Phthalates, adipates, BPA, and pesticides in school meals.

BACKGROUND: Exposure to phthalates, adipates, bisphenol-A (BPA), and pesticides may have important health consequences for children, but little is known regarding their presence in school meals, a major food source for children. The aims of this study were to determine the presence of phthalates, adipates, BPA, and pesticides in school meals. METHODS: Using a cross-sectional design, n = 50 school meal components were collected from four school districts in New England (n = 8 elementary/K-8 schools) differing preparation methods (on-site scratch cooking and pre-packaged heat and serve meals with plastic films) between 2019 and 2021. Meal components were tested for the presence of phthalates, adipates, BPA, and pesticides by an independent laboratory. RESULTS: One adipate, DEHA, was detected in 42% of samples (range 0.08 mg/kg - 50.39 mg/kg). Among the prepackaged foods, DEHA was detected in 86% of samples, which also contained the highest average concentrations among all the samples tested. The phthalate Diisononyl phthalate (DINP) was detected in only one sample, and BPA was not detected in any of the samples tested. Pesticides were detected in 64% of produce and 27% of entrées, but most had levels that were lower than the average levels detected by the USDA's Pesticide Data Program and only one sample had levels that exceeded those detected by the USDA (Cyfluthrin levels in one sample of apples were 0.038 mg/kg compared with an USDA average range of 0.004-0.032 mg/kg). CONCLUSIONS: Overall pesticides and phthalate levels in school meals are low and BPA was not detected. However, this study suggests that manufacturers may be changing to less studied plasticizers such as DEHA. More studies should examine the impact of DEHA on human health, particularly among children. As schools transition back from the COVID-19 pandemic, foods packaged in plastic should be minimized where possible. Overall, school meals remain one of the healthiest options for children and policies that support on site cooking can further strengthen the quality of school meals.

Restaurant dining during the COVID-19 pandemic among adults with low-income in the United States.

The COVID-19 pandemic caused widespread non-essential business closures in the U.S., which may have disproportionately impacted food consumption in lower-income communities, in part due to reduced access to healthy and affordable foods, as well as occupations that may have required working outside the home. The aims of this study were to examine restaurant dining behaviors (including drive-through, takeout, and delivery) at fast-food and non-fast-food (i.e., fast casual and full-service ['other']) restaurants and the impact on diet quality among racially/ethnically diverse low-income adults during the early months of the pandemic. Participants completed an online survey using CloudResearch regarding restaurant dining behaviors in the past week (during June 2020) and during a typical week prior to the pandemic. Diet quality was measured using the Prime Diet Quality Score (PDQS). Surveys from 1,756 low-income adults (incomes <250% of the Federal Poverty Level) were analyzed using chi-squared tests to examine differences in demographic characteristics among those dining at restaurants during the pandemic, as well as to examine differences in dining frequency compared with prior to COVID-19. Negative binomial regressions were used to examine the mean frequency of eating food from fast-food and other restaurants, adjusted for socio-demographic characteristics. This study found reductions in fast-food and other restaurant dining compared with prior to COVID-19, although overall restaurant consumption remained high with over half of participants reporting fast-food consumption in the week prior (average consumption of twice per week). Greater fast-food consumption was associated with poorer diet quality. In conclusion, while fast-food consumption was slightly lower during the pandemic, the overall high levels observed among socioeconomically disadvantaged adults remains concerning, highlighting the continued need for initiatives and policies to encourage greater access to and consumption of affordable and healthier foods.

Weighed Plate Waste Can Accurately Measure Children's Energy Consumption from Food in Quick-Service Restaurants.

BACKGROUND: Quick-service restaurants (QSRs) serve one-third of US children on any given day, yet no methods can directly measure energy (kcal) consumed in QSRs. Weighed plate waste is one feasible option, but the accuracy is unknown. OBJECTIVE: The objective of this study was to determine the accuracy of weighed plate waste for measuring children's energy consumption in QSRs. METHODS: Children's plate waste (entrées and sides) was collected for a larger study assessing a community-wide health messaging campaign to inform parents' orders for children in QSRs; a subsample (n = 194) was used for validation. Gross energy left over estimated by weighed plate waste combined with restaurant-stated nutrition information was compared to gross energy determined by bomb calorimetry, the gold-standard energy assessment technique. Analyses were conducted at the meal level (all food items, combined) and stratified by the number of items per meal (1, 2, or 3). Pearson correlations and paired t tests analyzed agreement; Bland-Altman statistics examined differences between energy estimations for the total and stratified subsample. RESULTS: Overall, significant agreement was observed between weighed plate waste and bomb calorimetry (r = 0.99, P < 0.001). On average, weighed plate waste underestimated energy content by <2 kcal compared with bomb calorimetry (mean percent difference ± SD of 0.3% ± 10.7%); 94% of estimations fell within the limits of agreement (-23.5 to 26.8 kcal), and 63% and 24% of estimations differed by <10 or <20 net kcal, respectively. Although stratification by item number showed slight variation, mean differences for all strata were <5 kcal (t test P > 0.80), suggesting the accuracy of weighed plate waste for measuring meals of various sizes. CONCLUSIONS: Weighed plate waste is an accurate and valid field technique for measuring children's energy consumption from food in QSRs. Future improvements to capturing beverages, self-serve condiments, and sharing behaviors may improve the overall feasibility and accuracy.

Product reformulation and nutritional improvements after new competitive food standards in schools.

OBJECTIVE: In 2012, Massachusetts enacted school competitive food and beverage standards similar to national Smart Snacks. These standards aim to improve the nutritional quality of competitive snacks. It was previously demonstrated that a majority of foods and beverages were compliant with the standards, but it was unknown whether food manufacturers reformulated products in response to the standards. The present study assessed whether products were reformulated after standards were implemented; the availability of reformulated products outside schools; and whether compliance with the standards improved the nutrient composition of competitive snacks. DESIGN: An observational cohort study documenting all competitive snacks sold before (2012) and after (2013 and 2014) the standards were implemented. SETTING: The sample included thirty-six school districts with both a middle and high school. RESULTS: After 2012, energy, saturated fat, Na and sugar decreased and fibre increased among all competitive foods. By 2013, 8 % of foods were reformulated, as were an additional 9 % by 2014. Nearly 15 % of reformulated foods were look-alike products that could not be purchased at supermarkets. Energy and Na in beverages decreased after 2012, in part facilitated by smaller package sizes. CONCLUSIONS: Massachusetts' law was effective in improving the nutritional content of snacks and product reformulation helped schools adhere to the law. This suggests fully implementing Smart Snacks standards may similarly improve the foods available in schools nationally. However, only some healthier reformulated foods were available outside schools.

How do we actually put smarter snacks in schools? NOURISH (Nutrition Opportunities to Understand Reforms Involving Student Health) conversations with food-service directors.

OBJECTIVE: In autumn 2012, Massachusetts schools implemented comprehensive competitive food and beverage standards similar to the US Department of Agriculture's Smart Snacks in School standards. We explored major themes raised by food-service directors (FSD) regarding their school-district-wide implementation of the standards. DESIGN: For this qualitative study, part of a larger mixed-methods study, compliance was measured via direct observation of foods and beverages during school site visits in spring 2013 and 2014, calculated to ascertain the percentage of compliant products available to students. Semi-structured interviews with school FSD conducted in each year were analysed for major implementation themes; those raised by more than two-thirds of participating school districts were explored in relationship to compliance. SETTING: Massachusetts school districts (2013: n 26; 2014: n 21). SUBJECTS: Data collected from FSD. RESULTS: Seven major themes were raised by more than two-thirds of participating school districts (range 69-100 %): taking measures for successful transition; communicating with vendors/manufacturers; using tools to identify compliant foods and beverages; receiving support from leadership; grappling with issues not covered by the law; anticipating changes in sales of competitive foods and beverages; and anticipating changes in sales of school meals. Each theme was mentioned by the majority of more-compliant school districts (65-81 %), with themes being raised more frequently after the second year of implementation (range increase 4-14 %). CONCLUSIONS: FSD in more-compliant districts were more likely to talk about themes than those in less-compliant districts. Identified themes suggest best-practice recommendations likely useful for school districts implementing the final Smart Snacks in School standards, effective July 2016.

A pilot and feasibility study to assess children's consumption in quick-service restaurants using plate waste methodology.

BACKGROUND: Children regularly consume foods from quick-service restaurants (QSR), but little is known about the foods that children order, the calories and nutrients consumed, the accuracy of stated calorie information, or the ability to assess food orders and consumption in QSRs. This study evaluated the feasibility of plate waste collection in QSRs and examined children's orders and consumption of meals from the standard and children's menus. Additional aims were to examine if the meals ordered met healthier standards for children's menu items and determine the accuracy of the QSR-stated energy content of foods. METHODS: Fifteen QSRs, two malls, and 116 eligible parents were approached to participate in the study in 2015. Among the families recruited, children's meal orders and consumption were analyzed using plate waste methodology, and a subsample of foods was analyzed using bomb calorimetry in 2015. RESULTS: Two individual QSRs and one mall food court with two QSRs agreed to participate, and n = 50 participants (parents with children between the ages of 5-10 years) were recruited. Children consumed on average 519 calories, 5.7 g saturated fat, 957 mg sodium, 3.7 g fiber, and 22.7 g sugar. Children ordered and consumed significantly fewer calories and less sodium and sugar with meals ordered exclusively from the children's menu compared with the standard menu. Overall there were no significant differences between the measured and stated energy contents of the QSR foods. CONCLUSIONS: Conducting plate waste research in QSRs is feasible and there is concordance with stated calorie information. Consuming foods exclusively from the children's menu may help limit overconsumption in QSRs.

Impact of Nutrition Standards on Competitive Food Quality in Massachusetts Middle and High Schools.

OBJECTIVES: To examine changes in competitive foods (items sold in à la carte lines, vending machines, and school stores that "compete" with school meals) in Massachusetts middle and high schools before and after implementation of a statewide nutrition law in 2012. METHODS: We photographed n = 10 782 competitive foods and beverages in 36 Massachusetts school districts and 7 control state districts to determine availability and compliance with the law at baseline (2012), 1 year (2013), and 2 years (2014) after the policy (overall enrollment: 71 202 students). We examined availability and compliance trends over time. RESULTS: By 2014, 60% of competitive foods and 79% of competitive beverages were compliant. Multilevel models showed an absolute 46.2% increase for foods (95% confidence interval = 36.2, 56.3) and 46.8% increase for beverages (95% confidence interval = 39.2, 54.4) in schools' alignment with updated standards from 2012 to 2014. CONCLUSIONS: The law's implementation resulted in major improvements in the availability and nutritional quality of competitive foods and beverages, but schools did not reach 100% compliance. This law closely mirrors US Department of Agriculture Smart Snacks in School standards, suggesting that complying with strict nutrition standards is feasible, and schools may experience challenges and improvements over time.

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.

Participation in the US Department of Agriculture's Summer Meal Programs: 2019-2021.

BACKGROUND: The US Department of Agriculture's (USDA) summer meal programs are designed to provide meals at no cost while school is out of session. In response to the COVID-19 pandemic, several regulatory waivers were enacted to facilitate meal distribution. The aim of this study was to assess the rates of meal distribution before and after these waivers were in effect. METHODS: Meal distribution patterns for 2019, 2020, and 2021 were examined through (1) a descriptive comparison of the number of participating districts, sponsors, meal sites, and meals distributed statewide, and (2) repeated measures ANOVAs to examine changes among districts in operation all years. RESULTS: The waivers were associated with an increase in the total number of participating districts, sponsors, and meal sites; an increase in the total number of meals distributed to children during the summer months; and an increase in meal distribution among sponsors that had been in place since 2019. CONCLUSION: Expanding the area eligibility criteria and enabling flexibility in meal distribution methods increased the number of meals provided. This study provides important preliminary evidence to suggest that the USDA should consider permanent regulatory changes to this program to maximize its reach.

Daily Saturated Fat and Sodium Content of Elementary School Meals in a Large Sample of 128 Geographically Diverse School Systems in the United States.

BACKGROUND: Despite federal regulations limiting saturated fat and sodium levels on a weekly average basis, daily nutrient content of school meals in the United States is not regulated, leading to potential large fluctuations and intake well in excess of dietary recommendations. OBJECTIVE: To assess the daily prevalence of potential public elementary school meal combinations that were high in saturated fat and sodium (using cutoffs based on the US Department of Agriculture weekly average reimbursable meal thresholds), and to identify saturated fat and sodium thresholds for entrées to limit full meals exceeding those cutoffs. DESIGN: Cross-sectional. PARTICIPANTS AND SETTING: Four weeks of publicly available public elementary school (kindergarten through grade five) breakfast and lunch menus with associated nutrition data were collected from a national stratified random sample of 128 school districts during fall 2019. MAIN OUTCOME MEASURES: Percent of meal combinations exceeding the saturated fat and Target 1 sodium thresholds were calculated, as well as thresholds for saturated fat and sodium levels in breakfast and lunch entrées. STATISTICAL ANALYSES: Descriptive statistics and logistic regression were used to examine the odds of alignment with sodium and saturated fat US Department of Agriculture thresholds. RESULTS: The prevalence of elementary breakfast and lunch meal combinations that were high in sodium was on average 11% and 12.4%, respectively, and for saturated fat was 10.6% and 34%, respectively. Entrées above certain thresholds (≥400 and ≥1,000 mg sodium and ≥4.5 and ≥6 g saturated fat for breakfast and lunch, respectively) had a higher odds of producing a reimbursable meal that was high in sodium and saturated fat. CONCLUSIONS: There is widespread availability of high-saturated fat and sodium elementary school meal combinations on a daily basis. Daily thresholds, in addition to weekly nutrient thresholds, as well as limits on sodium and saturated fat for entrées, may therefore be needed to prevent daily excess intake of saturated fat and sodium among elementary students.

School Meals for All: A Qualitative Study Exploring Lessons in Successful Advocacy and Policymaking in Maine and California.

BACKGROUND: The COVID-19 pandemic focused national attention on food insecurity, equity, and the role of school meal programs in supporting children, families, and communities. In doing so, the pandemic created a rare policy window-an opportunity to advance a longstanding public health goal of guaranteed access to free school meals for all students. In July 2021, California and Maine became the first states to authorize school meal for all legislation (also known as universal free meals). OBJECTIVE: The aim of this study was to explore perspectives of policymakers, state agency officials, and advocates on the conditions and mechanisms that facilitated passage of school meal for all legislation in California and Maine. DESIGN: A qualitative case study was conducted. PARTICIPANTS: Between December 2021 and June 2022, semistructured interviews were conducted with 30 policymakers, state agency officials, and advocates. STATISTICAL ANALYSIS PERFORMED: Interviews were analyzed using principles of content analysis. Key themes are organized using Kingdon's multiple streams framework for public policy. RESULTS: Eleven key themes were identified. Lessons are drawn from the policy and advocacy strategies used to advance laws in California and Maine. For instance, paving the way with incremental policy change, tailoring messaging to diverse audiences, and organizing at the grassroots and grasstops levels were critical to success of advocacy efforts. CONCLUSIONS: Promising practices can guide efforts to expand access to school meals and advance other child nutrition policies in other states and nationally. Moving forward, lessons learned from implementation of universal free school meal legislation in California, Maine, and other early adopters should be documented and shared.

The Benefits and Challenges of Providing School Meals during the First Year of California's Universal School Meal Policy as Reported by School Foodservice Professionals.

States in the U.S. are newly implementing universal school meal (USM) policies, yet little is known about the facilitators of their success and the challenges they confront. This study evaluated the challenges and facilitators faced by school food authorities (SFAs) implementing California's universal school meal (USM) policy during its inaugural year (2022-2023) using an online survey. In March 2023, 430 SFAs reported many benefits, including increased meal participation (64.2% of SFAs) and revenues (65.7%), reduced meal debt (41.8%) and stigma (30.9%), and improved meal quality (44.3%) and staff salaries (36.9%). Reported challenges include product/ingredient availability (80.9%), staffing shortages (77.0%), vendor/distributor logistics issues (75.9%), and administrative burden (74.9%). Top facilitators included state funding (78.2%) and increased federal reimbursement (77.2%). SFAs with fewer students eligible for free or reduced-price meals (as opposed to SFAs with more) reported greater increases in meal participation and reductions in stigma but also more administrative burdens. Larger SFAs reported greater increases in revenues, staff salaries, and improvements in meal quality than smaller SFAs but also more challenges. Overall, California's USM policy has enhanced student access to healthy meals while mitigating social and financial barriers. Understanding California's experience can inform other jurisdictions considering or implementing similar policies.

Students' Perspectives on the Benefits and Challenges of Universal School Meals Related to Food Accessibility, Stigma, Participation, and Waste.

OBJECTIVE: To reveal students' experiences and perspectives related to Universal School Meals (USM) under the federal coronavirus disease 2019 waivers during school years 2021-22. DESIGN: Qualitative; 17 focus groups in June-July 2022. SETTING: Virtual; students from 9 California regions in public and charter schools. PARTICIPANTS: 67 students (n = 31 in high school, n = 36 in middle school) from a racially and economically diverse sample. PHENOMENON OF INTEREST: Students' perceived benefits and drawbacks of USM. ANALYSIS: Thematic analysis using an immersion-crystallization approach. RESULTS: Students appreciated USM for increasing school meals' accessibility, promoting food security by financially supporting families, reducing the stigma associated with school meals, simplifying the payment system, and enhancing school meals convenience. An increase in school meal participation was observed. However, concerns emerged regarding a perceived decline in food quality and quantity and increased food waste. CONCLUSIONS AND IMPLICATIONS: Universal School Meals showed promise in increasing access to meals, reducing food insecurity, stigma, and increasing participation. Addressing food quality, quantity, and waste concerns is critical for its sustained success. Policymakers need to advocate for the expansion and continuous refinement of USM, prioritizing stakeholder feedback. Ensuring adequate funding to balance meal quality and quantity while minimizing waste is essential for an adequate school meal policy.

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.

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.

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.

Perceived impact of a state-level universal free school meal policy on households with varying income levels: An analysis of parental perspectives.

BACKGROUND: In the U.S., a means-tested approach is often used to provide free or reduced-price meals (FRPM) to students from lower-income households. However, federal income thresholds do not account for regional cost of living variations. Thus, many ineligible households may be at risk for food insecurity. Universal free school meal (UFSM) policies may help address this issue, especially in states with a higher cost of living. OBJECTIVE: To evaluate parent perceptions of the impact of Massachusetts' statewide UFSM policy on households eligible and ineligible for FRPM. DESIGN: Cross-sectional survey of parents across income categories conducted during the 2022-23 school year. PARTICIPANTS/SETTING: Massachusetts parents (n=403) with children in grades kindergarten-12 with incomes ranging from <185% of the Federal Poverty Line (FPL) to >300% of the FPL. MAIN OUTCOME MEASURES: Parents' perceived impact of Massachusetts' UFSM policy on their child and household. STATISTICAL ANALYSES PERFORMED: Analysis of variance examined differences in the perceived impact of UFSM by FRPM eligibility, adjusting for demographic characteristics. RESULTS: Households that were FRPM eligible or near eligible were significantly more likely to report that their ability to have enough food for their family would be harder without UFSM (p<0.0001) compared to those in the highest income category. Across all income categories, approximately 75% of parents reported that school meals should be free for all children, and UFSM saved their family money and time and reduced stress, with no significant differences by FRPM eligibility. Roughly half (52%) reported their household finances would be hurt and 42% of parents from households eligible for FRPM reported their child would be less likely to eat school meals if the UFSM policy ended. CONCLUSIONS: This study found strong parent support of UFSM policies regardless of income level. Additionally, parents perceived that discontinuing UFSM may adversely impact school meal participation, including among students from lower income households, as well as food security among households ineligible for FRPM, particularly in areas with higher costs of living. Policies to expand UFSM should be considered among additional states and at the national level.

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.

Within-store fast food marketing: The association between food swamps and unhealthy advertisement.

Previous studies have linked food consumption outside the home and fast food to poor diet quality and living within a food swamp to an increased likelihood of obesity. A growing amount of research has linked food marketing to food choice. Still, limited information is available on how this dynamic may work within fast food establishments and if the marketing strategies used may vary by neighborhood food swamp status. Utilizing the Environment Assessment (EAT) Tool, we examined the within-store marketing environment of fast food restaurants to understand the factors potentially influencing food choice. A cross-sectional study design surveyed fast food outlets (n = 170) for unhealthy advertisements. Each fast-food outlet was assigned an FSI score based on its geographic location and proximity to unhealthy outlets. Outlets were assessed for associations between food swamp status and unhealthy advertisements. Poisson Regression was performed to assess the relationship between unhealthy advertisements and FSI score. Low FSI had a mean unhealthy advertisement score of 36.79 (11.06). Moderate and High FSI had mean unhealthy advertisement scores of 33.03 (14.67) and 31.71 (12.63), respectively. The number of unhealthy advertisements did not differ by food swamp categories (Moderate FSI IRR: 0.90, 95% CI: 0.74-1.09; High FSI IRR: 0.86, 95% CI: 0.73-1.01 vs. low FSI). Differences in marketing environments by food swamp status were not observed. Future research should examine other factors of the food swamp environment and additional factors such as television or social media to understand its association with food choice.