摘要：Objectives. We analyzed the impact of Connecticut legislation incentivizing voluntary school district–level elimination of unhealthy competitive foods on National School Lunch Program (NSLP) participation. Methods. We analyzed data on free, reduced, and paid participation in the NSLP from 904 schools within 154 Connecticut school districts from the 2004–2005 to the 2009–2010 school year, resulting in 5064 observations of annual school-level meal participation. We used multilevel regression modeling techniques to estimate the impact of the state competitive food legislation on the count of NSLP lunches served per student in each school. Results. Overall, the state statute was associated with an increase in school lunch participation. We observed increases between 7% and 23% for middle- and high-school meal programs, and a slight decrease of 2.5% for the elementary school free meal eligibility category, leading to an estimated revenue increase of roughly $30 000 for an average school district per school year. Conclusions. This study provides support for national implementation of proposed rigorous competitive food standards that can improve the health of students while supporting local school district finances. Federal meal programs in the United States serve more than 30 million students every day, providing an unparalleled opportunity to improve the diet of the nation’s youths. 1 Recent changes to school meal program regulations will substantially improve the nutritional quality of meals that have already succeeded at preventing childhood nutritional deficiencies in the United States. 2–4 Public health efforts to reduce childhood obesity rates and improve diet quality in the United States have increasingly focused on improving the food environment in schools. 5–7 The sale of foods in schools outside the school meal programs, known as competitive foods, has been consistently linked with unhealthy diet and, in some but not all studies, 8 with increased risk of obesity. 9 Energy-dense, nutrient-poor competitive foods and beverages are widely available in US schools and are regularly consumed by children. 10–13 A number of local school district and statewide policy changes reducing or eliminating the sale of unhealthy competitive food and beverages at school have been shown to improve dietary outcomes, including reduced sugar-sweetened beverage consumption and increased consumption of fruits and vegetables. 14–16 Sanchez-Vaznaugh et al. reported that removing unhealthy competitive foods may be linked to a lower incidence of overweight in children in California. 17 Taber et al. reported findings based on the Early Childhood Longitudinal Study–Kindergarten showing that adolescents in states with strong competitive food standards from 2003 to 2006 gained 0.44 body mass index (BMI; defined as weight in kilograms divided by the square of height in meters) units less than adolescents in states without such standards. 18 Despite the success of some state and local policies, national policy efforts have so far failed to sufficiently address the negative impact of the sale of unhealthy competitive foods on children’s health. The Child Nutrition and WIC Reauthorization Act of 2004 required all school districts participating in the National School Lunch Program (NSLP) to develop wellness policies that include nutrition guidelines for all foods available at schools by the 2006–2007 school year. 19 However, the legislation did not require districts to implement specific competitive food policies. 5 A review of a nationally representative sample of wellness policies and related regulations from 2006–2007 up to 2008–2009 found that, although some districts have implemented strong policies, in general, rules governing competitive food sales were weak or nonexistent. 20 In response to concerns about the role of both the school meal programs and competitive foods in addressing the obesity epidemic, Congress passed The Healthy, Hunger-Free Kids Act of 2010. 21 The act required the US Department of Agriculture (USDA) to update the nutrition standards for the NSLP and the School Breakfast Program while providing a performance-based increase in reimbursement rate for lunches. The bill also for the first time gave the USDA authority to set nutrition standards for competitive foods sold throughout the school day. 21 Congress instructed the USDA to develop nutrition standards for competitive foods that align with the current Dietary Guidelines for Americans 22 while giving consideration to practical application of the standards. The USDA is currently developing competitive food standards with the goal of releasing final regulations in 2013. Reactions to the USDA’s revised nutrition standards for the school meal program suggest that the USDA may face strong opposition to nutritionally rigorous competitive food standards. 23,24 In addition to objections raised by food industry associations, the School Nutrition Association, which represents school food service professionals, commented to the USDA that improving the health quality of the school meals may reduce participation in the program if students instead purchase competitive foods or bring food from outside school. 25 However, creating rigorous new competitive food nutrition standards could support simultaneous implementation of improved meal program standards by removing unhealthy yet attractive alternatives to the meal program from school environments. A number of studies have found that reducing availability of unhealthy competitive foods results in increased meal program participation and limited impact on overall food service revenue. 26,27 On the basis of a systematic review that identified 7 studies that assessed the relationship between nutrition standards and school revenue, Wharton et al. concluded that fears of net negative financial impacts of improved nutrition standards are unfounded and that increased participation in NSLP may compensate for lost revenue from lower competitive food sales. 27 However, because there is a relatively limited evidence base, additional evidence showing that implementing stronger competitive food standards across a broad range of schools can increase school meal participation would support ongoing USDA efforts to implement rigorous national competitive food and school meal nutrition standards. Since 2006, Connecticut’s Healthy Food Certification (HFC) has offered school districts in the state a monetary incentive to comply with stringent competitive food nutrition standards that are updated annually. 28 The standards, which are based on the Dietary Guidelines for Americans, apply to all foods sold at school at all times. Exceptions can be granted by local school boards for food sold during events held outside the regular school day. Districts must annually file compliance forms with the Connecticut State Department of Education (CSDE), which reviews nutrition information for all foods sold in each district and conducts site visits in selected participating districts to ensure compliance. Districts that choose to comply with the voluntary standards are paid an additional 10 cents per lunch by the state, based on the total number of reimbursable lunches (paid, free, and reduced) served in the district in the previous school year. Previous research based on the program’s first year of implementation found that districts participating in HFC substantially reduced the availability of unhealthy competitive food and increased paid school meal participation in middle schools. 29 This study extends the initial evaluation of the program, and analyzes the impact of district participation in HFC on student participation in free, reduced, and paid lunches by using statewide school meal participation data from the 2004–2005 to 2009–2010 school years. It was hypothesized that district participation in HFC is positively related to student participation in the NSLP.
