ABSTRACT
BACKGROUND: The Healthy, Hunger-Free Kids Act (HHFKA) 2010 updated standards to increase the nutritional quality of school meals. Studies of HHFKA outcomes have focused primarily on fruit and vegetables, nutrient quality of whole meals, and plate waste. OBJECTIVE: To examine changes in school lunch entrée nutrient quality and student selections after HHFKA implementation. DESIGN: Descriptive, longitudinal study analyzing 1.7 million student-selected lunch entrées in eight entrée categories. PARTICIPANTS/SETTING: Three middle schools and three high schools in an urban school district in Washington State, from January 2011 to January 2014 (16 months before and 15 months after HHFKA implementation). MAIN OUTCOME MEASURES: Nutritional quality of each entrée category was assessed by analyzing mean adequacy ratio, energy density, and energy per serving. Selection was determined by analyzing number of entrées in each category selected by students. STATISTICAL ANALYSES PERFORMED: Comparison of indices of pre- and postimplementation nutritional quality using a combination of Wilcoxon two-sample test with t approximation and a two-sided alternative t test assuming equal variances and t test assuming unequal variances using Satterthwaite approximation. Quantity of entrée categories selected was also determined by Satterthwaite approximation. RESULTS: After implementation, there was significant improvement in mean adequacy ratio and energy per serving overall for all entrées combined. There were significant improvements in both mean adequacy ratio and energy per serving for salads, burritos, and pizza in middle schools and for hot sandwiches and burritos in high schools. For energy density, middle schools also had significant decreases for casseroles and salads, with no significant changes found in high schools. The variety of entrées decreased by 44%, and there were significant changes in the proportions of entrées selected from specific food categories. CONCLUSION: Nutritional quality of lunch entrées, variety of entrées available, and student entrée selections changed after implementation of HHFKA policy in one urban school district in Washington State.
