Inventory Versus Checklist Approach to Assess Middle School à la Carte Food Availability

While the epidemic of childhood obesity is well documented, the etiology of the disease is poorly understood.1,2 One venue that has been investigated for its contribution to the epidemic and called upon to help reduce the risk is the school environment.3,4 Beyond food served as part of the United States Department of Agriculture’s (USDA) National School Lunch Program (NSLP) and School Breakfast Program (SBP), it is well recognized that youth have many other options for eating and drinking during the school day. An important source of this additional food that is largely unregulated is the competitive foods or foods that “compete” with the regular meal pattern lunch such as foods offered as fund-raisers or incentives, foods available in vending and in schools stores or foods available on the a la carte line.5,6 A la carte foods are foods and beverages available in the cafeteria that are not part of the regular reimbursable meal pattern. Foods available through a la carte are of particular interest because of their availability in large numbers, the majority of which are high in fat and sugar.4,5 The presence of an a la carte line in schools has been shown to impact the dietary intake of youth across the entire day.7,8 Interest in understanding the role and extent of competitive foods in schools and attempting to encourage schools to offer more healthful options in a la carte and vending has been growing in the past 2 decades. In 1996, the Centers for Disease Control and Prevention published the Guidelines for School Health Programs to promote lifelong healthy eating, one of the first government documents to draw attention to other sources of food in schools and its potential to impact the health of school children.9 In 2004, USDA passed the Child Nutrition and Women, Infants, and Children (WIC) Reauthorization Act10 that required the development of a wellness policy that included, among other things, guidelines for competitive foods in schools. Most recently, the Institute of Medicine (IOM) published specific criteria to be applied to evaluate the healthfulness of foods offered outside of the NSLP.11 With this interest, a variety of stakeholders, including school staff, community interest groups, public health nutrition advocacy groups, and researchers, have attempted to assess and evaluate what schools are offering through their a la carte programs and the healthfulness of those choices. Current reports of a la carte foods tend to be descriptive in nature, for example, reporting the proportion of schools that offer salty snacks or soft drinks. While this information has been important in drawing attention to the types of foods that are offered in schools, more work needs to be done to increase our understanding of how the food environment of schools may be related to health.5 The intent of measuring the healthfulness of an environment is actually to assess an attribute of the environment that may affect health; for example an environment that offers more healthful options as compared to fewer healthful options. This characterization is most useful if it results in a measure that has construct validity (eg, being able to show that schools with more healthful foods in the environment have students who eat more healthful foods) or a measure that can rank order schools along a continuum that assesses the degree of obesogenic potential or conditions leading to obesity.12 We know very little about how tools compare with regard to their ability to rank order schools along some continuum of “healthfulness” or “obesogeneity.” A number of methods have been used to identify and quantify foods offered on school a la carte lines including the use of cash register data,13 inventories,7 and checklists.5 However, each method has its limitations with regard to expense, amount of data reduction required, validity, and reliability. There is a great need for tools that are efficient, reliable, and valid indicators of the “healthfulness” of the school food environment, both for school stakeholders and for researchers attempting to characterize school food environments along some continuum of healthfulness or obesogeneity. The purpose of this study is to compare 2 approaches for ranking schools with regard to healthfulness of foods available on the a la carte lines: a detailed inventory approach, and a checklist approach. The hypothesis is that a checklist approach is a valid method for assessing the healthfulness of the a la carte food environment of schools, particularly when resources for data collection may be limited.