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Nutrition Services and Foods and Beverages Available at School: Results From the School Health Policies and Programs Study 2006

Posted on: Saturday, 22 December 2007, 06:00 CST

By O'Toole, Terrence P Anderson, Susan; Miller, Clare; Guthrie, Joanne

ABSTRACT BACKGROUND: Schools are in a unique position to promote healthy dietary behaviors and help ensure appropriate nutrient intake. This article describes the characteristics of both school nutrition services and the foods and beverages sold outside of the school meals program in the United States, including state- and district-level policies and school practices.

METHODS: The Centers for Disease Control and Prevention conducts the School Health Policies and Programs Study every 6 years. In 2006, computer-assisted telephone interviews or self-administered mail questionnaires were completed by state education agency personnel in all 50 states plus the District of Columbia and among a nationally representative sample of school districts (n = 445). Computer-assisted personal interviews were conducted with personnel in a nationally representative sample of elementary, middle, and high schools (n = 944).

RESULTS: Few states required schools to restrict the availability of deep-fried foods, to prohibit the sale of foods that have low nutrient density in certain venues, or to make healthful beverages available when beverages were offered. While many schools sold healthful foods and beverages outside of the school nutrition services program, many also sold items high in fat, sodium, and added sugars.

CONCLUSIONS: Nutrition services program practices in many schools continue to need improvement. Districts and schools should implement more food preparation practices that reduce the total fat, saturated fat, sodium, and added sugar content of school meals. In addition, opportunities to eat and drink at school should be used to encourage greater daily consumption of fruits, vegetables, whole grains, and nonfat or low-fat dairy products.

Keywords: food service; nutrition; schools; school policy; surveys.

Citation: O'Toole TP, Anderson S, Miller C, Guthrie J. Nutrition services and foods and beverages available at school: results from the School Health Policies and Programs Study 2006. J Sch Health. 2007; 77: 500-521.

Healthy eating is an essential component of a healthy lifestyle1 and is associated with an increased life expectancy, increased quality of life, and reduced risk for many chronic diseases including cardiovascular disease,2 cancer,3 and diabetes.4 Dietary habits and preferences form in childhood and become habitual over time.5 As individuals move from childhood through adolescence and into adulthood, their dietary intake of key nutrients such as iron and calcium decreases.6"8 These factors highlight the need for school-based nutrition education and supportive school environments to help youth eat more healthfully.

The need to promote healthy eating among youth has intensified as a result of the growing national epidemic of obesity. Obesity is essentially caused by caloric imbalance: poor dietary choices contribute to an excess of caloric intake as compared with caloric expenditure. Since 1980, the percentage of children who are obese has more than doubled, and rates among adolescents have more than tripled.9-11 In 2004, 18.8% of 6- to 11-year-olds and 17.4% of 12- to 19-year-olds were considered obese, and an additional 20.4% of 6- to 11-year-olds and 15.3% of 12- to 19-year-olds were considered overweight.9 (Note that these classifications of obese and overweight do not reflect the classifications used in the articles cited, but rather the June 2007 recommendations from the Expert Committee on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity convened by the American Medical Association [AMA] and cofunded by AMA in collaboration with the Health Resources and Services AcLministration and the Centers for Disease Control and Prevention [CDC].) Healthy eating is also important in the prevention of type 2 diabetes, the prevalence of which has increased dramatically among young people and is often associated with obesity.12,13

Undernutrition during childhood may have longterm consequences for the physical health and development of children.14 Undernutrition also can have lasting effects on children's cognitive development and school performance.15 Whereas food insufficiency and hunger are associated with poor behavioral and academic functioning in low-income children,16 participation in school breakfast programs is associated with improved psychosocial and academic measures.17

Schools are in a unique position to promote healthy dietary behaviors and help ensure appropriate nutrient intake. In 2004, more than half (54%) of school-aged children in the United States received either school breakfast or school lunch, and 1 in 6 received both.18 In addition to these sources of foods and beverages, students at many schools obtain snacks from various other venues (eg, a la carte sales, vending machines, school stores, snack bars, classroom parties, and concession stands). School nutrition services staff can promote healthy eating through the foods they make available each day in the school cafeteria and the opportunities they have to reinforce nutrition education taught in the classroom. Teachers can help promote healthy eating by including behavior-focused nutrition education in classroom curricula. School administrators and policy makers also can help by adopting and implementing policies to improve the nutritional quality of foods and beverages available at school outside of the school breakfast and lunch programs.

The nutritional quality of school meals is addressed by federal regulations. In 1994, Congress passed the Healthy Meals for Healthy Americans Act (PL 103-448), which amended the National School Lunch Act.19 Regulations for the Act were released in 1995 by the US Department of Agriculture (USDA), which administers the reimbursable National School Lunch Program (NSLP) and the reimbursable School Breakfast Program (SBP), as part of the School Meals Initiative for Healthy Children.20 USDA requires schools to serve meals that adhere to the recommendations of the Dietary Guidelines for Americans (DGA). When averaged over a school week, school meals must meet limits on total fat and saturated fat, and meet specific percentages of the Recommended Daily Allowances for calories, protein, calcium, iron, vitamin A, and vitamin C. National studies conducted by the USDA found meaningful and statistically significant decreases between the 1991-1992 and 1998-1999 school years in levels of fat and saturated fat relative to calorie content in the lunches offered to students.21 However, the average total fat and saturated fat content of school breakfasts and lunches was still above DGA targets.

Many foods and beverages are available to students outside of the school meals program (ie, competitive foods) in venues throughout the school. Unlike school meals that must meet certain nutrition standards, foods and beverages sold or provided outside of the school meals program are largely exempt from federal requirements or standards.22 These competitive foods are relatively low in nutrient density and are relatively high in fat, added sugars, and calories. The ready availability of these foods might stigmatize participation in school meal programs because only children with money can purchase competitive foods. This, in turn, might affect the viability of school meal programs because children might perceive school meals as being primarily for poor children rather than being nutrition programs for all children.23 Competitive foods might also convey a mixed message to students. That is, when children are taught in the classroom about the value of healthy food choices but the school environment consists of vending machines, snack bars, school stores, and a la carte sales offering options that are low in nutrient density, they receive the message that good nutrition is an academic exercise not supported by the school administration and, therefore, not important to their health or education.23

The only federal regulations on competitive foods and beverages prohibit the sale of "foods of minimal nutritional value" (ie, carbonated soft drinks, chewing gum, water ices, and certain candies made primarily from sweeteners) in the food service area during school meal periods. However, foods of minimal nutritional value may be sold outside the cafeteria at any time. Thus, federal regulations do not prohibit schools from selling carbonated soft drinks in vending machines located near but not inside the food service area throughout the school day, nor do they restrict the sale of other foods of low nutritional value such as chips, most candy bars, and noncarbonated, high-sugar drinks that are not 100% juice anywhere on campus, including the food service area.

Attention is increasingly focused on the need to establish school nutrition standards and limit access to competitive foods. School nutrition policy initiatives have been implemented at the federal, state, and local levels. The recently released Institute of Medicine report Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth24 provides specific recommendations for foods and beverages served outside of the school meals program that schools, districts, and states should consider when developing or strengthening policies for nutrition in schools. This report concluded that while federally reimbursable school nutrition programs provide students access to foods that contribute to a healthful diet at school, many schools offer foods and beverages that compete with the school meals. Schools are encouraged to limit such opportunities. For schools that choose to make competitive foods available, they should encourage fruits, vegetables, whole grains, and nonfat or low-fat milk and dairy products that are consistent with the 2005 DGA. Selected Federal Support and Related Research

The USDA reimbursable NSLP operates in more than 90% of all public schools with 80% of those schools also offering a school breakfast.18 The SBP operates in more than 72,000 schools and institutions.25 These meal programs serve more than 27 million lunches and more than 9 million breakfasts daily.18 The USDA's Team Nutrition initiative has produced and widely disseminated numerous materials to help teachers integrate nutrition education into the school curriculum and to help nutrition services staff meet nutritional standards and reinforce classroom nutrition education.26 Most notably, USDA has produced Changing the Scene: Improving the School Nutrition Environment-A Local Guide to Action, a comprehensive multimedia guide to improving the overall school nutrition environment.27 Technical assistance materials for nutrition services staff also are available from the National Food Service Management Institute (NFSMI)28 and the School Nutrition Association.29

The CDC currently funds education agencies and health departments in 23 states to support school health programs and strengthen school health education to prevent youth from establishing behaviors, including poor dietary habits, that are associated with chronic diseases. The CDC also provides funding to 28 states for developing and implementing nutrition and physical activity interventions, particularly through population-based strategies (eg, policylevel changes, environmental supports), some of which are school based. In addition, the CDC has published guidelines30 that identify policy and programmatic strategies most likely to be effective in promoting healthy eating among young people. Tools developed to help schools implement the strategies recommended by the CDC guidelines include the CDC's School Health Index: A Self-Assessment and Planning Guide?1 which helps schools identify the strengths and weaknesses of current policies and practices and develop an action plan to improve them; the National Association of State Boards of Education's Fit, Healthy, and Ready to Learn: A School Health Policy Guide?2 which helps schools and local school districts establish strong policies on physical activity, nutrition, and other health issues in the context of a coordinated school health program; and Making It Happen,(TM) a joint publication by the USDA and the CDC, which describes innovative approaches schools and school districts have used to improve the nutritional quality of foods and beverages offered or sold on school campuses outside of federal meals programs.

The USDA periodically conducts studies of the NSLP and SBP, most notably the School Nutrition Dietary Assessment (SNDA) studies. The first SNDA assessed the nutrients and foods provided by public and private schools participating in the NSLP and SBP during the 1991- 1992 school year. A follow-up study, SNDA-II, did the same for public schools during the 1998-1999 school year.21 These studies also provided information about menu planning practices and the availability of alternatives to NSLP and SBP meals, such as a la carte food sales and sales from vending machines. In 2002, the USDA released a report on the third year of implementation of the School Meals Initiative for Healthy Children assessing the extent to which the initiative had led to changes in menu planning approaches, use of nutrient analyses, food procurement and preparation, and program costs.34

The US Congress recognizes that schools play a critical role in promoting student health, preventing childhood obesity, and combating problems associated with poor nutrition and physical inactivity. To formalize and encourage this role. Congress passed PL 108-265 requiring each local education agency participating in a program authorized by the federal school meals program to establish a local school wellness policy by school year 2006. The legislation also places the responsibility of developing a wellness policy at the local level, so the individual needs of each district can be addressed. According to the requirements for the Local Wellness Policy, school districts must set goals for nutrition education, physical activity, campus food provision, and other school-based activities designed to promote student wellness. Additionally, districts are required to involve a broad group of individuals in policy development and have a plan for measuring policy implementation.

This article updates and expands on data from the 2000 School Health Policies and Programs Study (SHPPS)35 and describes for the first time findings from SHPPS 2006 about state- and district-level policies and practices related to food service and child nutrition requirements and recommendations; menu planning, food ordering, and food preparation; professional preparation; nutrition services coordinators; staff development; program promotion; evaluation; collaboration; assistance to districts and schools; and food safety. At the school level, this article describes organization of the school nutrition services program, food ordering and food preparation, breakfast and lunch food and beverage variety and availability, a la carte food and beverage variety and availability, foods and beverages not sold through the school nutrition services program, professional preparation, school food service managers, staff development, program promotion, collaboration, and food safety. In addition, this article describes changes in key policies and practices from 2000 to 2006. While this article is primarily descriptive in nature, the CDC intends to conduct more detailed analyses and encourages others to conduct their own analyses using the questionnaires and public-use data sets available at www.cdc.gov/ shpps.

METHODS

Detailed information about SHPPS 2006 methods is provided in "Methods: School Health Policies and Programs Study 2006" elsewhere in this issue of the Journal of School Health. The following section provides a brief overview of SHPPS 2006 methods specific to the nutrition services component of the study.

SHPPS 2006 assessed nutrition services and foods and beverages sold outside the school nutrition services program at the state, district, and school levels. State-level data were collected from education agencies in all 50 states plus the District of Columbia. District-level data were collected from a nationally representative sample of public school districts. School-level data were collected from a nationally representative sample of public and private elementary schools, middle schools, and high schools.

Questionnaires

The state- and district-level nutrition services questionnaires assessed school nutrition policies and practices for grades K-12. Both questionnaires assessed required staffing, staff development, collaboration between nutrition services staff and other agency and organization staff, evaluation of the nutrition services program, child nutrition requirements and recommendations, assistance to districts or schools, and the educational background and credentials of the persons who oversee or coordinate nutrition services at the state and district levels. The district-level questionnaire also assessed menu planning, food purchasing and ordering, food preparation, and the promotion of nutrition services among families of students.

The school-level questionnaire assessed nutrition services practices in elementary, middle, and high schools. Specifically, the questionnaire assessed the provision of breakfast and lunch; food variety and availability; menu planning; food ordering; food preparation; characteristics of cafeterias; food safety issues; promotion of nutrition services among fami lies of students; collaboration between school nutrition services staff and other school and community personnel; and the educational background, credentials, and recent staff development of the person who oversees or coordinates nutrition services at the school. In addition, the SHPPS 2006 school-level healthy and safe school environment questionnaire assessed foods and beverages offered or sold outside of the school nutrition services program.

Data Collection and Respondents

State- and district-level data were collected by computer- assisted telephone interviews or selfacLministered mail questionnaires. Designated respondents for each of 7 school health program components (ie, health education, physical education and activity, health services, mental health and social services, nutrition services, healthy and safe school environment, and faculty and staff health promotion) completed the interviews or questionnaires. At the state level, the state-level contact designated a single respondent for each questionnaire. At the district level, the district-level contact could designate a different respondent for each questionnaire or questionnaire module. All designated respondents had primary responsibility for, or were the most knowledgeable about, the policies and programs addressed in the particular questionnaire or module.

After a state- or district-level contact identified respondents, each respondent was sent a letter of invitation and packet of study- related materials. Each packet contained a paper copy of the questionnaire^) so that respondents could prepare for the interview and provided a toll-free number and access code that respondents could use to initiate the interview. Respondents were told that the questionnaire^) could be used in preparation for their telephone interview or completed and returned if self-administration was preferred. One week after packets were mailed to respondents, trained interviewers from a call center placed calls to them to schedule and conduct telephone interviews. In April 2006, telephone interviewing ceased and most of the remaining state- and district- level data collection occurred via a mail survey. All remaining respondents were mailed paper questionnaires and return envelopes; however, interviewers remained available for respondents who chose to contact the call center. At the end of the data collection period (October 2006), 90% of the completed state-level nutrition services questionnaires had been completed via telephone interview, and 10% as paper questionnaires. The completed district-level questionnaires were completed via telephone interview 45% of the time.

School-level data were collected by computerassisted personal interviews. During recruitment, the principal or another school- level contact designated a faculty or staff respondent for each component, who had primary responsibility for or the most knowledge about the particular component. For the nutrition services interview, the most common respondents were food service managers and other school nutrition services staff.

Response Rates

One hundred percent (n = 51) of the state education agencies completed the state-level nutrition services questionnaire. At the district level, 705 districts were eligible for the nutrition services interview, and 64% (n = 455) completed the interview. At the school level, 1338 schools were eligible for the nutrition services interview, and 71% (n = 944) completed the interview.

Data Analysis

Data from state-level questionnaires are based on a census and are not weighted. District- and schoollevel data are based on representative samples and are weighted to produce national estimates. Because of missing data, the denominators for each estimate vary slightly. Figures 11 and 12 in Appendix 1 in this issue of the Journal of School Health show the estimated standard error associated with an observed percentage from the district- and school-level nutrition services questionnaires.

To analyze changes between SHPPS 2000 and SHPPS 2006, many variables from SHPPS 2000 were recalculated so that the denominators used for both years of data were defined identically. In most cases, this denominator included all states, districts, or schools, rather than a subset of states, districts, or schools. As a result of this recalculation, percentages previously reported for SHPPS 200035 might differ from those reported in this article. Only estimates from 2000 and 2006 based on this same denominator should be compared.

Because state-level data are based on a census, statistical tests for differences between 2000 and 2006 are not appropriate. Therefore, this article highlights changes over time meeting at least 1 of 2 criteria: (1) the difference was greater than 10 percentage points or (2) the 2006 estimate increased by at least a factor of 2 or decreased by at least half as compared with the 2000 estimate. At the district and school levels, f tests were used to compare SHPPS 2000 and SHPPS 2006 prevalence estimates. However, to account for multiple comparisons, this article only highlights changes over time meeting at least 2 of 3 criteria: (1) a p value less than .01 from the t test, (2) a difference greater than 10 percentage points, or (3) the 2006 estimate increased by at least a factor of 2 or decreased by at least half as compared with the 2000 estimate. A p value less than .01 was used as the sole criterion for reporting on statistically significant differences based on means and medians between 2000 and 2006. Note that not all variables meeting these criteria are presented in this article.

RESULTS

Nutrition Services at the State and District Levels

Child Nutrition Requirements and Recommendations. More than one third (37.3%) of all states had adopted a policy stating that each district will have someone to oversee or coordinate nutrition services in the district. More than 1 in 5 (21.6%) states and 73.7% of all districts had adopted a policy stating that each school will have someone to over see or coordinate nutrition services at the school.

Nationwide, 18.0% of states and 74.1% of districts had adopted a policy stating that all schools will offer breakfast to students. An additional 44.0% of states and 8.7% of districts had adopted a policy stating that some categories of schools, such as those with a certain percentage of students eligible for free or reduced-price meals, will offer breakfast to students. Further, 26.0% of states and 20.3% of districts had adopted a policy stating that schools will encourage breakfast consumption by allowing students to eat in locations other than the cafeteria, such as a school bus or classroom. Only 14.0% of states required and 36.0% recommended a minimum amount of time students would be given to eat breakfast once they were seated. Similarly, 22.3% of districts required and 37.5% recommended a minimum amount of time students would be given to eat breakfast.

Nationwide, 44.9% of states and 95.8% of districts had adopted a policy stating that schools will offer lunch to students. Only 12.0% of states required and 52.0% recommended a minimum amount of time students would be given to eat lunch once they were seated. Similarly, 40.4% of districts required and 42.7% recommended a minimum amount of time students would be given to eat lunch. Further, 94.0% of districts had adopted a policy stating that elementary schools will maintain closed campuses (ie, students are not allowed to leave school during the school day including during lunchtime), 85.6% of districts had adopted a similar policy for middle schools, and 73.1% of districts had adopted a similar policy for high schools.

Some states had requirements or recommendations about specific foods that schools offered to students each day for breakfast and lunch. Specifically, 14.0% of all states required and 18.0% recommended that schools offer students 3 or more different types of milk (eg, 1% chocolate milk or skim unflavored milk) each day for breakfast, and 14.0% of states required and 22.0% recommended that schools offer 3 or more different types of milk each day for lunch. In addition, 4.0% of states required and 42.0% recommended that schools offer students a choice between 2 or more different fruits or types of 100% fruit juice each day for lunch, 4.0% of states required and 40.0% recommended that schools offer students a choice between 2 or more different nonfried vegetables each day for lunch, and 6.0% of states required and 50.0% recommended that schools offer students a choice between 2 or more different entrees or main courses each day for lunch.

Some districts also had requirements or recommendations about specific foods that schools offer to students each day for breakfast and lunch. Specifically, 40.7% of districts required and 26.8% recommended that schools offer students 3 or more different types of milk (eg, 1% chocolate milk or skim unflavored milk) each day for breakfast, and 49.6% of districts required and 30.4% recommended that schools offer 3 or more different types of milk each day for lunch. In addition, 23.0% of districts required and 44.6% recommended that schools offer students a choice between 2 or more different fruits or types of 100% fruit juice each day for lunch, 23.9% of districts required and 38.9% recommended that schools offer students a choice between 2 or more different nonfried vegetables each day for lunch, and 30.3% of districts required and 36.0% recommended that schools offer students a choice between 2 or more different entrees or main courses each day for lunch.

In addition to the school breakfast and lunch programs, many schools also offered foods and beverages as a la carte sales (ie, food items sold individually rather than as part of a complete meal) during breakfast or lunch, and in after-school programs, school stores or snack bars, vending machines, student parties, family meetings, staff meetings, and concession stands. Only 4.0% of states required and 8.0% recommended, and 34.6% of districts required and 10.4% recommended, that schools prohibit brand-name fast foods, such as Pizza Hut or Taco Bell, from being offered as part of school meals or as a la carte items. Similarly, only 4.0% of states required and 38.0% recommended, and 6.6% of districts required and 37.1% recommended, that schools make fruits or vegetables available to students whenever food was offered or sold (eg, at school parties or school stores). Fewer than 1 in 5 states (18.4%) and districts (17.0%) required but more states (32.6%) and districts (46.0%) recommended that schools make healthful beverages such as bottled water or low-fat milk available to students whenever beverages were offered or sold. Nationwide, 14.0% of states required and 42.0% recommended and 42.1% of districts required and 34.9% recommended that schools restrict the availability of deep-fried foods.

"Junk foods" were defined as foods or beverages that have low nutrient density (ie, they provide calories primarily through fats or added sugars and have minimal amounts of vitamins and minerals). More than half of states required or recommended that schools prohibit junk foods as a la carte sales in the cafeteria; in school stores, canteens, or snack bars; and in vending machines (Table 1). Similarly, more than half of districts required or recommended that schools prohibit junk foods as a la carte sales in the cafeteria, at student parties, and in vending machines. Further, 46.0% of states required and 14.0% recommended, and 57.4% of districts required and 25.0% recommended, that schools restrict the times during the day that junk foods can be sold in any venue. In addition, 16.0% of states required and 34.0% recommended, and 13.8% of districts required and 37.3% recommended, that schools prohibit junk foods from being sold for fundraising purposes. Many states and districts required that schools prohibit student access to vending machines for at least part of the school day. Nationwide, 36.7% of states required and 24.5% recommended, and 73.7% of districts required and 16.2% recommended, that elementary schools prohibit student access to vending machines for at least part of the school day. Similarly, 32.6% of states required and 22.4% recommended, and 74.2% of districts required and 16.9% recommended, that middle schools prohibit student access to vending machines; 32.6% of states required and 22.4% recommended, and 67.2% of districts required and 17.7% recommended this prohibition for high schools.

Although 44.0% of states required and 30.0% recommended, and 63.0% of districts required and 21.6% recommended, that schools restrict the times during the day that soda pop, sports drinks, or fruit drinks that are not 100% juice could be sold in any venue, 80.4% of all districts still allowed schools to sell such soft drinks. Nationwide, 64.4% of all districts received a specified percentage of the soft drink sales receipts, and 32.5% received incentives (eg, cash awards or donations of equipment, supplies, or other items) once receipts totaled a specified amount. Further, 43.0% of all districts were prohibited from selling soft drinks produced by more than 1 company.

Nationwide, 2.0% of states required and 16.3% recommended, and 24.2% of districts required and 31.6% recommended, that schools prohibit advertising for candy, fast food restaurants, or soft drinks on school property. In addition, 20.9% of districts required and 28.4% recommended that schools restrict the distribution of products promoting candy, fast food restaurants, or soft drinks to students (eg, T-shirts, hats, or book covers). About one third (35.8%) of all districts allowed soft drink companies to advertise soft drinks in school buildings, and 46.6% allowed soft drink companies to advertise on school grounds, including on the outside of school buildings and on playing fields or other areas of campus.

Nationwide, 5.9% of states and 26.1% of districts had adopted a policy prohibiting schools from using food or food coupons as a reward for good behavior or good academic performance, and an additional 45.1% of states and 20.2% of districts discouraged schools from this practice.

Menu Planning, Food Ordering, and Food Preparation. Nationwide, 94.9% of district nutrition services programs had primary responsibility for planning the menus for meals for at least some schools in their district. Among these districts, 61.0% used Food- Based Traditional Menu Planning, 19.0% used Food-Based Enhanced Menu Planning, and 16.2% used either Nutrient Standard Menu Planning or Assisted Nutrient Standard Menu Planning. Among the districts with primary responsibility for menu planning, 42.8% routinely used a computer to analyze the nutritional content of the school menus, and 79.8% of those districts used a weighted nutrient analysis (ie, more weight was given to the nutrients in foods selected frequently and less weight to those foods selected less frequently).

Nationwide, 94.0% of district nutrition services programs had primary responsibility for deciding which foods to order for at least some schools in their district. Among these districts, most had a food procurement contract that specifically addressed food safety (83.5%), cooking methods for precooked items (eg, baked instead of deep fried) (77.7%), Hazard Analysis and Critical Control Points (HACCP) (74.1%), and nutritional standards for a la carte foods (55.1%).

Some districts are responsible for the actual cooking of school meals (eg, in a central kitchen), not just the reheating of food that was previously prepared. Nationwide, in 83.4% of districts, the district nutrition services program had primary responsibility for cooking foods for at least some schools. Four groups of healthy food preparation practices were assessed: substitution techniques (ie, substituting 1 type of ingredient for another), reduction techniques (ie, reducing the amount of an ingredient), fat reduction techniques when preparing meat and poultry, and vegetable preparation techniques. Among the 83.4% of districts that had primary responsibility for cooking foods for schools, during the 30 days preceding the study more than half always or almost always used nonstick spray or pan liners instead of grease or oil; used part- skim or low-fat cheese instead of regular cheese; used skim, low- fat, soy, or nonfat dry milk instead of whole milk; drained fat from browned meat; roasted, baked, or broiled meat rather than frying it; skimmed fat off warm broth, soup, stew, or gravy; spooned solid fat from chilled meat or poultry broth; either trimmed fat from meat or used lean meat; boiled, mashed, or baked potatoes rather than frying or deep frying them; and steamed or baked other vegetables (Table 2).

Professional Preparation. State certification, licensure, or endorsement for district food service directors was offered by 27.4% of states, and state certification, licensure, or endorsement for school food service managers was offered by 21.6% of states.

Nationwide, 24.4% of districts did not require newly hired district food service directors to have a minimum level of education, but 56.6% required a high school diploma or General Educational Development (GED) credential as the minimum level of education, 5.0% required an associate's degree in nutrition or a related field, 10.6% required an undergraduate degree in nutrition or a related field, and 3.5% required a graduate degree in nutrition or a related field. Further, 15.8% of all districts required a newly hired district food service director to be certified, licensed, or endorsed by the state. In addition, 69.2% of districts had other types of training and credentialing requirements for newly hired district food service directors. Specifically, 51.6% of all districts required newly hired district food service directors to have successfully completed a school food service training program provided or sponsored by the state, 18.6% required a School Nutrition Association (SNA) certification, 11.6% required a school food service and nutrition specialist credential from SNA, 4.2% required a registered dietitian (RD) credential from the American Dietetic Association (ADA), and 0.8% required a registered dietetic technician (DTR) credential from the ADA. Nationwide, 9.2% of all districts required and 31.3% recommended that newly hired district food service directors participate in the Orientation to Child Nutrition Management Workshop, sponsored by the NFSMI.

Nationwide, 54.0% of all districts required newly hired district food service directors to have a food safety certification. Specifically, 26.1% of all districts required a ServSafe food protection manager certification by the National Restaurant Association Educational Foundation, 2.4% required a certified professional food manager certification by Experior Assessments LLC, 3.5% required a certified food safety manager certification by the National Registry of Food Safety Professionals, and 23.4% required a food handler's card from a state or local health agency.

Nationwide, 22.1% of all districts did not require newly hired school food service managers to have a minimum level of education, but 74.1% required a high school diploma or GED as the minimum level of education, 1.8% required an associate's degree in nutrition or a related field, 1.5% required an undergraduate degree in nutrition or a related field, and 0.5% required a graduate degree in nutrition or a related field. Further, 16.0% of all districts required a newly hired school food service manager to be certified, licensed, or endorsed by the state. In addition, 63.8% of districts had other types of training and credentialing requirements for newly hired school food service managers. Specifically, 42.5% of districts required newly hired school food service managers to have successfully completed a school food service training program provided or sponsored by the state, 9.8% required an SNA certification, 6.1% required a school food service and nutrition specialist credential from SNA, 1.7% required an RD credential, and 0.1 % required a DTR credential.

Nationwide, 53.9% of all districts required newly hired school food service managers to hold a food safety certification. Specifically, 28.2% of all districts required a ServSafe food protection manager certification by the National Restaurant Association Educational Foundation, 1.4% required a certified professional food manager certification by Experior Assessments LLC, 2.7% required a certified food safety manager certification by the National Registry of Food Safety Professionals, and 22.1% required a food handler's card from a state or local health agency.

Nutrition Services Coordinators. Nationwide, 94.0% of states had a person who oversees or coordinates nutrition services for schools at the state level (eg, a state food service director or director of child nutrition), and 88.1% of districts had a person who oversees or coordinates nutrition services at the district level (eg, a district food service director).

Among the 94.0% of states with a state-level nutrition services coordinator, 67.4% had that person serve as the respondent to the state-level nutrition services questionnaire. One hundred percent of these respondents worked for the state education agency. Nearly all (96.8%) of these respondents had an undergraduate degree. Among those with an undergraduate degree, 33.3% majored in home economics or family and consumer sciences, 26.7% majored in nutrition or dietetics, 16.7% majored in food service administration or management, 16.7% majored in education, and 16.7% majored in business. Seventy percent of respondents with an undergraduate degree had an undergraduate minor, and among those with minors, 33.3% had a minor in education, 28.6% in business, 9.5% in food service administration or management, 9.5% in nutrition or dietetics, and 4.8% in home economics or family and consumer sciences. About three fourths of these respondents (74.2%) had a graduate degree. Among those with a graduate degree, 27.3% had that degree in nutrition or dietetics, 22.7% in food service administration or management, 18.2% in education, 18.2% in home economics or family and consumer sciences, and 13.6% in business. Among the respondents to the state-level nutrition services questionnaire, 24.1% held an RD credential, 17.2% were certified food safety managers, 10.3% had earned the school food service and nutrition specialist credential from SNA, and 3.4% were certified dietary managers. In addition, 31.0% had other food service certifications from a state agency or state-level professional group.

Among the 88.1% of districts with a nutrition services coordinator, 90.0% had that coordinator serve as the respondent to the district-level nutrition services questionnaire. Among these respondents, 93.1% worked for the school district and 8.4% worked for a food service management company. Among these respondents, 40.6% had an undergraduate degree. Among those with an undergraduate degree, 23.2% majored in nutrition or dietetics, 19.7% majored in food service administration or management, 17.6% majored in education, 14.8% majored in business, and 14.7% majored in home economics or family and consumer sciences. Fortythree percent of respondents with an undergraduate degree had an undergraduate minor, and among those, 17.4% had a minor in education, 14.2% in business, 8.9% in food service administration or management, 7.4% in nutrition or dietetics, and 5.4% in home economics or family and consumer sciences. Among respondents to the district-level nutrition services questionnaire, 19.8% had a graduate degree. Among them, 46.5% had their graduate degree in education, 16.2% in nutrition or dietetics, 13.1% in business, and 7.0% in food service administration or management, and 3.8% in home economics or family and consumer sciences.

Among the respondents to the district-level nutrition services questionnaire, 47.9% were certified food safety managers, 24.2% had earned the school food service and nutrition specialist credential from SNA, 13.0% were certified dietary managers, 5.4% held an RD credential, and 1.7% held a DTR credential. In addition, 40.4% had other food service certifications from a state agency or state- level professional group, and 30.6% had completed the Orientation to Child Nutrition Management Workshop offered by NFSMI.

Staff Development. Staff development was defined as workshops, conferences, continuing education, graduate courses, or any other kind of inservice on health topics or teaching methods. During the 2 years preceding the study, 100% of states and 96.3% of districts provided funding for staff development or offered staff development for nutrition services staff on at least 1 of the topics listed in Table 3. Specifically, more than three fourths of all states provided funding for staff development or offered staff development for nutrition services staff on competitive food policies to create a healthy food environment, customer service, financial management, food safety, food service for students with special dietary needs, healthy food preparation methods, implementing the DGA in school meals, increasing the percentage of students participating in school meals, making school meals more appealing, menu planning for healthy meals, using HACCP, and using the cafeteria for nutrition education (Table 3). More than three fourths of all districts provided funding for staff development or offered staff development for nutrition services staff on food safety, healthy food preparation methods, making school meals more appealing, menu planning for healthy meals, personal safety for food service staff, and using HACCP.

Program Promotion. During the 12 months preceding the study, many districts promoted the school nutrition services program among students and their families. For example, 98.7% of districts gave menus to students, 98.2% gave menus to students' families, 81.8% provided families with information on the school nutrition services program, 49.4% provided students with information on the nutrient and caloric content of foods available to them, and 39.8% provided families with this information.

Evaluation. Many states and districts evaluated their school nutrition services program during the 2 years preceding the study. All states (100%) and 85.0% of districts evaluated district or school nutrition services staff compliance with government regulations and recommendations. In addition, 98.0% of states and 85.9% of districts evaluated the nutritional quality of school meals, 92.2% of states and 83.6% of districts evaluated student participation in the nutrition services program, 90.2% of states and 92.5% of districts evaluated food safety procedures, 86.0% of states and 82.5% of districts evaluated nutrition services management practices, and 70.6% of states and 76.3% of districts evaluated nutrition services staff development or in-service programs. About one third (34.0%) of states and 51.7% of districts evaluated the amount of plate waste.

Collaboration. During the 12 months preceding the study, state- level and district-level nutrition services staff worked with others in the same stateor district-level agency on school food service or nutrition activities. Specifically, state nutrition services staff worked with state health education staff in 94.1% of states, with state health services staff in 82.4% of states, with state physical education staff in 78.4% of states, and with state mental health and social services staff in 53.1% of states. State nutrition services staff also worked with the state-level SNA in 98.0% of states, with a food commodity organization such as the Dairy Council or state produce growers association in 94.1%, with Action for Healthy Kids in 94.1%, with colleges or universities in 94.1%, with a state- level health organization (eg, the American Heart Association or American Cancer Society) in 76.5%, with a state-level school nurses' association in 68.6%, with the state department of agriculture in 64.7%, with businesses in 62.7%, and with a state-level physicians' organization (eg, the American Academy of Pediatrics) in 56.9%.

District nutrition services staff worked with health education staff in 59.9% of districts, with health services staff in 55.1%, with physical education staff in 44.3%, and with mental health and social services staff in 23.3%. In addition, district nutrition services staff worked with a food commodity organization in 45.2% of districts, with a local health department in 45.2%, with a county cooperative extension office in 32.3%, with local businesses in 19.9%, with a local health organization in 16.8%, with local colleges or universities in 11.8%, with a local hospital in 11.7%, and with a mental health or social services agency in 8.5%.

Assistance to Districts and Schools. During the 12 months preceding the study, many states and some districts provided ideas to districts or schools to help improve student nutrition or healthy eating. Specifically, 84.0% of states and 44.0% of districts provided ideas on how to involve school nutrition services staff in classrooms to teach students about nutrition or healthy eating; 82.0% of states and 51.4% of districts provided ideas on how to use the cafeteria as a place where students might learn about food safety, food preparation, or other nutritionrelated topics; and 88.0% of states and 51.3% of districts provided ideas for nutrition- related special events to teach students about nutrition or healthy eating. Also, during the 12 months preceding the study, 75.2% of districts provided assistance to schools in planning menus for students with chronic health conditions that require dietary modification (eg, diabetes), and 73.5% of districts provided assistance to schools in planning menus for students with food allergies. In addition, during the 2 years preceding the study, 86.0% of states provided model policies to districts or schools on how to promote healthy eating among students. These model policies might have addressed nutrition education, nutrition services, or other foods available at school. Model policies were defined as an example of what an actual policy on a particular topic or issue might address. The content might be based on scientific evidence, best practices, or state law or policy. Model policies are recommendations, not mandates.

Food Safety. Food safety was defined as the prevention of unintentional contamination of food that can cause illness. Nearly one third (32.0%) of states required and 30.0% of states recommended that districts or schools implement food safety practices school wide (ie, both inside and outside the cafeteria). Nationwide, 38.8% of districts required and 44.7% of districts recommended that schools implement food safety practices school wide. Further, 58.2% of districts required and 26.9% recommended that schools have written plans for implementation of a risk-based approach to food safety, such as a HACCP-based program, and 49.2% required and 33.2% recommended that schools have written plans for feeding students with severe food allergies. HACCP-based recipes-which include critical control points, such as cooking, and associated critical limits, such as time and temperature, in their directions-are designed to reduce the risk of food contamination and bacterial growth that could lead to food-borne illness. During the 30 days preceding the study, 69.0% of districts almost always or always used HACCP-based recipes. Irradiated meat is meat that has been exposed to a controlled amount of radiant energy to reduce the risk of food- borne illness by destroying harmful bacteria and other organisms. During the 30 days preceding the survey, only 2.2% of districts almost always or always used irradiated meat, and 87.2% of districts never used irradiated meat. Among the districts that never used irradiated meat, 47.5% indicated irradiated meat was not available, 27.9% indicated it was not necessary to use irradiated meat, 20.5% indicated public perception was that irradiated meat is unsafe, and 9.2% indicated irradiated meat was too expensive. Only 4.3% of all districts provided information about irradiated meat to students and families during the 12 months preceding the study.

Some districts required or recommended that school nutrition services programs have a written plan for crisis response in the event of natural disasters, such as blizzards or tornados (54.6% required and 24.4% recommended), water, gas, or electrical outages (47.9% required and 31.5% recommended), equipment failure such as refrigerator or freezer breakdown (42.6% required and 35.6% recommended), food biosecurity (ie, the prevention of intentional contamination of food to cause illness) breaches (37.9% required and 27.5% recommended), other terrorist events such as a bomb threat (52.7% required and 24.3% recommended), suspected food-borne illness outbreak (49.3% required and 30.9% recommended), and a food recall (50.4% required and 30.5% recommended).

Changes Between 2000 and 2006 at the State and District Levels. Between 2000 and 2006, many changes were detected in requirements and recommendations related to competitive foods. Specifically, increases were detected in the percentage of states and districts that required that schools be prohibited from offering junk foods as a la carte selections during breakfast and lunch periods (from 20.0% to 42.0% among states and from 23.1% to 38.9% among districts); at concession stands (from 2.0% to 6.1% among states and from 1.4% to 5.5% among districts); in school stores, canteens, or snack bars (from 6.0% to 32.0% among states and from 3.9% to 18.9% among districts); at student parties (from 2.0% to 8.0% among states and from 1.4% to 11.5% among districts); and in vending machines (from 8.0% to 32.0% among states and from 4.1% to 29.8% among districts). Increases also were detected in the percentage of districts that required that schools be prohibited from offering junk foods in after-school or extended day programs (from 7.3% to 14.7%) and at staff meetings (from 0.4% to 3.4%). Similarly, increases were detected in the percentage of states and districts that recommended that schools be prohibited from offering junk foods in after-school or extended day programs (from 18.0% to 34.0% among states and from 11.4% to 33.8% among districts); as a la carte selections during breakfast or lunch periods (from 20.0% to 36.0% among states and from 15.3% to 29.4% among districts); at concession stands (from 8.0% to 36.7% among states and from 7.8% to 31.4% among districts); at meetings attended by students' family members (from 4.0% to 20.0% among states and from 9.3% to 30.2% among districts); in school stores, canteens, or snack bars (from 6.0% to 36.0% among states and from 8.9% to 29.2% among districts); at staff meetings (from 4.0% to 20.0% among states and from 8.1% to 27.6% among districts); at student parties (from 8.0% to 36.0% among states and from 9.9% to 39.6% among districts); and in vending machines (from 10.0% to 38.0% among states and from 7.9% to 30.0% among districts). In addition, the percentage of states that discouraged schools from using food or food coupons as a reward increased from 13.0% to 45.1%, and the percentage of districts prohibiting this practice increased from 11.3% to 26.1%.

Between 2000 and 2006, increases were detected in the percentage of districts almost always or always using the following healthy food preparation practices during the 30 days preceding the study: using low-fat or nonfat yogurt, mayonnaise, or sour cream instead of regular mayonnaise, sour cream, or creamy salad dressings (from 26.8% to 39.8%); using part-skim or low-fat cheese instead of regular cheese (from 34.1% to 50.3%); using skim, low-fat, soy, or nonfat dry milk instead of whole milk (from 67.4% to 77.9%); removing skin from poultry or using skinless poultry (from 36.9% to 49.1%); and steaming or baking vegetables other than potatoes (from 59.5% to 77.7%). Also, the percentage of districts requiring a minimum time for students to eat lunch once they were seated increased from 21.9% to 40.4%.

Collaboration between nutrition services staff at the state and district level and other staff in their own agency increased between 2000 and 2006. Specifically, increases were detected in the percentage of states and districts in which nutrition services staff worked on nutrition services activities with health education staff (from 78.4% to 94.1% among states and from 25.9% to 59.9% among districts), mental health and social services staff (from 38.0% to 53.1% among states and from 8.7% to 23.3% among districts), and physical education staff (from 48.0% to 78.4% among states and from 13.9% to 44.3% among districts). An increase also was detected in the percentage of districts in which nutrition services staff worked on nutrition services activities with health services staff (from 23.9% to 55.1%). In addition, the percentage of states in which nutrition services staff worked with businesses increased from 49.0% to 62.7%, and the percentage of districts in which this occurred increased from 8.8% to 19.9%.

Two increases between 2000 and 2006 were detected in evaluation activities at the state level. During the 2 years preceding the study, the percentage of states that evaluated the amount of plate waste increased from 14.6% to 34.0%, and the percentage that evaluated the number of students participating in the school nutrition services program increased from 80.0% to 92.2%.

Some changes also occurred in professional preparation and staff development. Between 2000 and 2006, the percentage of districts that required newly hired food service managers to have at least a high school diploma or GED increased from 49.4% to 74.1%. Also, the percentage of states that provided funding for staff development or offered staff development, during the 2 years preceding the study, on procedures for food-related emergencies increased from 34.7% to 60.0%, but the percentage that provided funding for staff development or offered staff development on selecting and ordering food decreased from 84.3% to 72.5%.

Finally, increases also were observed in the percentage of districts providing schools with ideas on how to involve school nutrition services staff in classrooms to teach students about nutrition or healthy eating (from 32.7% to 44.0%), ideas on how to use the cafeteria as a place where students might learn about food safety, food preparation, or other nutrition-related topics (from 36.9% to 51.4%), and ideas for nutrition-related special events (from 38.6% to 51.3%).

Nutrition Services at the School Level

Organization of the School Nutrition Services Program. Nationwide, 68.6% of schools offered breakfast to students, 63.0% participated in the USDA reimbursable SBP, and 11.9% offered other breakfast meals to students. Among the 68.6% of schools that offered breakfast, 97.2% served it in the cafeteria, 4.5% served it in classrooms, and 0.2% served it on school buses. In addition, 15.4% allowed students to bring breakfast into the classroom. Nationwide, 99.3% of schools offered lunch to students, 84.2% participated in the USDA reimbursable NSLP, and 25.6% offered other lunch meals to students.

In 24.4% of all schools that offered breakfast or lunch, an outside food service management company operated (ie, had primary responsibility for planning menus and deciding which foods to order) the school nutrition services program. A food service management company provided breakfast meals in 12.4% of all schools, a la carte breakfast items in 9.7% of all schools, lunch meals in 22.4% of all schools, and a la carte lunch items in 14.4% of all schools. Some schools (11.7% of elementary schools, 19.0% of middle schools, and 23.5% of high schools) offered brand-name fast foods from companies such as Pizza Hut, Taco Bell, or Subway. During a typical week, 94.7% of these schools offered brand-name fast foods to students for breakfast meals 1 day per week or less often; 2.2% offered them 2, 3, or 4 days; and 2.9% offered them 5 days. In addition, 88.2% of these schools offered brandname fast foods as a la carte breakfast items 1 day per week or less often; 2.1% offered them 2, 3, or 4 days; and 9.7% offered them 5 days. During a typical week, 74.5% of these schools offered brand-name fast foods for lunch meals 1 day per week or less often; 17.2% offered them 2, 3, or 4 days; and 8.2% offered them 5 days. Finally, 67.9% of these schools offered these foods as a la carte lunch items 1 day per week or less often; 16.2% offered them 2, 3, or 4 days; and 15.4% offered them 5 days.

Nationwide, 95.3% of schools had a cafeteria. During peak meal time, the cafeteria was less than 50% full in 10.6% of these schools, 50-75% full in 35.9%, 76-100% full in 51.0%, and over the maximum seating capacity in 2.5%.

On average, students had 21.1 minutes to eat breakfast once they were seated and 22.8 minutes to eat lunch. Further, 93.4% of schools gave students at least 10 minutes to eat breakfast once they were seated, and 79.0% of schools gave students at least 20 minutes to eat lunch once they were seated. One fourth (25.4%) of schools started serving lunch before 11:00 am, 62.6% started serving lunch between 11:00 am and 12:00 pm, and 12.0% started serving lunch after 12:00 pm. Ninety-four percent of elementary schools, 96.0% of middle schools, and 73.1% of high schools implemented a closed-campus policy (ie, students are not allowed to leave school during the school day, including during lunchtime). Food Ordering and Food Preparation. Nationwide, in 37.6% of schools, staff working at the district nutrition services office had primary responsibility for deciding which foods to order; in 21.9% of schools, food service management company staff had this responsibility; and in 37.0% of schools, school staff had this responsibility.

Among the schools in which staff at the school level had responsibility for deciding what food to order, during a typical school week 21.3% ordered at least some whole milk, 57.9% ordered at least some 2% or reduced fat milk, 45.6% ordered at least some 1% or low-fat milk, and 34.0% ordered at least some skim or nonfat milk. Further, 23.6% of these schools ordered only 1 of these types of milk, 42.2% ordered 2 of these types, 23.9% ordered 3 of these types, and 6.6% ordered all 4 of these types of milk. More than three fourths (77.4%) of these schools included either 1% low-fat milk or skim milk in their orders, and 36.3% included both of these types of milk. On average, 41.1% of all milk ordered was 1%, 34.3% was 2%, 14.0% was skim milk, and 9.3% was whole milk. On average, 56.3% of all milk ordered was chocolate or flavored milk. Most of the chocolate or flavored milk ordered was either 1% milk (48.1% of all chocolate or flavored milk ordered) or 2% milk (26.8% of all chocolate or flavored milk ordered). Most of the white milk ordered was either 2% milk (46.4% of all white milk ordered) or 1% milk (32.4% of all white milk ordered). In addition, 2.1% of schools ordered at least some buttermilk during a typical school week, 2.0% ordered at least some soy milk, and 1.1% ordered at least some lactose-free milk.

Nationwide, in 23.9% of schools, staff working at the district nutrition services office had primary responsibility for cooking foods (not counting the reheating of prepared foods) for students; in 11.8% of schools, food service management company staff had this responsibility; and in 62.7% of schools, school staff had this responsibility.

Among the schools in which school staff had responsibility for cooking foods for students, during the 30 days preceding the study more than half almost always or always used nonstick spray or pan liners instead of grease or oil; used skim, low-fat, or nonfat dry milk instead of whole milk; drained fat from browned meat; removed skin from poultry or used skinless poultry; roasted, baked, or broiled meat rather than frying it; skimmed fat off warm broth, soup, stew, or gravy; spooned solid fat from chilled meat or poultry broth; trimmed fat from meat or used lean meat; boiled, mashed, or baked potatoes rather than frying or deep frying; prepared vegetables without using butter, margarine, cheese, or creamy sauce; and steamed or baked other vegetables (Table 2).

Breakfast and Lunch Food and Beverage Variety and Availability. Each day for breakfast, 61.7% of the 68.6% of schools that offered breakfast offered students 3 or more different types of milk. The percentage of schools offering 3 or more different types of milk was lower among elementary schools (54.1%) than among middle schools (68.4%) and high schools (72.5%). Each day for lunch, 63.4% of the 99.3% of schools that offered lunch offered students 3 or more different types of milk (61.1% of elementary schools, 63.0% of middle schools, and 70.5% of high schools). Each day for lunch, 58.7% of elementary schools, 70.8% of middle schools, and 77.4% of high schools that offered lunch offered a choice between 2 or more different fruits or types of 100% fruit juice; 64.0% of elementary schools, 69.3% of middle schools, and 81.4% of high schools offered a choice between 2 or more entrees or main courses; and 55.8% of elementary schools, 66.8% of middle schools, and 76.7% of high schools offered a choice between 2 or more different nonfried vegetables. The sale of deep-fried foods at lunch either as part of a meal or as a la carte items also varied by school level: 82.6% of elementary schools, 70.4% of middle schools, and 48.6% of high schools did not sell any fried foods as part of school lunch; 14.5% of elementary schools, 22.6% of middle schools, and 26.2% of high schools sold deep-fried foods at lunch, but fewer than 5 days per week; and 2.1% of elementary schools, 6.7% of middle schools, and 24.0% of high schools sold deep-fried foods each day at lunch. When salad dressing was offered, 80.1 % of schools offered students a low- fat dressing.

In 10.0% of elementary schools, 14.1% of middle schools, and 19.2% of high schools, students could get butter or margarine only by asking for it (ie, it was not available in the cafeteria serving line or on the tables). In 34.5% of elementary schools, 46.3% of middle schools, and 47.6% of high schools, students could get butter or margarine in the cafeteria serving line or on the tables. In 12.8% of elementary schools, 15.8% of middle schools, and 10.2% of high schools, students could get salt only by asking for it (ie, it was not available in the cafeteria serving line or on the tables). In 14.4% of elementary schools, 34.1% of middle schools, and 60.6% of high schools, students could get salt in the cafeteria serving line or on the tables.

A La Carte Food and Beverage Variety and Availability. Schools were asked whether certain foods and beverages were sold as a la carte items. These a la carte items did not include items sold in vending machines. During a typical week, more than two thirds of all elementary schools offered fruit; lettuce, vegetable, or bean salads; and other vegetables as a la carte items (Table 4). More than two thirds of all middle schools offered 100% fruit juice or 100% vegetable juice; bread sticks, rolls, bagels, pita bread, or other bread products; fruit; lettuce, vegetable, or bean salads; other vegetables; and pizza, hamburgers, or sandwiches as a la carte items. More than two thirds of all high schools offered 100% fru

Source: Journal of School Health, The

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