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Parental attitudes towards soft drink vending machines in high schools
RESEARCH Research and Professional Briefs
Parental Attitudes Towards Soft Drink Vending Machines in High Schools MAIA HENDEL-PATERSON, MPH; SIMONE A. FRENCH, PhD; MARY STORY, PhD, RD
ABSTRACT Soft drink vending machines are available in 98% of US high schools. However, few data are available about parents’ opinions regarding the availability of soft drink vending machines in schools. Six focus groups with 33 parents at three suburban high schools were conducted to describe the perspectives of parents regarding soft drink vending machines in their children’s high school. Parents viewed the issue of soft drink vending machines as a matter of their children’s personal choice more than as an issue of a healthful school environment. However, parents were unaware of many important details about the soft drink vending machines in their children’s school, such as the number and location of machines, hours of operation, types of beverages available, or whether the school had contracts with soft drink companies. Parents need more information about the number of soft drink vending machines at their children’s school, the beverages available, the revenue generated by soft drink vending machine sales, and the terms of any contracts between the school and soft drink companies. J Am Diet Assoc. 2004;104:1597-1600.
D
uring the past 2 decades, soft drink consumption among adolescents doubled for girls and tripled for boys (1). High rates of teen soft drink consumption are of concern because of health implications including obesity (2-4), bone health (5), dental caries (6), and disrupted sleep due to caffeine intake (7). Nonetheless, soft drinks are widely available in schools across the nation. Nationally, 98% of high schools had beverages (the vast majority of which are soft drinks, sports drinks, or juice drinks) available for students to purchase (8). Seventynine percent of 14- to 17-year-old boys and 45% of girls
M. Hendel-Paterson is a training coordinator for the Minnesota Office of Justice Programs, St Paul, MN. S. A. French is a professor, University of Minnesota, Division of Epidemiology, Minneapolis. M. Story is a professor, University of Minnesota, Division of Epidemiology. Address correspondence to: Simone A. French, PhD, Professor, University of Minnesota, Division of Epidemiology, 1300 S Second St, Suite 300, Minneapolis, MN 55454-1015. E-mail: [email protected] Copyright © 2004 by the American Dietetic Association. 0002-8223/04/10410-0009$30.00/0 doi: 10.1016/j.jada.2004.07.003
© 2004 by the American Dietetic Association
that age consume soft drinks on any given day (1), and adolescents are drinking more servings of soft drinks than fruit juices, fruit drinks, or milk (9). Concerns about the health of students and the overall school environment prompted the Los Angeles Unified School District, the second largest school district in the nation, to ban the sale of soft drinks in all schools during the school day (10). Other states are considering similar measures (11). Parental support was cited as one factor influencing the Los Angeles Unified School District ban (12). However, little data are available about parents’ opinions of soft drink vending machines in high schools. The purpose of this study was to describe the perspectives of parents regarding soft drink vending machines in their children’s high schools. METHODS/ANALYSIS The lead author and a co-facilitator conducted six focus groups with 33 parents at three suburban Minneapolis, MN high schools in October 2001. Participating schools were primarily white (84% to 93%) and middle to uppermiddle class, with 2% to 8% of students eligible for free or reduced-price lunch. Parents were recruited through newsletters, parent–teacher conferences, and fliers, and were offered $25 for their participation. Eligibility included having a child attend the high school, and only one parent per child could participate per group. Focus group procedures followed those outlined by Krueger (13) and were standardized across all six groups (Figure 1). Informed consent was obtained from participants before discussion began. The University of Minnesota Institutional Review Board approved the study. Qualitative methods only were used to analyze the focus group data. Verbatim focus group transcripts were analyzed using an “inverse outlining” method (14). First, responses to each question were grouped together. Relevant comments not falling under specific questions were included in a “secondary” section. Grouped responses were then read for specific themes. Once major themes were identified, individual responses were regrouped according to each theme. For example, the topic of “parental knowledge” was evident across questions and discussion groups and thus identified as a major theme. Quotations regarding questions or information that parents had were grouped together under the main heading of “parental knowledge.” Lastly, the original transcripts were given to a second coder who performed an analysis of the data. The major themes identified by the second coder agreed with those found by the lead author and are included in the results section, by order of importance, as determined by the
Journal of the AMERICAN DIETETIC ASSOCIATION
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Opening Question: First name and your favorite beverage. Introductory Questions: Do you think that drinking soft drinks has any impact on students’ health? How? In your opinion, what are some arguments for/against having soft drink machines available to students in high schools? Transition Questions: When do you think the soft drink machines should be turned on for students? Do you think guidelines about when soft drink machines can be turned on has an impact on what students choose to drink when they are in the high school? How so? Who do you think should be involved in making guidelines about soft drink machines in high schools? (Government? School district? School administration? Parents? Teachers? Students?) Should guidelines be district-wide or created by each high school? Why? Key Questions: Given the two sides, that soft drinks impact student health and that schools need the money they can get from soft drink companies to pay teachers and buy materials, what do you think school districts should do when they are given an offer for an exclusive contract? What do you think of a bill prohibiting the sale of soft drinks from school vending machines during the day being brought before the legislature? Would you support this bill? Finally, what guidelines would you most support regarding soft drink vending machines in high schools? Figure 1. Focus group questions assessing parental attitudes toward soft drink vending machines in high schools.
Figure 2. Summary of main themes identified from focus group discussions about soft drink vending machines in high schools, in order of importance.
time spent discussing and frequency of the topic across groups and questions. RESULTS/DISCUSSION Five major themes emerged from the focus groups (in order of importance): student control/choice, regulations, parental knowledge, the purpose of soft drink vending machines in schools, and the health impact of soft drinks (Figure 2).
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Student Control/Choice The main theme discussed was the issue of student control/choice. All groups saw high school as a time during which it is appropriate for children to have more freedom in decision-making and more responsibility for taking care of themselves. Making beverage choices was cited as one way for adolescents to take more responsibility. However, parents also expressed frustration that the school environment did not reflect
health messages that they were trying to teach at home.
drinks was lower down on their list of priorities, below cigarettes, alcohol, drugs, or even coffee.
Regulations Parents agreed that having regulations on the soft drink vending machines would impact what students drank at school. If soft drinks were not available, their children would choose something else, or nothing, to drink. Some parents also commented that if soft drinks were not available at school, children would bring them from home or buy them at a store before school. Most parents, though, were supportive of the school limiting access to the machines. The majority of parents were opposed to state regulations, preferring regulations be made locally, with input from parents, students, teachers, and administrators. The most supported regulation was limiting hours that soft drinks were available to students. Parents also wanted to see more alternative drinks available in vending machines.
DISCUSSION The main theme of the parent focus group discussions was student control/choice. Parents saw the issue of soft drink vending machines more as a matter of personal choice than as an issue of a healthful school environment. Parents felt it was appropriate for high school students to start making their own decisions regarding soft drink consumption. However, the lack of parental knowledge about the soft drink vending machines (location, hours, revenue generated, offerings) was a topic that ran throughout all groups and through many questions. Parents had little knowledge or awareness about the nature or extent of soft drink vending in their children’s schools. Whereas many parents are involved as classroom volunteers in their children’s schools during the elementary school years, there is much less direct parent involvement in schools during high school (15). The lack of knowledge may also reflect the low priority parents give to the issue of soft drink consumption; health consequences of soft drink consumption was the least important of the discussion themes. Studies have found that the majority of foods available in high school vending machines are high-fat and high-sugar items with little nutritional value (16,17). Parents should be aware of the impact that the school food environment has on adolescents’ food choices and dietary quality. National data show that foods eaten at lunch (from all sources, including a la carte, vending machines, and school lunch) comprise 35% to 40% of high school students’ total daily energy intake (18). Thus, schools provide an important setting for food and beverage intake. This study had several limitations. Participants were a self-selected group of motivated parents. Furthermore, all participants were from mainly white and middle- to upper-middle-class suburban Minneapolis area schools. However, because little data have been published on parental knowledge and attitudes about soft drink machines in high schools, the data from these groups provide a base for development of further studies in more diverse settings to assess parental knowledge and attitudes.
Parental Knowledge Overall, parents did not know much about the soft drink vending machines currently at the schools. In every group, parents asked if anyone knew the types, hours, number, and location of the school’s machines and if there were any school rules about soft drinks. Parents also had questions about contracts between the schools and soft drink companies. Most parents did not know if the schools had a contract with a company and were curious about how much money was involved, either in the form of bonuses from a contact or profits from sales. Purpose of Soft Drink Vending Machines in the Schools Even though parents generally did not know how much money the machines generated for the schools or where the money went, all groups agreed that making money was the primary reason schools had the machines. Parents felt that if their child were going to drink a soft drink anyway, they would like to see the school (rather than a gas station or supermarket) benefit. Parents also felt that machines were there not only for students, but to serve the wider community. In general, parents were more supportive of the machines if they offered a wide variety of choices, including different brands and “healthier” alternatives, including water and juices. Health Impact All groups agreed that drinking soft drinks, particularly in excess, has negative physical effects, including: tooth/ dental problems, inhibition of calcium absorption, dehydration, and poor athletic performance. Parents were also concerned about effects of sugar and caffeine on their children, empty calories in soft drinks, and replacement of healthful drinks (such as milk, juice, and water) or food with soft drinks. Despite being knowledgeable about the harmful health effects of soft drinks and voicing concerns about schools sending conflicting messages about health and soft drinks, parents felt that the health impact of soft
CONCLUSIONS Dietetics professionals can help educate parents by providing information about the soft drink vending machines available to students at school. Parents need more information about the number of machines, the hours of operation, available beverage choices, the revenue generated by the machines, and the terms of any contracts that schools have with soft drink companies. Dietetics professionals, as respected nutrition experts, can be a resource and work with parents and school foodservice directors to advocate for the development and implementation of healthful nutrition policies in schools and school districts. References 1. French SA, Lin B, Guthrie JF. National trends in soft drink consumption among children and adolescents aged 6-17 years: Prevalence, amounts and sources,
Journal of the AMERICAN DIETETIC ASSOCIATION
1599
2.
3.
4. 5. 6. 7. 8.
9.
10.
1600
1977/78 through 1994/98. J Am Diet Assoc. 2003;103: 1326-1331. Troiano RP, Briefel RR, Carroll MD, Bialostosky K. Energy and fat intakes of children and adolescents in the United States: Data from the National Health and Nutrition Examination Surveys. Am J Clin Nutr 2000;72(suppl):S1343-S1353. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: A prospective, observational analysis. Lancet. 2001;357:505-508. Harnack L, Stang J, Story M. Soft drink consumption among US children and adolescents: Nutritional consequences. J Am Diet Assoc. 1999;99:436-441. Wyshak G. Teenaged girls, carbonated beverage consumption, and bone fractures. Arch Pediatr Adolesc Med. 2000;154:610-613. Erickson PR, Alevizos DL, Rindelaub DJ. Soft drinks: Hard on teeth. Northwest Dent. 2001;80:15-19. Pollak CP, Bright D. Caffeine consumption and weekly sleep patterns in US seventh-, eighth-, and ninth-graders. Pediatrics. 2003;111:42-46. Wechsler H, Brener ND, Kuester S, Miller C. Foodservice and foods and beverages available at school: Results from the school health policies and programs study 2000. J Sch Health. 2001;71:313-324. Rampersaud GC, Bailey LB, Kauwell GPA. National survey beverage consumption data for children and adolescents indicate the need to encourage a shift toward more nutritive beverages. J Am Diet Assoc. 2003;103:97-100. Canter M, Hayes GH, Korenstein J, Tokofsky D. Motion to promote healthy beverage sales. Resolution passed by the Los Angeles Unified School
October 2004 Volume 104 Number 10
11.
12.
13. 14. 15.
16. 17. 18.
District. Noticed June 11, 2002. Available at: www. publichealthadvocacy.org. Accessed August 29, 2002. Center for Science in the Public Interest. Maine legislature tackles obesity. February 14, 2003. Available at: www.cspinet.org/new/200302141.html. Accessed April 13, 2003. Robertson J, Walter CG. What it took to ban soft drinks in the LAUSD. Lean Times. 2003;November: 1-5. Available at: www.californiaprojectlean.org/ about/news. Accessed April 21, 2003. Krueger RA. Focus Groups: A Practical Guide for Applied Research. Thousand Oaks, CA: Sage Publications, 1994. Eisenberg ME, Wagenaar A, Neumark-Sztainer D. Viewpoints of Minnesota students on school-based sexuality education. J Sch Health. 1997;67:322-326. US Congress, Office of Technology Assessment. Schools and discretionary time. In: Adolescent Health Volume II. Background and the Effectiveness of Selected Prevention and Treatment Services. OTA-H466. Washington, DC: US Government Printing Office, November 1991. Story M, Hayes M, Kalina B. Availability of foods in high schools: Is there cause for concern. J Am Diet Assoc. 1996;96:123-126. Story M, Neumark-Sztainer D. Competitive foods in schools: Issues, trends and future directions. Topics Clin Nutr. 1999;15:37-47. US Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and Evaluation. Children’s diets in the mid-1990s: Dietary intake and its relationship with school meal participation, CN01-CD1, by Phil Gleason and Carol Suitor. Alexandria, VA; 2001.
Parental Attitudes Towards Soft Drink Vending Machines in High Schools MAIA HENDEL-PATERSON, MPH; SIMONE A. FRENCH, PhD; MARY STORY, PhD, RD
ABSTRACT Soft drink vending machines are available in 98% of US high schools. However, few data are available about parents’ opinions regarding the availability of soft drink vending machines in schools. Six focus groups with 33 parents at three suburban high schools were conducted to describe the perspectives of parents regarding soft drink vending machines in their children’s high school. Parents viewed the issue of soft drink vending machines as a matter of their children’s personal choice more than as an issue of a healthful school environment. However, parents were unaware of many important details about the soft drink vending machines in their children’s school, such as the number and location of machines, hours of operation, types of beverages available, or whether the school had contracts with soft drink companies. Parents need more information about the number of soft drink vending machines at their children’s school, the beverages available, the revenue generated by soft drink vending machine sales, and the terms of any contracts between the school and soft drink companies. J Am Diet Assoc. 2004;104:1597-1600.
D
uring the past 2 decades, soft drink consumption among adolescents doubled for girls and tripled for boys (1). High rates of teen soft drink consumption are of concern because of health implications including obesity (2-4), bone health (5), dental caries (6), and disrupted sleep due to caffeine intake (7). Nonetheless, soft drinks are widely available in schools across the nation. Nationally, 98% of high schools had beverages (the vast majority of which are soft drinks, sports drinks, or juice drinks) available for students to purchase (8). Seventynine percent of 14- to 17-year-old boys and 45% of girls
M. Hendel-Paterson is a training coordinator for the Minnesota Office of Justice Programs, St Paul, MN. S. A. French is a professor, University of Minnesota, Division of Epidemiology, Minneapolis. M. Story is a professor, University of Minnesota, Division of Epidemiology. Address correspondence to: Simone A. French, PhD, Professor, University of Minnesota, Division of Epidemiology, 1300 S Second St, Suite 300, Minneapolis, MN 55454-1015. E-mail: [email protected] Copyright © 2004 by the American Dietetic Association. 0002-8223/04/10410-0009$30.00/0 doi: 10.1016/j.jada.2004.07.003
© 2004 by the American Dietetic Association
that age consume soft drinks on any given day (1), and adolescents are drinking more servings of soft drinks than fruit juices, fruit drinks, or milk (9). Concerns about the health of students and the overall school environment prompted the Los Angeles Unified School District, the second largest school district in the nation, to ban the sale of soft drinks in all schools during the school day (10). Other states are considering similar measures (11). Parental support was cited as one factor influencing the Los Angeles Unified School District ban (12). However, little data are available about parents’ opinions of soft drink vending machines in high schools. The purpose of this study was to describe the perspectives of parents regarding soft drink vending machines in their children’s high schools. METHODS/ANALYSIS The lead author and a co-facilitator conducted six focus groups with 33 parents at three suburban Minneapolis, MN high schools in October 2001. Participating schools were primarily white (84% to 93%) and middle to uppermiddle class, with 2% to 8% of students eligible for free or reduced-price lunch. Parents were recruited through newsletters, parent–teacher conferences, and fliers, and were offered $25 for their participation. Eligibility included having a child attend the high school, and only one parent per child could participate per group. Focus group procedures followed those outlined by Krueger (13) and were standardized across all six groups (Figure 1). Informed consent was obtained from participants before discussion began. The University of Minnesota Institutional Review Board approved the study. Qualitative methods only were used to analyze the focus group data. Verbatim focus group transcripts were analyzed using an “inverse outlining” method (14). First, responses to each question were grouped together. Relevant comments not falling under specific questions were included in a “secondary” section. Grouped responses were then read for specific themes. Once major themes were identified, individual responses were regrouped according to each theme. For example, the topic of “parental knowledge” was evident across questions and discussion groups and thus identified as a major theme. Quotations regarding questions or information that parents had were grouped together under the main heading of “parental knowledge.” Lastly, the original transcripts were given to a second coder who performed an analysis of the data. The major themes identified by the second coder agreed with those found by the lead author and are included in the results section, by order of importance, as determined by the
Journal of the AMERICAN DIETETIC ASSOCIATION
1597
Opening Question: First name and your favorite beverage. Introductory Questions: Do you think that drinking soft drinks has any impact on students’ health? How? In your opinion, what are some arguments for/against having soft drink machines available to students in high schools? Transition Questions: When do you think the soft drink machines should be turned on for students? Do you think guidelines about when soft drink machines can be turned on has an impact on what students choose to drink when they are in the high school? How so? Who do you think should be involved in making guidelines about soft drink machines in high schools? (Government? School district? School administration? Parents? Teachers? Students?) Should guidelines be district-wide or created by each high school? Why? Key Questions: Given the two sides, that soft drinks impact student health and that schools need the money they can get from soft drink companies to pay teachers and buy materials, what do you think school districts should do when they are given an offer for an exclusive contract? What do you think of a bill prohibiting the sale of soft drinks from school vending machines during the day being brought before the legislature? Would you support this bill? Finally, what guidelines would you most support regarding soft drink vending machines in high schools? Figure 1. Focus group questions assessing parental attitudes toward soft drink vending machines in high schools.
Figure 2. Summary of main themes identified from focus group discussions about soft drink vending machines in high schools, in order of importance.
time spent discussing and frequency of the topic across groups and questions. RESULTS/DISCUSSION Five major themes emerged from the focus groups (in order of importance): student control/choice, regulations, parental knowledge, the purpose of soft drink vending machines in schools, and the health impact of soft drinks (Figure 2).
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October 2004 Volume 104 Number 10
Student Control/Choice The main theme discussed was the issue of student control/choice. All groups saw high school as a time during which it is appropriate for children to have more freedom in decision-making and more responsibility for taking care of themselves. Making beverage choices was cited as one way for adolescents to take more responsibility. However, parents also expressed frustration that the school environment did not reflect
health messages that they were trying to teach at home.
drinks was lower down on their list of priorities, below cigarettes, alcohol, drugs, or even coffee.
Regulations Parents agreed that having regulations on the soft drink vending machines would impact what students drank at school. If soft drinks were not available, their children would choose something else, or nothing, to drink. Some parents also commented that if soft drinks were not available at school, children would bring them from home or buy them at a store before school. Most parents, though, were supportive of the school limiting access to the machines. The majority of parents were opposed to state regulations, preferring regulations be made locally, with input from parents, students, teachers, and administrators. The most supported regulation was limiting hours that soft drinks were available to students. Parents also wanted to see more alternative drinks available in vending machines.
DISCUSSION The main theme of the parent focus group discussions was student control/choice. Parents saw the issue of soft drink vending machines more as a matter of personal choice than as an issue of a healthful school environment. Parents felt it was appropriate for high school students to start making their own decisions regarding soft drink consumption. However, the lack of parental knowledge about the soft drink vending machines (location, hours, revenue generated, offerings) was a topic that ran throughout all groups and through many questions. Parents had little knowledge or awareness about the nature or extent of soft drink vending in their children’s schools. Whereas many parents are involved as classroom volunteers in their children’s schools during the elementary school years, there is much less direct parent involvement in schools during high school (15). The lack of knowledge may also reflect the low priority parents give to the issue of soft drink consumption; health consequences of soft drink consumption was the least important of the discussion themes. Studies have found that the majority of foods available in high school vending machines are high-fat and high-sugar items with little nutritional value (16,17). Parents should be aware of the impact that the school food environment has on adolescents’ food choices and dietary quality. National data show that foods eaten at lunch (from all sources, including a la carte, vending machines, and school lunch) comprise 35% to 40% of high school students’ total daily energy intake (18). Thus, schools provide an important setting for food and beverage intake. This study had several limitations. Participants were a self-selected group of motivated parents. Furthermore, all participants were from mainly white and middle- to upper-middle-class suburban Minneapolis area schools. However, because little data have been published on parental knowledge and attitudes about soft drink machines in high schools, the data from these groups provide a base for development of further studies in more diverse settings to assess parental knowledge and attitudes.
Parental Knowledge Overall, parents did not know much about the soft drink vending machines currently at the schools. In every group, parents asked if anyone knew the types, hours, number, and location of the school’s machines and if there were any school rules about soft drinks. Parents also had questions about contracts between the schools and soft drink companies. Most parents did not know if the schools had a contract with a company and were curious about how much money was involved, either in the form of bonuses from a contact or profits from sales. Purpose of Soft Drink Vending Machines in the Schools Even though parents generally did not know how much money the machines generated for the schools or where the money went, all groups agreed that making money was the primary reason schools had the machines. Parents felt that if their child were going to drink a soft drink anyway, they would like to see the school (rather than a gas station or supermarket) benefit. Parents also felt that machines were there not only for students, but to serve the wider community. In general, parents were more supportive of the machines if they offered a wide variety of choices, including different brands and “healthier” alternatives, including water and juices. Health Impact All groups agreed that drinking soft drinks, particularly in excess, has negative physical effects, including: tooth/ dental problems, inhibition of calcium absorption, dehydration, and poor athletic performance. Parents were also concerned about effects of sugar and caffeine on their children, empty calories in soft drinks, and replacement of healthful drinks (such as milk, juice, and water) or food with soft drinks. Despite being knowledgeable about the harmful health effects of soft drinks and voicing concerns about schools sending conflicting messages about health and soft drinks, parents felt that the health impact of soft
CONCLUSIONS Dietetics professionals can help educate parents by providing information about the soft drink vending machines available to students at school. Parents need more information about the number of machines, the hours of operation, available beverage choices, the revenue generated by the machines, and the terms of any contracts that schools have with soft drink companies. Dietetics professionals, as respected nutrition experts, can be a resource and work with parents and school foodservice directors to advocate for the development and implementation of healthful nutrition policies in schools and school districts. References 1. French SA, Lin B, Guthrie JF. National trends in soft drink consumption among children and adolescents aged 6-17 years: Prevalence, amounts and sources,
Journal of the AMERICAN DIETETIC ASSOCIATION
1599
2.
3.
4. 5. 6. 7. 8.
9.
10.
1600
1977/78 through 1994/98. J Am Diet Assoc. 2003;103: 1326-1331. Troiano RP, Briefel RR, Carroll MD, Bialostosky K. Energy and fat intakes of children and adolescents in the United States: Data from the National Health and Nutrition Examination Surveys. Am J Clin Nutr 2000;72(suppl):S1343-S1353. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: A prospective, observational analysis. Lancet. 2001;357:505-508. Harnack L, Stang J, Story M. Soft drink consumption among US children and adolescents: Nutritional consequences. J Am Diet Assoc. 1999;99:436-441. Wyshak G. Teenaged girls, carbonated beverage consumption, and bone fractures. Arch Pediatr Adolesc Med. 2000;154:610-613. Erickson PR, Alevizos DL, Rindelaub DJ. Soft drinks: Hard on teeth. Northwest Dent. 2001;80:15-19. Pollak CP, Bright D. Caffeine consumption and weekly sleep patterns in US seventh-, eighth-, and ninth-graders. Pediatrics. 2003;111:42-46. Wechsler H, Brener ND, Kuester S, Miller C. Foodservice and foods and beverages available at school: Results from the school health policies and programs study 2000. J Sch Health. 2001;71:313-324. Rampersaud GC, Bailey LB, Kauwell GPA. National survey beverage consumption data for children and adolescents indicate the need to encourage a shift toward more nutritive beverages. J Am Diet Assoc. 2003;103:97-100. Canter M, Hayes GH, Korenstein J, Tokofsky D. Motion to promote healthy beverage sales. Resolution passed by the Los Angeles Unified School
October 2004 Volume 104 Number 10
11.
12.
13. 14. 15.
16. 17. 18.
District. Noticed June 11, 2002. Available at: www. publichealthadvocacy.org. Accessed August 29, 2002. Center for Science in the Public Interest. Maine legislature tackles obesity. February 14, 2003. Available at: www.cspinet.org/new/200302141.html. Accessed April 13, 2003. Robertson J, Walter CG. What it took to ban soft drinks in the LAUSD. Lean Times. 2003;November: 1-5. Available at: www.californiaprojectlean.org/ about/news. Accessed April 21, 2003. Krueger RA. Focus Groups: A Practical Guide for Applied Research. Thousand Oaks, CA: Sage Publications, 1994. Eisenberg ME, Wagenaar A, Neumark-Sztainer D. Viewpoints of Minnesota students on school-based sexuality education. J Sch Health. 1997;67:322-326. US Congress, Office of Technology Assessment. Schools and discretionary time. In: Adolescent Health Volume II. Background and the Effectiveness of Selected Prevention and Treatment Services. OTA-H466. Washington, DC: US Government Printing Office, November 1991. Story M, Hayes M, Kalina B. Availability of foods in high schools: Is there cause for concern. J Am Diet Assoc. 1996;96:123-126. Story M, Neumark-Sztainer D. Competitive foods in schools: Issues, trends and future directions. Topics Clin Nutr. 1999;15:37-47. US Department of Agriculture, Food and Nutrition Service, Office of Analysis, Nutrition and Evaluation. Children’s diets in the mid-1990s: Dietary intake and its relationship with school meal participation, CN01-CD1, by Phil Gleason and Carol Suitor. Alexandria, VA; 2001.