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 United States Congress authorized the United States 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. Since 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=1,110) and Maine (n=80). Qualitative interviews were then conducted with a subset of these parents in California (n=46) and Maine (n=20) using ZoomTM. Most survey participants (708 out of 1,190; 59.5%) and interviewees (40 out of 66; 60.6%) were parents of students who were eligible for free or reduced-price meals (FRPM). MAIN OUTCOME MEASURES: Parents' perceptions of UFSM, school meal quality, and experiences applying for FRPM 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. Additionally, UFSM reduced parents' stress and reduced stigma for children and for parents, who described feelings of embarrassment when they previously filled out paperwork for FRPM. While 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.

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.

Creating Novel Surveillance Data Products for Briefing Health Department Leadership and Elected Officials During the COVID-19 Pandemic in Texas.

Beginning in March 2020, the Texas Department of State Health Services (DSHS) developed several internal surveillance tools for briefing state health department leadership and elected officials on the status of the COVID-19 pandemic in Texas. This case study describes the initial conceptualization and daily production of 3 of these internal surveillance tools: (1) a COVID-19 data book displaying daily case, fatality, hospitalization, and testing data by county; (2) graphs and data files displaying new daily COVID-19 fatalities among residents of long-term care facilities in Texas; and (3) graphs and data files comparing COVID-19 cases and hospitalizations between the 4 COVID-19 waves in Texas. In addition, this case study uses qualitative interview data to describe how DSHS leadership used these surveillance products during the pandemic. Finally, details on challenges and lessons learned around creating and maintaining these tools are provided. These surveillance products are easily replicable, and our methods and lessons learned may be helpful for researchers or health department officials working on COVID-19 or other disease surveillance teams.

Evaluation of a Healthy Checkout Lane "Nudge" on Grocery and Convenience Store Sales of a Price-Promoted Nutritious Food.

Grocery store intervention trials, including trials testing behavioral economics "nudges," may change food-purchasing behaviors and improve diet quality. This study aimed to design and evaluate a grocery store healthy checkout lane "nudge" intervention on sales of a targeted healthy item. We conducted a randomized controlled trial based on the behavioral economic concept of cognitive fatigue and the marketing concept of impulse buying. Six grocery stores from one North Carolina-based chain were randomized to the intervention (n = 3) or control (n = 3) condition. Researchers tested a 4-week healthy checkout lane intervention, in which intervention stores moved 6-ounce cans of peanuts to the cash registers. Cashiers were instructed to upsell the peanuts to all shoppers at checkout. While not a component of the intervention, the retailer decreased the price of the peanuts from $1.99 to $1.50 during the first 2 weeks of the intervention. Fidelity to the checkout display was high. Fidelity to the upsell was low. The main outcome measure was aggregated store-level sales of the promoted peanuts for 4 weeks before the intervention and during the 4-week intervention period. On average, sales increased by 10 units/week in intervention stores (5.83 vs. 15.83 units, p = .04) with no significant change in control stores (1.42 vs. 1.17 units, p = .64). The difference (10 vs. -0.25 units, p = .02) was likely due to displaying the peanuts at checkout combined with the price promotion. Larger randomized controlled trials should examine whether healthy checkout lane interventions are effective "nudges" for promoting purchases of healthier foods in grocery stores.

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.

Examining Changes in Food Security, Perceived Stress, and Dietary Intake in a Cohort of Low-Wage Workers Experiencing an Increase in Hourly Wage.

OBJECTIVE: To determine whether an increase in hourly wages was associated with changes in food security and perceived stress among low-wage workers. We also determined whether changes in food security and stress were associated with changes in diet. SETTING: Wages is a prospective cohort study following 974 low-wage workers in Minneapolis, MN, where an ordinance is incrementally increasing minimum wage to US$15/hr from 2018 to 2022, and a comparison community with no minimum wage ordinance (Raleigh, NC). Interaction models were estimated using generalized estimating equations. PARTICIPANTS: Analyses used two waves of data (2018 [baseline], 2019) and included 219 and 321 low-wage workers in Minneapolis and Raleigh (respectively). RESULTS: Average hourly wages increased from US$9.77 (SD US$1.69) to US$11.67 (SD US$4.02). Changes in wages were not associated with changes in food security (odds ratio = 1.05, 95% confidence interval [CI] [0.89, 1.23], p = .57) or stress (ß = -0.01, 95% CI [-0.04, 0.03], p = .70) after 1 year of policy implementation. Changes in food security were not associated with changes in diet. However, we found significant changes in the frequency of fruit and vegetable intake across time by levels of stress, with decreased intake from Wave 1 to 2 at low levels of stress, and increased intake at high levels of stress (incidence rate ratio = 1.17, 95% CI [1.05, 1.31], p = .01). CONCLUSIONS: Changes in wages were not associated with changes in food security or stress in a sample of low-wage workers. Future research should examine whether full implementation of a minimum wage increase is associated with changes in these outcomes.

Association between hourly wages and dietary intake after the first phase of implementation of the Minneapolis minimum wage ordinance.

OBJECTIVE: In 2018, Minneapolis began phased implementation of an ordinance to increase the local minimum wage to $15/h. We sought to determine whether the first phase of implementation was associated with changes in frequency of consumption of fruits and vegetables (F&V), whole-grain-rich foods, and foods high in added sugars among low-wage workers. DESIGN: Natural experiment. SETTING: The Wages Study is a prospective cohort study of 974 low-wage workers followed throughout the phased implementation of the ordinance (2018-2022). We used difference-in-difference analysis to compare outcomes among workers in Minneapolis, Minnesota, to those in a comparison city (Raleigh, North Carolina). We assessed wages using participants' pay stubs and dietary intake using the National Cancer Institute Dietary Screener Questionnaire. PARTICIPANTS: Analyses use the first two waves of Wages data (2018 (baseline), 2019) and includes 267 and 336 low-wage workers in Minneapolis and Raleigh, respectively. RESULTS: After the first phase of implementation, wages increased in both cities, but the increase was $0·84 greater in Minneapolis (P = 0·02). However, the first phase of the policy's implementation was not associated with changes in daily frequency of consumption of F&V (IRR = 1·03, 95 % CI: 0·86, 1·24, P = 0·73), whole-grain-rich foods (IRR = 1·23, 95 % CI: 0·89, 1·70, P = 0·20), or foods high in added sugars (IRR = 1·13, 95 % CI: 0·86, 1·47, P = 0·38) among workers in Minneapolis compared to Raleigh. CONCLUSIONS: The first phase of implementation of the Minneapolis minimum wage policy was associated with increased wages, but not with changes in dietary intake. Future research should examine whether full implementation is associated dietary changes.

Evaluation of three behavioural economics 'nudges' on grocery and convenience store sales of promoted nutritious foods.

OBJECTIVE: To evaluate the association between three behavioural economics 'nudges' and store sales of promoted healthier foods. DESIGN: Multiple interrupted time series. SETTING: Two predominantly rural counties in central North Carolina, USA. PARTICIPANTS: Aggregated store transaction data from two grocery stores (one intervention, one control) and two convenience stores (one intervention, one control) were analysed using ANOVA to examine the association between three 'nudges' and store sales of promoted items. The nudges included: a 'cognitive fatigue' experiment, in which floor arrows guided customers to the produce sections; a 'scarcity' experiment, in which one sign in one area of the produce section portrayed a 'limited amount' message; and a 'product placement' experiment, where granola bars were moved into the candy bar aisle. RESULTS: In convenience stores, there were no significant differences between sales of the promoted items during the intervention period for any of the nudges when implemented individually. However, compared with baseline sales, implementation of all three nudges simultaneously was associated with an increase in sales during the intervention period based on proportional computations (P = 0·001), whereas no significant changes in sales were observed in the control convenience store. Among the grocery stores, there were no significant differences in sales during the intervention period for any of the nudges or the combined intervention compared with baseline sales. CONCLUSIONS: Implementing three nudges concurrently in a convenience store setting may increase sales of promoted items. However, before stores consider implementing these nudges to increase sales of nutritious foods, additional research is warranted.

Pilot Evaluation of Aggregate Plate Waste as a Measure of Students' School Lunch Consumption.

BACKGROUND: Weighing an individual's plate waste provides reliable estimates of food intake by physically weighing individual food components to the nearest gram before and after a meal. Weighing aggregate, school-level food waste may be an inexpensive and less time-consuming alternative. However, it has not been determined whether aggregate plate waste is an accurate measure of individually weighed plate waste. OBJECTIVE: This pilot study aimed to evaluate the accuracy of aggregate plate waste for quantifying food waste in a school cafeteria setting in comparison with individually weighed plate waste. DESIGN: A pilot validation study in which aggregate plate waste was compared against individually weighed plate waste in a school cafeteria setting. PARTICIPANTS/SETTING: This study took place in an urban, low-income school district in Massachusetts in the spring of 2014. Four elementary schools with identical cafeterias and meals participated in the study. Approximately 1,700 students participated in this study. MAIN OUTCOME MEASURES: For individually weighed plate waste, the percent discarded was calculated by dividing the weight of each discarded item by the average weight of the food item served and the percent consumed was calculated as the residual. For aggregate-level measurements, waste was separated by component (entrée, vegetable, fruit, and milk), and the weight discarded was calculated based on the weight of the cumulative amount remaining and an average weight for each food item served, with the percent consumed calculated as the residual. STATISTICAL ANALYSES PERFORMED: Intraclass correlation coefficients (ICCs) were calculated to assess the agreement between aggregate plate waste and individual-level plate waste values. RESULTS: Agreement was excellent for entrées (ICC=0.90) and vegetables (ICC=0.78), but poor for milk (ICC=0.22) and fruits (ICC=0.23). The overall agreement for all four components combined was excellent (ICC=0.75). CONCLUSIONS: Results suggest that aggregate plate waste may provide a reasonable estimate of individually weighed plate waste, but additional research is warranted.

Factors Associated with School Lunch Consumption: Reverse Recess and School "Brunch".

BACKGROUND: While school foods have become healthier under the Healthy, Hunger Free Kids Act, research suggests there is still substantial food waste in cafeterias. It is therefore necessary to study factors that can impact food consumption, including holding recess before lunch ("reverse recess") and starting lunch periods very early or very late. OBJECTIVE: This study examined the association between the timing of recess (pre-lunch vs post-lunch recess), the timing of the lunch period, and food consumed by students at lunch. DESIGN: We conducted a secondary data analysis from a repeated cross-sectional design. PARTICIPANTS/SETTING: An 8-week plate waste study examining 20,183 trays of food was conducted in New Orleans, LA, in 2014. The study involved 1,036 fourth- and fifth-grade students from eight public schools. MAIN OUTCOME MEASURES: We measured percent of entrées, fruit, vegetables, and milk consumed by students at lunch. STATISTICAL ANALYSES PERFORMED: We used mixed-model analyses, controlling for student sex, grade, and the timing of the lunch period, and examined the association between reverse recess and student lunch consumption. Mixed-model analyses controlling for student sex, grade, and recess status examined whether the timing of the lunch period was associated with student lunch consumption. RESULTS: On average, students with reverse recess consumed 5.1% more of their fruit than students with post-lunch recess (P=0.009), but there were no significant differences in entrées, vegetables, or milk intake. Compared to students with "midday" lunch periods, on average students with "early" lunch periods consumed 5.8% less of their entrées (P<0.001) and 4.5% less of their milk (P=0.047). Students with "late" lunch periods consumed 13.8% less of their entrées (P<0.001) and 15.9% less of their fruit (P<0.001). CONCLUSIONS: Reverse recess was associated with increased fruit consumption. "Early" lunch periods were associated with decreased entrée and milk consumption, and "late" lunch periods were associated with decreased entrée and fruit consumption. Additional research is recommended to determine whether these associations are causal.