摘要：Objectives. We assessed the impact of legislation that established nutrition standards for foods and beverages that compete with reimbursable school meals in California. Methods. We used documentation of available foods and beverages, sales accounts, and surveys of and interviews with students and food service workers to conduct 3 studies measuring pre- and postlegislation food and beverage availability, sales, and student consumption at 99 schools. Results. Availability of nutrition standard–compliant foods and beverages increased. Availability of noncompliant items decreased, with the biggest reductions in sodas and other sweetened beverages, regular chips, and candy. At-school consumption of some noncompliant foods dropped; at-home consumption of selected noncompliant foods did not increase. Food and beverage sales decreased at most venues, and food service à la carte revenue losses were usually offset by increased meal program participation. Increased food service expenditures outpaced revenue increases. Conclusions. Regulation of competitive foods improved school food environments and student nutritional intake. Improvements were modest, partly because many compliant items are fat- and sugar-modified products of low nutritional value. Additional policies and actions are needed to achieve more substantive improvements in school nutrition environments and student nutrition and health. The current obesity epidemic in the United States has been associated with environmental factors such as the proliferation of unhealthy foods in schools and neighborhoods, as well as promotion of unhealthy foods in media environments. 1 – 4 An effective way to support children in being active and eating healthfully is to change institutional practices within schools by improving physical education and the nutritional value and quality of foods served. 5 , 6 Schools participating in the federally reimbursed National School Lunch Program and School Breakfast Program serve meals that must meet federal nutrition guidelines. However, foods that are not part of the meal programs are only subject to minimal federal regulation, and these “competitive” foods have become increasingly widespread in schools over the last 40 years. 7 Sold throughout schools in vending machines, school stores, snack bars, and at fundraisers, competitive foods and beverages are of lower nutritional quality and are typically high in added sugars, salt, and fat. Common examples of competitive foods include soft drinks and other sweetened beverages, potato chips, candy, cookies, and pastries. 8 – 11 In an effort to combat childhood obesity, state and local policymakers have recently begun to regulate competitive school food offerings by enacting stricter school nutrition standards. 12 These efforts were reinforced by provisions in the Child Nutrition and WIC Reauthorization Act of 2004, which required school districts receiving federal meal program funding to enact wellness policies—including guidelines for all foods and beverages served—by the 2006–2007 school year. 13 The wellness policies of 92 out of 100 large school districts polled by the School Nutrition Association in 2007 included nutrition standards limiting times or offerings of competitive foods and beverages in school à la carte services, stores, and vending machines. 14 Although the effects of state and local regulations of competitive foods are only beginning to be evaluated, 15 emerging evidence suggests that school policies that decrease access to competitive foods of limited nutritional value are associated with less frequent student consumption of these foods during the school day. 16 , 17 In California, Senate Bill 12 (SB 12), which applied nutrition standards to competitive foods sold in K–12 schools, took effect in July 2007. The law imposed the following limits on foods in secondary schools 18 : Individually sold snacks must contain no more than: 35% of calories from fat (with some exceptions, such as legumes, nuts, and eggs); 10% of calories from saturated fat (excluding eggs and cheese); 35% sugar by weight (excluding fruits and vegetables); and a total of 250 calories. Individually sold entrées must contain no more than 36% of calories from fat and 400 calories per entrée. At elementary schools, the only competitive foods allowed are individually sold portions of nuts, nut butters, seeds, eggs, cheese packaged for individual sale, fruit, vegetables that have not been deep-fried, legumes, and dairy or whole-grain foods that meet the nutrient limits described previously and contain no more than 175 calories. A second law, SB 965, limited the competitive beverages that could be offered during the school day. 18 The limits went into full effect in July 2007 for elementary and middle schools; at high schools, 50% of beverages had to comply by July 2007, and 100% of beverages had to comply by July 2009. The law limits competitive beverages to the following: fruit-based and vegetable-based drinks that are at least 50% fruit juice without added sweeteners; drinking water without added sweeteners; milk products and nondairy milks that have no more than 2% fat and 28 g of total sugars per 8 oz; and electrolyte replacement beverages with no caffeine and no more than 42 g of added sweetener per 20 oz (not allowed at elementary schools). Three studies—the Healthy Eating, Active Communities study (HEAC), the High School Study (HSS), and the School Wellness Study (SWS), all conducted by the authors of this article, assessed different aspects of the implementation and impact of California's school nutrition standards in diverse settings ( Table 1 ). Each study examined unique aspects of the legislation while also using some measures that were common to all 3 studies. The combined results of the 3 studies, presented here, provide a more complete picture of the effectiveness and limitations of current nutrition standards and answer the following research questions: TABLE 1 Summary of Study Methodologies: Healthy Eating, Active Communities Study (HEAC), High School Study (HSS), and School Wellness Study (SWS), California, 2004–2009 Data Collection Dates Data Collection Methodology Purpose Studies Included No. Prelegislation Postlegislationa On-site observations: One-day site visits were made to each school. Information on all competitive foods and beverages available for sale was documented by trained staff who used standardized forms. We determined the nutrient profile of each item by using a validated nutrient composition database or information obtained from packaging, recipes, or manufacturer Web sites. To assess changes made to foods and beverages offered and to quantify change in degree of compliance with the nutrition standards. HEAC 6 elementary schools, 6 middle schools, 6 high schools, 1 K-12 school Spring 2005 Spring 2008 HSS 56 high schools Spring 2007 Spring 2008 SWS 8 elementary schools, 8 middle schools, 8 high schools Fall 2007 Spring 2009 Student survey: Paper questionnaires—proctored on-site by trained research staff—were completed by seventh- and ninth-grade students. To understand the impact on student dietary intake and food and beverage purchases. HEAC 3527 students prelegislation; 3828 students postlegislation Spring 2006 Spring 2008 Food and beverage sales: Information was provided by school food service and school administration and entered onto standardized forms. To determine the financial impact of implementing the nutrition standards. HEAC 6 elementary schools, 6 middle schools, 6 high schools 2004–2005 2007–2008 Food service survey: Interactive PDF questionnaire was sent electronically and was completed by school food service directors or supervisors (1 per school). To ascertain the perceived benefits of and challenges to implementation of the standards. HSS 56 high schools Spring 2007 Spring 2008 School wellness team interviews: One on-site group interview with school wellness personnel was conducted by trained research staff at each school. To ascertain the perceived benefits of and challenges to implementation of the standards. SWS 8 elementary schools, 8 middle schools, 8 high schools Fall 2007 Spring 2009 Open in a separate window aHEAC postlegislation data were collected at the midpoint of the project. HEAC endpoint data were collected in spring of 2010 and were not yet available for inclusion in this article at press time. To what extent did schools comply with nutrition standards? What changes did schools make in foods and beverages offered? What was the impact on student dietary intake? What was the impact on food and beverage sales? What were the benefits of and challenges to implementation?
