摘要：Meals served through the National School Lunch Program (NSLP) must meet rigorous nutritional standards; however, barriers to student participation may limit the program's health and social equity benefits. Unsubsidized meals and food offerings competing with the NSLP offerings in school lunch environments may be lowering qualified student participation either directly or via identification of subsidized low-income students or stigmatization of the NSLP. We document a pilot intervention conducted in San Francisco in 2009 and 2010 that demonstrated gains in NSLP participation after removal of separate competitive à la carte lunch meal offerings. Our observations suggest the need for greater attention to the potential discriminatory effects of competitive foods and to the issue of stigma by school nutrition program administrators, researchers, regulators, and policymakers. The National School Lunch Program (NSLP), first authorized by the National School Lunch Act (NSLA) of 1946, operates in more than 96 000 public and nonprofit private schools and provides low-cost or free lunches meeting nutritional standards to more than 31 million children daily. 1 – 3 The NSLP in itself is a significant accomplishment with respect to child health and social equity 4 – 7 ; furthermore, the US Department of Agriculture (USDA) is continuing to strengthen nutritional standards for meals served under the program. 8 However, realizing improved childhood nutrition through the NSLP requires equal attention to ensuring the participation of the qualified low-income students the program intends to benefit. Participation in the NSLP varies substantially among schools and age groups. USDA data for the 2004–2005 school year show that on average, 85% of students at the middle school level and 79% of students at the high school level who qualified for free and reduced-price lunches usually participated 9 ; however, according to a 2009 national survey 25% of high schools had less than a 32% participation rate, and 10% had less than a 14% participation rate among qualified students. 10 Barriers to participation are numerous, including those related to enrollment and outreach, limited menu options, student preferences, lunch service capacity, and open campuses. The widespread availability of unsubsidized foods competing with the NSLP, ranging from snacks to à la carte entrees and meals, may represent a further barrier to program participation. 11 , 12 Practices that identify low-income students who have received subsidized meals under the NSLP, which could inhibit participation by stigmatizing program participants, are officially prohibited. However, in schools where there are few nonsubsidized students participating in the NSLP meal program, participation itself may be an easily visible marker of income status. Competitive foods may contribute to the stigma associated with NSLP participation. As Shirley Watkins, a former undersecretary of the USDA, acknowledged in her report to Congress in 2001, [C]ompetitive foods undermine the nutrition integrity of programs and discourage participation… . Since only children with money can purchase competitive foods, children may perceive that school meals are primarily for poor children rather than nutrition programs for all children. 13 School food quality has been a long-standing public priority in San Francisco, California. In 2004, the San Francisco Unified School District (SFUSD) adopted nutritional standards for competitive food and also banned sales of sugared beverages in cafeterias and vending machines. 14 In 2007, the city and county of San Francisco began providing financial support to augment NSLP offerings with salad bars. 15 Although the nutritional quality of all foods offered has improved locally over the past decade, low participation has remained a persistent challenge. Fifty-four percent (31 321) of SFUSD students qualified for free or reduced-price meals in 2007; however, NSLP participation rates of qualified students in elementary, middle, and high schools were only 77%, 42%, and 34%, respectively. 16 In 2007, concerns regarding the impact of out-of-school competitive foods on child nutrition and school lunch participation led to local legislation to prohibit mobile food vendors within 1500 feet of schools. 17 In this context, staff of the San Francisco Department of Public Health (SFDPH) evaluated other causes of low participation. Through field observations at school sites, staff identified a 2-tiered system with NSLP meals and a cash-only à la carte competitive meal available in separate lunch lines. 18 Although the NSLP status of students purchasing à la carte foods could not be identified, few nonsubsidized students consumed NSLP meals. These observations suggested that competitive foods and stigma might be acting cumulatively to reduce the participation of qualified students in the NSLP. Subsequently, SFDPH and SFUSD implemented a pilot intervention during 2009 and 2010 to remove competitive à la carte offerings in 3 schools while providing greater diversity of meal offerings for all students. Here, we describe the preliminary field observations motivating the intervention. We also detail the intervention and its evaluation. Finally, we consider stigma and competitive food as potential factors mediating observed changes in participation rates. Our observations suggest the need for greater attention to the potential discriminatory effects of competitive foods and to the issue of stigma by school nutrition program administrators, researchers, regulators, and policymakers.
