Impact of the National School Lunch Program on Fruit and Vegetable Selection in Northeastern Elementary Schoolchildren,

Transcription

1 Brief Reports Impct of the Ntionl School Lunch Progrm on Fruit nd Vegetble Selection in Northestern Elementry Schoolchildren, Srh A. Amin, MPH Bethny A. Yon, PhD Jennifer C. Tylor, MS b Rchel K. Johnson, PhD, MPH, RD ABSTRACT Incresing children s fruit nd vegetble (FV) consumption is n importnt gol of the U.S. Deprtment of Agriculture s (USDA s) Ntionl School Lunch Progrm. Since 2012, the USDA s requirement tht children select FVs t lunch s prt of the reimbursble school mel hs been met with concern nd evidence of food wste. We compred elementry schoolchildren s FV selection, consumption, nd wste before (10 school visits, 498 try observtions) nd fter (11 school visits, 944 try observtions) implementtion of this requirement using vlidted dietry ssessment mesures. More children selected FVs in higher mounts when FVs were required compred with when they were optionl (0.69 cups vs cups, p,0.001); however, consumption decresed slightly (0.51 cups vs cups, p50.01) nd wste incresed (0.25 cups vs cups, p,0.001) when FVs were required compred with when they were optionl. More exposure to FVs in schools through progrmmtic efforts nd in the home environment my help fmilirize children with FV offerings nd encourge consumption. University of Vermont Burlington, Deprtment of Nutrition nd Food Sciences, Burlington, VT b University of Cliforni, Deprtment of Nutrition, Dvis, CA Address correspondence to: Srh A. Amin, MPH, University of Vermont Burlington, Deprtment of Nutrition nd Food Sciences, 352 Crrign Wing, Burlington, VT 05405; tel ; fx ; e-mil <smin@uvm.edu> Assocition of Schools nd Progrms of Public Helth 453

2 454 Brief Reports The mjority of U.S. children do not consume recommended mounts of fruit nd vegetbles (FVs). 1 Incresing children s consumption of FVs is n importnt gol of the Ntionl School Lunch Progrm, which feeds nerly 31 million children ech school dy. 2 As of the 2012 school yer, the U.S. Deprtment of Agriculture (USDA) requires schoolchildren to select either fruit or vegetble with reimbursble mel. 3 Implementtion of this requirement rised concerns mong school nutrition professionls surrounding opertionl chllenges, FV wste, nd incresed costs. 4 Two yers lter, school districts nd sttes reported incresed wste by students. 5,6 In recent survey completed by 240 school nutrition directors, more thn 80% subjectively reported n increse in the mount of FVs (especilly vegetbles) wsted by students. 6 However, limited number of studies exist tht used rigorous, vlidted dietry ssessment methods to mesure schoolchildren s FV selection, consumption, nd wste. 7,8 Such studies re criticl to inform nd evlute interventions imed t incresing children s FV consumption. We imed to compre schoolchildren s FV selection, consumption, nd wste using vlidted dietry ssessment methods when FVs were optionl compred with when they were required with school lunch by the USDA. METHODS Two northestern elementry schools were enrolled in the study; both hd student bodies tht were 84% 90% white. Both schools hd 40% 60% of children qulifying for free or reduced mels, mrker for low socioeconomic sttus. We collected dt s prt of lrger study to vlidte the use of digitl imging to ccurtely mesure children s FV consumption. 9 We collected rndom smples of lunch trys from third-, fourth-, nd fifth-grde children with no identifying informtion gthered from students. We dhered uniquely numbered nd colored stickers to ll lunch trys nd observed one color t ech visit. These stickers helped identify trys from third- through fifth-grde students tht my hve been mixed with ones from students in other grdes nd to rndomly select trys from the trget smple for the fesibility of dt collection. We objectively mesured students selection, consumption, nd wste of FVs using vlidted methods (i.e., digitl imging, direct observtion, nd weighed plte wste) 9 when FVs were optionl in spring 2012 (10 visits, 498 try observtions) nd the following school yer in spring 2013 fter the USDA implemented the new rule requiring FVs (11 visits, 944 try observtions). We mesured FV consumption bsed on food selections (i.e., serving weights) nd plte wste for ech FV item per try. We included ll FVs offered on the lunch menu in these estimtes (i.e., whole FVs; 100% fruit juice; nd FVs in mixed dishes, such s lsgn, pizz, nd soup). The fesibility, relibility, nd vlidtion of the three dietry ssessment methods hve been previously published. 9 For weighed plte wste, we weighed FVs to the nerest grm nd converted this mesurement to cups. For direct observtion nd digitl imging, we used six-point scle to estimte the percentge consumed. 10 We estimted the FV selections by counting the number of servings selected of ech FV item served in stndrdized portions, such s vegetble soup or bby crrots. We lso weighed FV items served in vrible portion sizes (e.g., sld greens) nd converted the weight to cups (using weighed plte wste) or estimted to the nerest one-qurter cup (using direct observtion nd digitl imging). For weighed plte wste nd direct observtion, the reserch ssocites determined the children s FV selections before they exited the lunch line. With digitl imging, reserchers coded the children s FV selections by referencing imges of FVs in vrious portion sizes. To help with estimting FV selection nd percentge consumed for the direct observtion method, reserch ssocites stood ner the cshier sttions nd observed the mount of FVs selected on trgeted trys by counting the number of servings tken of FV items offered in stndrdized portions nd visully estimting selections of sld greens to the nerest one-qurter cup. With digitl imging, reserch ssocites compred try selections nd plte wste to reference imges of stndrd serving sizes of ech FV item. They lso clculted selection, consumption, nd wste for ll FVs on ech student s try. We used chi-squred tests to compre children s selection of no FVs, both FVs, fruit only, nd vegetble only. We lso conducted independent smple t-tests to compre children s totl FV selection, consumption, nd wste before nd fter the new USDA rule. All nlyses were two-tiled tests performed using SPSS version RESULTS When FVs were optionl, 15.7% (95% confidence intervl [CI] 8.6, 22.8) of lunch trys did not contin FVs, compred with 2.5% (95% CI 0.5, 5.5) when FVs were required (p,0.001) (Figure). When students were required to select FVs, the men mount of FVs on children s trys incresed by 0.20 cups (p,0.001). When we excluded trys where children did not select

3 Children s Response to Specific School Lunch Requirements 455 Figure. Percentge of elementry schoolchildren s (grdes 3 5) lunch trys with fruit nd/or vegetbles when optionl (spring 2012, n=498) vs. when required (spring 2013, n=944) t two northestern elementry schools Percent of trys 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% The lines tht extend from ech br show the 95% confidence intervls. FV 5 fruit nd vegetble Optionl (n5498 trys) Required (n5944 trys) No FV Both FV Fruit only Vegetble only FV ctegory ny FVs (pre- nd post-new rule), the men mount of FVs tht children selected incresed once required by 0.09 cups (p50.001) (Tble). Reserch ssocites could not determine consumption for 2% nd 9% of lunch trys before nd fter the new rule, respectively, due to missing evidence from inedible food portions or visul obstructions on the trys. While the mount of FVs selected incresed when the USDA required schoolchildren to include them on their lunch trys, more children did not consume ny of their selections (4% FV optionl vs. 12% FV required, p,0.001). On verge, children consumed fewer FVs (0.06 cup or bout 1 tblespoon, p50.01) nd wsted more FVs (0.14 cup or bout 2 tblespoons, p,0.001) when FVs were required compred with when they were optionl (Tble). DISCUSSION Children consumed fewer FVs nd wsted more FVs during the school yer immeditely following implementtion of the USDA rule tht required them to tke one fruit or vegetble t lunch. Averge wste incresed from one-qurter cup to more thn one-third of cup/try, with bout one-eighth cup/try more FVs discrded, or totl of bout 56 cups/dy/school (bsed on n verge of 400 lunches served/dy). In the current study, 2.5% of students did not hve n FV on their try under the new requirements. It is possible tht few students my hve proceeded through the lunch line without the cfeteri personnel reminding them to go bck nd select n FV. Previous studies of elementry schoolchildren s food consumption hve corroborted the incresed FV wste 12,13 nd decresed FV consumption 8 following the new USDA rule. However, there hve been some promising findings regrding the impct of the new USDA rule on schoolchildren s FV consumption, including n incresed percentge of students who consumed t lest one serving of FVs in smple of three schools (20% FV optionl vs. 28% FV required, p,0.01). 13 The new USDA regultions not only require schoolchildren to select n FV, but lso require schools to offer greter vriety of vegetbles. 3 Cohen nd collegues reported tht lthough the percentge of trys with vegetble did not increse in third- through eighth-grde elementry schoolchildren fter implementtion of the new rule, vegetble consumption incresed (0.13 cup vs cup, p,0.001). 7 Children entering elementry school under the new USDA rule my respond better to the FV requirement. Under the new requirement, younger children (grdes 1 3) were found to consume more FVs when required compred with older children (grdes 4 5). 8 Adjustment to the new requirement my tke time, especilly becuse older children were ccustomed to hving the option of whether or not to choose n FV. Limittions This study ws subject to severl limittions. One limittion of this study ws tht it only ssessed differences in men FV selection, consumption, nd plte wste, but not individul consumption. However, our reserch is consistent with other studies tht ssessed the impct of the USDA rule on chnges in students school mel consumption behviors. 7,8,12,13 Reserchers my consider conducting future studies to better understnd how to impct individul-level responses to chnges in FV offerings. Second, lthough the reserch tem mde every effort to unobtrusively collect try dt nd not

4 456 Brief Reports disturb the cfeteri environment, the presence of the reserch tem my hve bised students FV selection nd consumption behvior. Third, we ssessed FV consumption behvior in two northestern elementry schools; therefore, the results my not be generlizeble to schools in different regions of the country. Lstly, other chrcteristics (e.g., sociodemogrphic nd cfeteri environmentl fctors) lso my ffect FV consumption behviors. CONCLUSIONS In the current study, children s incresed selection of FVs my hve been influenced by hving more choices. However, while children were willing to select FVs in lrger portions, it my tke time nd repeted exposure to the new foods for them to become fmilir with nd develop preferences for the FV offerings. 14 Becuse more children did not even tste the FVs they chose t lunch when required in the current study, school nutrition professionls need strtegies to encourge children to try the unfmilir FVs they select. It is importnt to ensure the vilbility of FV offerings tht children my lredy enjoy. 15 However, becuse children prefer FVs in the form of 100% fruit juice or mixed dishes, such s pizz or lsgn, 15 one should consider dditionl fctors, such s the types of whole FVs offered nd how the cfeteri stff prepres them Cutting up vegetbles nd serving them with dip 16,17 nd slicing fruit, such s ornges 18 nd pples, 18,19 cn positively influence students FV selection nd consumption by mking FVs more ccessible nd ppeling. Chnges to school mel policies my reinforce positive behviors in children, such s the Smrt Sncks in Schools policy, which sets limits on the mount of clories, slt, sugrs, nd ft contined in school sncks Tble. Elementry schoolchildren s (grdes 3 5) selection, consumption, nd wste of fruit nd vegetbles t two northestern elementry schools during school lunch before (spring 2012) nd fter (spring 2013) implementtion of updted Ntionl School Lunch Progrm regultions Vrible Spring 2012 N (percent) Spring 2013 N (percent) Percentge-point chnge P-vlue Totl trys observed 498 (100) 944 (100) Trys with ny FVs 419 (84) 919 (97) 13.3,0.001 FV CBD trys 38 (2) 85 (9) NA NA Cups b Men (95% CI) Cups b Men (95% CI) Percent chnge P-vlue All trys FV selected c 0.69 (0.63, 0.73) 0.89 (0.85, 0.92) 29.0,0.001 FV consumed d 0.51 (0.47, 0.54) 0.45 (0.42, 0.47) FV wsted d 0.25 (0.21, 0.28) 0.39 ( ) 56.0,0.001 Only trys with ny FV selected e FV selected f 0.82 (0.76, 0.86) 0.91 (0.87, 0.94) FV consumed g 0.52 (0.48, 0.54) 0.45 (0.42, 0.47) FV wsted g 0.25 (0.22, 0.28) 0.39 (0.36, 0.42) 56.0,0.001 CBD represents trys for which dt could not be determined due to missing evidence from inedible food portions or visul obstructions on the trys. b Becuse consumption nd wste were unble to be determined for 2% 9% of lunch trys, the summed vlue in cups does not equl the selected mount of FVs. c Includes ll observed lunch trys with nd without FVs selected (498 trys before nd 944 trys fter implementtion of updted Ntionl School Lunch Progrm [NSLP] regultions) d Includes ll observed lunch trys with nd without FVs selected (417 trys before nd 862 trys fter implementtion of updted NSLP regultions) e Excludes lunch trys with no FV selections f Includes only lunch trys where children selected FVs (419 trys before nd 919 trys fter implementtion of updted NSLP regultions) g Includes only lunch trys where children selected FVs (410 trys before nd 862 trys fter implementtion of updted NSLP regultions) FV 5 fruit nd vegetble CBD 5 could not be determined NA 5 not pplicble

5 Children s Response to Specific School Lunch Requirements 457 nd promotes FVs s one of the min ingredients. 20 Beyond the cfeteri, schools cn explore progrms, such s Frm to School, to complement their mels. Frm to School hs gined ntionl recognition for its potentil to positively influence correltes of children s FV consumption behviors, such s ttitudes, knowledge, nd exposure, through strtegies tht include grdening, cooking, or tste testing. 21,22 Exposure to Frm to School progrmming ws ssocited with incresed FV consumption mong prticipnts who initilly hd the lowest FV intke. 22 Public helth prctitioners should lso consider strtegies extending to the home becuse more frequent exposure to FVs t home my result in children consuming vriety of FVs t school. 23 Our reserch findings, tht children selected more FVs but consumed less nd wsted more fter the new regultions were in plce, support the importnce of public helth prctitioners ddressing the environmentl, home, nd personl fctors tht encourge children s FV consumption. While these dt from one geogrphic re my not be generlizble to other regions, we bsed the mesures of consumption nd wste on vlidted, objective mesures. 9 Furthermore, the findings re consistent with those from other prts of the country where requiring child to select n FV lso corresponded with decresed consumption 8 nd incresed food wste. 12,13 Future reserch should explore brriers to consuming FVs during school lunch nd how offerings could better lign with children s tste preferences. The University of Vermont s Institutionl Review Bord pproved the study nd wived written consent; however, the uthors notified techers, stff, school dministrtors, nd prents t the prticipting schools of the study. Funding for the reserch ws provided by the U.S. Deprtment of Agriculture (USDA)/Vermont Agriculturl Experiment Sttion nd the University of Vermont Bickford Scholr Reserch Fund. The views expressed in this rticle re those of the uthors nd do not necessrily represent the views of the USDA. REFERENCES 1. Centers for Disese Control nd Prevention (US). Trends in the prevlence of obesity, dietry behviors, nd weight control prctices. Ntionl YRBS [cited 2014 Aug 18]. Avilble from: URL: _obesity_trend_yrbs.pdf 2. Food, Reserch, nd Action Center. Ntionl School Lunch Progrm [cited 2014 Aug 18]. Avilble from: URL: /federl-foodnutrition-progrms/ntionl-school-lunch-progrm 3. Deprtment of Agriculture (US), Food nd Nutrition Service. Nutrition stndrds in the Ntionl School Lunch nd School Brekfst Progrms. Finl rule. Fed Reg 2012 Jn 26;77: Byker CJ, Pinrd CA, Yroch AL, Serrno EL. New NSLP guidelines: chllenges nd opportunities for nutrition eduction prctitioners nd reserchers. J Nutr Educ Behv 2013;45: Government Accountbility Office (US). School lunch: implementing nutrition chnges ws chllenging nd clrifiction of oversight requirements is needed. GAO Wshington: GAO; Jnury Also vilble from: URL: /ssets/670/ pdf [cited 2014 Aug 18]. 6. School Nutrition Assocition. School nutrition trends survey, 2014 [cited 2014 Sep 9]. Avilble from: URL: 7. Cohen JFW, Richrdson S, Prker E, Ctlno PJ, Rimm EB. Impct of the new U.S. Deprtment of Agriculture mel stndrds on food selection, consumption, nd wste. Am J Prev Med 2014;46: Wengreen H, Aguilr S, Mdden G, Jones B. Do the new nutrition stndrds help students to consume more fruits nd vegetbles? J Nutr Educ Behv 2014;46(4 Suppl):S Tylor JC, Yon BA, Johnson RK. Relibility nd vlidity of digitl imging s mesure of school children s fruit nd vegetble consumption. J Acd Nutr Diet 2014;114: Comstock EM, St Pierre RG, Mckiernn YD. Mesuring individul plte wste in school lunches. Visul estimtion nd children s rtings vs. ctul weighing of plte wste. J Am Diet Assoc 1981;79: IBM Corp. SPSS : Version Armonk (NY): IBM Corp.; Byker CJ, Frris AR, Mrcenelle M, Dvis GC, Serrno EL. Food wste in school nutrition progrm fter implementtion of new lunch progrm guidelines. J Nutr Educ Behv 2014;46: Just D, Price J. Defult options, incentives, nd food choices: evidence from elementry-school children. Public Helth Nutr 2013;16: Birch LL, Mrlin DW. I don t like it; I never tried it: effects of exposure on two-yer old children s food preferences. Appetite 1982;3: Amin SA, Yon BA, Tylor JC, Johnson RK. When fruits nd vegetbles re optionl, elementry school children choose processed over whole offerings. J Child Nutr Mng 2014; Olsen A, Ritz C, Krmer L, Møller P. Serving styles of rw snck vegetbles: wht do children wnt? Appetite 2012;59: Svge JS, Peterson J, Mrini M, Bordi PL, Birch LL. Addition of plin or herb-flvored reduced-ft dip is ssocited with improved preschoolers intke of vegetbles. J Acd Nutr Diet 2013;113: Swnson M, Brnscum A, Nkyim PJ. Promoting consumption of fruit in elementry school cfeteri. The effects of slicing pples nd ornges. Appetite 2009;53: Wnsink B, Just DR, Hnks AS, Smith LE. Pre-sliced fruit in school cfeteris: children s selection nd intke. Am J Prev Med 2013;44: Deprtment of Agriculture (US), Food nd Nutrition Service. Ntionl School Lunch Progrm nd school brekfst progrm: nutrition stndrds for ll foods sold in school s required by the Helthy, Hunger- Free Kids Act of Interim finl rule. Fed Reg 2013 Jun 28;78: Ntionl Frm to School Network. The benefits of Frm to School, 2013 [cited 2015 Mr 27]. Avilble from: URL: Bontrger Yoder AB, Liebhrt JL, McCrty DJ, Meinen A, Schoeller D, Vrgs C, et l. Frm to elementry school progrmming increses ccess to fruits nd vegetbles nd increses their consumption mong those with low intke. J Nutr Educ Behv 2014;46: Korinek EV, Brtholomew JB, Jowers EM, Ltimer LA. Fruit nd vegetble exposure in children is linked to the selection of wider vriety of helthy foods t school. Mtern Child Nutr 2013 Apr (online).