School Meals: Types of Foods Offered to and Consumed by Children at Lunch and Breakfast

RESEARCH Current Research

School Meals: Types of Foods Offered to and Consumed by Children at Lunch and Breakfast ELIZABETH M. CONDON, MS, RD; MARY KAY CREPINSEK, MS, RD; MARY KAY FOX, MEd

ABSTRACT Background Children’s food intakes do not meet dietary recommendations. Meals offered through the National School Lunch Program and School Breakfast Program make substantial contributions to school-aged children’s diets. Objectives This article describes foods offered in school meals and consumed by children at lunch and breakfast, and differences in foods consumed by children who did and did not participate in the school meal programs. Design Data were collected as part of the third School Nutrition Dietary Assessment Study, a cross-sectional, nationally representative study conducted in 2005. School menu surveys were used to identify the foods offered in school meals, and 24-hour dietary recalls were used to assess the foods children consumed. Subjects/setting Foodservice managers in 398 public schools and 2,314 children (grades 1 to 12) from 287 of these schools participated in the study. Statistical analyses performed Descriptive tabulations report percentages of daily menus that offered and percentages of children that consumed specific food groups and foods at lunch and breakfast. Two-tailed t tests were used to assess differences between school meal program participants and nonparticipants. Results Most school menus offered nonfat or 1% milk, fruit or 100% juice, and vegetables daily. Starchy vegetables were more common than dark green/orange vegetables or legumes. School lunch participants were significantly more likely than nonparticipants to consume milk, fruit, and vegetables, and significantly less likely to consume desserts, snack items, and beverages other than milk or 100% juice. At breakfast, participants were significantly

E. M. Condon is a research analyst and M. K. Crepinsek and M. K. Fox are senior researchers, Mathematica Policy Research, Inc, Cambridge, MA. STATEMENT OF CONFLICT OF INTEREST: See page S77. Address correspondence to: Elizabeth M. Condon, MS, RD, Mathematica Policy Research, Inc, 955 Massachusetts Ave, Suite 801, Cambridge, MA 02139. E-mail: [email protected] Address reprint requests to: Jackie Allen, Mathematica Policy Research, Inc, PO Box 2393, Princeton, NJ 08543-2393. E-mail: [email protected] Published by Elsevier Inc. on behalf of the American Dietetic Association. 0002-8223/09/10902-1007$0.00/0 doi: 10.1016/j.jada.2008.10.062

more likely than nonparticipants to consume milk and fruit (mainly 100% juice), and significantly less likely to consume beverages other than milk or 100% juice. Conclusions Consumption of school meals is positively related to children’s intakes of key food groups at lunch and breakfast. Offering more fresh fruit, whole grains, and a greater variety of vegetables could lead to additional health benefits. J Am Diet Assoc. 2009;109:S67-S78.

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ealthful eating habits are essential to reducing children’s risk of immediate and long-term health problems. Nutrition-related health problems of children range from growth retardation, iron-deficiency anemia, and dental caries to chronic diseases such as obesity, heart disease, type 2 diabetes, and osteoporosis (1,2). The MyPyramid food guidance system, which reflects the recommendations of the Dietary Guidelines for Americans, provides information on the amounts of food from major food groups and subgroups that are recommended for consumption to promote health and reduce risk of chronic diseases (3). Studies using data from the 1999-2002 National Health and Nutrition Examination Survey (NHANES) show that the foods consumed by most US children are not consistent with current dietary recommendations, especially those for fruits, vegetables, milk, and whole grains. A recent study revealed that 80% to 90% of children 4 to 13 years old have low intakes of fruits and vegetables relative to the MyPyramid recommendations, and that children’s intakes of dark-green and orange vegetables are especially low (4). Children 9 to 18 years old are consuming ⬍2 cups of dairy per day, far less than the MyPyramid recommendation of 3 cups per day, while children 4 to 8 years old fall just short of the recommended 2 cups per day (5). Similarly, consumption of whole grains has been found to be low, with children aged 6 to 19 years consuming no more than one serving per day (6). Schools can make important contributions to improving children’s food and nutrient intakes (2,7,8). Schoolaged children spend at least 6 hours at school every school day and obtain up to 47% of their calories from meals and snacks consumed at school (9). For many children, the federally sponsored school meal programs—the National School Lunch Program (NSLP) and the School Breakfast Program (SBP)—are major sources of foods obtained at school. Almost all US public schools participate in the NSLP, and ⬎80% of NSLP schools also participate in the SBP (10). On an average school day in 2006-2007, ⬎30 million children ate a school lunch, and ⬎10 million ate a school breakfast (11,12). Current fed-

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eral regulations stipulate that school lunches and breakfasts should provide one third and one fourth, respectively, of children’s daily needs for energy (calories) and key nutrients, and should be consistent with the recommendations for fat and saturated fat in the Dietary Guidelines for Americans 1995 (13). In addition, schools are encouraged to reduce levels of sodium and cholesterol and to increase the fiber content of the meals. Schools participating in the NSLP and SBP can use either a food-based or a nutrient-based approach in planning menus that meet nutrient requirements (14). However, decisions about the types of foods to be offered in school menus are made by local school food authorities (school districts or groups of districts that offer the NSLP). The only federal regulations that govern specific food offerings are that fluid milk must be offered in a variety of fat contents; and foods of minimal nutritional value, defined as carbonated beverages, water ices, chewing gum, and certain candies, cannot be offered as part of school meals or anywhere in the foodservice area during mealtimes (15). Schools participating in the NSLP also have the ability to select from a variety of commodity foods from the US Department of Agriculture (USDA), including fruits, vegetables, fruit juices, meats, cheeses, beans, and grain products such as rice, pasta, and flour. In 2004, the Child Nutrition and WIC Reauthorization Act (P.L. 108-265) required that the USDA Food and Nutrition Service, which administers the school meal programs, issue regulations that promote increased consumption of foods and ingredients consistent with the most recent Dietary Guidelines. In 2008, Food and Nutrition Service commissioned the Institute of Medicine to undertake a study to review and recommend changes to existing meal patterns and nutrient standards. The Institute of Medicine recommendations are to reflect new developments in nutrition science; increase the availability of key food groups in the school meal programs, as appropriate; and enhance the ability of school meals to foster healthful eating habits and safeguard children’s health (16). Until final recommendations to update meal patterns and nutrition requirements for the school meal programs have been adopted, the USDA will encourage schools to incorporate the recommendations of the Dietary Guidelines for Americans 2005 into current school lunch and breakfast menus (17). This article uses data from the third School Nutrition Dietary Assessment Study (SNDA-III), a national study of the NSLP and SBP in school year 2004-2005, to describe the foods offered to children in school meals and the foods included in the lunches and breakfasts children consumed on school days. The following research questions are addressed: What types of foods were offered in reimbursable school lunch and breakfast menus? What types of foods did children consume at lunch and breakfast on school days? and How did foods consumed at lunch and breakfast differ for children who did and did not participate in the school meal programs? Findings provide an important “baseline” with which to compare future data on the school meal programs and children’s food intakes, after changes in school meal patterns and nutrient standards have been implemented.

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METHODS Sample Design SNDA-III was a nationally representative study of public schools and public school children in 2005. The study first sampled school food authorities, then schools served by these school food authorities, and then children who attended a randomly selected subset of these schools. Generally, three schools were randomly selected from each sampled school food authority (one elementary, one middle, and one high school). Schools were eligible for the study if they had at least one grade from 1 to 12 and participated in the NSLP. Children were randomly selected from lists of children enrolled in grades 1 to 12. Final samples included 130 school food authorities, 398 schools, and 2,314 children. Response rates and other information about the SNDA-III sample are reported earlier in this Supplement (10). Data Collection and Food Coding Data collection took place largely between January and June 2005. Foodservice managers in all 398 schools completed a menu survey that provided information about the foods offered in reimbursable meals (meals eligible for subsidies through the NLSP or SBP) each school day during a specified “target week.” The menu survey collected detailed information about all foods and beverages offered in reimbursable lunches and breakfasts, including food name and description, preparation method, vitamin/ mineral fortification, recipe, manufacturer information (including product code), portion size, and the number of portions served/sold in reimbursable meals each day. Telephone technical assistance was provided before and during the target week. After the completed surveys were returned, follow-up calls were made to resolve unclear or missing data. Children completed an in-person, 24-hour dietary recall with trained interviewers who used a modified version of the USDA Automated Multiple Pass Method software (version 2.3, 2003, Agricultural Research Service, Food Surveys Research Group, Beltsville, MD). The 24hour recall interview collected detailed information on the types and quantities of foods and beverages consumed, eating occasions (breakfast, brunch, lunch, supper, dinner, snack), time of day, and where the food was obtained. All data collection instruments and procedures were reviewed and approved by the Food and Nutrition Service, the 2004 Education Information Advisory Committee of the Council of Chief State School Officers, and the Office of Management and Budget. In addition, the study worked with any institutional review process a school district required. Active or passive consent forms were used to obtain consent from parents or guardians of all children before completing the 24-hour dietary recall. The school menu and dietary recall data were coded using SurveyNet (version 3.14, 2004, USDA, Agricultural Research Service) to link reported items to the Food and Nutrient Database for Dietary Studies (version 1.0, 2004, USDA, Agricultural Research Service). Trained nutrition coders reviewed and entered the data using standardized procedures and coding guidelines. Additional details on food and nutrient coding, including quality control procedures, are provided in the SNDA-III technical report (18).

A food-grouping system was developed to support analyses of the types of foods and beverages offered in school lunch and breakfast menus and consumed by children in the 24-hour recalls. Each item was assigned to one of nine major food groups—milk; fruit; vegetables; combination entrées (sandwiches, pizza, Mexican-style entrées, mixed dishes); meat/meat alternates; grains/breads; desserts; accompaniments (condiments and toppings); and other items, such as salty snacks, juice drinks, and bottled water. The major food groups were divided into ⬎100 subgroups (minor food groups). For example, vegetables were further classified based on the MyPyramid subgroups for legumes and dark green, orange, starchy, and other vegetables (3). Ready-to-eat (RTE) cereals were classified as sweetened or unsweetened based on the current criterion for cereals under the Special Supplemental Nutrition Program for Women, Infants, and Children. Thus, a cereal was classified as sweetened if it contained ⱖ21.3 g sugar per 100-g serving. A complete listing of the SNDA-III major and minor food groups is in the technical report (19). Analysis Methods The analyses for this article focused on food groups and foods that the 2005 Dietary Guidelines encourage children to consume, or to limit, in their diets (17). Data are presented for milk, fruits, vegetables, grains/breads, grainbased combination entrées, desserts and snack-type items, and beverages other than milk and 100% juice. Note that the analyses are based on foods as discrete items, in the forms in which they are offered in school meals or consumed by children. That is, combination entrées, such as pizza, were not disaggregated into ingredients— grains (crust), vegetables (tomato sauce and vegetable toppings), and meat/meat alternates (cheese and meat toppings)— before categorizing them into food groups. Information on the total amount or number of equivalents (servings) of MyPyramid food groups or subgroups was not available for this analysis. The MyPyramid Equivalents Database for USDA Survey Food Codes, which converts food data into guidance-based amounts for all food groups and subgroups defined by MyPyramid, was released after the coding and analysis were completed for SNDA-III. Thus, this article is focused on the types of foods offered in school meals and consumed by children at lunch and breakfast, so the prevalence of distinct foods reported here should be interpreted as a lower-bound estimate of the true prevalence if all sources of the food were included. Defining Lunch and Breakfast. To categorize foods and beverages as being part of a child’s lunch or breakfast, rules developed for previous national studies were used (20,21). All foods reported between 5:00 AM and 9:30 AM, and foods reported between 9:30 AM and 10:30 AM that were reported as being part of breakfast, were counted as breakfast foods. “Lunch” included all foods reported between 10:00 AM and 2:00 PM, unless reported as breakfast; all foods reported between 9:30 AM and 10:00 AM that were reported as lunch, supper, or dinner; and all foods reported between 2:00 PM and 3:30 PM that were reported as being part of lunch. Defining Lunch and Breakfast Foods. Foods and beverages reported at lunch and breakfast included foods obtained

from school meals as part of a reimbursable school lunch or breakfast, foods obtained in school outside the school meal programs (including competitive foods), and foods that were brought from or consumed at home. Tabulations include only children who consumed a lunch or breakfast. Determining School Meal Participation. To compare the food intakes of school meal participants and nonparticipants, we first determined whether a child participated in the NSLP or SBP on the day referenced in the 24-hour recall. Information on the foods children reported was combined with information from the school menus and children’s self-reports of whether they ate a “regular (reimbursable) school lunch” that day (data about eating a “regular school breakfast” were not collected). Details of the methods used to define school meal program participation for SNDA-III are reported by Clark and colleagues in this Supplement (22). Statistical Analysis The Statistical Analysis Software (SAS) program (version 8.2, 2001, SAS Institute, Inc, Cary, NC) was used for creation of data files. Because of the complex sample design, the SUDAAN statistical package (release 9, 2005, Research Triangle Institute, Research Triangle Park, NC) was used to calculate percentages and standard errors. Data were tabulated for all schools combined and separately by school level (elementary, middle, and high schools). Differences in estimates for participants and nonparticipants in the school meal programs were tested for statistical significance using two-tailed t tests and a minimum significance level of P⬍0.05. These analyses did not adjust for differences in observable characteristics of participants and nonparticipants; therefore, any differences in the types of foods consumed should not be interpreted as causal effects of the school meal programs. RESULTS Foods Offered in Reimbursable School Lunch Menus Table 1 presents data on the percentages of daily lunch menus that offered specific food groups or foods. At all school levels, 1% milk was the most commonly offered type of milk, available in 83% of lunch menus. Just over half the lunch menus (52%) gave children the option of selecting skim/nonfat milk. The majority of the 1% and skim/nonfat milk available was flavored (chocolate, strawberry, vanilla). Two-percent milk, the second-leading type of milk (by fat content) at lunch, was offered in 58% of the menus, while whole milk was offered in roughly a third (31%). At least nine of 10 lunch menus included some type of fruit or 100% fruit juice. Canned fruit, including peaches, pears, pineapple, and fruit cocktail, was offered more frequently than fresh fruit or 100% juice. Half of all lunch menus included fresh fruit (mostly apples, oranges, and bananas), and a little less than a third (31%) offered 100% fruit juice. Nearly all menus (96%) offered one or more vegetable options (as discrete items), excluding vegetables that were part of an entrée salad bar or other food bar. Starchy vegetables, such as french fries, corn, and other white

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Table 1. Percentage of National School Lunch Program (NSLP) menus offering food group or specific foodab All School Menus (nⴝ1,915)

Elementary School Menus (nⴝ699)

Middle School Menus (nⴝ609)

High School Menus (nⴝ607)

Food group/food

%

SEc

%

SE

%

SE

%

SE

Milk 1% 1% flavored 2% 2% flavored Skim/nonfat Skim/nonfat flavored Whole All flavored milks Fruits and juices Canned fruit Fresh fruit Fruit juice, 100% Vegetables Vegetables, except french fries Starchy French fries Corn White potatoes Lettuce salads (non-entrée) Orange/dark green Other vegetables Legumes Grains/breads White breads, rolls, bagels Crackers and pretzels Buttered toast, bagels with cream cheese Rice Corn/tortilla chips Biscuits, croissants, cornbread Whole-grain breads and rolls Pasta Grain-based combination entrées Sandwiches with plain meat or poultry Peanut butter sandwiches Pizza with meat Mexican-style entrées Cheeseburgers Sandwiches with breaded meat, poultry, or fish Desserts and snacks Cookies, cakes, brownies Dessert items containing fruit or juice Juice drinks (not 100%) Dairy-based desserts Snack chips

100 83 66 58 9 52 31 31 99 94 62 50 31 96 88 56 29 16 15 39 29 23 10 68 30 25 9 6 6 5 5 4 89 28 26 22 21 17 17 40 19 7 7 7 3

0.0 3.2 3.8 3.3 1.8 3.6 3.7 3.3 0.4 1.1 2.3 3.0 2.9 1.0 1.6 1.8 1.5 1.3 1.4 2.6 2.1 1.3 1.0 2.1 1.8 2.3 1.8 0.6 0.8 0.6 0.8 0.8 1.5 2.3 2.9 1.7 1.3 1.5 1.5 2.0 1.3 1.1 1.4 0.9 0.7

100 85 68 57 8 49 30 30 99 94 59 48 32 95 86 49 21 14 14 34 31 23 8 66 27 25 7 5 5 5 5 3 88 25 28 13 18 8 9 37 17 8 5 6 1

0.0 4.7 5.1 4.9 2.5 5.1 5.0 4.7 0.5 1.4 3.2 4.0 4.1 1.5 2.4 2.4 1.5 1.6 1.9 3.7 2.9 1.9 1.3 3.0 2.6 3.2 2.0 0.8 1.0 0.8 1.1 0.9 2.0 3.2 4.0 1.6 1.8 1.2 1.3 2.6 1.8 1.6 1.8 1.2 0.5

100 81 65 58 12 51 28 32 98 91 61 55 29 97 89 64 40 17 15 47 28 23 12 71 32 25 10 8 7 6 5 5 94 32 30 36 26 32 30 41 19 7 10 6 2

0.0 4.7 5.4 5.4 3.4 5.0 5.0 5.2 1.4 2.6 3.5 4.7 3.9 1.2 2.0 3.0 3.5 1.9 1.7 4.3 2.5 2.3 2.0 3.2 3.0 3.7 5.3 1.4 1.9 1.0 1.3 1.3 1.6 3.8 5.8 4.2 2.9 4.2 3.5 3.6 1.9 1.2 3.2 1.3 0.7

100 76 60 59 11 60 35 29 99 95 73 53 31 99 91 72 45 23 21 45 23 24 13 72 35 25 12 7 7 6 5 8 90 36 15 40 28 32 32 47 24 4 10 9 7

0.1 4.9 9.4 5.5 3.9 7.4 9.8 6.1 0.5 1.7 4.7 8.0 6.4 0.3 2.0 4.0 5.4 2.7 3.3 5.2 4.1 1.6 2.5 3.4 3.4 4.7 4.7 1.5 1.7 1.7 1.3 1.9 4.1 6.2 4.8 6.7 2.6 5.8 5.6 5.0 2.4 1.3 3.1 2.1 3.3

a Data are from the third School Nutrition Dietary Assessment Study, Menu Survey, school year 2004-2005. Tabulations are weighted to be nationally representative of public NSLP schools. Sample sizes are unweighted and include menus from 397 schools (145 elementary schools, 126 middle schools, and 126 high schools). b Table excludes fruits, vegetables, or grain/bread items included in mixed dishes, such as noodles in macaroni and cheese, or vegetable toppings on pizza. c SE⫽standard error.

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potatoes, were the most frequently offered vegetables at all three school levels (49% to 72% of menus). Almost half of high school lunch menus included french fries or similar potato products, compared to one fifth of elementary school menus. In addition, high school menus included deep-fried french fries in 22% of menus, compared to only 3% of elementary school menus (data not shown in Table 1). Lettuce salads, including side salad bars (non-entrée), were available in about one third of elementary school menus and close to half of middle and high school menus. Less than a third of menus (29%) offered orange or darkgreen vegetables, mainly raw carrots and broccoli. The availability of legumes, mostly baked beans and kidney/ pinto beans, was limited to 10% of daily lunch menus. Over two thirds of school lunch menus offered a separate grain/bread item in addition to those served as part of a sandwich, mixed dish, or other combination entrée (such as pizza, taco or burrito, spaghetti with meat sauce, stir fry with rice). The vast majority of separately offered breads, rolls, and bagels were made with refined white flour. Only 5% of lunch menus offered whole-grain breads/rolls, such as 100% whole wheat, some whole wheat, multigrain, or rye. Crackers or pretzels were available to children in one fourth of all lunch menus. Other separately offered grain/bread items, including buttered toast, rice, corn/tortilla chips (creditable as grain/bread items in the school meal programs), biscuits, croissants, cornbread, and pasta, were available in ⬍10% of menus. Grain-based combination entrées were offered in roughly 90% of lunch menus. In elementary school menus, the most commonly offered grain-based combination entrées were peanut butter sandwiches (28%); sandwiches with plain meat or poultry, such as turkey or ham sandwiches (25%); and Mexican-style entrées, such as burritos, tacos, and nachos (18%). The most commonly offered grain-based combination entrées in middle school lunch menus were pizza with meat (36%), sandwiches with plain meat or poultry (32%), and cheeseburgers (32%). And in high schools, pizza with meat (40%), sandwiches with plain meat or poultry (36%), cheeseburgers (32%), and sandwiches with breaded meat, poultry, or fish (32%) were the most commonly offered items. Desserts and other snack-type items were offered in almost half (47%) of high school lunch menus, 41% of middle school menus, and 37% of elementary school menus. Cookies, cakes, and brownies were the leading desserts offered at lunch, available in one in five menus. Juice drinks (not 100% juice) and snack chips (excluding corn/tortilla chips) were relatively uncommon in lunch menus (not ⬎10% of menus) and were included with greater frequency in middle and high school menus than in elementary school menus. Foods Consumed at Lunch by NSLP Participants and Nonparticipants Table 2 presents the percentage of NSLP participants and nonparticipants who consumed selected food groups and specific foods at lunch as discrete food items (not as components of a mixed dish or other combination entrées). For all children, the most common type of milk consumed was 1% milk, and a very small proportion of participants and nonparticipants consumed whole milk (2% and 1%, respectively). For both participants and non-

participants, the percentage of children consuming milk decreased from elementary school to middle school and from middle school to high school. Three of four NSLP participants drank milk at lunch, compared to about one of five (19%) nonparticipants. High school nonparticipants were the least likely to consume any milk at lunch (9%). The positive relationship between NSLP participation and milk consumption was statistically significant at all school levels and for almost all milk types. This includes flavored milk, for which the disparity is substantial—50% of NSLP participants drank flavored milk at lunch, compared to 9% of nonparticipants. Forty-five percent of participants consumed fruit or 100% juice at lunch, compared to 30% of nonparticipants. The percentage of both participants and nonparticipants consuming fruit or 100% juice declined from elementary school to middle and high school. Among elementary and middle school children, there were no significant differences between NSLP participants and nonparticipants in the percentage who consumed at least one type of fruit or 100% juice at lunch. However, among high school children, NSLP participants were significantly more likely than nonparticipants to consume fruit or 100% juice. Across all school levels, NSLP participants were significantly more likely than nonparticipants to consume canned fruit at lunch. However, much of the difference in fruit consumption overall can be attributed to the significantly greater proportions of high school participants who consumed canned fruit and 100% juice relative to nonparticipants. Among middle school children, a significantly smaller percentage of NSLP participants (7%) consumed fresh fruit compared to nonparticipants (17%). Across all school levels, more than twice as many NSLP participants as nonparticipants consumed at least one vegetable (as a distinct food item) at lunch (51% vs 23%). The differences remained significant even after excluding french fries and similar potato products, which were the most commonly consumed vegetable for both participants and nonparticipants. NSLP participants in middle and high schools were significantly more likely than their nonparticipant counterparts to consume french fries, and across all school levels, participants were more likely to consume other forms of white potatoes. No more than 6% of children consumed a vegetable from each of the other subgroups (lettuce salads, orange/dark-green vegetables, other vegetables, or legumes). At lunch, one third of children consumed a grain/bread item other than those included in combination items like sandwiches and burgers. Participants and nonparticipants were equally likely to consume a separate grain/ bread item. NSLP participants were more likely to consume a slice of bread, a roll, or similar bread product, while nonparticipants were more likely to consume corn/ tortilla chips, crackers, and pretzels. Only 1% of children reported consuming whole-grain breads/rolls as discrete items at lunch. Among middle and high school children, roughly 75% of participants consumed a grain-based combination entrée at lunch compared to 58% of nonparticipants. Participants were significantly more likely to consume pizza; sandwiches with breaded meat, poultry, or fish; hamburgers; and hot dogs, while nonparticipants were more likely to consume sandwiches with plain meat or poultry and peanut butter sandwiches.

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Table 2. Percentage of National School Lunch Program (NSLP) participants and nonparticipants consuming food group or specific food at lunchab All Children Food group/food

Participants (nⴝ1,386)

Nonparticipants (nⴝ844)

Elementary School Children Participants (nⴝ531)

Nonparticipants (nⴝ191)

Middle School Children Participants (nⴝ497)

Nonparticipants (nⴝ259)

High School Children Participants (nⴝ358)

Nonparticipants (nⴝ394)

4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™ % (standard error) ™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™3 Milk 1% 1% flavored Skim/nonfat Skim/nonfat flavored 2% 2% flavored Whole All flavored milks Fruits and juices Canned fruit Fresh fruit Fruit juice, 100% Vegetables Vegetables, except french fries Starchy vegetables French fries White potatoes Corn Lettuce salads (non-entrée) Orange/dark green Other vegetables Legumes Grains/breads White breads, rolls, bagels Corn/tortilla chips Crackers and pretzels Whole-grain breads and rolls Grain-based combination entrées Pizza with meat Pizza without meat Sandwiches with plain meat or poultry Sandwiches with breaded meat, poultry, or fish Hamburgers Hot dogs/corndogs Peanut butter sandwiches Desserts and snacks Cookies, cakes, brownies Candy Dairy-based desserts Snack chips Dessert items containing fruit or juice Granola and fruit cereal bars Other beverages Juice drinks (not 100%) Bottled water Carbonated soda Tea/coffee

75 (2.3) 41 (3.5) 29 (3.2) 19 (3.0) 16 (2.8) 13 (2.2) 4 (1.2) 2 (0.6) 50 (2.4) 45 (2.4) 20 (2.1) 16 (1.8) 11 (2.2) 51 (2.8) 30 (2.4) 38 (3.2) 24 (3.0) 7 (2.0) 6 (1.5) 6 (1.1) 6 (1.3) 6 (0.9) 2 (0.8) 34 (2.9) 12 (2.3) 9 (1.0) 7 (1.3) 1 (0.5) 67 (3.4) 11 (2.3) 10 (2.0) 7 (1.2)

19** (2.7) 9** (2.3) 5** (0.9) 3** (1.1) 2** (1.0) 6** (1.6) 2 (0.9) 1** (0.3) 9** (1.4) 30** (2.2) 6** (1.4) 19 (2.1) 8 (1.2) 23** (2.5) 11** (1.9) 16** (2.2) 14** (2.1) 1** (0.4) 3 (1.4) 2** (0.6) 4 (0.8) 2** (0.5) 0** (0.3) 33 (2.7) 5** (1.0) 13** (1.3) 13* (2.5) 1 (0.4) 61 (2.6) 6* (1.0) 2** (0.5) 17** (2.0)

83 (2.9) 48 (4.7) 33 (4.3) 21 (3.9) 19 (3.9) 13 (2.8) 4 (1.8) 2 (0.6) 57 (3.4) 55 (3.5) 25 (3.1) 22 (2.7) 11 (3.2) 51 (3.9) 35 (3.6) 37 (4.4) 20 (4.0) 8 (3.0) 8 (2.5) 7 (1.4) 8 (2.2) 7 (1.4) 3 (1.3) 35 (4.4) 15 (3.5) 8 (1.3) 9 (2.1) 1 (0.4) 62 (4.8) 8 (3.1) 11 (2.9) 5 (1.4)

30** (5.0) 14** (4.2) 5** (1.8) 4** (2.4) 4** (2.4) 10 (3.8) 4 (1.9) 1 (0.6) 14** (3.2) 45 (4.3) 9** (2.5) 28 (4.3) 14 (2.8) 24** (5.0) 16** (4.0) 15** (4.1) 11 (3.7) 1* (0.5) 6 (2.9) 1** (0.6) 5 (1.6) 3* (1.3) 1 (0.7) 38 (5.6) 7 (2.5) 13 (2.7) 20 (5.8) 1 (0.7) 67 (4.6) 3 (1.6) 2** (1.1) 19** (3.9)

65 (3.7) 32 (3.9) 24 (3.5) 16 (3.1) 12 (2.5) 14 (3.2) 5 (2.2) 3 (1.0) 41 (3.4) 26 (2.9) 11 (2.2) 7 (1.6) 8 (2.1) 45 (3.9) 24 (2.9) 32 (3.9) 24 (4.2) 4 (1.3) 4 (1.1) 6 (1.5) 4 (1.1) 5 (1.1) 0 (0.3) 31 (3.5) 11 (2.6) 11 (1.8) 5 (1.3) 0 (0.0) 76 (2.7) 18 (3.2) 7 (1.9) 4 (1.2)

18** (3.5) 11** (3.4) 7** (2.5) 2** (0.8) 1** (0.4) 3** (1.5) 2 (0.9) 1 (0.8) 9** (2.7) 29 (4.1) 5* (1.8) 17** (3.4) 8 (2.1) 22** (4.0) 9** (1.9) 15** (3.6) 14** (3.7) 1* (0.6) 1 (1.1) 2** (1.0) 4 (1.6) 1* (1.0) 0 (0.2) 35 (3.7) 5* (1.4) 17* (2.4) 13** (2.8) 1 (0.7) 58** (5.0) 8** (2.6) 1* (0.8) 19** (2.9)

60 (4.5) 29 (4.9) 23 (4.3) 14 (3.6) 11 (3.3) 13 (3.1) 3 (1.4) 4 (1.6) 38 (4.3) 32 (3.7) 14 (2.6) 8 (2.3) 15 (4.0) 54 (4.9) 23 (4.0) 46 (4.9) 34 (4.7) 8 (3.1) 4 (1.5) 7 (2.6) 2 (0.8) 3 (1.1) 0 (0.1) 32 (3.1) 7 (1.9) 10 (2.2) 5 (1.6) 4 (1.9) 75 (4.3) 12 (2.4) 7 (1.9) 16 (3.4)

9** (1.8) 4** (1.1) 3** (1.0) 1** (0.7) 0** (0.0) 3** (1.1) 1 (0.7) 0* (0.3) 4** (1.2) 18** (2.2) 2** (0.8) 12 (2.1) 4** (1.2) 24** (3.3) 7** (2.0) 18** (2.9) 17** (2.7) 1* (0.6) 1* (0.6) 3 (1.3) 2 (0.7) 1* (0.3) 0 (0.0) 27 (2.6) 4 (1.1) 10 (1.9) 7 (1.5) 1 (0.5) 58** (2.8) 8 (1.4) 1** (0.7) 14 (2.2)

5 (1.4) 6 (1.9) 5 (1.5) 4 (1.1) 38 (2.7) 18 (2.5) 7 (0.8) 7 (1.7) 4 (0.7) 3 (0.8) 1 (0.4) 18 (1.8) 9 (1.0) 4 (0.7) 3 (0.6) 3 (0.8)

2* (0.5) 1** (0.3) 2* (0.6) 15** (2.3) 52** (2.9) 20 (1.8) 17** (1.6) 6 (2.3) 12** (1.4) 6* (1.1) 6** (1.3) 56** (2.6) 27** (2.2) 11** (1.5) 16** (1.6) 5 (1.0)

4 (2.0) 8 (3.0) 6 (2.2) 5 (1.7) 40 (4.2) 19 (4.1) 5 (0.9) 10 (2.6) 4 (1.1) 4 (1.2) 1 (0.5) 8 (1.6) 4 (1.1) 3 (0.8) 1 (0.5) 1 (0.5)

0 (0.2) 1* (0.7) 1* (0.8) 24** (4.8) 62** (5.2) 25 (4.0) 17** (2.8) 12 (5.3) 13** (2.8) 12** (2.7) 6 (2.5) 46** (5.1) 31** (4.2) 7* (1.8) 8** (2.7) 1 (0.6)

6 (1.7) 5 (1.9) 3 (0.8) 2 (0.8) 38 (3.3) 20 (2.6) 8 (1.9) 5 (1.2) 5 (1.2) 2 (0.9) 0 (0.4) 28 (3.6) 15 (2.5) 4 (1.3) 4 (1.1) 6 (2.1)

0** (0.4) 0* (0.2) 3 (1.9) 13** (2.7) 49 (4.7) 20 (3.3) 12 (2.5) 3 (1.4) 12** (2.4) 5 (1.4) 4* (1.4) 56** (4.2) 32** (3.1) 9** (2.0) 11* (2.8) 5 (1.3)

10 (2.4) 3 (1.1) 4 (2.0) 1 (0.7) 33 (3.3) 16 (2.3) 13 (2.0) 3 (1.2) 4 (1.3) 1 (0.5) 1 (0.8) 35 (3.6) 16 (2.6) 9 (1.6) 8 (1.8) 7 (2.0)

5* (1.1) 1* (0.6) 1 (0.7) 8** (1.8) 44* (2.7) 15 (1.9) 18 (2.3) 3 (0.8) 11** (1.9) 2 (0.7) 6** (1.7) 64** (3.2) 20 (2.7) 16* (2.5) 25** (2.4) 8 (1.8)

a Data are from the third School Nutrition Dietary Assessment Study, 24-Hour Dietary Recalls, school year 2004-2005. Tabulations are weighted to be nationally representative of children in public NSLP schools. Sample sizes are unweighted and exclude children who did not consume a lunch. b Table excludes fruits, vegetables, or grain/bread items included in mixed dishes, such as noodles in macaroni and cheese, or vegetable toppings on pizza. *Difference between participants and nonparticipants is significantly different from zero at the P⬍0.05 level. **Difference between participants and nonparticipants is significantly different from zero at the P⬍0.01 level.

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Table 3. Percentage of School Breakfast Program menus offering food group or specific foodab All School Menus (nⴝ1,605)

Elementary School Menus (nⴝ579)

Middle School Menus (nⴝ532)

High School Menus (nⴝ494)

Food group/foodc

%

SEd

%

SE

%

SE

%

SE

Milk 1% 1% flavored 2% 2% flavored Skim/nonfat Skim/nonfat flavored Whole All flavored milks Fruits and juices Fruit juice, 100% Fresh fruit Canned fruit Grains/breads RTE cereale Sweetened Unsweetened Sweet rolls, doughnuts, toaster pastries Buttered toast, bagels with cream cheese White breads, rolls, bagels Pancakes, waffles, French toast Biscuits, croissants, cornbread Muffins, sweet/quick breads Crackers (mainly graham) Granola and fruit cereal bars Whole-grain breads and rolls Grain-based combination entrées Breakfast sandwiches Pizza (all types)

99 71 48 56 6 44 29 29 79 99 88 26 14 95 78 72 27 29 24 20 19 17 15 9 5 4 35 13 11

0.5 4.3 4.0 3.7 1.6 4.0 4.2 3.7 3.1 0.6 1.9 2.6 1.9 1.1 2.6 2.8 2.8 2.0 3.0 2.4 1.4 1.7 1.5 1.7 1.1 1.1 2.5 1.4 1.3

99 72 46 52 6 41 27 29 73 99 85 22 15 94 76 70 26 21 24 16 19 15 13 11 4 4 31 9 10

0.8 5.8 5.4 5.4 2.4 5.6 5.6 5.3 4.7 0.6 2.8 3.5 2.8 1.6 3.7 4.0 3.9 2.5 3.9 3.3 2.0 2.4 1.9 2.7 1.5 1.7 3.2 1.4 1.7

100 76 52 56 8 43 26 30 81 98 89 31 12 97 80 70 27 40 26 22 20 17 17 9 4 4 42 18 12

0.0 5.3 6.2 5.8 3.0 6.1 5.4 5.5 4.3 2.2 3.3 4.2 2.6 1.1 4.0 5.0 4.4 4.3 6.0 4.3 2.4 2.6 3.4 2.4 1.7 1.8 4.1 3.1 2.2

100 62 53 69 6 56 38 28 95 100 97 31 9 98 83 80 29 44 19 32 17 23 20 3 5 2 42 22 13

0.0 11.5 10.5 7.1 2.3 8.8 11.4 7.0 1.9 0.2 1.4 6.7 2.8 1.2 4.7 5.0 6.9 5.6 6.9 5.0 1.7 3.9 3.3 1.0 2.2 1.5 7.7 5.0 3.4

a Data are from the third School Nutrition Dietary Assessment Study, Menu Survey, school year 2004-2005. Tabulations are weighted to be nationally representative of public National School Lunch Program schools. Sample sizes are unweighted and include menus from 331 schools (120 elementary schools, 109 middle schools, and 102 high schools). b Table excludes fruits or grain/bread items included in mixed dishes, such as a biscuit in a breakfast sandwich. c Vegetables (mainly potato products) were offered in fewer than 5% of breakfast menus and are not included in the table. d SE⫽standard error. e RTE cereal⫽ready-to-eat cereal.

NSLP participants were significantly less likely than nonparticipants to consume desserts and snack foods at lunch (38% vs 52%). Among elementary school children, participants were less likely than nonparticipants to consume candy, snack chips, and dessert items containing fruit (such as fruit juice bars and fruited gelatin). Among middle and high school children, NSLP participants were less likely than nonparticipants to consume snack chips and granola/cereal bars. Nonparticipants were more than three times as likely as participants (56% vs 18%) to consume a beverage other than milk or 100% fruit juice at lunch. Juice drinks were the most common beverage among elementary school and middle school nonparticipants (31% and 32%). One quarter of nonparticipants in high schools consumed carbonated soda at lunch, compared to only 8% of high school NSLP participants. Bottled water was also consumed by a significantly greater percentage of nonparticipants (11%) than participants (4%).

Foods Offered in Reimbursable School Breakfast Menus One-percent milk was the leading type of milk offered in elementary and middle school menus, whereas 2% milk was most common in high school menus (Table 3). At the same time, more than half of high school menus (56%) offered skim/nonfat milk at breakfast, compared to 41% to 43% of elementary and middle school menus. As in lunch menus, whole milk was the least offered milk in breakfast menus. Flavored milk was offered less frequently at breakfast than at lunch, particularly in elementary and middle school menus. At all school levels, 100% juice was more widely offered at breakfast than fresh fruit or canned fruit. Both citrus (primarily orange juice) and noncitrus juices (apple juice and juice blends) were widely available, and about one fourth of the noncitrus juices were reported as “with added vitamin C” (not shown in Table 3). Fresh fruit was

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Table 4. Percentage of School Breakfast Program participants and nonparticipants consuming food group or specific food at breakfastab All Children Food group/foodc

Participants (nⴝ381)

Nonparticipants (nⴝ1,578)

Elementary School Children Participants (nⴝ160)

Nonparticipants (nⴝ515)

Middle School Children Participants (nⴝ127)

Nonparticipants (nⴝ501)

High School Children Participants (nⴝ94)

Nonparticipants (nⴝ562)

4™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™ % (standard error) ™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™3 Milk 1% 1% flavored 2% 2% flavored Whole Skim/nonfat Skim/nonfat flavored All flavored milks Fruits and juices Fruit juice, 100% Canned fruit Fresh fruit Grains/breads RTE cereald Sweetened Unsweetened Sweet rolls, doughnuts, toaster pastries Pancakes, waffles, French toast Biscuits, croissants, cornbread Crackers (mainly graham) Muffins, sweet/quick breads White breads, rolls, bagels Whole-grain breads and rolls Grain-based combination entrées Desserts and snacks Candy Cookies, brownies, cakes Granola and fruit cereal bars Other beverages Juice drinks (not 100%) Bottled water Tea/coffee Carbonated soda

75 (3.3) 35 (5.6) 12 (2.8) 29 (5.3) 4 (1.8) 7 (1.8) 7 (1.7) 6 (1.6) 22 (3.4) 63 (4.2) 56 (4.4) 6 (3.3) 5 (1.7) 77 (3.8) 34 (3.8) 29 (3.9) 5 (1.4)

53** (1.6) 7** (0.8) 1** (0.4) 30 (1.6) 2 (0.5) 11* (1.3) 4 (0.7) 0** (0.2) 3** (0.6) 30** (1.7) 22** (1.6) 1 (0.2) 9* (1.0) 73 (1.6) 37 (1.7) 29 (1.6) 8 (0.9)

81 (4.4) 42 (7.3) 14 (3.8) 31 (6.9) 5 (2.6) 8 (2.3) 4 (1.7) 4 (1.7) 23 (4.5) 66 (5.4) 57 (6.0) 8 (5.0) 7 (2.5) 79 (5.3) 38 (5.3) 32 (5.5) 6 (2.0)

56** (2.7) 8** (1.4) 1** (0.7) 34 (2.4) 3 (0.9) 12 (2.0) 3 (.01) 0 (0.4) 5** (1.1) 33** (2.9) 24** (3.0) 0 (0.3) 11 (1.6) 79 (2.3) 39 (3.1) 32 (2.9) 7 (1.4)

71 (4.9) 27 (5.6) 10 (3.4) 24 (5.8) 4 (2.6) 8 (2.9) 14 (4.3) 10 (4.0) 24 (4.6) 53 (5.9) 51 (6.0) 1 (0.5) 3 (1.9) 78 (5.1) 29 (4.9) 24 (5.0) 5 (2.4)

56* (2.4) 9** (1.4) 0** (0.3) 25 (2.0) 1 (0.5) 13* (2.1) 6 (1.3) 0* (0.0) 1** (0.6) 28** (2.1) 22** (2.0) 0 (0.3) 7 (1.3) 73 (2.1) 40* (2.3) 33 (2.1) 8 (1.2)

55 (6.8) 16 (4.1) 8 (3.1) 24 (5.4) 2 (1.2) 5 (2.4) 11 (4.3) 8 (3.4) 18 (4.2) 62 (7.0) 59 (7.1) 1 (1.5) 3 (1.8) 67 (7.7) 22 (5.6) 21 (5.6) 2 (1.2)

46 (2.2) 6* (1.2) 0* (0.1) 26 (2.1) 0 (0.3) 10 (1.6) 4 (1.0) 0* (0.0) 1** (0.5) 26** (2.1) 19** (1.6) 1 (0.5) 8* (1.3) 63 (2.2) 31 (2.3) 21 (2.0) 10** (1.5)

17 (3.1) 12 (3.7) 10 (2.6) 8 (3.6) 7 (3.6) 6 (1.5) 2 (0.9) 23 (4.2) 17 (2.1) 8 (1.8) 6 (1.4) 1 (0.6) 11 (2.0) 4 (1.2) 3 (1.6) 3 (1.1) 2 (0.8)

10* (1.1) 10 (1.2) 2** (0.4) 3 (0.6) 2 (0.4) 9 (0.8) 4 (0.5) 7** (0.8) 20 (1.5) 8 (1.0) 7 (1.0) 4** (0.7) 24** (1.5) 8** (0.9) 8* (0.8) 5 (0.6) 6** (0.8)

16 (4.2) 16 (5.5) 6 (2.7) 11 (5.1) 9 (5.4) 5 (2.1) 3 (1.4) 23 (5.7) 16 (2.5) 7 (2.1) 7 (1.9) 1 (0.7) 11 (2.7) 4 (1.5) 4 (2.4) 2 (1.2) 2 (1.1)

13 (1.8) 14 (2.2) 1 (0.6) 4 (1.3) 2 (0.7) 10* (1.4) 3 (0.8) 6** (1.1) 20 (2.2) 6 (1.4) 9 (1.8) 4* (0.9) 19* (2.4) 8 (1.4) 4 (1.0) 4 (0.8) 4 (1.0)

16 (4.1) 4 (1.8) 16 (5.8) 3 (1.7) 6 (3.3) 7 (2.7) 1 (0.7) 19 (4.6) 10 (2.9) 7 (2.8) 2 (1.3) 1 (0.6) 7 (2.7) 3 (1.7) 2 (1.3) 2 (1.1) 1 (1.0)

8 (1.3) 10* (1.4) 2* (0.7) 2 (0.6) 3 (0.9) 7 (1.2) 4** (0.9) 7* (1.2) 15 (1.9) 7 (1.5) 4 (0.9) 5** (0.9) 25** (2.2) 10** (1.4) 8** (1.4) 3 (0.8) 5* (1.2)

22 (7.0) 3 (1.7) 20 (7.0) 2 (1.9) 2 (1.5) 8 (3.5) 1 (0.6) 28 (6.8) 27 (6.5) 16 (6.4) 6 (2.8) 5 (2.6) 14 (5.4) 5 (3.2) 1 (1.1) 6 (4.6) 2 (1.3)

8 (1.4) 5 (1.0) 2** (0.5) 2 (0.7) 2 (0.6) 8 (1.1) 5** (0.9) 8** (1.6) 22 (2.2) 12 (1.5) 5 (1.3) 5 (1.3) 34** (2.6) 8 (1.4) 12** (1.7) 8 (1.2) 8** (1.4)

a Data are from the third School Nutrition Dietary Assessment Study, 24-Hour Dietary Recalls, school year 2004-2005. Tabulations are weighted to be nationally representative of children in public National School Lunch Program schools. Sample sizes are unweighted and exclude children who did not consume a breakfast. b Table excludes fruits or grain/bread items included in mixed dishes, such as a biscuit in a breakfast sandwich. c Vegetables (mainly potato products) were consumed by only 2% of children at breakfast and are not included in the table. d RTE cereal⫽ready-to-eat cereal. *Difference between participants and nonparticipants is significantly different from zero at the P⬍0.05 level. **Difference between participants and nonparticipants is significantly different from zero at the P⬍0.01 level.

available in close to one in four elementary school breakfast menus and one in three middle and high school menus. RTE cereal was the leading grain/bread item available at breakfast, offered in more than three fourths of menus. Most of this cereal was sweetened, with only 27% of menus offering an unsweetened cereal. Pastrylike items, such as toaster pastries, sweet rolls/honey buns, doughnuts, and fruit turnovers, were included in twice as many middle and high school menus as elementary school menus. Whole-grain varieties of separately offered bread items were virtually unavailable to children, offered in 4% of breakfast menus. Grainbased combination entrées were available in 42% of middle and high school breakfast menus, compared to 31% of elementary school menus. Breakfast sandwiches (sandwiches with sausage, egg, cheese, ham or other meat on a biscuit, English muffin, bagel, or croissant) were the leading type of grain-based combination

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entrées in middle and high school menus (18% and 22%, respectively). Pizza was the leading combination entrée in elementary school menus, appearing in 10% of breakfast menus. Foods Consumed at Breakfast by SBP Participants and Nonparticipants Overall, 75% of SBP participants drank milk at breakfast, compared to 53% of nonparticipants (Table 4). Among participants, 1% milk was the leading type consumed, followed by 2% milk. In contrast, the leading source of milk at breakfast for nonparticipants was 2% milk, followed by whole milk. SBP participants were significantly more likely to consume flavored milk (22%) than nonparticipants (3%). Almost two thirds of participants consumed 100% juice or some type of fruit at breakfast, compared to a significantly smaller proportion of nonparticipants (30%). Fresh fruit was consumed by 5%

of SBP participants at breakfast compared to a slightly but significantly greater percentage of nonparticipants (9%). For both participants and nonparticipants, 100% fruit juice was the most commonly consumed fruit item. The proportions of children consuming discrete grain/ bread items at breakfast did not differ between SBP participants and nonparticipants. For both groups, RTE cereals were consumed most frequently. Among high school children, 10% of nonparticipants consumed unsweetened cereals compared to 2% of participants, but there were no significant differences in the consumption of sweetened cereals at any school level. SBP participants were considerably more likely than nonparticipants to consume sweet rolls, doughnuts, and similar items and to consume biscuits, croissants, and cornbread at breakfast. In addition, a significantly greater percentage of middle and high school nonparticipants consumed whole-grain breads or rolls at breakfast—4% of middle school and 5% of high school nonparticipants, compared to 1% of participants. Grain-based combination entrées, such as breakfast sandwiches and pizza, were consumed at breakfast by a significantly larger proportion of participants than nonparticipants (23% vs 7%). Roughly one in five children consumed dessert and snack-type items (mainly candy, cookies, and granola/ cereal bars) at breakfast, and there were no significant differences in the percentage of participants and nonparticipants who consumed these items. High school participants (27%) were the most likely to consume dessert and snack-type items at breakfast, while their nonparticipant counterparts (34%) were the most likely to drink beverages other than milk or 100% juice. Nearly one fourth of nonparticipants (24%) consumed beverages other than milk or 100% juice at breakfast, compared to 11% of participants. The variation can be attributed to differences among middle and high school children: participants were significantly less likely than nonparticipants to consume bottled water and carbonated soda. DISCUSSION Results of these analyses offer insight into potential strengths and weaknesses of the menus and foods provided to children in school meals—a major component of the school food environment—and potential ways in which menu offerings can be changed to improve children’s dietary intakes. Findings suggest that school meals offer children a selection of healthful food items, but availability of these items within school meals may not be enough to influence children’s consumption of healthful foods. Efforts are needed not only to increase the availability and accessibility of healthful foods, but also to educate children on appropriate food choices within and among food groups. These analyses, however, have three important limitations. The first limitation is that the food and nutrient database used allowed us to look only at foods reported as distinct food items. For example, our tabulations of the proportion of menus offering vegetables or children consuming whole grains do not include vegetables or whole grains that may have been included in combination items such as entrée salad bars, pizza, or sandwiches. The second limitation is that the analysis does not consider portion size. Children were credited as consuming a food or food group even if a very small portion size was reported. Because of these limitations, findings from these analyses do not pro-

vide information about the total amounts of food offered and consumed from the MyPyramid food groups and subgroups or about how meal offerings or children’s intakes compare to MyPyramid recommendations. Work on linking the foods reported in the SNDA-III dietary recalls to the MyPyramid Equivalents Database was underway but had not been completed when this article was prepared (23). This linked dataset will allow researchers to assess children’s intakes of MyPyramid food groups relative to recommendations. Future research should expand this analysis to assess the MyPyramid food group content of the meals offered to children through the school meal programs. The third limitation of this study is that differences in the types of foods consumed by school meal participants and nonparticipants cannot be interpreted as effects of the school meal programs because estimates were not adjusted for differences in characteristics of participants and nonparticipants. Availability and Consumption of Milk To promote bone health and contribute to an overall healthful diet, the 2005 Dietary Guidelines stress the importance of consuming fat-free and lowfat milk and milk products, especially during childhood and adolescence (17). Although 1% milk was the most common type offered in school lunch menus, roughly a third of lunch menus offered whole milk, and more than half offered 2% milk. A comparable pattern was found in breakfast menus. Using data from SNDA-III, Crepinsek and colleagues (24) found that a large proportion of US public schools did not meet federal nutrition standards for total fat and saturated fat in the average lunch offered to children. Removing or reducing the availability of 2% and whole milk would lower the total fat and saturated fat content of the meals offered to children. Federal regulations require that schools offer milks in a variety of fat contents but do not require that whole or 2% milk be offered.

Efforts are needed not only to increase the availability and accessibility of healthful foods, but also to educate children on appropriate food choices within and among food groups. Flavored milk, available in virtually all school lunch menus, was offered less frequently in breakfast menus, but was increasingly available at higher school levels. The widespread availability of flavored milks (especially in lunch menus) and the large proportion of participants consuming flavored milk may raise concerns about added sugars. Research suggests, however, that the positive contribution of flavored milks to children’s diets may outweigh the potential negative effect of the added sugar. For example, Johnson and colleagues found that children who consumed flavored milk were more likely than those who did not consume flavored milk to drink more milk

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overall without consuming more fat and calories and were more likely to meet their calcium needs (25). Similarly, Murphy and colleagues found that children who drank milk, including flavored milk, had higher intakes of vitamin A, calcium, phosphorus, magnesium, and potassium and had body mass indexes that were lower or comparable to those of non-milk drinkers (26). The lower prevalence of milk consumption at lunch and breakfast for both participants and nonparticipants at higher school levels is troubling, but may be attributable to the greater proportion of older children consuming other beverages, such as carbonated soda, fruit drinks, and bottled water. This decline in the consumption of milk during middle and high school is consistent with findings by Clark and colleagues on children’s mean intakes of calcium (22). Results showed that middle and high school children had mean calcium intakes that were less than the Adequate Intake level, but elementary school children had a mean calcium intake that was greater than the Adequate Intake. Because dietary calcium needs increase during adolescence, efforts are needed to increase children’s consumption of milk, especially among older children, and schools should explore ways to incorporate lowfat and fat-free milk and milk products into the types of foods children are likely to consume. Availability and Consumption of Fruits and Vegetables The USDA has taken many steps to increase the availability of fruits and vegetables in the school meal programs (27). A comparison of SNDA-III data to data from SNDA-II, conducted in school year 1998-1999, indicates that the availability of fresh fruit has increased in both lunch menus (41% of menus in SNDA-II vs 50% in SNDAIII) and breakfast menus (17% of menus in SNDA-II vs 26% in SNDA-III) (28). Although school meals have increased offerings of fresh fruits and vegetables, improvements can be made to the type and variety of fruits and vegetables offered. For example, very few daily menus provided berries, melons, or other colorful fruits, and school lunch menus were more likely to include starchy vegetables than any other vegetable subgroup. Changes in the types of fruits and vegetables offered in school lunch and breakfast menus can help school meals more closely align with the 2005 Dietary Guidelines, which recommend a variety of fruits and vegetables each day. As noted, the vast majority of school meals offered daily fruit and vegetable items, and children consuming school meals were more likely to include fruits and vegetables in their lunch and breakfast. At the same time, a large proportion of children did not consume fruit or vegetables (especially dark-green vegetables, orange vegetables, or legumes) at lunch and breakfast. Additional research is needed to account for fruit and vegetable components in mixed dishes (including combination entrées) in order to provide a more precise estimate of the total amount of fruits and vegetables available in school meals and consumed by children. However, these results suggest that efforts to increase children’s consumption of fruits and vegetables at lunch and breakfast need to extend beyond improving access to and increasing availability of fruits and vegetables. Strategies to help children incorporate more fruits and vegetables in lunch and breakfast need to be explored. For example, changes in preparation meth-

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ods or improvements in the presentation of fruits and vegetables could make these items more appealing to children. In addition, children may benefit from interventions such as incentive programs, nutrition education, and tasting opportunities that specifically target fruit and vegetable consumption. Availability and Consumption of Grains/Breads School menus provided limited opportunities for children to select separate whole-grain products and few children consumed whole-grain breads (as distinct items) at lunch or breakfast. It is important to reiterate that whole grains within combination items were not accounted for in this analysis. Opportunities do exist for schools to incorporate whole-grain products into current lunch and breakfast menu items. Children’s food choices at lunch show that a larger proportion of children consumed grain-based combination entrées in comparison to separate grain/bread items. This suggests that efforts to increase whole-grain consumption at lunch could focus on incorporating whole grains into combination entrées rather than promoting individual whole-grain items. For example, because a large proportion of children consume pizza at lunch, schools that prepare dough from scratch could begin to gradually use whole-grain flours to develop a whole-grain pizza crust. The apparent popularity of sweetened RTE cereals in school menus and in children’s breakfasts may provide schools with opportunities to increase children’s consumption of whole grains. Currently, no standards exist for the type of cereals allowed in school meals. Requirements related to the whole-grain content of RTE cereals can help schools substitute current cereal offerings with ones that may have greater potential to contribute more positively to children’s daily intake of whole grains. In addition, children who did not participate in the SBP were more likely than participants to consume wholegrain breads or rolls at breakfast. The whole-grain items were most likely from foods that were brought from home or consumed at home, which suggests that children are willing to consume whole-grain breads if they are offered. Availability and Consumption of Desserts, Snack-Type Items, and Beverages Other than Milk and 100% Juice Although less than half of school lunch menus offered desserts and snack-type items to children, the availability of such items has not changed much since SNDA-II (44% of menus in SNDA-II compared to 40% in SNDAIII), when regulations had just been established for levels of fat and saturated fat in school meals (28). In SNDA-III, children at higher school levels had increased access to desserts and snack-type items as part of the school lunch. Children’s intake of low-nutrient, energy-dense foods and beverages like grain-based desserts (cookies, cakes, and brownies), dairy-based desserts, and salty snacks (potato chips) has been associated with higher energy intake and decreased intake of several key micronutrients (29). In SNDA-III, almost half of school children consumed a dessert or snack-type item at lunch, including cookies, candy, ice cream, and potato chips. Children’s participation in the NSLP was associated with a lower likelihood of con-

suming desserts, snack-type items, and beverages other than milk and 100% juice. With the high prevalence of obesity among children and adolescents, it is important for schools to limit low-nutrient, energy dense foods (eg, desserts, snack-type items, and juice drinks), which tend to compete with healthier options within school meals.

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CONCLUSIONS Schools can help children increase their intake of foods that are likely to have important health benefits and limit intake of the foods that are not recommended as part of a healthful diet. The federally sponsored NSLP and SBP are important venues for providing children with healthful, balanced meals. This article provides valuable information on school menu offerings and children’s food choices. It shows that consumption of school meals is positively related to children’s intake of key food groups at lunch and breakfast and that additional health benefits could be realized by offering more fresh fruits, whole grains, and a greater variety of vegetables. Registered dietitians and other food and nutrition professionals can work with school districts and individual schools to plan menus that meet nutrient requirements and include foods that children will eat. They can advocate for enhancing the type and variety of foods offered in school meals to include even more fresh fruits, vegetables, whole grains, and fat-free or lowfat milk and milk products. When developing strategies for incorporating these foods into school meals, it will be important to consider the potential effects on children’s participation in the school meal programs and foodservice costs. Food and nutrition professionals working with schools can promote and provide nutrition education to children to encourage the selection of more healthful foods. While children ultimately have to make food choices about what they consume, improving the food options available at school will make it easier for children to select healthful meals. STATEMENT OF CONFLICT OF INTEREST: The authors have no conflict of interest to report with the sponsor of this supplement article or products discussed in this article. The third School Nutrition Dietary Assessment Study was funded by the Food and Nutrition Service, US Department of Agriculture (contract numbers 43-3198-3-3716, 433198-4-0060, AG-3198-D-05-0071). The Robert Wood Johnson Foundation provided support for the preparation of this manuscript (grant number 60542). The opinions expressed are those of the authors and do not necessarily represent the views or recommendations of the funding organizations or Mathematica Policy Research, Inc. The authors thank Anne Gordon, PhD, and Ander Wilson who contributed to the analysis and Eileen Curley, MS, for preparation of the manuscript. We also thank the school districts, schools, students, and parents who provided information for the study.

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