School feeding programs in developing countries: impacts on children's health and educational outcomes.

School feeding programs (SFPs) are intended to alleviate short-term hunger, improve nutrition and cognition of children, and transfer income to families. The present review explores the impact of SFPs on nutritional, health, and educational outcomes of school-aged children in developing countries. Peer-reviewed journal articles and reviews published in the past 20 years were identified and screened for inclusion. Analysis of the articles revealed relatively consistent positive effects of school feeding in its different modalities on energy intake, micronutrient status, school enrollment, and attendance of the children participating in SFPs compared to non-participants. However, the positive impact of school feeding on growth, cognition, and academic achievement of school-aged children receiving SFPs compared to non-school-fed children was less conclusive. This review identifies research gaps and challenges that need to be addressed in the design and implementation of SFPs and calls for theory-based impact evaluations to strengthen the scientific evidence behind designing, funding, and implementing SFPs.

Student involvement in wellness policies: a study of Pennsylvania local education agencies.

OBJECTIVE: Explore student-involvement goals in local wellness policies (LWPs) of local education agencies (LEAs) in Pennsylvania (PA) and investigate associations with LEA characteristics. DESIGN: An observational study that helped examine student-involvement goals. SETTING: Public PA LEAs. PARTICIPANTS: LWPs submitted by 539 PA public LEAs. MAIN OUTCOME MEASURES: Six student-involvement goals analyzed as dependent variables. Correlations between demographic and policy characteristics of LEAs and student-involvement goals were measured. ANALYSIS: Policies developed by LEAs were abstracted and analyzed. Logistic regression models were developed to analyze relationships between student-involvement goals and the demographic and policy characteristics of LEAs. RESULTS: Majority of LEAs included policy goals that address student involvement in an array of activities related to wellness policy, food service, and role modeling. Regression models showed that LEAs with comprehensive and strong policies were most likely to include student-involvement goals regardless of LEA location, enrollment, or socioeconomic status of students. CONCLUSIONS AND IMPLICATIONS: Student engagement in school nutrition policies has been shown to increase student acceptance in an array of health-related areas and is therefore promising in the area of obesity prevention. Comprehensiveness and rigor of LWPs were strongly correlated with the inclusion of student-involvement goals on LWPs. The upcoming reauthorization of the Child Nutrition programs in 2010 creates a good opportunity to address student involvement in LWPs.

Lessons from Pennsylvania's mixed response to federal school wellness law.

Federal legislation aimed at tackling the nation's soaring childhood obesity rate through changes to school meals and nutrition and wellness programs has met with mixed results. An examination of Pennsylvania's response to the Child Nutrition and Women, Infants, and Children (WIC) Reauthorization Act of 2004, one of the most comprehensive state responses, found improvements to the nutritional quality of foods offered à la carte in conjunction with school meal programs. However, multiple weaknesses remain. Consistent wellness policy implementation steps were not followed, and there was inadequate statewide enforcement. Despite this, Pennsylvania can offer lessons for other states in moving forward with programs to promote good nutrition and wellness.

A comprehensive coding system to measure the quality of school wellness policies.

In 2006, all local education agencies in the United States participating in the National School Lunch Program were required to establish school wellness policies that covered nutrition education, nutrition standards for school foods, and physical activity. The purpose of this psychometric study was to develop and evaluate the properties of a comprehensive and quantitative coding system to evaluate the quality of these policies. A 96-item coding tool was developed to evaluate seven goal areas: nutrition education, standards for US Department of Agriculture child nutrition programs and school meals, nutrition standards for competitive and other foods and beverages, physical education, physical activity, communication and promotion, and evaluation. Each goal area subscale and the total scale were scored on two dimensions: comprehensiveness and strength. Reliability was assessed by having pairs of researchers from four different states code a sample of 60 polices between July 2007 and July 2008. Goal area subscales were internally reliable (Cronbach's alpha=.60 to .93). Adequate interrater reliability scores were obtained at each level of scoring: total comprehensiveness and strength scores (intraclass correlation coefficient 0.82), subscale scores (intraclass correlation coefficient 0.70), and individual items (intraclass correlation coefficient 0.72). This coding system provided a reliable method for analyzing and comparing school district wellness policies in single or multistate studies.

Statewide assessment of local wellness policies in Pennsylvania public school districts.

With the passage of the Child Nutrition and Women, Infants, and Children Reauthorization Act of 2004, schools that sponsor school meals programs are required to establish local wellness policies to address childhood obesity. Little is known about how school districts will respond to this mandate, the nature of local wellness policies, and their compliance with this mandate. The objectives of this cross-sectional descriptive study, conducted in early 2007, were to assess local wellness policies established by Pennsylvania public school districts, compare these policies to local wellness policy mandate requirements, and provide information about local wellness policy development and implementation. Local wellness policies were collected from all Pennsylvania public school districts that sponsor school meals programs (N=499). School district representatives also completed and submitted a local wellness policy checklist, providing information about local wellness policy development and implementation. Policy goal data were abstracted and entered into a Microsoft Access database along with local wellness policy data. Frequencies were calculated. All required public school districts (N=499) submitted local wellness policies. Most school district local wellness policies (85.6%-100%) met each mandate requirement (eg, included goals for nutrition education, physical activity, etc.). The most common policy goals were general and may be difficult to measure, suggesting school staff may need assistance developing action plans and measuring policy implementation. Most respondents identified the superintendent (n=377; 75.6%) and school foodservice director (n=301; 60.3%) as responsible for ensuring local wellness policy implementation. Questions remain about feasibility of these district-level personnel to ensure policy implementation at the school level. The ability of local wellness policies to impact childhood obesity will depend on efforts at both the school and district levels to implement and enforce local wellness policies.

Addressing childhood overweight through schools.

Rates of childhood obesity in have reached alarming proportions in many countries. Sixteen percent of school-aged children and adolescents in the U.S. are overweight. Legislation implemented in 2004 in the U.S. requires local education agencies (LEAs) that sponsor school meal programs to establish local wellness policies to address childhood obesity. Project PA, a collaboration between a state agency and a university providing school-based interventions focuses on the school environment and policy changes. Interventions have targeted foodservice personnel, administrators, teachers, parents and students. In two recent projects schools assessed their school nutrition environments, developed nutrition policies, and implemented strategies to encourage healthier food selections. Schools identified weaknesses in the areas of marketing and communication of policies. Media attention on the childhood obesity facilitated policy changes. Time and cost were identified as barriers to policy development and there were concerns about weak enforcement of policies. These themes are discussed.

Existence and predictors of soft drink advertisements in Pennsylvania high schools.

The objective of this study was to describe the extent and locations of soft drink advertisements on high school campuses in Pennsylvania and identify factors related to extent of these advertisements. Surveys were distributed to 271 school foodservice directors in a random sample of high schools in Pennsylvania. These high schools were selected to be representative of the entire population of high schools in Pennsylvania based on chosen demographic characteristics. A three-phase survey strategy was used, involving distribution of a postcard reminder 1 to 2 weeks after the initial survey distribution, and mailing of a second survey to nonrespondents 1 to 2 weeks after mailing of the postcard. Two hundred twenty-eight school foodservice directors (84%) returned surveys. Linear multiple regression analyses were done using SPSS (version 11.5.1, 2002, SPSS Inc, Chicago, IL). Approximately two thirds (66.5%) of respondents indicated soft drink advertisements exist in at least one location in their school, with the most prevalent locations being on vending machines (62%) and school grounds, such as playing fields (27%). Slightly more than 10% of respondents indicated soft drink advertisements displayed in the cafeteria. Extent of soft drink advertisement locations was positively related to existence of a pouring-rights contract, subscription to Channel One, and receipt of incentives from soft drink bottlers based on sales, but negatively related to average daily participation in school lunch. These findings suggest that commercialization and sales incentives might interact to contribute to school environments that are not "nutrition-friendly." Schools' efforts to establish wellness policies as mandated by the Child Nutrition and WIC Reauthorization Act of 2004 provide ideal opportunities to examine school environments for advertising that might conflict with the healthful environments they are aiming to establish, and perhaps to develop policies to address these practices.

Factors associated with the offering and sale of competitive foods and school lunch participation.

OBJECTIVE: The objective of this study was to identify factors that predict offering and sale of competitive foods, as well as factors that predict average daily participation in school lunch. DESIGN: Surveys were distributed to 271 school foodservice directors in a random sample of high schools in Pennsylvania that were selected to be representative of the entire population of high schools in Pennsylvania based on chosen demographic characteristics. SUBJECTS: Two hundred twenty-eight school foodservice directors (84%) returned surveys. STATISTICAL ANALYSES: Descriptive and multiple regression analyses were done using SPSS version 11.5 (2002, SPSS Inc, Chicago, IL). RESULTS: Percentage of students eligible for free or reduced-price meals and timing of lunch were significant predictors of a la carte sales. Enrollment was negatively associated with number of vending machines per student. The number of less nutritious food items offered in vending machines and existence of soft drink machines owned by soft drink companies, for which the school receives a percent of sales, both predicted number of vending machines per student. Enrollment was inversely related to average daily participation in school lunch. The percentage of students eligible for free/reduced-price meals and enforcement of a policy prohibiting parents or students from bringing food into the cafeteria from local fast-food establishments positively predicted average daily participation in school lunch. CONCLUSIONS: These findings may be useful to school wellness councils in developing wellness policies as mandated by the Child Nutrition and WIC Reauthorization Act of 2004, as well as in structuring school environments to promote more healthful food choices by students.

School competitive food policies: perceptions of Pennsylvania public high school foodservice directors and principals.

The objectives of this study were to describe the extent, nature, and enforcement of school competitive food policies in Pennsylvania public high schools and to determine if there are differences between school foodservice directors' and principals' perceptions of the existence and enforcement of these policies. A survey was distributed to 271 school foodservice directors and 100 principals in a representative, random sample of high schools. Two hundred twenty-eight school foodservice directors (84%) and 79 principals (79%) returned surveys. Descriptive statistics, chi2 analyses, and a proportions test were done using SPSS statistical software (SPSS base 11.5 for Windows, 2002, SPSS Inc, Chicago, IL). Few nutrition policies were reported related to setting nutritional standards for competitive foods (0.5% to 15.0%). Respondents' reporting of existence of policies not always enforced ranged from 0% to 12.8%. School foodservice directors reported uncertainty about existence of several policies outside their direct domain, but with potential effect on school meals participation. Differences were found between school foodservice directors' and principals' reporting of policies, with principals more often reporting policy existence and enforcement. These findings suggest the need for communication, both about existence of policies and chain of command in enforcement of policies. Given the local wellness policy provision of the Child Nutrition and WIC Reauthorization Act of 2004, opportunities exist for nutrition professionals to contribute to development of policies that influence the nutritional quality of school foods.

Competitive foods available in Pennsylvania public high schools.

OBJECTIVE: This study examined the types and extent of competitive foods available in public high schools in Pennsylvania. DESIGN: We developed, pilot tested, and distributed surveys to school foodservice directors in a random sample of 271 high schools in Pennsylvania. SUBJECTS: Two hundred twenty-eight surveys were returned, for a response rate of 84%. Statistical analyses were performed: Descriptive statistics were used to examine the extent of competitive food sales in Pennsylvania public high schools. The survey data were analyzed using SPSS software version 11.5.1 (2002, SPSS base 11.0 for Windows, SPSS Inc, Chicago, IL). RESULTS: A la carte sales provide almost dollar 700/day to school foodservice programs, almost 85% of which receive no financial support from their school districts. The top-selling a la carte items are "hamburgers, pizza, and sandwiches." Ninety-four percent of respondents indicated that vending machines are accessible to students. The item most commonly offered in vending machines is bottled water (71.5%). While food items are less often available through school stores and club fund-raisers, candy is the item most commonly offered through these sources. CONCLUSIONS: Competitive foods are widely available in high schools. Although many of the items available are low in nutritional value, we found several of the top-selling a la carte options to be nutritious and bottled water the item most often identified as available through vending machines.

Food safety knowledge, perceptions, and behaviors among middle school students.

OBJECTIVE: To assess the level of food safety knowledge, perceptions, and self-reported food-handling behaviors among middle school students. DESIGN: Baseline questionnaire administered in class that assessed background characteristics, knowledge, behaviors, and perceptions related to food safety. PARTICIPANTS: 178 seventh and eighth grade students from 4 schools in central Pennsylvania. MAIN OUTCOME MEASURES: Food safety knowledge, perceptions, and self-reported food-handling behaviors. ANALYSIS: Independent samples t test tested differences between genders and bivariate correlation analysis explored associations among knowledge, perceptions, and behavior (P <.05). RESULTS: Food safety knowledge score was 7.2 +/- 1.6 of a maximum of 10 points. Perceived self-efficacy and severity of a foodborne illness were high, but perceived susceptibility was low. Girls scored higher on the self-efficacy and severity scale (P <.01). Self-efficacy correlated positively with knowledge and behavior (P <.0001) and severity with knowledge (P <.01). One fifth reported taking risks in food handling and one fifth reported having been sick because of something they ate. CONCLUSIONS AND IMPLICATIONS: There is a disconnection between middle school students' food safety knowledge, perceptions, and behaviors. A need for relevant and motivating food safety education exists in this group.

Body image among older, rural, African-American women with type 2 diabetes.

Type 2 diabetes and obesity co-occur in high prevalence among African-American women. The positive value placed on large body size has both historic and contemporary biosocial relevance. The maintenance of weight at medically recommended levels is a cornerstone of both prevention and treatment of Type 2 diabetes. This study of overweight, elderly, rural African-American women with Type 2 diabetes found they generally preferred smaller body sizes compared to previous studies. Normal to slim body images as presented in a photographic array were selected as being more attractive, less likely to have diabetes and hypertension, healthier and to be more medically compliant than obese, grossly obese or very thin images. Body image is a psychosocial variable that should be included in weight control initiatives.