fast-food restaurants) also require attention to
reduce obesity risks from consuming sugar-sweetened
beverages and other low-nutrient, energy-dense items.
Further research on the consumption patterns of schoolaged children at school in comparison to consumption at
home and away from home or school would provide additional insight into the role of school food policies among
school meal participants and nonparticipants [see Briefel
and colleagues in this issue (13)]. Additional research on
the family environment, as well as on factors such as
household income and food security and parental views of
diet and physical activity, would provide a better understanding of the complex interactions of the school and
home food environments and the important role that
school meals and policies play in children’s diet and wellbeing.
Limitations
Limitations of this study include the cross-sectional nature
of the data, the use of self-report of dietary intake by children (and their parents, for elementary school children),
and self-report of information on selected school practices by
principals and school foodservice directors. The cross-sectional nature of the data limits our ability to determine
causality and to measure changes in policies and child diet
outcomes. Future research using a longitudinal design to
measure changes in policies and their effects on child dietary outcomes, coupled with observations of child diet in
schools, would address this limitation, but this would be
difficult and costly to undertake in a national study.
STATEMENT OF CONFLICT OF INTEREST: The authors have no conflict of interest to report with the sponsor of this supplement article or products discussed in
this article.
This research was supported by a grant from the Robert Wood Johnson Foundation (no. 57930). The opinions
expressed are those of the authors and do not necessarily
represent the views or recommendations of Mathematica
Policy Research, Inc, the Robert Wood Johnson Foundation, the Food and Nutrition Service, or the US Department of Agriculture.
The authors thank Michael Ponza, PhD, and Anne
Gordon, PhD, for their review of an earlier draft of the
manuscript, as well as Allison Hedley Dodd, PhD, and
February 2009 ● Supplement to the Journal of the AMERICAN DIETETIC ASSOCIATION
S105
Mary Kay Fox, MEd, for helpful input on the conceptual
framework and analysis plan. The authors also thank
Elizabeth Condon, MS, RD, and Elaine Hill for assistance
with construction of the variables used to characterize
school food practices and related descriptive tabulations.
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