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Classroom Parties in US Elementary Schools: The Potential for Policies to Reduce Student Exposure to Sugary Foods and Beverages
Research Article Classroom Parties in US Elementary Schools: The Potential for Policies to Reduce Student Exposure to Sugary Foods and Beverages Lindsey Turner, PhD; Jamie F. Chriqui, PhD, MHS; Frank J. Chaloupka, PhD ABSTRACT Objective: To examine associations among school, district, and state policies regarding classroom birthday and holiday parties. Design: School-level policies assessed by survey during the 2009–2011 school years, with collection of corresponding district policies and state laws. Setting: United States public elementary schools. Participants: Surveys from 1,204 schools (response rate, 60.9%). Variables Measured: Prevalence of school-wide restrictions on sugary items served during parties. Predictor variables included district policy and state law. Analysis: Multivariate logistic regressions to examine associations between school-level restrictions (outcome) and district policies and state laws, controlling for demographics and school year. Results: Approximately one half of schools discouraged or prohibited sugary items during parties, or did not allow parties. Schools with a district policy and state law were 2.5 times more likely to restrict sweet items at parties than were schools with no corresponding policy or law. School-level limits were more common where policy and law addressed specific nutritional aspects of foods and beverages served in classroom parties (odds ratios, > 2.0; P < .001). Conclusions and Implications: Prohibitions on sugary party fare were uncommon at all levels. Even though most policies were framed as recommendations rather than requirements, policy and law were associated with increased school-level restrictions, which demonstrates the value of policy. Key Words: schools, health policy, child, sugar-sweetened beverages, overweight (J Nutr Educ Behav. 2013;45:611-619.)
INTRODUCTION Improving the nutritional quality of foods and beverages in schools is a key aspect of obesity prevention efforts.1 Considering that one third of United States (US) children ages 6–11 years were overweight or obese during 2009–2010,2 these efforts are essential. Foods and beverages sold in schools are grouped into 2 categories: (1) school meals; and (2) competitive foods and beverages, which include all items sold or offered to students outside of meals. Competitive products are typically sold in vending machines, school stores or snack bars,
a la carte in the cafeteria, or via in-school fundraisers, and they are also offered to students during parties or as rewards in the classroom.3 Competitive items are widely available in schools4; during 2004–2005, 73% of public elementary schools offered at least 1 source of competitive foods and beverages, including sales venues (vending machines, school stores or snack bars, and a la carte lines) as well as fundraisers, parties, and rewards in the classroom. Furthermore, 29% of elementary school students consumed competitive items during the average school day.5 Although many studies have examined the avail-
Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois Address for correspondence: Lindsey Turner, PhD, Bridging the Gap Research Program, Institute for Health Research and Policy, University of Illinois at Chicago, 1747 W. Roosevelt Rd, #558, Chicago, IL 60608; Phone: (312) 355-2388; Fax: (312) 355-2801; E-mail: [email protected] Ó2013 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR http://dx.doi.org/10.1016/j.jneb.2013.04.261
Journal of Nutrition Education and Behavior Volume 45, Number 6, 2013
ability of competitive foods and beverages in traditional sales venues,5,6,7,8 scant evidence is available regarding the frequency and characteristics of classroom parties. Some research— albeit from small-scale studies—has documented that what children eat and drink during classroom parties is unhealthy; for example, direct observation of 6 separate classroom parties in pre-kindergarten, kindergarten, and first-grade classrooms at 1 urban elementary school9 indicated that sugary foods and beverages were offered at all 6 parties, and cupcakes and sugarsweetened beverages were offered at 5 of the 6 parties. On average, students consumed an estimated 444 ( 221) kilocalories from items served at each party, and were also given take-home goody bags with an estimated total of 638 kilocalories.9 Previous work from the same authors showed similar results during 4 elementary school birthday parties, with cake, sugarsweetened beverages, and other sugary items served at all parties, and an
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612 Turner et al estimated caloric intake for students ranging from 259 to 455 kilocalories at each party.10 In addition, some evidence suggests that calories consumed in the classroom are associated with higher student body mass index (BMI). For example, a study of 3,088 eighth-grade students in the Minneapolis–St. Paul metropolitan area found that the BMI of students increased by a 0.10 BMI unit for each additional food practice (eg, fundraisers, rewards) allowed in school.11 Importantly however, a comprehensive review of recent research12 concluded that competitive food and beverage policies—addressing items sold, and those offered in the classroom—are associated with children's diets and weight status. Nationwide research found that changes in state policies regarding school parties were associated with reduced soda consumption among high school students.13 Furthermore, analysis of objectively measured weight and height status for 6,300 middle school students nationwide revealed that weight outcomes (ie, changes in BMI) were healthier for students in states where laws restricted competitive foods than in states without such laws.14 Such findings support the promise of policy approaches for improving the school food environment. Recently, lawmakers have recognized the potential for state laws and school district policies to have a role in promoting healthy school food environments. The Child Nutrition and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Reauthorization Act of 200415 mandated that school districts participating in federal child nutrition programs adopt and implement a wellness policy by the first day of the 2006–2007 school year; these policies were to include nutrition guidelines for all foods and beverages. Each district was responsible for establishing the guidelines, which allowed much variability in policy focus, strength, and implementation. Since 2006–2007, district policies addressing competitive foods and beverages have become more prevalent, but party restrictions are rare; as of 2008–2009, only 2% of public elementary school students nationwide were enrolled in a district with strong nutritional restrictions on items served during school parties.16
Journal of Nutrition Education and Behavior Volume 45, Number 6, 2013 Actions at the school, district, and state levels regarding classroom celebrations have often been met with controversy, resistance from parents and community members, and mixed coverage in the media.17-19 Some state-level legislation has been proposed20 to protect children's rights to bring cupcakes to school celebrations. Resistance to changes that involve traditions with strong emotional investment—such as celebrating birthdays with cupcakes—is inevitable. However, the challenge is to balance the need to respect cultural norms and traditions with the public health goal of providing a healthy school environment. With the increasing prevalence of district policies and state laws regarding competitive foods—as well as push-back on cupcake bans and resistance to top-down legislation regarding school practices—it is crucial to examine the strength of the evidence that state- and district-level policies improve school practices. In the 6 years since the wellness policy mandate went into effect, the literature on this topic has been increasing steadily. Initially, many districts were slow to develop and implement policies,16,21,22 but competitive foods policies have strengthened over time.23 There is scant data on the current prevalence of state laws and districtand school-level policies regarding classroom parties, and whether state laws and district policies are associated with school-level nutrition restrictions regarding parties. This study used nationally representative cross-sectional data from US public elementary schools during 2009– 2010 and 2010–2011 to examine the multilevel linkages among state laws, district policies, and school-level policies regarding classroom parties.
METHODS Data were gathered by Bridging the Gap,24 a research program supported by the Robert Wood Johnson Foundation. The Institutional Review Board at the University of Illinois at Chicago approved the study.
School-level Data
Sampling and weighting. The school sample was developed at the Institute
for Social Research at the University of Michigan, based on sampling frames developed from the public-use Common Core of Data maintained by the National Center for Education Statistics.25 All public elementary schools containing a third-grade class with at least 20 students, from the contiguous US, were eligible for sampling. In each year, 1,070 schools were sampled; schools determined to be closed or ineligible (ie, no third grade) were not recruited. The response rate26 was 64.5% in 2009–2010 (n ¼ 680 of 1,055 eligible schools) and 57.4% in 2010–2011 (n ¼ 598 of 1,042 eligible schools). Weights were developed and adjusted for school nonresponse bias.
Procedure. Surveys were mailed to principals in January of each school year, with subsequent follow-up by mail, e-mail, and telephone until recruitment ended in June. Instructions requested that the survey be completed by the principal or other staff with knowledge of school practices pertaining to student health. A $100 incentive was offered to the respondent or school.
Measures. The survey measure to be completed by principals included 10 pages of items pertaining to a variety of food and nutrition practices (ie, timing and duration of meals, participation in federal meal programs, availability of competitive foods), physical activity (ie, physical education and recess), and other aspects of wellness (eg, policy development). Researchers developed the surveys to be consistent with surveys from an existing, parallel study of practices in middle and high schools,27 as well as a review of prior research, and original development of items of interest to the research team. The research team developed the items used in the current analyses based on preliminary data gathered in previous years as well as the researchers' personal knowledge of party practices in schools and input from school principals. The multipart item was worded, ‘‘Are there any policies limiting sugar-sweetened items (eg, candy, cupcakes, cookies) from being served or brought in either at snack time or for parties during the school day?’’
Journal of Nutrition Education and Behavior Volume 45, Number 6, 2013 One set of responses was for ‘‘birthday parties’’ and another was for ‘‘holiday parties’’ (snack time data are not reported here). Response options were: (1) no policy; (2) decision is up to each teacher; (3) sweetened items discouraged school-wide; (4) sweetened items prohibited school-wide; and (5) not applicable, no parties.
Contextual factors. School-level demographic data were obtained from public use data files from the National Center for Education Statistics (Common Core of Data 2009–1010)25 for use as covariates in regression analyses. Demographics were coded as follows: school size (total number of students in the school), coded as small (< 451 students), medium (451–621 students), and large (> 621 students; referent); percentage of students eligible for free or reduced-price lunch, coded as highest (> 66%), medium (# 66% to > 33%), and lowest (# 33%; referent); census region, coded as West, Northeast, Midwest and South (referent); and locale, coded as rural, town, suburban, and urban (referent). For racial/ethnic composition, each school was coded as 1 of 4 exhaustive and mutually exclusive categories: predominantly ($ 66%) white (referent); majority ($ 50%) Latino; majority ($ 50%) black; and diverse (no majority).
District-level Policy Data Collection Formal, ‘‘on-the-books,’’ policy documents (ie, wellness policies, associated rules and regulations, and other policies embedded by reference into the wellness policy or rules) were collected from the corresponding school district for all schools. Trained research assistants gathered hard copies of policies using an established protocol via Internet searches, with telephone calls and/or mailings to obtain policies unavailable online and to verify complete collection for policies obtained online. All district policies were reviewed and doublecoded by two trained researchers using a well-documented coding rubric.16,28 After double-coding, a consensus review was conducted to discuss any discrepancies.
Policy provisions regarding classroom parties or other school celebrations were coded as: 0 ¼ no policy, if no food or beverage standards; 1 ¼ weak policy, if restrictions on items served were vague, suggested but not required, only applied to a limited set of products (eg, foods of minimal nutritional value), or applied for less than the whole school day; 2 ¼ strong policy, if specific nutrition standards were required for all items served at class parties; and 3 ¼ complete ban, if all competitive foods were banned. Codes for 4 specific nutrition limits regarding items served in parties were also used, pertaining to: (1) candy, (2) sugar content of food, (3) fat content of food, and (4) soda. These were collapsed to binary variables, as 0 ¼ no policy vs 1 ¼ any policy (item was restricted, prohibited, or if there was a complete ban on competitive foods or parties).
State Law Data Collection State laws, effective as of the beginning of September of each school year, were compiled through natural language and Boolean key word searches of the full text, tables of contents, and indices of codified state statutory and administrative (regulatory) laws commercially available from subscription-based online legal research services Westlaw (Thomson Reuters, Eagan, MN, 2013) and LexisNexis (LexisNexis, Los Angeles, CA, 2013). Codified state statutory laws include legislation enacted by the state legislatures, whereas codified administrative laws include all rules and regulations promulgated by state Boards of Education. The codified state laws (including regulations) were validated against publicly available sources.29-31 State laws were coded using the same methods and rubric as for district policies.
Data Analysis The initial sample included 1,278 schools. Respondents at 40 schools skipped the relevant survey items, and district policy data were unavailable for 30 additional schools (schools within 28 unique districts). Data were unavailable on free
Turner et al 613 or reduced-price lunch eligibility (a covariate) for 4 schools. Thus, the sample size for these analyses was 1,204 schools. Analyses were conducted in STATA (STATA/SE version 12.0, StataCorp, College Station, TX, 2011) and accounted for the clustering of schools within districts and states. Data were weighted to provide inference to all US public elementary schools. School-level prohibitions on sugary items were rare (Table 1). To create a dichotomous outcome for logistic regressions, school-level outcomes were collapsed so that 1 ¼ sugary items discouraged or prohibited school-wide during parties, or no parties were allowed, vs 0 ¼ no restrictions or left up to each teacher. Across the 2 years, responding schools were located in 824 unique districts, with schools in 397 unique districts in 2009–2010 only, 383 unique districts in 2010–2011 only, and 44 districts in both years. Only 1 district (0.1%) had a strong policy, and 175 districts (21.2%) had a weak policy regarding classroom parties. Responding schools were located in 47 states (all except Alaska, Hawaii, Wyoming, and the District of Columbia), of which only 1 state had a strong law and 8 had weak laws. Thus, state law and district policy dimensions were each collapsed into binary variables to compare no policy (¼ 0) vs any policy (¼ 1). By cross-tabulating the binary district policy and state law variables, each school was classified into 1 of 4 mutually exclusive and exhaustive categories: (1) no district policy and no state law, (2) district policy only, (3) state law only, and (4) both district policy and state law (Table 2). In regression models (Table 3), each of the latter 3 categories was compared against the first (no policy). Table 3 also presents predicted margins, which are the adjusted prevalence of schools that placed restrictions on parties, controlling for covariates. Finally, analyses examined school characteristics by concordance with district policies and state laws. Table 4 presents the percentage of schools with or without school-level restrictions on sugary items at parties, among the schools where district policy and state law both addressed party fare.
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Table 1. Demographic Characteristics of the School Sample (n ¼ 1,204 Schools) and Prevalence of School-level Restrictions on Classroom Parties, 2009–2011 School Years Characteristic School demographics Region South Northeast Midwest West Locale City Suburb Town Rural Race/ethnicity of students Predominantly ($ 66%) white Majority ($ 50%) black Majority ($ 50%) Latino students Diverse Student eligibility for free or reduced-price lunch Lowest (# 33% eligible) Medium (> 33% to 66% eligible) Highest (> 66% eligible) School size Large (> 621 students) Medium (451–621 students) Small (< 451 students) School policy outcomes Limits on sugary items for birthday parties No limitations Up to each teacher Discouraged school-wide Prohibited school-wide No parties Limits on sugary items for holiday parties No limitations Up to each teacher Discouraged school-wide Prohibited school-wide No parties
Schools, %a
35.2 16.5 25.1 23.2 32.0 30.5 11.1 26.5 46.9 11.1 16.8 25.1 25.9 37.1 37.0 20.6 31.1 48.3
22.0 30.2 31.5 7.3 9.1 21.1 34.3 35.5 6.4 2.7
a
Data are weighted to the school level. Percentages sum to 100 within category, but because of rounding, they may not sum to exactly 100.
RESULTS Data were examined from 1,204 schools, located in 824 unique districts and 47 states, during the 2009– 2011 school years. Fewer than 10% of survey respondents reported that their school prohibited sugary items during classroom parties, either for birthdays (7.3%) or holidays (6.4%) (Table 1). Approximately one third of schools discouraged sugary items, but about half either had no restrictions or left the decision up to each teacher.
When district policy and state law were examined in combination (Table 2), many schools were located in a district with an overall party policy, either at only the district level (49.8% of schools) or at both the district and state levels (18.5%). However, specific policy provisions regarding candy and soda, as well as sugar and fat content of food, were uncommon, whereby more than two thirds of schools were subject to no policy restriction on specific party foods or beverages (at neither the state nor district level).
As shown in Table 3, results were similar for regression models to predict both outcomes (birthday parties and holiday parties). Considering overall policy restrictions on parties, schools with a combination of a state law and a district policy were 2.5 times more likely to restrict sweet items at parties than were schools where there was no corresponding law or policy. In addition, the combination of district policy and state law for all specific nutrition provisions was associated with school-level restrictions, with the exception of policies and laws regarding candy, which were not associated with school-level restrictions. State law alone was not associated with any outcomes, nor was district policy alone, with the exception of provisions prohibiting soda. Although state law and district policy were associated with an increased prevalence of school-level restrictions, even where state law and district policy addressed party items, covariate-adjusted prevalence estimates (Table 3) showed that only 63.1% of schools had restrictions on birthday parties and 58.2% had restrictions on holiday parties. Subsequent analysis (Table 4) indicated that school-level policies were not necessarily concordant with state law and district policy. This varied by region and locale; school-level birthday party restrictions were concordant with district policy and state law among only 26.3% of schools in the west vs 63.7% of schools in the south and 78.2% of schools in the northeast (P < .01). Percentages for holiday parties were similar. Concordance between school-level outcomes and state laws and district policies did not differ by school size, free or reduced-price lunch eligibility, or racial/ethnic composition.
DISCUSSION Elementary school-level restrictions on classroom parties were related to relevant state law and district policy, although schools did not consistently follow such laws and policies. State laws on this topic were rare, perhaps not surprisingly, given the political challenges of enacting such laws and the controversies and media debate
Journal of Nutrition Education and Behavior Volume 45, Number 6, 2013 Table 2. Number and Percentage of Elementary Schools (n ¼ 1,204) in Districts and/or States With Policies or Lawsa Restricting Sugary Items in School Parties, 2009–2011 School Years Policy Category Overall restrictions on party items None District policy only State law only District policy and state law
Schools, Unweighted, n
Specific limits on types of products offered at classroom parties Candy restriction/ban None District policy only State law only District policy and state law Sugar content of food None District policy only State law only District policy and state law Fat content of food None District policy only State law only District policy and state law Soda restriction/ban None District policy only State law only District policy and state law
Schools, %b
369 585 30 220
29.0 49.8 2.7 18.5
1,029 113 8 54
84.8 9.6 0.7 4.9
920 178 34 50
79.7 14.3 2.6 3.3
799 298 29 58
67.8 26.0 2.1 4.0
875 193 28 68
76.6 15.1 2.2 6.0
a
Policy provisions reflect ‘‘any’’ provisions (including those that were encouraged, required, or imposed a complete ban) governing classroom parties; bData are weighted to the school level. Percentages sum to 100 within category, but because of rounding, they may not sum to exactly 100. that so-called ‘‘cupcake bans’’ have provoked. However, district-level policies were more common, but almost all were written as recommendations rather than as required limitations (also likely because of the political nature of such restrictions). The significant effect for the combination of both district policy and state law may be the result of a reinforcing relationship, in which district policies reiterated what was present in state law; alternatively, the similarities at both jurisdictions may have reflected local norms, in which some states—and districts therein—had a climate more or less tolerant of regulation. Nevertheless, policies were associated with school practices, even though most policies were weak (ie, recommendations rather than outright restrictions on sugary items at parties). This shows the potential for policies to affect
school practice on this topic, even when policy provisions are only worded as recommendations. However, even where recommendations existed at both the state and district levels, schools were not necessarily consistent in following such recommendations, as evidenced by the percentages of schools that did not report having limitations on items served at classroom parties. Where district policy and state law addressed classroom parties, just slightly more than half of schools reported having a school-level policy. Concordance was higher among schools in the northeast than other regions, which offers an intriguing area for further examination. Possible explanations for regional variations are that some states and districts had provisions requiring policy enforcement, or that certain states and districts were more
Turner et al 615 effective at conveying policy information to the school level. For instance, nationally representative research showed that in 2007–2008, 41% of districts posted their policies online (which would thus make this information more accessible to schoollevel officials), and online posting was more common in non-southern than southern districts.32 Encouragingly, districts have continued to develop and strengthen their wellness policies16,23 and district policies and state laws have been associated with school competitive food practices.12 For example, district policies reduced the availability of sugar-sweetened beverages in schools,33,34 and nutrition improvements were documented after enactment of various state laws.13,35,36 Given that the items typically served at parties have been shown to be high in sugar, fat, and calories,9,10 making party fare more healthy would be prudent. Recommendations from model wellness policies and suggestions for healthy celebrations include limiting parties to 1 per month, serving only healthy foods, offering nonfood items in goody bags, and conducting party activities and games that do not involve food.37,38 Further refinements in district policies can be expected after the Healthy, Hunger-Free Kids Act of 2010,39 which continues to require district-level wellness policies that address competitive foods and beverages in schools. The Healthy, Hunger-Free Kids Act of 2010 also directed the US Department of Agriculture (USDA)40 to develop nationwide regulations for competitive foods and beverages. Because party fare is offered outside the meals program, it falls under the category of competitive foods. However, the proposed USDA competitive food regulations that were released in early 2013 did not address foods and beverages served during school parties. It is thus unlikely that the final USDA rule will address party fare, which makes this important aspect of the school food environment one that will need to be addressed with policy efforts at state, district, and/or school levels. Although the current analyses were based on a large, nationally representative sample, several limitations are evident. Use of survey measures
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Table 3. Summary of Multivariate Logistic Regression Modelsa to Predict School-level Limits on Sugary Items Served at Birthday Parties and Holiday Parties, US Public Elementary Schools (n ¼ 1,204) During the 2009–2010 and 2010–2011 School Years Limits on Sugary Items at Birthday Parties State/District Predictorsb
Adjusted Prevalence, % AOR
95% CI
Any restriction on foods served at class parties or other school celebrations None District policy only State law only District policy and state law
40.8 46.6 41.2 63.1
1.00 1.28 1.02 2.54
(Referent) 0.91–1.79 0.36–2.86 1.66–3.88
Specific limits on candy None District policy only State law only District policy and state law
44.9 56.3 74.4 79.8
Specific limits on sugar content of food None District policy only State law only District policy and state law
Limits on Sugary Items at Holiday Parties P
Adjusted Prevalence, % AOR
95% CI
P
< .001
36.6 44.9 31.2 58.2
1.00 1.42 0.78 2.47
(Referent) 1.03–1.96 0.28–2.15 1.67–3.65
1.00 1.59 3.63 4.94
(Referent) 0.93–2.73 0.86–15.32 2.19–11.11 < .001
42.0 50.9 75.0 73.9
1.00 1.44 4.28 4.04
(Referent) 0.83–2.52 0.96–19.10 1.97–8.31 < .001
45.3 51.2 59.1 58.2
1.00 1.28 1.77 1.71
(Referent) 0.84–1.95 0.79–3.96 0.86–3.39
41.9 48.6 56.4 57.6
1.00 1.33 1.84 1.93
(Referent) 0.86–2.05 0.86–3.93 0.97–3.82
Specific limits on fat content of food None District policy only State law only District policy and state law
44.6 50.8 58.8 62.6
1.00 1.30 1.81 2.12
(Referent) 0.93–1.81 0.71–4.56 1.16–3.89
.02
41.2 47.6 54.8 61.8
1.00 1.31 1.77 2.39
(Referent) 0.95–1.82 0.74–4.20 1.31–4.36
.005
Specific limits on soda None District policy only State law only District policy and state law
43.6 53.1 67.9 74.7
1.00 1.47 2.78 3.91
(Referent) 0.99–2.20 1.19–6.49 1.95–7.81
.02 < .001
40.8 50.1 62.3 70.0
1.00 1.47 2.46 3.50
(Referent) 0.97–2.23 1.07–5.62 1.85–6.65
.03 < .001
.03 < .001
AOR indicates adjusted odds ratio; CI, confidence interval. a All models include school-level covariates (year, school size, locale, region, student race/ethnicity, and percentage of students eligible for free or reduced-price lunch). Analyses were weighted to school level. Adjusted prevalence shows the percentage of schools limiting sugary items in parties, by state/district policy status. Outcomes were coded 1 where sugary items are discouraged school-wide or prohibited school-wide, or parties were not allowed; bData reflect any provisions (including those that were encouraged, required, or imposed a complete ban) governing classroom parties. Note: For birthday parties, n ranged from 1,159 to 1,199. For holiday parties, n ranged from 1,161 to 1,200. Only P < .05 is reported.
limited the ability to evaluate party practices in detail; even within schools there was variability in party frequency and calories offered. In practice, some teachers may allow parties on a weekly basis, whereas some may have a quarterly party with no food. The survey measure did not capture detailed information about classroom practices, or student dietary intake or student weight status. This is essential for future work. The survey inquired about ‘‘school-wide policies,’’ but such poli-
cies may not necessarily have been enforced. That is, although respondents indicated that school-wide restrictions on parties were in place, parents might have brought in foods for parties without being aware of school-level recommendations, or recommendations may have existed but been ignored by teachers. Conversely, even at schools without policies, some teachers may have prohibited classroom celebrations, which would not have been reflected here. Despite these measurement chal-
lenges, the goal of the current study was not to obtain detailed information on classroom practices, but to examine the potential impact of policy on the school environment. The current study allowed the ability to examine how policy efforts at higher jurisdictions (ie, district and state) were associated with schoollevel restrictions. Whether—and how—schools are implementing such recommendations in practice is yet another question of great importance.
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Table 4. Percentage of Schools With School-level Restrictions on Classroom Parties, by School Demographic Characteristics, Only for Schools Where State Laws and District Policies Place Nutritional Restrictions on Classroom Parties Birthday Parties
Holiday Parties
No School School Policy Policy (n ¼ 99) (n ¼ 119) Region South Northeast Midwest West
36.3 21.8 49.8 73.7
63.7 78.2 50.2 26.3
Locale City Suburb Town Rural
45.5 30.1 60.6 28.3
54.5 69.9 39.4 71.7
Race/ethnicity of students Predominantly ($ 66%) white Majority ($ 50%) black Majority ($ 50%) Latino Diverse
35.1 22.7 48.8 43.9
64.9 77.3 51.2 56.1
Student eligibility for free or reduced-price lunch Lowest (# 33% eligible) Medium (> 33% to # 66% eligible) Highest (> 66% eligible)
34.9 43.7 33.6
65.1 56.3 66.4
School size Large (> 621 students) Medium (451–621 students) Small (< 451 students)
43.4 37.9 35.3
56.6 62.1 64.7
P
No School School Policy Policy (n ¼ 89) (n ¼ 129)
P
.006
42.2 29.0 49.8 69.8
57.8 71.0 50.2 30.2
.05
.03
54.6 37.3 47.6 32.5
45.4 62.7 52.4 67.5
.05
.15
37.3 45.4 46.1 47.4
62.7 54.6 53.9 52.6
.73
.50
40.1 39.3 47.0
59.9 60.7 53.0
.66
.75
48.9 41.5 40.5
51.1 58.5 59.5
.72
Note: P is associated with c test. 2
As with any survey, estimates might have been affected by biases, but the weights accounted for nonresponse. Finally, the district policies and state laws were assessed based on their inclusion in wellness and related policies and codified state laws, and evaluated formal policies on the books rather than any informal guidelines, handbooks, or policies in practice. Thus, estimated policy prevalence was conservative, but additional informal policies would likely solidify the relationships found here. Few elementary schools prohibited serving sugary items during classroom parties. Although few districts and even fewer states had strong policies about classroom parties, many had weak recommendations—but not outright restrictions—about party fare. Where such recommendations existed at both the district and state levels, schools were more likely to have school-wide restrictions in place
regarding the foods and beverages served at parties. The significant association between weak district or state policies and school-level policies suggests that definitive policy limits may not be necessary to change school practices. Policy recommendations such as limiting parties to a few times a year or encouraging healthier fare may be sufficient to decrease the availability of sugary products at parties. Given the controversy about cupcake bans and the difficulty of changing norms regarding in-school celebrations, it will be challenging to alter school practices, but policy recommendations are a promising strategy to promote change.
IMPLICATIONS FOR RESEARCH AND PRACTICE Policy restrictions on sugary party items were associated with an in-
creased likelihood of schools placing restrictions on serving sugary items at classroom holiday and birthday parties. Although most policies were framed as recommendations, such policy strategies appear to be effective for reducing the availability of sugary items in classroom parties. Parents, teachers, and policy makers are encouraged to consider the role of energy-dense party fare in children's diets and to promote healthier practices in schools.
ACKNOWLEDGMENTS This work was funded by the Robert Wood Johnson Foundation. The authors gratefully acknowledge the state and district policy research and analysis support provided by Linda Schneider, Rebecca Schermbeck, Tessa Adcock, and Camille Gourdet, JD; and support for the school survey data collection from Anna Sandoval.
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REFERENCES
diets and childhood obesity: research review, July 2012. Healthy Eating Research and Bridging the Gap. http:// www.healthyeatingresearch.org/images/ stories/her_research_briefs/RRComp Foods7-2012.pdf. Accessed June 10, 2013. Taber DR, Stevens J, Evenson KR, et al. State policies targeting junk food in schools: racial/ethnic differences in the effect of policy change on soda consumption. Am J Public Health. 2011; 101:1769-1775. Taber DR, Chriqui JF, Perna FM, Powell LM, Chaloupka FJ. Weight status among adolescents in states that govern competitive food nutrition content. Pediatrics. 2012;130:437-444. Child Nutrition and WIC Reauthorization Act of 2004, Pub L No. 108–265. http://www.govtrack.us/congress/bills/ 108/s2507/text. Published January 1, 2004. Accessed June 10, 2013. Chriqui JF, Schneider L, Chaloupka FJ, et al. School District Wellness Policies: Evaluating Progress and Potential for Improving Children’s Health Three Years After the Federal Mandate. School Years 2006-07, 2007-08 and 2008-09, Vol 2. Chicago, IL: Bridging the Gap, Health Policy Center, University of Illinois at Chicago; 2010. Pallarito K. Reviewing the school cupcake ban. Washington Post. http://www. washingtonpost.com/wp-dyn/content/ article/2007/01/29/AR2007012901388 .html. Published January 30, 2007. Accessed June 10, 2013. Wiehl L. Schools move to ban cupcakes to help quell childhood obesity. Fox News. http://www.foxnews.com/ story/0,2933,304222,00.html. Published October 22, 2007. Accessed June 10, 2013. Brigid Schulte. Once just a sweet birthday treat, the cupcake becomes a cause. Washington Post. http://www. washingtonpost.com/wp-dyn/content/ article/2006/12/10/AR2006121001008 .html. Published December 11, 2006. Accessed June 10, 2013. Donaldson-Evans C. New York politician proposes bill to help rescue the cupcake from school bans. Fox News. http://www.foxnews.com/story/0,2933, 298532,00.html. Published September 28, 2007. Accessed June 10, 2013. Belansky ES, Cutforth N, Delong E, et al. Early effects of the federally mandated Local Wellness Policy on school nutrition environments appear modest in Colorado’s rural, low-income ele-
1. Institute of Medicine. Accelerating Progress in Pbesity Prevention: Solving the Weight of the Nation. Washington, DC: National Academies Press; 2012. 2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA. 2012;307:483-490. 3. United States Department of Agriculture. About School Meals. http:// www.fns.usda.gov/cnd/About/faqs.htm# CompetitiveFoods. Accessed June 10, 2013. 4. Gordon A, Fox MK. School Nutrition Dietary Assessment Study–III: Summary of Findings. Alexandria, VA: US Dept of Agriculture, Food and Nutrition Service; 2007. 5. Fox MK, Gordon A, Nogales R, Wilson A. Availability and consumption of competitive foods in US public schools. J Am Diet Assoc. 2009; 109(suppl 2):S57-S66. 6. O’Toole TP, Anderson S, Miller C, Guthrie J. Nutrition services and foods and beverages available at school: results from the School Health Policies and Programs Study 2006. J Sch Health. 2007;77:500-521. 7. Pasch KE, Lytle LA, Samuelson AC, Farbakhsh K, Kubik MY, Patnode CD. Are school vending machines loaded with calories and fat: an assessment of 106 middle and high schools? J Sch Health. 2011;81:212-218. 8. Turner L, Chaloupka FJ. Wide availability of high-calorie beverages in US elementary schools. Arch Pediatr Adolesc Med. 2011;165:223-228. 9. Isoldi KK, Dalton S. Calories in the classroom: celebration foods offered and consumed during classroom parties at an elementary school in a lowincome, urban community. Child Obes (Lond). 2012;8:378-383. 10. Isoldi KK, Dalton S, Rodriguez DP, Nestle M. Classroom ‘‘cupcake’’ celebrations: observations of foods offered and consumed. J Nutr Educ Behav. 2012;44:71-75. 11. Kubik MY, Lytle LA, Story M. Schoolwide food practices are associated with body mass index in middle school students [erratum Arch Pediatr Adolesc Med. 2006 Jun;160(6):614]. Arch Pediatr Adolesc Med. 2005;159: 1111-1114. 12. Chriqui JF. Influence of competitive food and beverage policies on children’s
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mentary schools. J Am Diet Assoc. 2010;110:1712-1717. Longley CH, Sneed J. Effects of federal legislation on wellness policy formation in school districts in the United States. J Am Diet Assoc. 2009;109: 95-101. Taber DR, Chriqui JF, Chaloupka FJ. Geographic disparities in state and district policies targeting youth obesity. Am J Prev Med. 2011;41:407-414. Bridging the Gap Research Project. http://www.bridgingthegapresearch .org. Accessed January 27, 2013. National Center for Education Statistics. Common core of data. http:// nces.ed.gov/ccd/index.asp. Accessed January 27, 2013. American Association for Public Opinion Research. Standard definitions: final dispositions of case codes and outcome rates for surveys, 2011. http:// www.aapor.org/Content/aapor/Advocacy andInitiatives/StandardsandEthics/ StandardDefinitions/StandardDefinitions 2011.pdf. Accessed June 10, 2013. Johnston LD, O’Malley PM, TerryMcElrath YM, Freedman-Doan P, Brenner JS. School Policies and Practices to Improve Health and Prevent Obesity: National Secondary School Survey Results, School Year 2006-07 and 2007-08, Vol. 1. Ann Arbor, MI: Bridging the Gap Program, Survey Research Center, Institute for Social Research; 2011. Chriqui JF, Schneider L, Ide K, Gourdet C, Bruursema A. Bridging the Gap program School District Wellness Policy Coding Tool, Version 2. http:// www.bridgingthegapresearch.org/_asset/ 6g5t8y/WP_2009_coding_tool.pdf. Accessed June 13, 2013. National Cancer Institute. Classification of Laws about School Students. http:// class.cancer.gov/About.aspx. Accessed May 17, 2013. National Association of State Boards of Education. State School Health Policy Database. http://www.nasbe.org/healthy_ schools/hs/index.php. Accessed May 17, 2013. National Conference of State Legislatures. Childhood Obesity Update of Legislative Policy Options. http://www.ncsl.org/ issues-research/health/childhood-obesity2010.aspx. Accessed May 17, 2013. Chriqui JF, Chaloupka FJ. Transparency and oversight in local wellness policies. J Sch Health. 2011;81:114-121. Johnson DB, Bruemmer B, Lund AE, Evens CC, Mar CM. Impact of school district sugar-sweetened beverage
Journal of Nutrition Education and Behavior Volume 45, Number 6, 2013 policies on student beverage exposure and consumption in middle schools. J Adolesc Health. 2009;45(Suppl 3):30-37. 34. Taber DR, Chriqui JF, Powell LM, Chaloupka FJ. Banning all sugarsweeted beverages in middle schools: reduction of in-school access and purchasing but not overall consumption. Arch Pediatr Adolesc Med. 2012;166: 256-262. 35. Mendoza JA, Watson K, Cullen KW. Change in dietary energy density after implementation of the Texas
Public School Nutrition Policy. J Am Diet Assoc. 2010;110:434-440. 36. Phillips MM, Raczynski JM, West DS, et al. Changes in school environments with implementation of Arkansas Act 1220 of 2003. Obesity. 2010;18:S54-S61. 37. Center for Science in the Public Interest. Healthy school celebrations. http://cspinet.org/new/pdf/healthy_ school_celebrations.pdf. Accessed June 10, 2013. 38. National Alliance for Nutrition and Activity. Model school wellness
Turner et al 619 policies. http://www.schoolwellness policies.org. Accessed June 10, 2013. 39. Healthy, Hunger-Free Kids Act of 2010. Pub L No. 111–296. http:// www.govtrack.us/congress/bills/111/ s3307/text. Published January 1, 2010. Accessed June 10, 2013. 40. United States Department of Agriculture. The Healthy, Hunger-Free Kids Act of 2010. http://www.fns. usda.gov/cnd/Governance/Legislation/ CNR_2010.htm. Accessed January 27, 2013.
INTRODUCTION Improving the nutritional quality of foods and beverages in schools is a key aspect of obesity prevention efforts.1 Considering that one third of United States (US) children ages 6–11 years were overweight or obese during 2009–2010,2 these efforts are essential. Foods and beverages sold in schools are grouped into 2 categories: (1) school meals; and (2) competitive foods and beverages, which include all items sold or offered to students outside of meals. Competitive products are typically sold in vending machines, school stores or snack bars,
a la carte in the cafeteria, or via in-school fundraisers, and they are also offered to students during parties or as rewards in the classroom.3 Competitive items are widely available in schools4; during 2004–2005, 73% of public elementary schools offered at least 1 source of competitive foods and beverages, including sales venues (vending machines, school stores or snack bars, and a la carte lines) as well as fundraisers, parties, and rewards in the classroom. Furthermore, 29% of elementary school students consumed competitive items during the average school day.5 Although many studies have examined the avail-
Health Policy Center, Institute for Health Research and Policy, University of Illinois at Chicago, Chicago, Illinois Address for correspondence: Lindsey Turner, PhD, Bridging the Gap Research Program, Institute for Health Research and Policy, University of Illinois at Chicago, 1747 W. Roosevelt Rd, #558, Chicago, IL 60608; Phone: (312) 355-2388; Fax: (312) 355-2801; E-mail: [email protected] Ó2013 SOCIETY FOR NUTRITION EDUCATION AND BEHAVIOR http://dx.doi.org/10.1016/j.jneb.2013.04.261
Journal of Nutrition Education and Behavior Volume 45, Number 6, 2013
ability of competitive foods and beverages in traditional sales venues,5,6,7,8 scant evidence is available regarding the frequency and characteristics of classroom parties. Some research— albeit from small-scale studies—has documented that what children eat and drink during classroom parties is unhealthy; for example, direct observation of 6 separate classroom parties in pre-kindergarten, kindergarten, and first-grade classrooms at 1 urban elementary school9 indicated that sugary foods and beverages were offered at all 6 parties, and cupcakes and sugarsweetened beverages were offered at 5 of the 6 parties. On average, students consumed an estimated 444 ( 221) kilocalories from items served at each party, and were also given take-home goody bags with an estimated total of 638 kilocalories.9 Previous work from the same authors showed similar results during 4 elementary school birthday parties, with cake, sugarsweetened beverages, and other sugary items served at all parties, and an
611
612 Turner et al estimated caloric intake for students ranging from 259 to 455 kilocalories at each party.10 In addition, some evidence suggests that calories consumed in the classroom are associated with higher student body mass index (BMI). For example, a study of 3,088 eighth-grade students in the Minneapolis–St. Paul metropolitan area found that the BMI of students increased by a 0.10 BMI unit for each additional food practice (eg, fundraisers, rewards) allowed in school.11 Importantly however, a comprehensive review of recent research12 concluded that competitive food and beverage policies—addressing items sold, and those offered in the classroom—are associated with children's diets and weight status. Nationwide research found that changes in state policies regarding school parties were associated with reduced soda consumption among high school students.13 Furthermore, analysis of objectively measured weight and height status for 6,300 middle school students nationwide revealed that weight outcomes (ie, changes in BMI) were healthier for students in states where laws restricted competitive foods than in states without such laws.14 Such findings support the promise of policy approaches for improving the school food environment. Recently, lawmakers have recognized the potential for state laws and school district policies to have a role in promoting healthy school food environments. The Child Nutrition and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Reauthorization Act of 200415 mandated that school districts participating in federal child nutrition programs adopt and implement a wellness policy by the first day of the 2006–2007 school year; these policies were to include nutrition guidelines for all foods and beverages. Each district was responsible for establishing the guidelines, which allowed much variability in policy focus, strength, and implementation. Since 2006–2007, district policies addressing competitive foods and beverages have become more prevalent, but party restrictions are rare; as of 2008–2009, only 2% of public elementary school students nationwide were enrolled in a district with strong nutritional restrictions on items served during school parties.16
Journal of Nutrition Education and Behavior Volume 45, Number 6, 2013 Actions at the school, district, and state levels regarding classroom celebrations have often been met with controversy, resistance from parents and community members, and mixed coverage in the media.17-19 Some state-level legislation has been proposed20 to protect children's rights to bring cupcakes to school celebrations. Resistance to changes that involve traditions with strong emotional investment—such as celebrating birthdays with cupcakes—is inevitable. However, the challenge is to balance the need to respect cultural norms and traditions with the public health goal of providing a healthy school environment. With the increasing prevalence of district policies and state laws regarding competitive foods—as well as push-back on cupcake bans and resistance to top-down legislation regarding school practices—it is crucial to examine the strength of the evidence that state- and district-level policies improve school practices. In the 6 years since the wellness policy mandate went into effect, the literature on this topic has been increasing steadily. Initially, many districts were slow to develop and implement policies,16,21,22 but competitive foods policies have strengthened over time.23 There is scant data on the current prevalence of state laws and districtand school-level policies regarding classroom parties, and whether state laws and district policies are associated with school-level nutrition restrictions regarding parties. This study used nationally representative cross-sectional data from US public elementary schools during 2009– 2010 and 2010–2011 to examine the multilevel linkages among state laws, district policies, and school-level policies regarding classroom parties.
METHODS Data were gathered by Bridging the Gap,24 a research program supported by the Robert Wood Johnson Foundation. The Institutional Review Board at the University of Illinois at Chicago approved the study.
School-level Data
Sampling and weighting. The school sample was developed at the Institute
for Social Research at the University of Michigan, based on sampling frames developed from the public-use Common Core of Data maintained by the National Center for Education Statistics.25 All public elementary schools containing a third-grade class with at least 20 students, from the contiguous US, were eligible for sampling. In each year, 1,070 schools were sampled; schools determined to be closed or ineligible (ie, no third grade) were not recruited. The response rate26 was 64.5% in 2009–2010 (n ¼ 680 of 1,055 eligible schools) and 57.4% in 2010–2011 (n ¼ 598 of 1,042 eligible schools). Weights were developed and adjusted for school nonresponse bias.
Procedure. Surveys were mailed to principals in January of each school year, with subsequent follow-up by mail, e-mail, and telephone until recruitment ended in June. Instructions requested that the survey be completed by the principal or other staff with knowledge of school practices pertaining to student health. A $100 incentive was offered to the respondent or school.
Measures. The survey measure to be completed by principals included 10 pages of items pertaining to a variety of food and nutrition practices (ie, timing and duration of meals, participation in federal meal programs, availability of competitive foods), physical activity (ie, physical education and recess), and other aspects of wellness (eg, policy development). Researchers developed the surveys to be consistent with surveys from an existing, parallel study of practices in middle and high schools,27 as well as a review of prior research, and original development of items of interest to the research team. The research team developed the items used in the current analyses based on preliminary data gathered in previous years as well as the researchers' personal knowledge of party practices in schools and input from school principals. The multipart item was worded, ‘‘Are there any policies limiting sugar-sweetened items (eg, candy, cupcakes, cookies) from being served or brought in either at snack time or for parties during the school day?’’
Journal of Nutrition Education and Behavior Volume 45, Number 6, 2013 One set of responses was for ‘‘birthday parties’’ and another was for ‘‘holiday parties’’ (snack time data are not reported here). Response options were: (1) no policy; (2) decision is up to each teacher; (3) sweetened items discouraged school-wide; (4) sweetened items prohibited school-wide; and (5) not applicable, no parties.
Contextual factors. School-level demographic data were obtained from public use data files from the National Center for Education Statistics (Common Core of Data 2009–1010)25 for use as covariates in regression analyses. Demographics were coded as follows: school size (total number of students in the school), coded as small (< 451 students), medium (451–621 students), and large (> 621 students; referent); percentage of students eligible for free or reduced-price lunch, coded as highest (> 66%), medium (# 66% to > 33%), and lowest (# 33%; referent); census region, coded as West, Northeast, Midwest and South (referent); and locale, coded as rural, town, suburban, and urban (referent). For racial/ethnic composition, each school was coded as 1 of 4 exhaustive and mutually exclusive categories: predominantly ($ 66%) white (referent); majority ($ 50%) Latino; majority ($ 50%) black; and diverse (no majority).
District-level Policy Data Collection Formal, ‘‘on-the-books,’’ policy documents (ie, wellness policies, associated rules and regulations, and other policies embedded by reference into the wellness policy or rules) were collected from the corresponding school district for all schools. Trained research assistants gathered hard copies of policies using an established protocol via Internet searches, with telephone calls and/or mailings to obtain policies unavailable online and to verify complete collection for policies obtained online. All district policies were reviewed and doublecoded by two trained researchers using a well-documented coding rubric.16,28 After double-coding, a consensus review was conducted to discuss any discrepancies.
Policy provisions regarding classroom parties or other school celebrations were coded as: 0 ¼ no policy, if no food or beverage standards; 1 ¼ weak policy, if restrictions on items served were vague, suggested but not required, only applied to a limited set of products (eg, foods of minimal nutritional value), or applied for less than the whole school day; 2 ¼ strong policy, if specific nutrition standards were required for all items served at class parties; and 3 ¼ complete ban, if all competitive foods were banned. Codes for 4 specific nutrition limits regarding items served in parties were also used, pertaining to: (1) candy, (2) sugar content of food, (3) fat content of food, and (4) soda. These were collapsed to binary variables, as 0 ¼ no policy vs 1 ¼ any policy (item was restricted, prohibited, or if there was a complete ban on competitive foods or parties).
State Law Data Collection State laws, effective as of the beginning of September of each school year, were compiled through natural language and Boolean key word searches of the full text, tables of contents, and indices of codified state statutory and administrative (regulatory) laws commercially available from subscription-based online legal research services Westlaw (Thomson Reuters, Eagan, MN, 2013) and LexisNexis (LexisNexis, Los Angeles, CA, 2013). Codified state statutory laws include legislation enacted by the state legislatures, whereas codified administrative laws include all rules and regulations promulgated by state Boards of Education. The codified state laws (including regulations) were validated against publicly available sources.29-31 State laws were coded using the same methods and rubric as for district policies.
Data Analysis The initial sample included 1,278 schools. Respondents at 40 schools skipped the relevant survey items, and district policy data were unavailable for 30 additional schools (schools within 28 unique districts). Data were unavailable on free
Turner et al 613 or reduced-price lunch eligibility (a covariate) for 4 schools. Thus, the sample size for these analyses was 1,204 schools. Analyses were conducted in STATA (STATA/SE version 12.0, StataCorp, College Station, TX, 2011) and accounted for the clustering of schools within districts and states. Data were weighted to provide inference to all US public elementary schools. School-level prohibitions on sugary items were rare (Table 1). To create a dichotomous outcome for logistic regressions, school-level outcomes were collapsed so that 1 ¼ sugary items discouraged or prohibited school-wide during parties, or no parties were allowed, vs 0 ¼ no restrictions or left up to each teacher. Across the 2 years, responding schools were located in 824 unique districts, with schools in 397 unique districts in 2009–2010 only, 383 unique districts in 2010–2011 only, and 44 districts in both years. Only 1 district (0.1%) had a strong policy, and 175 districts (21.2%) had a weak policy regarding classroom parties. Responding schools were located in 47 states (all except Alaska, Hawaii, Wyoming, and the District of Columbia), of which only 1 state had a strong law and 8 had weak laws. Thus, state law and district policy dimensions were each collapsed into binary variables to compare no policy (¼ 0) vs any policy (¼ 1). By cross-tabulating the binary district policy and state law variables, each school was classified into 1 of 4 mutually exclusive and exhaustive categories: (1) no district policy and no state law, (2) district policy only, (3) state law only, and (4) both district policy and state law (Table 2). In regression models (Table 3), each of the latter 3 categories was compared against the first (no policy). Table 3 also presents predicted margins, which are the adjusted prevalence of schools that placed restrictions on parties, controlling for covariates. Finally, analyses examined school characteristics by concordance with district policies and state laws. Table 4 presents the percentage of schools with or without school-level restrictions on sugary items at parties, among the schools where district policy and state law both addressed party fare.
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Table 1. Demographic Characteristics of the School Sample (n ¼ 1,204 Schools) and Prevalence of School-level Restrictions on Classroom Parties, 2009–2011 School Years Characteristic School demographics Region South Northeast Midwest West Locale City Suburb Town Rural Race/ethnicity of students Predominantly ($ 66%) white Majority ($ 50%) black Majority ($ 50%) Latino students Diverse Student eligibility for free or reduced-price lunch Lowest (# 33% eligible) Medium (> 33% to 66% eligible) Highest (> 66% eligible) School size Large (> 621 students) Medium (451–621 students) Small (< 451 students) School policy outcomes Limits on sugary items for birthday parties No limitations Up to each teacher Discouraged school-wide Prohibited school-wide No parties Limits on sugary items for holiday parties No limitations Up to each teacher Discouraged school-wide Prohibited school-wide No parties
Schools, %a
35.2 16.5 25.1 23.2 32.0 30.5 11.1 26.5 46.9 11.1 16.8 25.1 25.9 37.1 37.0 20.6 31.1 48.3
22.0 30.2 31.5 7.3 9.1 21.1 34.3 35.5 6.4 2.7
a
Data are weighted to the school level. Percentages sum to 100 within category, but because of rounding, they may not sum to exactly 100.
RESULTS Data were examined from 1,204 schools, located in 824 unique districts and 47 states, during the 2009– 2011 school years. Fewer than 10% of survey respondents reported that their school prohibited sugary items during classroom parties, either for birthdays (7.3%) or holidays (6.4%) (Table 1). Approximately one third of schools discouraged sugary items, but about half either had no restrictions or left the decision up to each teacher.
When district policy and state law were examined in combination (Table 2), many schools were located in a district with an overall party policy, either at only the district level (49.8% of schools) or at both the district and state levels (18.5%). However, specific policy provisions regarding candy and soda, as well as sugar and fat content of food, were uncommon, whereby more than two thirds of schools were subject to no policy restriction on specific party foods or beverages (at neither the state nor district level).
As shown in Table 3, results were similar for regression models to predict both outcomes (birthday parties and holiday parties). Considering overall policy restrictions on parties, schools with a combination of a state law and a district policy were 2.5 times more likely to restrict sweet items at parties than were schools where there was no corresponding law or policy. In addition, the combination of district policy and state law for all specific nutrition provisions was associated with school-level restrictions, with the exception of policies and laws regarding candy, which were not associated with school-level restrictions. State law alone was not associated with any outcomes, nor was district policy alone, with the exception of provisions prohibiting soda. Although state law and district policy were associated with an increased prevalence of school-level restrictions, even where state law and district policy addressed party items, covariate-adjusted prevalence estimates (Table 3) showed that only 63.1% of schools had restrictions on birthday parties and 58.2% had restrictions on holiday parties. Subsequent analysis (Table 4) indicated that school-level policies were not necessarily concordant with state law and district policy. This varied by region and locale; school-level birthday party restrictions were concordant with district policy and state law among only 26.3% of schools in the west vs 63.7% of schools in the south and 78.2% of schools in the northeast (P < .01). Percentages for holiday parties were similar. Concordance between school-level outcomes and state laws and district policies did not differ by school size, free or reduced-price lunch eligibility, or racial/ethnic composition.
DISCUSSION Elementary school-level restrictions on classroom parties were related to relevant state law and district policy, although schools did not consistently follow such laws and policies. State laws on this topic were rare, perhaps not surprisingly, given the political challenges of enacting such laws and the controversies and media debate
Journal of Nutrition Education and Behavior Volume 45, Number 6, 2013 Table 2. Number and Percentage of Elementary Schools (n ¼ 1,204) in Districts and/or States With Policies or Lawsa Restricting Sugary Items in School Parties, 2009–2011 School Years Policy Category Overall restrictions on party items None District policy only State law only District policy and state law
Schools, Unweighted, n
Specific limits on types of products offered at classroom parties Candy restriction/ban None District policy only State law only District policy and state law Sugar content of food None District policy only State law only District policy and state law Fat content of food None District policy only State law only District policy and state law Soda restriction/ban None District policy only State law only District policy and state law
Schools, %b
369 585 30 220
29.0 49.8 2.7 18.5
1,029 113 8 54
84.8 9.6 0.7 4.9
920 178 34 50
79.7 14.3 2.6 3.3
799 298 29 58
67.8 26.0 2.1 4.0
875 193 28 68
76.6 15.1 2.2 6.0
a
Policy provisions reflect ‘‘any’’ provisions (including those that were encouraged, required, or imposed a complete ban) governing classroom parties; bData are weighted to the school level. Percentages sum to 100 within category, but because of rounding, they may not sum to exactly 100. that so-called ‘‘cupcake bans’’ have provoked. However, district-level policies were more common, but almost all were written as recommendations rather than as required limitations (also likely because of the political nature of such restrictions). The significant effect for the combination of both district policy and state law may be the result of a reinforcing relationship, in which district policies reiterated what was present in state law; alternatively, the similarities at both jurisdictions may have reflected local norms, in which some states—and districts therein—had a climate more or less tolerant of regulation. Nevertheless, policies were associated with school practices, even though most policies were weak (ie, recommendations rather than outright restrictions on sugary items at parties). This shows the potential for policies to affect
school practice on this topic, even when policy provisions are only worded as recommendations. However, even where recommendations existed at both the state and district levels, schools were not necessarily consistent in following such recommendations, as evidenced by the percentages of schools that did not report having limitations on items served at classroom parties. Where district policy and state law addressed classroom parties, just slightly more than half of schools reported having a school-level policy. Concordance was higher among schools in the northeast than other regions, which offers an intriguing area for further examination. Possible explanations for regional variations are that some states and districts had provisions requiring policy enforcement, or that certain states and districts were more
Turner et al 615 effective at conveying policy information to the school level. For instance, nationally representative research showed that in 2007–2008, 41% of districts posted their policies online (which would thus make this information more accessible to schoollevel officials), and online posting was more common in non-southern than southern districts.32 Encouragingly, districts have continued to develop and strengthen their wellness policies16,23 and district policies and state laws have been associated with school competitive food practices.12 For example, district policies reduced the availability of sugar-sweetened beverages in schools,33,34 and nutrition improvements were documented after enactment of various state laws.13,35,36 Given that the items typically served at parties have been shown to be high in sugar, fat, and calories,9,10 making party fare more healthy would be prudent. Recommendations from model wellness policies and suggestions for healthy celebrations include limiting parties to 1 per month, serving only healthy foods, offering nonfood items in goody bags, and conducting party activities and games that do not involve food.37,38 Further refinements in district policies can be expected after the Healthy, Hunger-Free Kids Act of 2010,39 which continues to require district-level wellness policies that address competitive foods and beverages in schools. The Healthy, Hunger-Free Kids Act of 2010 also directed the US Department of Agriculture (USDA)40 to develop nationwide regulations for competitive foods and beverages. Because party fare is offered outside the meals program, it falls under the category of competitive foods. However, the proposed USDA competitive food regulations that were released in early 2013 did not address foods and beverages served during school parties. It is thus unlikely that the final USDA rule will address party fare, which makes this important aspect of the school food environment one that will need to be addressed with policy efforts at state, district, and/or school levels. Although the current analyses were based on a large, nationally representative sample, several limitations are evident. Use of survey measures
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Table 3. Summary of Multivariate Logistic Regression Modelsa to Predict School-level Limits on Sugary Items Served at Birthday Parties and Holiday Parties, US Public Elementary Schools (n ¼ 1,204) During the 2009–2010 and 2010–2011 School Years Limits on Sugary Items at Birthday Parties State/District Predictorsb
Adjusted Prevalence, % AOR
95% CI
Any restriction on foods served at class parties or other school celebrations None District policy only State law only District policy and state law
40.8 46.6 41.2 63.1
1.00 1.28 1.02 2.54
(Referent) 0.91–1.79 0.36–2.86 1.66–3.88
Specific limits on candy None District policy only State law only District policy and state law
44.9 56.3 74.4 79.8
Specific limits on sugar content of food None District policy only State law only District policy and state law
Limits on Sugary Items at Holiday Parties P
Adjusted Prevalence, % AOR
95% CI
P
< .001
36.6 44.9 31.2 58.2
1.00 1.42 0.78 2.47
(Referent) 1.03–1.96 0.28–2.15 1.67–3.65
1.00 1.59 3.63 4.94
(Referent) 0.93–2.73 0.86–15.32 2.19–11.11 < .001
42.0 50.9 75.0 73.9
1.00 1.44 4.28 4.04
(Referent) 0.83–2.52 0.96–19.10 1.97–8.31 < .001
45.3 51.2 59.1 58.2
1.00 1.28 1.77 1.71
(Referent) 0.84–1.95 0.79–3.96 0.86–3.39
41.9 48.6 56.4 57.6
1.00 1.33 1.84 1.93
(Referent) 0.86–2.05 0.86–3.93 0.97–3.82
Specific limits on fat content of food None District policy only State law only District policy and state law
44.6 50.8 58.8 62.6
1.00 1.30 1.81 2.12
(Referent) 0.93–1.81 0.71–4.56 1.16–3.89
.02
41.2 47.6 54.8 61.8
1.00 1.31 1.77 2.39
(Referent) 0.95–1.82 0.74–4.20 1.31–4.36
.005
Specific limits on soda None District policy only State law only District policy and state law
43.6 53.1 67.9 74.7
1.00 1.47 2.78 3.91
(Referent) 0.99–2.20 1.19–6.49 1.95–7.81
.02 < .001
40.8 50.1 62.3 70.0
1.00 1.47 2.46 3.50
(Referent) 0.97–2.23 1.07–5.62 1.85–6.65
.03 < .001
.03 < .001
AOR indicates adjusted odds ratio; CI, confidence interval. a All models include school-level covariates (year, school size, locale, region, student race/ethnicity, and percentage of students eligible for free or reduced-price lunch). Analyses were weighted to school level. Adjusted prevalence shows the percentage of schools limiting sugary items in parties, by state/district policy status. Outcomes were coded 1 where sugary items are discouraged school-wide or prohibited school-wide, or parties were not allowed; bData reflect any provisions (including those that were encouraged, required, or imposed a complete ban) governing classroom parties. Note: For birthday parties, n ranged from 1,159 to 1,199. For holiday parties, n ranged from 1,161 to 1,200. Only P < .05 is reported.
limited the ability to evaluate party practices in detail; even within schools there was variability in party frequency and calories offered. In practice, some teachers may allow parties on a weekly basis, whereas some may have a quarterly party with no food. The survey measure did not capture detailed information about classroom practices, or student dietary intake or student weight status. This is essential for future work. The survey inquired about ‘‘school-wide policies,’’ but such poli-
cies may not necessarily have been enforced. That is, although respondents indicated that school-wide restrictions on parties were in place, parents might have brought in foods for parties without being aware of school-level recommendations, or recommendations may have existed but been ignored by teachers. Conversely, even at schools without policies, some teachers may have prohibited classroom celebrations, which would not have been reflected here. Despite these measurement chal-
lenges, the goal of the current study was not to obtain detailed information on classroom practices, but to examine the potential impact of policy on the school environment. The current study allowed the ability to examine how policy efforts at higher jurisdictions (ie, district and state) were associated with schoollevel restrictions. Whether—and how—schools are implementing such recommendations in practice is yet another question of great importance.
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Turner et al 617
Table 4. Percentage of Schools With School-level Restrictions on Classroom Parties, by School Demographic Characteristics, Only for Schools Where State Laws and District Policies Place Nutritional Restrictions on Classroom Parties Birthday Parties
Holiday Parties
No School School Policy Policy (n ¼ 99) (n ¼ 119) Region South Northeast Midwest West
36.3 21.8 49.8 73.7
63.7 78.2 50.2 26.3
Locale City Suburb Town Rural
45.5 30.1 60.6 28.3
54.5 69.9 39.4 71.7
Race/ethnicity of students Predominantly ($ 66%) white Majority ($ 50%) black Majority ($ 50%) Latino Diverse
35.1 22.7 48.8 43.9
64.9 77.3 51.2 56.1
Student eligibility for free or reduced-price lunch Lowest (# 33% eligible) Medium (> 33% to # 66% eligible) Highest (> 66% eligible)
34.9 43.7 33.6
65.1 56.3 66.4
School size Large (> 621 students) Medium (451–621 students) Small (< 451 students)
43.4 37.9 35.3
56.6 62.1 64.7
P
No School School Policy Policy (n ¼ 89) (n ¼ 129)
P
.006
42.2 29.0 49.8 69.8
57.8 71.0 50.2 30.2
.05
.03
54.6 37.3 47.6 32.5
45.4 62.7 52.4 67.5
.05
.15
37.3 45.4 46.1 47.4
62.7 54.6 53.9 52.6
.73
.50
40.1 39.3 47.0
59.9 60.7 53.0
.66
.75
48.9 41.5 40.5
51.1 58.5 59.5
.72
Note: P is associated with c test. 2
As with any survey, estimates might have been affected by biases, but the weights accounted for nonresponse. Finally, the district policies and state laws were assessed based on their inclusion in wellness and related policies and codified state laws, and evaluated formal policies on the books rather than any informal guidelines, handbooks, or policies in practice. Thus, estimated policy prevalence was conservative, but additional informal policies would likely solidify the relationships found here. Few elementary schools prohibited serving sugary items during classroom parties. Although few districts and even fewer states had strong policies about classroom parties, many had weak recommendations—but not outright restrictions—about party fare. Where such recommendations existed at both the district and state levels, schools were more likely to have school-wide restrictions in place
regarding the foods and beverages served at parties. The significant association between weak district or state policies and school-level policies suggests that definitive policy limits may not be necessary to change school practices. Policy recommendations such as limiting parties to a few times a year or encouraging healthier fare may be sufficient to decrease the availability of sugary products at parties. Given the controversy about cupcake bans and the difficulty of changing norms regarding in-school celebrations, it will be challenging to alter school practices, but policy recommendations are a promising strategy to promote change.
IMPLICATIONS FOR RESEARCH AND PRACTICE Policy restrictions on sugary party items were associated with an in-
creased likelihood of schools placing restrictions on serving sugary items at classroom holiday and birthday parties. Although most policies were framed as recommendations, such policy strategies appear to be effective for reducing the availability of sugary items in classroom parties. Parents, teachers, and policy makers are encouraged to consider the role of energy-dense party fare in children's diets and to promote healthier practices in schools.
ACKNOWLEDGMENTS This work was funded by the Robert Wood Johnson Foundation. The authors gratefully acknowledge the state and district policy research and analysis support provided by Linda Schneider, Rebecca Schermbeck, Tessa Adcock, and Camille Gourdet, JD; and support for the school survey data collection from Anna Sandoval.
618 Turner et al
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