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Volume
2:
Special Issue, November 2005
COMMUNITY CASE STUDY
The Vending and à la Carte Policy Intervention in Maine
Public High Schools
Anne-Marie Davee, MS, RD, Janet E. Whatley Blum, ScD, Rachel L.
Devore, Christina M. Beaudoin, PhD, Lori A. Kaley, MS, MSB, Janet L. Leiter,
MS, RD, Debra A. Wigand, MEd
Suggested citation for this article: Davee A-M, Whatley Blum JE, Devore
RL, Beaudoin CM, Kaley LA, Leiter JL, et al. The Vending and à la Carte
Policy Intervention in Maine public high schools. Prev Chronic Dis [serial
online] 2005 Nov [date cited]. Available from: URL:
http://www.cdc.gov/pcd/issues/2005/
nov/05_0076.htm.
PEER REVIEWED
Abstract
Background
A healthy school nutrition environment may be important for decreasing
childhood overweight. This article describes a project to make healthier snacks
and beverages available in vending machines and à la carte programs in Maine
public high
schools.
Context
Seven public high schools in Maine volunteered to participate in this
project. Four schools made changes to the nutrition environment, and three
schools that served as controls did not. The nutrition guidelines were to offer
only low-fat (not more than 30% of total calories from fat) and low-sugar (not
more than 35% by weight of sugar) items in vending machines and à la carte
programs.
Methods
Strategies to implement the project included early communications with
school officials, monetary stipends for participation, identification of a
school liaison, and a committee at each school to promote the healthy changes.
Baseline nutrient content and sales of all competitive foods and beverages were
assessed to develop the guidelines for changes in the four schools. Student
volunteers at all seven schools were measured for height, weight, diet quality,
and physical activity level to assess the impact of the change to the nutrition
environment. Baseline measures were taken in the spring semester of 2004.
Nutrition changes were made to the à la carte programs and vending machines in
the four intervention schools at the start of the fall semester of 2004.
Follow-up nutrition assessment and student data collection occurred in the
spring semester of 2005.
Consequences
Healthy changes in vending machines were more easily achieved than those made in the à
la carte programs. Technical assistance and ongoing support were essential for
successful implementation of this intervention.
Interpretation
It is possible to improve the nutrition environment of Maine public high schools.
Stakeholder support is essential to sustain healthy changes.
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Background
The statistics on youth overweight, levels of physical inactivity, and poor
food choices have become a public health concern. The prevalence of overweight
among U.S. children has more than doubled in the last 20 years and tripled among
adolescents (1). Overweight in youth is related to numerous long-term health
consequences, including elevated blood cholesterol levels and high blood
pressure, and may precipitate immediate ailments such as respiratory disorders,
orthopedic conditions, and hyperinsulinemia (2).
Schools play an important role in influencing the diet of children and
adolescents. Schools reach more than 95% of youth between the ages of 5 and 17 years
(2). More than 50% of youth in the United States consume one of three meals in
school, and 10% eat two of three meals in school (2). Students consume 25% to
33% of their daily calories at school (3). Therefore, efforts to monitor and
improve the nutritional quality of food choices in schools are indicated (3). A
healthy school nutrition environment helps students adopt and maintain healthy
eating behaviors and promotes academic achievement (4).
Because of the upward trend in childhood overweight, concern has arisen about
the nutritional quality of foods and beverages sold in schools outside of
federally regulated meal programs. Reimbursable school meals offered through the
U.S. Department of Agriculture’s National School Lunch Program (NSLP)
must meet federally mandated nutrition guidelines, whereas foods and beverages
sold outside of the NSLP — known as competitive foods — are not required
to do so (5). Nationally, 51% of school-aged children eat less than one serving
of fruit per day, and 29% eat less than one serving a day of vegetables that is
not fried (4). Depending upon age and sex, 56% to 85% of children consume soda
on any given day (4). Of particular concern is the shift in beverage consumption
from milk products to soda and fruit drinks in all age groups (4). It has been
reported that vending machines account for an estimated 23% of the foods sold at
school (6). Therefore, strategies to moderate fat and added sugar in children’s
diets should include making changes to food and beverage choices in school
vending machines and à la carte programs. Moderating intake of fat and added
sugar to achieve caloric balance is consistent with the 2005 Dietary
Guidelines for Americans (7).
Schools can play a key role in reversing the trends in childhood overweight
by establishing school nutrition policies that provide healthy food choices,
requiring nutrition education curricula, and encouraging participation in the
NSLP (2). Research suggests that environmental approaches in combination with
educational approaches may be most effective in bringing about positive changes
in students' eating behaviors (8). This article describes an environmental
intervention to make healthier snacks and beverages available in vending
machines and à la carte programs in Maine public high schools.
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Context
The rates of overweight and at risk for overweight for children and
adolescents in Maine correspond with national trends. Thirteen percent of high
school students in Maine are overweight, and 15% are at risk for overweight; 13%
of middle school students are also overweight, with 18% at risk for overweight
(9). Seventy-seven percent of high school students in Maine do not eat the
recommended five servings of fruit and vegetables each day (9). To promote
better nutrition at school, Maine requires that competitive foods sold during
the school day meet a 5% minimal nutritional value rule; this rule means that
each vending machine or à la carte item must provide at least 5% of the
Reference Daily Intake (RDI) for one of eight specified nutrients per 100
calories. Despite this rule, concern remains that students’ food and beverage
choices are too high in fat, sugar, and calories.
To address this concern, a project was developed through the Maine Bureau of
Health’s Physical Activity and Nutrition Program to make nutrition changes in
vending and à la carte programs in Maine public high schools and to assess the
impact of the changes on student diet and health. This project, the Vending and
à la Carte Policy Intervention, was funded through the Centers for Disease Control and
Prevention’s (CDC’s) Obesity Prevention Program. The nutrition guidelines stated
that only low-fat items (no more than 30% of total calories from fat, excluding
fat from nuts, seeds, and peanut butter) and low-sugar items (no more than 35%
by weight of sugar, excluding sugars found naturally in fruit and dairy
products) could be sold in high school vending machines and à la carte programs. The
guidelines were developed following a review of recommendations from the Maine Dietetic Association and Maine School Food Service Association (10) and
other sources; the guidelines are consistent with the CDC’s sample list of
vending machine food and beverage choices that are low in saturated fat (2).
Guidelines for maximum portion sizes in each category of items were also
developed. No changes were made to the NSLP.
In November 2003, the Maine Department of Education sent out an
informational letter electronically to all public school districts in the state
asking for voluntary participation either to implement nutritional changes or
make no changes for one school year in their vending and à la carte programs.
Interested high schools were screened to meet project criteria, which included
participation in the NSLP and the presence of at least one student beverage and
one student snack vending machine. Seven public high schools volunteered to participate
and met the criteria. These schools were located in six counties throughout the
southern and central regions of Maine. Community populations in these locations
ranged from 2500 to 23,000 (11). According to the U.S. Census Bureau’s Census
2000, median household incomes for these communities ranged from $28,390 to
$56,491 (12).
Four of the seven schools volunteered to implement the nutrition
recommendations in vending and à la carte programs, while three schools agreed
to serve as controls and make no changes for one school year. All seven schools
had a similar variety of foods and beverages available in vending and à la carte
programs, with an average of 10 vending machines at each site. Among the
schools, approximately 46% of the beverage items and 20% of the snack items sold
in vending machines met the program nutrition guidelines, while an estimated 31% of à la carte items met
the guidelines. Average high school student enrollment was 800, with an average
of four (25-minute) lunch periods and an average of 458 students per day eating
in each school cafeteria.
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Methods
This nutrition project had a prospective, quasi-experimental nonrandomized
design. It was approved by the Institutional Review Board (IRB) of the
University of Southern Maine and by the Bureau of Health, Maine Department of
Health and Human Services. The project team consisted of four individuals: an
intervention coordinator, a registered dietitian, a research assistant, and a
trained project specialist. Strategies to implement the project included early
communication between the project team and schools, monetary stipends to
participating schools, identification of a liaison at each school, and the
creation of a committee at each school to promote the changes.
School communications
Early in 2004, visits were made to all seven schools to begin communication,
obtain the cooperation of school administration, and meet food service
personnel. Initial communication focused on introducing the project team,
clarifying the objectives of the project, and defining the expectations for
participation in the project. Each superintendent signed a contract that
required identification of a school liaison, willingness to allow recruitment
and measurement of student volunteers, and cooperation with the data collection
process.
The liaison identified at each school was responsible for establishing a
committee to promote the healthy changes in the vending machines and à la carte
menus at their schools. Expectations for the committees were discussed in detail
with each school liaison; these expectations included recruitment of
representatives from all stakeholder groups — school administration, faculty,
students, parents, and food service personnel — and the completion of at least
four activities over the course of the school year to promote the healthy
changes. A list of recommended activities with resources was provided, and a
member of the project team was assigned to attend each committee meeting. All
schools received a stipend of $1500 for each school year of participation, a
third of which was used to support the liaison.
Nutrition assessment and implementation of changes
Before implementation of any nutritional changes, baseline assessment of
the nutritional value of each vending and à la carte food or beverage item was
conducted, and sales trends for the à la carte programs were documented. The data
collection occurred during a 1-week period at each school during the
winter/spring semester of 2004. During this period, the project team
communicated regularly with the school liaison, faculty, food service staff, and
students eating in the cafeterias. In each school’s cafeteria, a daily total
student lunch count and bag lunch count was also recorded.
Student volunteers were recruited through presentations in selected classes
as well as through schoolwide posters and announcements on the public address
system. Only freshmen, sophomores, and juniors were eligible because of the
2-year participation requirement. Students were offered a $10 gift certificate
to a sporting goods store for each year of participation. Parental and student
written consent was obtained before taking measurements. The written consent
form included a summary explaining the purpose and plans for the project. A
total of 581 students volunteered to participate from the seven schools, an
average of 83 students per school; 309 of those students were from the four
intervention schools, and 272 were from the three control schools. Student
measurements were taken confidentially in the spring semester of 2004.
During the summer of 2004, the project team visited the four schools
implementing nutrition changes. These visits included contacts with school
administration and the school liaison and meetings with food service staff. The
project team also met directly with each food and beverage supplier for each
school to present the nutrition guidelines and identify those items that met the
criteria. The suppliers were expected to make the changes to vending machine
items by the start of the fall semester. Food service managers were given lists
of the foods and beverages from their existing suppliers that met the nutrition
guidelines. The project team also offered suggestions and recipes for acceptable
substitutions for those that did not meet the nutrition criteria.
Presentations that emphasized the potential for the environmental change to
have a positive impact on student health were provided for faculty at the start
of the school year in each school making changes. In addition, letters were sent
home to inform students and their parents of upcoming changes in the vending and
à la carte programs. Implementation of the majority of the changes in the vending and à la carte
programs occurred on the first day of the 2004–2005 school year so that when
students and faculty arrived, primarily low-fat and low-sugar items were
available in the vending machines and à la carte programs.
Biweekly then monthly visits were made by a project team member to each
school that implemented the changes to provide ongoing technical support
throughout the first 6 months of the school year. To maintain communication, visits were also made
periodically to the schools that did not make changes.
In the spring semester of 2005, a follow-up nutrition assessment of vending
machine and à la carte food items was conducted in all seven schools, and data
on sales of the à la carte items were collected. Because of the proprietary nature
of vending machine sales, the purchase of foods and beverages located in locked
vending machines could not be assessed accurately.
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Consequences
Baseline assessments of the vending machines in all seven schools showed that
approximately 80% of the snack items and 54% of the beverage items did not meet the nutrition
guidelines. Baseline assessment of the à la carte programs showed that an
estimated 69% of
items did not meet the nutrition guidelines. In the four intervention schools,
items in vending machines that did not meet the guidelines were removed and
replaced by the suppliers with alternatives that did meet the nutrition
criteria, such as granola bars, nuts, dried fruits, pretzels, crackers, and
baked chips (Figure). No changes were made to the competitive food choices at
the other three schools.
Figure. Sample vending machine at
a Maine public high school before (left) and after
(right)
implementation of the Vending and à la Carte Policy Intervention, 2004. Only
food items that met established nutrition criteria were available in vending
machines postintervention.
There were unanticipated barriers to obtaining both the sales and nutritional
information for vending machine products. Suppliers did not collect sales
information by item nor did they keep inventories of the stock in each machine.
Sales data are considered proprietary and were therefore not obtainable from the
many vendors in each school. Nutrition facts were not available on some product
labels; in those cases, the information was obtained from the suppliers.
Response to nutrition changes
More than 50 Maine school districts contacted the intervention coordinator to
inquire about this intervention after learning about it from the informational
letter. This response demonstrated statewide interest in offering healthier
food and beverage choices in schools. Because of proposed legislation
to improve vending machine options in Maine, the à la carte programs were added to the
project design. Adding all à la carte foods and beverages to the project
increased the scope of changes required for implementation.
Two schools that implemented the healthy changes in the vending and à la
carte programs did so with minimal reactions. In these schools, the school
administrators and liaisons actively promoted and supported the change to the
nutrition environment with faculty, food service staff, and students with an
emphasis on the overall potential for positive impact on student health.
In the other two schools, anecdotal evidence showed that the responses to the
change in the nutrition environment by faculty, staff, and students were mixed.
Students and faculty reacted most to the nutrition changes in the à la carte
programs. Comments were made about the removal of specific items (carbonated
beverages, cookies, and high-fat snacks), the perceived lack of food and
beverage choices, and smaller portion sizes with similar costs. It was evident
that the students and faculty did not anticipate the depth and impact of the
changes on their daily food and beverage choices in the school nutrition
environment. The changes to vending machine choices, however, did not evoke
adverse reactions, with the exception of the elimination of carbonated beverages
in the faculty rooms.
In one school, negative responses from students and faculty appeared to have
a significant impact on the food service staff. In this school, the food service
staff expressed concerns about how the changes made in the à la carte program would
affect their daily responsibilities and potentially their job security.
Committee activities to promote nutrition changes
Committee activities at the four schools that made changes included
taste-testing of healthier foods, display of banners encouraging consumption of
fruits and vegetables, and visual demonstrations of the amounts of fat and sugar
in foods. These activities varied among the four schools by meeting frequency,
number of participating stakeholders, and the commitment to the promotion and
support of the project. The liaisons at two of the schools changed, and the food
service director resigned at one of the schools during the intervention. These
circumstances as well as other variables affected the ability of the committees
to complete their required activities. A model vending and à la carte nutrition
policy was developed for adoption by each school after implementation of the
intervention to sustain the environmental change.
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Interpretation
Changes in the nutrition environment to meet guidelines for healthier foods
and beverages and smaller portion sizes in à la carte programs and vending
machines are achievable in Maine public high schools. Food and beverage suppliers were
able to provide items that met the nutrition guidelines. Frequent school visits
that included regular communication and ongoing technical assistance were
essential during the implementation phase.
Vending machine changes were easily implemented and well accepted by
students. Changes in the à la carte programs were more difficult, especially in
the schools lacking support from all stakeholders. Future interventions to
change school nutrition environments should consider early communication with
all stakeholders, including students, parents, faculty, administrators, and food
service personnel. Inclusion of all stakeholders in an organized communication
plan developed in collaboration with the school and directed by an internal
leader may result in increased awareness of the quality of the school nutrition
environment and enhance support for healthy changes in the food venues. Food
service personnel should be provided with opportunities to increase their
knowledge about nutrition and health as well as training to implement simple
changes in food preparation to provide healthier choices in schools.
Sustainability of the environmental change is more likely if a school
nutrition policy is adopted. A written policy may help schools maintain healthy food
choices during times of transition, such as turnover in school administrative or food service personnel
and shifts in food preferences among faculty and students. A committee that
includes stakeholders and selected decision makers may be best positioned to
accomplish this.
Follow-up data will provide insight into the impact of the nutrition
environmental change on student variables. The authors anticipate that the
findings will provide additional support for adopting a school nutrition policy
on competitive foods to sustain healthy changes.
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Acknowledgments
The Maine Vending and à la Carte Policy Intervention is an intervention of
Maine's Physical Activity and Nutrition Program, funded by the CDC’s
Nutrition and Physical Activity Program to prevent obesity and other chronic
diseases.
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Author Information
Corresponding Author: Anne-Marie Davee, MS, RD, Muskie School of Public
Service, University of Southern Maine, 295 Water St, Augusta, ME 04330.
Telephone: 207-626-5275. E-mail: Anne-Marie.Davee@maine.gov.
Author Affiliations: Janet E. Whatley Blum, ScD, Rachel L. Devore, Christina
M. Beaudoin, PhD, Department of Sports Medicine, University of Southern Maine,
Gorham, Me; Lori A. Kaley, MS, MSB, Muskie School of Public Service, University
of Southern Maine, Augusta, Me; Janet L. Leiter, MS, RD, Maternal and Child Health Nutrition
Program, Debra A. Wigand, MEd, Cardiovascular Health Program, Bureau of Health,
Maine Department of Health and Human Services, Augusta, Me.
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References
- The National Center for Health Statistics, Centers for Disease Control and
Prevention. Prevalence of overweight among children and adolescents: United
States, 1999-2002. Hyattsville (MD): National Center for Health Statistics;
2001 [cited 2001 Oct 31]. Available from: URL: http://www.cdc.gov/nchs/products/pubs/pubd/hestats/
overwght99.htm.
- Centers for Disease Control and Prevention.
Guidelines for school health programs to promote lifelong healthy eating.
MMWR Recomm Rep 1996;45(No. RR-9):1-41.
- Farris RP, Nicklas TA, Webber LS, Berenson GS.
Nutrient contribution of the school lunch program: implications for healthy people 2000. J Sch
Health 1992;62(5):180-4.
- Briggs M, Safaii S, Beall DL, American Dietetic Association, Society for
Nutrition Education, American School Food Service Association.
Position of the American Dietetic Association, Society for Nutrition Education
and American School Food Service Association — Nutrition services: an
essential component of comprehensive school health programs. J Am Diet
Assoc 2003;103(4):505-14.
- Stang J, Bayerl CT.
Position of the American Dietetic Association: child and adolescent food and
nutrition programs. J Am Diet Assoc 2003;103(7):887-93.
- Wildey MB, Pampalone SZ, Pelletier RL, Zive MM, Elder JP, Sallis JF.
Fat and sugar levels are high in snacks purchased from student stores in
middle schools. J Am Diet Assoc 2000;100(3):319-22.
- U.S. Department of Health and Human Services, U.S. Department of
Agriculture. Dietary Guidelines for Americans 2005. 6th ed. Washington (DC):
U.S. Department of Agriculture; 2005. Available from: URL: http://www.health.gov/dietaryguidelines/dga2005/document/ pdf/dga2005.pdf.
- Neumark-Sztainer D, Story M, Resnick MD, Blum RW.
Lessons learned about adolescent nutrition from the Minnesota Adolescent
Health Survey. J Am Diet Assoc 1998;98(12):1449-56.
- Maine Department of Education. Maine Youth Risk Behavioral Surveillance
System, 2003. Augusta (ME): Maine Department of Education; 2003.
- Maine Dietetic Association. Joint position of the Maine Dietetic
Association and the Maine School Food Service Association [Internet] — nutrition services
in Maine schools; 2003 Oct. Westbrook (ME): Maine Dietetic Association; 2003.
Available from: URL: http://www.eatrightmaine.org*.
- Maine Department of Health and Human Services, Bureau of Health, Office of
Data, Research and Vital Statistics, 1999. Augusta (ME): Maine Department of
Health and Human Services; 1999 Sep.
- Maine State Planning Office, U.S. Census Bureau [Internet]. Census 2000. Maine median
household income. Augusta (ME): Maine State Planning Office; 2000. Available
from: URL: http://www.state.me.us/spo/economics/economics/ medianinc.php*.
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service to our users. URLs do not constitute an endorsement of any organization
by CDC or the federal government, and none should be inferred. CDC is
not responsible for the content of Web pages found at these URLs.
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