EFFECT OF NUTRITION CHANGES ON FOODS SELECTED BY STUDENTS IN A MIDDLE SCHOOL-BASED DIABETES PREVENTION INTERVENTION PROGRAM: THE HEALTHY EXPERIENCE

The HEALTHY study group, Connie C. Mobley, Diane D. Stadler, Myrlene A. Staten, Laurie EI Ghormli, Bonnie Gills, Jill Harstein, Anna Maria Siega-Riz, Amy Virus

Presented by Aubrey Mahall

TSFE (Total School Food Environment)

Access to food determines dietary behaviors Children consume 35%-47% of daily intake

in school food environments NSLP and SBP

USDA provides nutritional standards and requirements

Federally subsidized “Competitive” food locations

A la carte, vending machines, school stores, and other school sponsored venues

“Competitive” Foods

Connecticut’s Healthy Food Certification (HFC) Provides monetary incentives to school districts that

choose to implement state nutrition standards for all foods sold to students outside of reimbursable school meals

For the 2006-2007 school year HFC (monetary incentives) were provided Food service directors were surveyed about the

availability of competitive foods before and after intervention

Food items frequently not purchased after HFC: Candy, full-fat ice cream, pastries, and cookies.

The HEALTHY Experience

4 integrated components: Nutrition Physical activity Behavioral knowledge and skills Communications and social marketing

Changes to TSFE enhanced by: Educational outreach Behavior change activities Promotional messaging

Purpose/Goal

To serve food and beverages of higher nutrient quality and

appropriate quantities

Hypothesis: The improvements in foods and beverages offered in TSFE would improve those selected and served to the students

Methods/Design

3 year, randomized, multicenter, school-based primary prevention trial 6 middle schools serving minority and low-

income pop’s Across 10 school districts located at 7 sites

across the country 4,603 students

6th – 8th graders Fall 2006 – Spring 2009

Procedures

Registered Dietitian at each site provided training and guidance to each school’s food service manager Coordinated achievement study goals for

district/school Educational events held during

lunchtime “Taste tests” of new products Unfamiliar food introduction Comparison of available items

Food departments given $3000 per year

Data Collection

Baseline and end of study Conducted by trained staff not involved in

implementation Aim to eliminate researcher bias

Nutrition data extracted from food service mgmt: Work production sheets, food/beverage

product specification sheets, and labels, recipes, and menus

Portion control: “Taken off the line,” selected by, or sold

Data Analysis

Nutrition Data System for Research Outputs a complete breakdown of nutrients

USDA Nutrient Data Laboratory NSLP

Entrees with high protein/carb and 400 kcal SBP

Considered high-fat if >30% kcal from fat High-fiber foods

Grain-based food or legumes > 2g dietary fiber per serving

A la carte Category specific: cookies, pizza, and ice cream

Results: Table 1

Results

More intervention than control schools had success in all goals except for fiber, fruit, and vegetable goals

High percents of both schools served no more than 6 oz 100% fruit juice and only low-fat milk at SBP

Little change in participation numbers of NSLP and SBP More students participate in NSLP than SBP

Intervention schools served significantly more grams of fiber from grain-based foods Yet still no difference in servings per student of high-

fiber grain-based foods

Results: Figure 1

Discussion

Changes in food served contribute to future beneficial effects: Greater reductions in BMI, % of students with

waist circum. > 90th percentile, and fasting insulin levels.

Reduction in high-fat foods, desserts, and added-sugar beverages was successful for NSLP

Research RD’s requested greater availability of high-fiber products Higher cost of fiber-rich foods

Discussion: What can we do?

Barriers to F/V consumption: Food service decisions controlled by

district, not school Cost and availability of F/V at given time Lack of student familiarity with variety

of F/V Juicing?

Allows student control and creativity in choosing

Drawbacks: cost of juicers, cost of all the added fruits and veggies, cleaning juicers after each student may take a long time for a lunch period

Strengths Challenges

Integrates nutrition with education, physical activity, and

learning experiences

Integrative nature: can’t single out which changes

most effective

Sample size: 4000+ Annual food bidding process

Middle schools across the country A la carte items finance school activities

Use of dietitian Availability and cost of F/V or higher-fiber options

Educational events held during lunchtime

Potential better method of tracking a la carte

computations

$3000 per year to schools No knowledge of serving consumption/plate waste

Implications

Basis for future research Education on “competitive” foods and

changing their availability/desirability As RD’s:

Our knowledge and skills are crucial in school food service systems in order to combat childhood obesity

This study outlines the major barriers to fruit/vegetable/fiber intake

Need for creativity and innovative ideas to accomplish these goals

BB Questions

Stacy: As a future Dietitian would you recommend instead a focus on removing processed foods, foods high in sugar (including fruit juice), and starchy foods like corn and potatoes (often referred to as vegetables) from the school menu instead? 

Rachel: At the end of the article, the Healthy Hungry Free-Kids Act was mentioned. I’ve heard of it before, but not much beyond that. How has this act affected school meal programs?

Smart Snacks

in School

Smart Snacks in School

“The Smart Snacks in School nutrition standards support better health for our kids and echo the good work already taking place in schools across the country. The new standards preserve flexibility for time-honored traditions like fundraisers and bake sales, and provide ample transition time for schools.”

Targets: More of the foods we should encourage Less of the foods we should avoid. Targeted beverage standards allowing variation by age

group. Flexibility for important traditions. Ample time for implementation.

Sources

Mobley C, Stadler D, Virus A, et al. Effect of Nutrition Changes on Foods Selected by Students in a Middle School-Based Diabetes Prevention Intervention Program: The HEALTHY Experience. Journal Of School Health [serial online]. February 2012;82(2):82-90. Available from: Academic Search Complete, Ipswich, MA. Accessed September 3, 2013.

Long M, Henderson K, Schwartz M. Evaluating the Impact of a Connecticut Program to Reduce Availability of Unhealthy Competitive Food in Schools. Journal Of School Health [serial online]. October 2010;80(10):478-486. Available from: Academic Search Complete, Ipswich, MA. Accessed September 3, 2013.

Kakarala M, Keast D, Hoerr S. Schoolchildren's Consumption of Competitive Foods and Beverages, Excluding à la Carte. Journal Of School Health [serial online]. September 2010;80(9):429-435. Available from: Academic Search Complete, Ipswich, MA. Accessed September 3, 2013.

Snelling A, Yezek J. The Effect of Nutrient-Based Standards on Competitive Foods in 3 Schools: Potential Savings in Kilocalories and Grams of Fat. Journal Of School Health [serial online]. February 2012;82(2):91-96. Available from: Academic Search Complete, Ipswich, MA. Accessed September 3, 2013.

United States Department of Agriculture. Smart Snacks in School. http://www.fns.usda.gov/cnd/governance/legislation/allfoods.htm Accessed: September 9th, 2013.