Prevalence of Recess and Supportive Practices at a Nationwide Sample of Public Elementary Schools in the United States.

BACKGROUND: Recess provides an important opportunity for children to be physically active during weekdays. Updated, nationally representative, prevalence estimates of elementary school recess practices in the United States are needed. METHODS: Surveys were sent to a nationally representative sample of 1010 public elementary schools in the 2019-2020 school year. Results were compared by region (Northeast, Midwest, South, West), urbanicity, size, racial and ethnic composition, and socioeconomic status (percent eligible for free/reduced-priced meals). RESULTS: A total of 559 responses were obtained. About 87.9% of schools provided at least 20 minutes of daily recess and 26.6% had trained recess supervisors. Most schools did not allow students to voluntarily stay inside during recess (71.6%) and around half prohibited withholding recess for poor behavior (45.6%) or to complete schoolwork (49.5%). Several practices varied by region, and withholding recess was more prevalent among schools with lower student socioeconomic makeup. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: Regular national surveillance of recess practices can inform policy needs and efforts to advance equitable access to recess. Quality and access should be considered when developing recess policies. CONCLUSIONS: Most United States elementary schools provide recess. However, regional and economic disparities exist. Promoting supportive practices for recess, particularly for schools serving lower-income communities, is necessary.

Universal School Meals During the Pandemic: A Mixed Methods Analysis of Parent Perceptions From California and Maine.

BACKGROUND: In response to the COVID-19 pandemic, the US Congress authorized the US Department of Agriculture to waive a variety of school meal regulations and funded school meals daily for all students at no charge regardless of family income. Because federal Universal Free School Meals (UFSM) ended with the 2021-2022 school year, several states, including California and Maine, adopted state-level UFSM policies. OBJECTIVE: This study aimed to understand parent perceptions of school meals and the federal and new state UFSM policies in California and Maine, including potential challenges and benefits to students and households. DESIGN: A mixed methods study design was used. A quantitative cross-sectional survey was administered, and semi-structured interviews were conducted in English and Spanish during the 2021-2022 school year. PARTICIPANTS/SETTING: The quantitative survey was administered to parents of students in elementary, middle, and high schools in rural, suburban, and urban communities in California (n = 1110) and Maine (n = 80). Qualitative interviews were then conducted with a subset of these parents in California (n = 46) and Maine (n = 20) using Zoom (Zoom Video Communications). Most survey participants (708 of 1190 [59.5%]) and interviewees (40 of 66 [60.6%]) were parents of students who were eligible for free or reduced-price meals. MAIN OUTCOME MEASURES: Parents' perceptions of UFSM, school meal quality, and experiences applying for free or reduced-price meals were examined. ANALYSES PERFORMED: Tests of proportions were used to analyze survey data. Using grounded theory, interview transcripts were analyzed qualitatively by 2 trained research assistants, applying principles of content analysis to identify themes and domains. Inter-rater reliability was conducted. RESULTS: Parents perceived that school meals and UFSM saved families money and time, as parents had fewer meals to purchase and prepare for their children. In addition, UFSM reduced parents' stress and reduced stigma for children and for parents, who described feelings of embarrassment when they previously filled out paperwork for free or reduced-price meals. Although parent perceptions of school meal quality and healthfulness were mixed, most parents reported feeling grateful for school meals. CONCLUSIONS: Parents had mixed opinions on the quality and healthfulness of school meals, but believed UFSM saved them money and time and reduced their stress. Parents also felt UFSM reduced stigma for families.

Parent perceptions of school meals and how perceptions differ by race and ethnicity.

Parental perceptions of school meals can affect student participation and overall support for school meal policies. Little is known about parental school meal perceptions under universal free school meals (UFSM) policies. We assessed California parents' perceptions of school meals during the COVID-19 emergency response with federally funded UFSM and whether perceptions differed by race/ethnicity. Among 1110 California parents of K-12 students, most reported school meals benefit their families, saving them money (81.6%), time (79.2%), and stress (75.0%). Few reported that their child would be embarrassed to eat school meals (11.7%), but more parents of White students than Hispanic students reported this. Many parents reported that their child likes to eat lunch to be with friends (64.7%); about half felt their child has enough time to eat (54.2%). Fewer parents perceived school lunches to be of good quality (36.9%), tasty (39.6%), or healthy (44.0%). Parents of Hispanic and Asian students had less favorable perceptions of school meal quality, taste, and healthfulness than parents of White students. Parents report that school meals benefit their families, but policy efforts are needed to ensure schools have the resources needed to address cultural appropriateness. Schools should address parental perceptions of meals to optimize participation, nutrition security, and health.

Parent Perceptions of School Meals Influence Student Participation in School Meal Programs.

OBJECTIVE: To evaluate if parent perceptions of school meals influence student participation. DESIGN: In May 2022, an online survey was used to evaluate parents' perceptions of school meals and their children's participation. PARTICIPANTS: A total of 1,110 California parents of kindergarten through 12th-grade students. MAIN OUTCOME MEASURES: Student participation in school lunch and breakfast. ANALYSIS: Principal component analysis and Poisson regression models. RESULTS: Three groups of parental perceptions were identified: (1) positive perceptions (eg, liking school meals and thinking that they are tasty and healthy), (2) perceived benefits to families (eg, school meals save families money, time, and stress), and (3) negative (eg, concerns about the amount of sugar in school meals and stigma). More positive parental perceptions about school meals and their benefits to families were associated with greater student meal participation. In contrast, more negative parental perceptions were associated with reduced student participation in school meals (P < 0.05). CONCLUSION AND IMPLICATIONS: Parent perceptions of school meals may affect student participation in school meal programs. Working to ensure parents are familiar with the healthfulness and quality of school meals and the efforts schools are making to provide high-quality, appealing meals may be critical for increasing school meal participation rates.

Competitive Foods' Nutritional Quality and Compliance with Smart Snacks Standards: An Analysis of a National Sample of U.S. Middle and High Schools.

Snacks and beverages are often sold in addition to meals in U.S. schools ("competitive foods"), but their current nutritional quality and compliance with national Smart Snacks standards are unknown. This study assessed competitive foods in a national sample of 90 middle and high schools. Differences in compliance by school characteristics were measured using mixed methods analysis of variance. Overall, 80% of the schools in the sample sold competitive foods; but they were less commonly available in schools with universal free school meal (UFSM) policies. A total of 840 unique products were documented and, on average, 75% were compliant with Smart Snacks standards. A total of 56% aligned with recommended added sugar limits (<10% of calories); and 340 unique products (40%) aligned with both sugar and Smart Snacks standards. Approximately one-fifth of competitive foods contained synthetic dyes, and 31% of beverages contained artificial sweeteners. Smart Snacks standards compliance was greater when competitive foods were overseen by food service departments, in comparison with others (e.g., principals, student organizations, or outside vendors [77% vs. 59% compliance; p = 0.003]). Therefore, district wellness policies should consider requiring food service departments to oversee competitive foods. Federal and state policies should limit added sugars, artificial sweeteners, and synthetic dyes. This appears to be highly feasible, given the substantial number of products that meet these criteria. UFSM policies should also be considered to support healthier school meal environments more broadly.

Alternative School Breakfast Service Models and Associations with Breakfast Participation, Diet Quality, Body Mass Index, Attendance, Behavior, and Academic Performance: A Systematic Review.

The United States (US) School Breakfast Program provides Breakfast After The Bell (BATB) to alleviate hunger, provide nutrition, and ensure students have a healthy start to the day. This study aims to review the evidence regarding the impact of BATB on students' diet and academic outcomes, including participation, diet quality and consumption, body mass index (BMI) and weight status, attendance, classroom behavior, and academic performance. The articles were extracted from three electronic databases and published since the start of the literature through December 2022. Studies were peer-reviewed; quantitative research articles or government reports; and conducted in public or private elementary, middle, and high schools. Quality was assessed using the Newcastle-Ottawa Scale. Thirty-seven studies were included in this review. This review found BATB increased school breakfast participation, improved diet quality, and improved classroom behavior particularly among students from racial and ethnic minority backgrounds and students eligible for free or reduced-price meals. The impact of BATB on BMI and weight status, academic achievement and attendance was mixed. This review is particularly timely given free school meals and updated school nutrition standards are being prioritized over the next decade in the US. Thus, it is important to evaluate the nutritional and educational outcomes of BATB. (PROSPERO registration: CRD42021289719).

Strategies to Increase Student Participation in School Meals in the United States: A Systematic Review.

BACKGROUND: School meals play a critical role in promoting child nutrition and advancing equity. An understanding of which evidence-based strategies can increase meal participation is needed to improve student school meal consumption and foodservice finances. OBJECTIVE: Our aim was to systematically review the evidence on interventions, initiatives, and policies to increase school meal participation in the United States. METHODS: Four electronic databases were searched (PubMed, Academic Search Ultimate, Education Resources Information Center, and Thomson Reuters' Web of Science) to identify peer-reviewed and government studies conducted in the United States and published in English through January 2022. Qualitative studies; studies focused on snacks, afterschool meals, or universal free meals as the sole exposure; and studies conducted in schools not participating in the federal school meal programs or outside of the school year were excluded. Risk of bias was assessed using an adapted version of the Newcastle-Ottawa Scale. Articles were grouped according to type of intervention or policy and were narratively synthesized. RESULTS: Thirty-four articles met inclusion criteria. All studies examining alternative breakfast models (eg, breakfast in the classroom or grab-and-go breakfast) and restrictions on competitive foods found increases in meal participation. There is also some evidence that stronger nutrition standards do not negatively impact meal participation and, in some cases, may promote meal participation. There is limited evidence on other strategies, including taste tests, modified menu options, changes to the meal period length, changes to the cafeteria environment, and wellness policies. CONCLUSIONS: There is evidence that alternative breakfast models and restrictions on competitive foods promote meal participation. There is a need for additional rigorous evaluation of other strategies to promote meal participation.

Trends in Quick-Service Restaurants near Public Schools in the United States: Differences by Community, School, and Student Characteristics.

BACKGROUND: More than one-third of children and adolescents consume foods from quick-service restaurants (QSRs) daily, which is associated with an increased risk of diet-related adverse health conditions. OBJECTIVE: To examine trends in the proximity of top-selling QSR chains to all public schools across the United States between 2006 and 2018 by community-, school-, and student-level characteristics. DESIGN: This longitudinal study examined changes in the number QSRs between the 2006-2007 and 2017-2018 school years using data from National Center for Education Statistics, Infogroup US Historical Business Data, and the US Department of Agriculture's Economic Research Service. STATISTICAL ANALYSIS: A mixed-model analysis of variance using census tract as a random effect and accounting for repeated measures by school was used to examine the proximity of QSRs near schools. Models adjusted for demographic characteristics and census tract population density. Data were analyzed in 2021. RESULTS: During 2006, 9% of schools had QSRs within 400 m, and 25% of schools in the most populated areas had at least one QSR within 400 m. There were more QSRs near schools with a high percentage of poverty (12%), and near schools with high school students with the highest population of Black or African American (16%) and Hispanic or Latino (18%) students. By 2018, the percent of all public schools within 400 m of QSRs increased to 12%. The increase over time was greater near schools with a high percentage of poverty (16%) and near schools with high school students with the highest population of Black or African American students (22%) and Hispanic or Latino (23%) students. CONCLUSIONS: This is the first nationwide study to examine trends in QSR proximity to all public schools. QSRs were most likely to be located near schools with high school students, near schools with a high percentage of poverty, and near schools with a higher proportion of racial and ethnic minority students. Over time, there were greater increases in QSRs near these schools which may have important implications for children's health and diet-related disparities.

Teachers' Resources to Support School Lunch: Professional Development Is Warranted.

In the United States, many children who come from low-income backgrounds and experience food insecurity do not take and eat school lunch, despite it being a nutritious meal. Teachers could play a role in encouraging students' consumption of school lunch; however, teachers in America are traditionally uninvolved in the lunch period. The purpose of this research was to understand the resources kindergarten through twelfth grade (K-12) teachers need to encourage students to take and eat school lunch. Two data collection workshops and semi-structured follow-up interviews were conducted with K-12 teachers. The workshops and interviews were recorded, transcribed, and analyzed for salient themes. Ten teachers participated in the workshops and six teachers participated in the follow-up interviews. In general, teachers believe school meals are essential for students' focus and behavior in the classroom. However, to encourage students to take and eat school lunch, teachers need support and resources. From the workshops and interviews, three themes emerged: (1) improvements in the food quality; (2) school community support; and (3) professional development. The data suggests professional development is the greatest resource teachers need, as professional development can enhance teachers' motivation to advocate for better food quality and engage school community support. Greater teacher involvement in school lunch could lay the groundwork for future healthier generations.

Teachers' Experiences Implementing a School Wellness Initiative in Anchorage, AK: A Qualitative Study.

BACKGROUND: Teachers are uniquely poised to support students' healthy eating habits and physical activity. However, research is needed to examine the successes and challenges teachers face when implementing a school wellness initiative. The purpose of this study was to examine teachers' experiences implementing and managing a pilot school wellness initiative where students had longer lunch and recess, and more physical activity throughout the day. STATISTICAL ANALYSIS: Using a grounded theory approach, transcripts were analyzed qualitatively using principles of content analysis to identify themes and domains. Application of the codes and interrater reliability were conducted with a trained research assistant. METHODS: Focus groups were conducted to understand the challenging and successful experiences of teachers as they implemented and managed a school wellness initiative. The participants were teachers (N = 39) from six purposively selected elementary schools participating in a school wellness initiative. Focus groups were conducted in-person at participating schools. RESULTS: Teachers observed calmer students who ate more lunch with longer lunch periods. In addition, teachers observed improved focus in the classroom and fewer behavior issues with more physical activity opportunities. Successful strategies included reversing lunch and recess and implementing physical activity into daily lessons. However, some teachers had difficulty managing the extra time in the cafeteria and scheduling physical activity throughout the day, particularly in schools where administrators were not as supportive of the initiative. In the schools with greater administrative buy-in and support, teachers had easier, more positive experiences implementing the wellness initiative. CONCLUSIONS: School wellness initiatives in which teachers play a large role have the potential to support teachers and students. This study found that teachers value student health and understand students need to be nourished to learn, but teachers' experiences suggest they need support and buy-in from their administrators to be successful.

Implementation of Universal School Meals during COVID-19 and beyond: Challenges and Benefits for School Meals Programs in Maine.

School meals play a major role in supporting children's diets and food security, and policies for universal school meals (USM) have the potential to contribute to positive child health outcomes. During the COVID-19 pandemic, schools provided free school meals to all students in the United States, but this national USM policy ended in school year (SY) 2022-2023; however, a few states have adopted policies to continue USM statewide for SY 2022-2023. Research examining the challenges and strategies for successful continuation of USM is essential, along with studying pandemic-related challenges that are likely to persist in schools. Therefore, we conducted a study in Maine (with a USM policy) to evaluate the impact of COVID-19 and the concurrent implementation of USM, as well as examine differences in implementation by school characteristics, throughout the state. A total of n = 43 school food authorities (SFAs) throughout Maine completed surveys. SFAs reported multiple benefits of USM including increased school meal participation; reductions in the perceived stigma for students from lower-income households and their families; and no longer experiencing unpaid meal charges and debt. SFAs also experienced challenges due to the COVID-19 pandemic, particularly regarding costs. When considering future challenges, most respondents were concerned with obtaining income information from families, product and ingredient availability, and the costs/financial sustainability of the school meal programs. Overall, USM may have multiple important benefits for students and schools, and other states should consider implementation of a USM policy.

Nutrient Content and Compliance with Sodium Standards in Elementary School Meals in the United States Pre- and Post-COVID-19.

Various federal policies have weakened school meal nutrition standards in the United States since the passage of the Healthy, Hunger-Free Kids Act in 2010, including temporary school meal nutrition waivers to promote post-COVID-19 pandemic recovery. This study used school menu and nutrient data from a nationally representative sample of 128 elementary school districts to examine differences in nutrients (average calories, total fat, saturated fat, sodium, total sugar, and fiber) and alignment with United States Department of Agriculture (USDA) sodium targets in 2019 (pre-pandemic) and in 2022 (post-pandemic). Data were analyzed using analysis of variance accounting for repeated measures within school districts, adjusting for geographic region and urbanicity. Small differences in the nutrient content for both breakfast and lunch were observed between 2019 and 2022. Most weeks met USDA sodium Target 1 for breakfast (≥95% of weeks) and Target 1 (≥96% of weeks) and Target 1A for lunch (≥92% of weeks) in both 2019 and 2022, although compliance decreased slightly when condiments were included. Additionally, meals provided on average 57 g of total sugar. Overall, many meals are already in alignment with lower sodium targets. Simple strategies, such as offering lower sodium condiments, can further reduce sodium in school meals. The total sugar levels observed highlight that the USDA should consider limits on added sugars in school meals.