Children's eating behavior: the importance of nutrition standards for foods in schools.

School nutrition services provide access to a variety of nutritious foods that promote students’ health and their capacity to attend to academic tasks.1 About 94% of schools in the United States, both private and public, participate in the National School Lunch Program (NSLP). Schools are therefore uniquely positioned to promote healthy eating behaviors and attitudes toward food among the vast majority of American children.2–4 Nutrition service programs in NSLP-participating schools must abide by federal and state policies that mandate compulsory nutrient-based standards for school meals. The Healthy Meals for Healthy Americans Act of 1994 requires that NSLP-participating schools serve balanced and nutritious meals that comply with the United Stated Department of Agriculture (USDA) Dietary Guidelines for Americans.5,6 Participating schools are required to serve lunches that provide at least one third of children’s recommended daily food and nutrient intake, meet specific macronutrient and micronutrient requirements, and include a variety of meat/meat alternatives, whole grains, fruits, vegetables, and low-fat dairy options.6,7 The availability of nutritious foods as part of school meals increases children’s consumption of whole grains,8,9 fruits,10 vegetables,10 and low-fat milk.11,12 In the past decade, there have been several notable improvements to school meals with respect to the nutrient properties of available foods and the use of healthier food preparation practices.3,13,14 In addition, the Centers for Disease Control & Prevention (CDC) and the Institute of Medicine (IOM) issued a set of recommended nutrition standards for foods offered in competition with federally reimbursable meals in 2007.15 Preliminary evidence suggests that high fat/calorie and low nutrient “competitive” foods/beverages are becoming less available in some schools,16,17 but the IOM’s recommendations are not yet legislated at the federal level and the degree to which they have been adopted at local levels is unknown. Currently, high fat/calorie and low nutrient foods remain abundantly available in many schools through a la carte services in the cafeteria, school stores, and vending machines.14,15 Most states (58%) and the majority of school districts (61%) permit the sale of competitive foods and beverages, which are neither regulated by federal nutrition guidelines nor likely to conform to nutrient intake recommendations.15 Access to competitive foods may counteract the beneficial effects of nutritious school meals and pose a significant barrier to the establishment of health-promoting school environments.15,18,19 Despite the potential importance of school nutrition programs to students’ health, there has been limited research attention given to how program policies and practices affect students’ overall eating behavior, particularly outside of school.19 We conducted an observational study to test the hypothesis that the availability of nutritious foods during school lunch periods, as indicated by compliance with USDA recommendations, would be positively associated with children’s healthier eating behavior both in and out of school. Furthermore, we expected that the frequency with which students purchased school meals would enhance the positive effect of healthier food availability on student behavior, whereas the frequency of competitive (a la carte) food purchasing would diminish this effect.