State Legislation Related to School Nutrition: Predictors of Bill Passage From 2010-2019.

OBJECTIVE: This study aimed to discover the prevalence of school nutrition state legislation and to identify the correlates of enactment. DESIGN, SETTING, AND PARTICIPANTS: An online legislative database, Legiscan, was used to collect bills related to school nutrition from the US from 2010 to 2019. Bills were coded and compiled into a study database with state-level dietary variables (obesity prevalence, fruit, and vegetable intake, sugar-sweetened beverage consumption), community variables (percent White, poverty), and bill-characteristic variables (party affiliation in legislature, strength of language, party of governor, school gardens, vegetable intake, and other salient variables). Multivariable models were built to examine predictors of bill enactment. RESULTS: Of the 462 bills introduced, 38.7% (n = 156) were enacted. In a multivariable model, the strength of bill language, political party affiliation, implementation of school gardens, and vegetable intake were the variables associated with bill passage. Bills with strong language were less likely to be enacted (P <0.001). Bills introduced by Democrats were more likely to be enacted (P = 0.01). CONCLUSION AND IMPLICATION: This study showed a better understanding of legislative support for child nutrition via policy surveillance of bills and their correlates of enactment. This information can be used to prioritize advocacy efforts and identify ways research can better inform policy.

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.

Healthy School Meals for All in Utah.

BACKGROUND: The National School Lunch and School Breakfast programs reduce food insecurity and improve dietary intake. During the COVID-19 pandemic, school meals were provided to all children at no cost, regardless of income. This policy is known as Healthy School Meals For All (HSMFA). The purpose of the study was to examine the feasibility of a HSMFA policy in Utah. METHODS: A mixed-methods approach was used, including qualitative interviews for policymakers, surveys for school foodservice directors, and financial modeling of Utah Child Nutrition Programs data. Analysis included a phenomenological analytic approach for qualitative data, descriptive statistics for surveys, and development of a cost model with 6 scenarios. RESULTS: Qualitative data revealed themes of (1) awareness; (2) responsibility; (3) perspectives on school meals; and (4) new opportunities. Most (81%) foodservice directors believed HSMFA should continue post-pandemic. HSMFA would cost $51,341,436 to $82,358,375 per year. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: HSMFA would result in the equitable treatment of all children regarding access to healthy school meals. CONCLUSIONS: Given the support of foodservice directors but the lack of political consensus, considering stepwise implementation and providing cost estimates may increase feasibility of a HSMFA policy in Utah.

Race/Ethnicity Predicts School Meal Participation.

BACKGROUND: School meals have demonstrated positive effects on dietary habits of children and adolescents, yet opportunities to increase participation exist. Little is known about how participation differs by race/ethnicity or by acculturation levels, thus this study aims to identify acculturation and race/ethnicity on school meal participation of middle school students. METHODS: A national convenience sample of adolescents (n = 617) was recruited to participate in a survey about acculturation and obesogenic behaviors through a Qualtrics panel. Data were analyzed in SAS version 9.4 where 2 logistic regression models were built to examine associations between school meal participation and other salient variables. RESULTS: More than a quarter (26.2%) of participants indicated they eat school lunch daily and 17.4% eat school breakfast daily. In a multivariable model, race/ethnicity, preference for school meals, taste, convenience, cost, and parent influence were all significantly related to daily school lunch participation. Race/ethnicity, time lived outside of the United States, healthiness of school meals, preference of school meals, taste, and cost were significantly related to daily school breakfast participation. CONCLUSIONS: This study establishes differences in participation rates by race/ethnicities and other factors. Child nutrition professionals should consider students from minoritized populations to understand their lack of participation, particularly because these students likely have poorer diets compared to whites. Additional factors should be considered for increasing participation, including cost, taste, and perceived healthiness.

Beyond Proximity: Utility-Based Access from Location-Based Services Data.

Understanding who in a community has access to its resources-parks, libraries, grocery stores, etc.-has profound equity implications, but typical methods to understand access to these resources are limited. Travel time buffers require researchers to assert mode of access as well as an arbitrary distance threshold; further, these methods do not distinguish between destination quality attributes in an effective way. In this research, we present a methodology to develop utility-based accessibility measures for parks, libraries, and grocery stores in Utah County, Utah. The method relies on passive location-based services data to model destination choice to these community resources; the destination choice model utility functions in turn allow us to develop a picture of regional access that is sensitive to: the quality and size of the destination resource; continuous (non-binary) travel impedance by multiple modes; and the sociodemographic attributes of the traveler. We then use this measure to explore equity in access to the specified community resources across income level in Utah County: the results reveal a discrepancy between which neighborhoods might be targeted for intervention using space-based analysis.

Driving Distance and Food Accessibility: A Geospatial Analysis of the Food Environment in the Navajo Nation and Border Towns.

The Navajo Nation, an area home to approximately 173,000 people in the southwest United States, experiences the highest rates of food insecurity in the United States and is classified as a food desert. The present study assessed the accessibility to food outlets (grocery stores, convenience stores, and restaurants) as measured by driving time on the Navajo Nation and in selected surrounding border towns. Food outlets located in neighboring border towns were examined using network analysis tools in ArcGIS Pro to calculate driving distance and examine the potential impact of driving time within the Navajo Nation on accessibility to nutritious foods. There were 14 grocery stores, 21 convenience stores, and 65 restaurants identified in the Navajo Nation using Mergent Intellect, a proprietary database, as compared to border towns which had a total of 542 grocery stores, 762 convenience stores, and 3,329 restaurants equaling a ratio of about 50:1 (grocery, 39:1; convenience, 36:1; restaurants, 51:1) when comparing food outlets nearby versus on the Navajo Nation. This ecological study presents a visual representation of driving time and food accessibility, revealing geographic areas within the Navajo Nation where access to border town food stores is sparse, and food insecurity may be elevated.

School Nutrition Professionals' Experiences with Food Safety and Special Diets in School Meals during the Initial COVID-19 Pandemic.

ABSTRACT: Federally funded school meals, such as the National School Lunch Program and School Breakfast Program, can help alleviate food insecurity. Meals served as part of these programs are required by law to be modified when medically necessary, such as food allergies and special diets. The coronavirus disease 2019 (COVID-19) pandemic caused many schools across the United States to close, but schools quickly modified meal-serving models. The purpose of this study was to understand the experiences of school nutrition professionals relative to food safety and providing special diets through modified serving models. A survey was distributed to a convenience sample of child nutrition professionals via social media recruitment and e-mails (n = 504). The survey had both closed-ended questions and one open-ended question exploring food safety and special diet accommodations. At the time of the survey, most respondents (68.3%) had been involved in COVID-19 emergency feeding for 3 to 4 weeks. Results indicated that although most child nutrition professionals did not find food safety easier or more difficult during the initial onset of COVID-19, 34.8% of respondents were not taking food temperatures for hot and cold meals during meal service and were not able to obtain (or did not have enough) equipment necessary for holding hot foods (53.0%). Most respondents (60.2%) also indicated that they were not accommodating children with special diets. Themes from the qualitative analysis indicated participants had challenges obtaining specialty items, had little time to make accommodations, or had a limited supply from vendors to accommodate these diets. To prevent food insecurity and to maintain health during the pandemic, specific solutions for at-risk populations, such as those who experience food allergies, must be considered.

An Educational Intervention for Improving the Snacks and Beverages Brought to Youth Sports in the USA.

OBJECTIVES: The purpose of this study was to test a small-scale intervention and its ability to decrease total sugar intake and number of calories offered at youth sports games. METHODS: This study was a pre/post-test quasi-experimental design. A flier was developed and distributed to parents. The flier aimed to decrease the sugar-sweetened beverages and increase the nutritional quality of food brought to games. Baseline data were collected in 2018 (n = 61). The flier was distributed prior to the start of the league, once during the league, and posted online in 2019. Postintervention data were collected in the intervention group (n = 122) and a comparison group (n = 74). Nutritional information was collected through direct observation. RESULTS: The average amount of total sugar provided per game per child was 25.5 g at baseline when snacks/beverages were provided at games. After the intervention, the average amount of total sugar provided significantly decreased (16.7 g/game/child, p < 0.001). CONCLUSIONS: The intervention reduced total sugar offered and the number of sugar-sweetened beverages brought to games. It was low-cost and could be easily implemented by public health practitioners and/or parks and recreation administrators. Further, considerations could be made to implement policies relative to snacks and beverages at youth sports games.

Parent-Child Relationships and the COVID-19 Pandemic: An Exploratory Qualitative Study with Parents in Early, Middle, and Late Adulthood.

The impact of the COVID-19 pandemic on families is currently unknown. Parents and children have experienced a variety of changes as public health interventions have been implemented to slow the spread of the virus. The current exploratory qualitative study recruited parents (n = 365) in early (ages 20-34), middle (ages 35-64), and late (ages 65 and older) adulthood to understand how the early weeks of the pandemic influenced their parent-child relationships. Participants completed an online survey between March 21 and 31, 2020. Three themes emerged through qualitative content analysis: (1) relational steadiness, (2) navigating COVID-19 challenges in relationships, and (3) relational enhancement.

Disaster Management and School Nutrition: A Qualitative Study of Emergency Feeding During the COVID-19 Pandemic.

BACKGROUND: School nutrition programs mitigate child food insecurity across the United States. With the onset of the coronavirus disease 2019 (COVID-19) pandemic, kindergarten through grade 12 physical school campuses closed, which led to those programs transitioning to emergency feeding. The Sendai Framework for Disaster Risk Reduction has 4 action priorities that guided the assessment of school nutrition employees' emergency response during the COVID-19 pandemic. OBJECTIVE: Our aim was to explore the experience of school nutrition employees as they provided emergency feeding services during the COVID-19 pandemic and evaluate their actions based on the Sendai Framework for Disaster Risk Reduction . DESIGN: A qualitative study with semi-structured interviews (n = 34) was conducted via videoconferencing software. A purposive sample of school nutrition employees across all 7 US Department of Agriculture regions who were involved in the COVID-19 emergency feeding response participated during April and May 2020. PARTICIPANTS/SETTING: School nutrition employees were selected randomly for participation from those indicating willingness to be interviewed during their participation in a related survey. Recruitment continued until all 7 US Department of Agriculture regions were represented. Participants held various roles, ranging from state agency leaders to front-line supervisors, although most were district-level directors or assistant directors. ANALYSIS: Data were analyzed using a phenomenological qualitative analytic approach. RESULTS: Four themes emerged. First, participants described the progression of the initial shock associated with the pandemic and service disruption, the flexibility they practiced, and the development of new routines. Second, keeping people (children, coworkers, and the community) safe was highlighted. The next theme captured participants' feeling that they came "out of the shadows" as communities and stakeholders recognized their important contribution to children's food security. Finally, they shared insight on communication and accountability during the emergency feeding response. CONCLUSIONS: These programs demonstrated flexibility, resilience, and commitment to children during this crisis. As the pandemic continues and future disasters are considered, school nutrition programs and leaders can use the Sendai Framework for Disaster Risk Reduction's "build back better" concept to refine disaster preparedness plans and advocate for changes that will continue to combat child food insecurity in the United States.

School Nutrition Professionals' Employee Safety Experiences During the Onset of the COVID-19 Pandemic.

OBJECTIVE: To explore the real-time personal/employee safety experiences and perspectives of school nutrition professionals ranging from frontline staff to state leadership across the US as they responded to the initial weeks of the coronavirus pandemic. METHODS: A cross-sectional survey was administered electronically March 31-April 20, 2020, to school nutrition staff, managers, directors, and state agency personnel. Descriptive statistics were calculated, and a thematic analysis of an open-ended item was conducted. RESULTS: School nutrition professionals (n = 504) from 47 states responded. Most (86.6%) reported that ensuring employee safety was somewhat or much more difficult during the pandemic, and they were unaware of an emergency plan. Themes from open-ended responses regarding employee safety concerns included, exposure and transmission risk, processes, and personal concerns. CONCLUSIONS AND IMPLICATIONS: Attention to the safety and concerns of school nutrition employees is vital for continuation of these programs during this pandemic and for future emergency situations.

Diet Quality Is Lower for Those Who Skip Lunch Among a Sample of Predominantly Black Adolescents.

PURPOSE: To compare the dietary quality among adolescents who skip lunch and those who do not and explore associations between school-level variables, demographic variables and lunch skipping. DESIGN: Cross-sectional. SETTING: Public schools in New Orleans, Louisiana (n = 21). PARTICIPANTS: 718 adolescents. METHODS: Adolescents participated in a 24-hour dietary recall using the Automated Self-Administered 24-Hour (ASA24) Dietary Assessment Tool early in 2013. Data were converted into Healthy Eating Index (HEI-2010) scores. Mean scores were compared between students who skipped lunch and those who did not. A multilevel analysis was conducted to assess relationships between school environment, demographics, and lunch skipping. RESULTS: Of the 718 respondents, 88.3% were Black and 15.3% skipped lunch. Students who ate lunch had a mean HEI score of 46.6 compared to a mean score of 41.7 for students who skipped lunch (p < .001). Students who skipped lunch also had significantly lower intake of total vegetables (p = .02), whole fruits (p < .001), total dairy (p = .003), total protein (p < .001). CONCLUSIONS: Skipping lunch was associated with lower quality diet, though diet quality was low among all students. Considering over 15% of the sample did not eat lunch in a closed-campus school setting, further research should consider how to encourage students to participate in the National School Lunch Program, which has the ability to increase diet quality in adolescents.

Do Youth Consume More Calories than they Expended in Youth Sports Leagues? An Observational Study of Physical Activity, Snacks, and Beverages.

Objectives: Childhood obesity rates remain high. The youth sports environment is an opportunity to combat obesity. The purpose of this study was to determine the types of beverages/ snacks provided at youth sports and determine associations between energy consumption and expenditure. Methods: This cross-sectional study observed 4 different sports in a youth sports league (N = 189). The System for Observing Fitness Instruction Time (SOFIT) was used to quantify physical activity. Food environmental scans were used to quantify caloric intake. A t-test was conducted to examine differences between energy consumption and expenditure. We conducted a separate analysis for games that did not offer snacks/beverages. Results: The average energy expenditure was 170.3 calories per game; males were more physically active than females. The average caloric content was 213.3 calories for games that did not offer snacks/beverages and average sugar provided was 26.4 grams per game. The majority of sugar came from sugar-sweetened beverages. Conclusions: Calorie intake was higher than expenditure. Children were consuming more sugar in one game than daily recommendations. Youth sports would benefit from an intervention aimed at the food environment.

Teachers' Experience and Perspectives of Traditional Breakfast and Breakfast in the Classroom.

OBJECTIVE: To understand teachers' perceptions about Breakfast in the Classroom and traditional breakfast. DESIGN: An electronic survey was sent to teachers across the state of Utah. Teachers responded to an open-ended question exploring what they liked and/or disliked about Breakfast in the Classroom and traditional breakfast. SETTING: Schools across the state of Utah. PARTICIPANTS: Kindergarten through grade 12 teachers who were members of the Utah Education Association. PHENOMENON OF INTEREST: Teachers' opinions regarding Breakfast in the Classroom and traditional school breakfast ANALYSIS: Researchers independently coded all responses and then grouped codes into themes. Themes were reviewed recursively over time. RESULTS: The 3 overarching themes were food and nutrition, administration of school breakfast, and student outcomes. Aspects most commonly disliked were the nutrition or quality of food, the mess created, the time required, coordination and logistical issues, behavioral issues, and waste. Aspects most commonly liked were breakfast being available to all students, students being fed or not hungry, coordination and logistics, and student learning and academics. CONCLUSIONS AND IMPLICATIONS: Teachers liked and disliked aspects of Breakfast in the Classroom and traditional breakfast. Schools could potentially increase efforts to garner support and feedback from teachers to create buy-in and identify best practices. Future research could focus on identifying the effect that the School Breakfast Program model has on teachers' perceptions as well as confirming results with a larger and more diverse population.

Who Eats School Breakfast? Parent Perceptions of School Breakfast in a State With Very Low Participation.

BACKGROUND: Having breakfast is correlated with health and academic benefits; yet, many children do not consume breakfast, and participation in the federal School Breakfast Program remains low. The purpose of this study was to examine parent perceptions of school breakfast and identify relationships between those who consume breakfast at school and those who do not. METHODS: A random sample of 100 schools, representing 29 school districts, across the state of Utah was selected to participate in the survey. Administrators were asked to distribute an online survey link to the parents of their school. Parents answered questions about their oldest kindergarten through 12th grade child. Qualitative and quantitative analyses were performed. RESULTS: A total of 488 parents completed the survey. In a multilevel model, child grade level, participation in free and reduced-price lunch, and perceive benefits to school breakfast were significantly related to eating breakfast at school. Some major themes from the qualitative analysis included no need for school breakfast, perception of regional values, and logistical issues. CONCLUSIONS: Parent perception of school meals is related to participation. This study identifies several areas of perception that could be address through parent education to increase school breakfast participation.

The FIT Game III: Reducing the Operating Expenses of a Game-Based Approach to Increasing Healthy Eating in Elementary Schools.

OBJECTIVE: Previously published versions of the healthy eating "FIT Game" were administered by teachers in all grades at elementary schools. The present study evaluated whether the game would retain its efficacy if teachers were relieved of this task; presenting instead all game materials on visual displays in the school cafeteria. MATERIALS AND METHODS: Participants were 572 children attending two Title 1 elementary schools (grades K-5). Following a no-intervention baseline period in which fruit and vegetable consumption were measured from food waste, the schools played the FIT Game. In the game, the children's vegetable consumption influenced events in a good versus evil narrative presented in comic book-formatted episodes in the school cafeteria. When daily vegetable-consumption goals were met, new FIT Game episodes were displayed. Game elements included a game narrative, competition, virtual currency, and limited player autonomy. The two intervention phases were separated by a second baseline phase (within-school reversal design). Simulation Modeling Analysis (a bootstrapping technique appropriate to within-group time-series designs) was used to evaluate whether vegetable consumption increased significantly above baseline levels in the FIT Game phases (P < 0.05). RESULTS: Vegetable consumption increased significantly from 21.3 g during the two baseline phases to 42.5 g during the FIT Game phases; a 99.9% increase. The Game did not significantly increase fruit consumption (which was not targeted for change), nor was there a decrease in fruit consumption. CONCLUSION: Labor-reductions in the FIT Game did not reduce its positive impact on healthy eating.

Lunch Salad Bars in New Orleans' Middle and High Schools: Student Intake of Fruit and Vegetables.

The school lunch salad bar (SB) is a recommended food environmental strategy to increase access to, and consumption of fruit and vegetables (F/V). In a study to examine use of school lunch SBs, middle and high school students provided data via the Automated Self-Administered 24-h dietary recall (24HDR) tool for kids (ASA24-Kids-2012), a web-based data collection platform. Kilocalories were computed, food groups were assigned and F/V sources were obtained. Students (n = 718) from 12 schools with SBs and nine schools without SBs were approximately 87% African American, over 64% female and most were 7th and 8th graders. SB school students had higher median energy consumption at lunch but a higher percent of non-SB students reported eating fruit at lunch compared to SB students. Most students reporting eating F/V at lunch obtained F/V from the cafeteria main line; only 19.6% reported eating F/V exclusively from the SB. In SB schools median intake of cups F/V was higher among students using the SB (0.92) compared to those not using the SB (0.53). Results of this study are mixed, but encouraging. Additional factors, e.g., nutrition education, marketing, and kinds of foods offered on the SB need to be examined for potential influence on SB use.

Individual- and School-Level Factors Related to School-Based Salad Bar Use Among Children and Adolescents.

BACKGROUND: Consumption levels of fruits and vegetables (F/V) among children/adolescents are low. Programs like school-based salad bars (SB) provide children/adolescents increased F/V access. AIMS: The purpose of this study was to examine the relationship between SB use and individual and school-level factors among elementary and secondary school students in New Orleans public schools. METHOD: Twelve schools receiving SB units from the Let's Move Salad Bars to Schools Campaign participated in this study. Self-reported data were collected from students ( n = 1,012), administrators ( n = 12), and food service staff ( n = 37). School environmental data were obtained through direct observation. Generalized estimating equation regression methods were used to develop a multilevel model including both school-level (e.g., length of lunchtime, SB marketing, vending machines) and individual-level (e.g., sex, food preferences, nutrition knowledge) effects. RESULTS: Female students had higher odds of using the SB compared to males. Students with healthier food preferences had higher odds of using the SB than those who reported less healthy food preferences. Within the multilevel model for all students, only sex and healthy food preferences remained significant. In a multilevel model assessing secondary students only, student encouragement toward others for healthy eating and school-based SB marketing were significantly related to SB use. CONCLUSIONS: Little research has examined factors related to school-based SB use. These findings suggest recommendations that may help improve student use of SBs. For example, increasing the promotion of SB, particularly in secondary schools, might encourage their use among students.