Jessica L. Thomson, PhD USDA Agricultural Research Service March 11, 2013 JNEB Journal Club Webinar

Jessica L. Thomson, PhD USDA Agricultural Research Service March 11, 2013 JNEB Journal Club Webinar

Learning Objectives Understand the purpose of the School Health Policies and Practices Study (SHPPS) Identify school characteristics significantly associated with the school nutrition environment Explain the implications of these associations for school administrators

Childhood Obesity Reached epidemic proportions in US Places children at risk for serious physical, metabolic, and psychological health problems Factors Behavioral Environmental Genetic Hormonal

Schools Children 5 years of age Spend 6 hours/day Consume 1-3 meals Natural choice for childhood obesity prevention efforts

Foodservice Managers Cooperation essential to success of school-based childhood obesity prevention and reduction efforts Responsible for Coordinating daily operations of school cafeterias Ordering food Overseeing food preparation & distribution Training other foodservice (FS) personnel Little known about how FS manager characteristics are associated with school nutrition environment

School-based Nutrition Interventions Characteristics of successful programs Behavioral focus Theory driven Family involvement Multi-component strategies Modification of school environment Teacher training Developmentally appropriate

Team Nutrition USDA initiative Possesses qualities of successful school-based nutrition program Comprehensive & integrative Provides training & technical assistance for school personnel Provides nutrition education for children & caregivers Schools focal point but also involves parents & community Evaluated in terms of impact on children s eating habits but not on school nutrition environment

Team Nutrition (www.fns.usda.gov/tn)

Team Nutrition Resources

Study Objective Few studies have taken comprehensive approach to assess school nutrition environment despite knowledge of its significant impact on children s nutritional health Assess school characteristics associated with healthy and unhealthy FS practices or healthy food preparation practices in nationally representative sample of public & private US schools

School Health Policies & Practices Study (SHPPS) National survey conducted every 6 years by Centers for Disease Control & Prevention (CDC) Designed to assess school health policies & practices at state, district, school & classroom levels Completed by nationally representative sample of public & private elementary, middle & high schools

SHPPS (continued) 8 components of school health assessed Health education Physical education & activity Health services Mental health & social services Nutrition services Healthy & safe school environment Faculty & staff health promotion Family & community involvement

Present Study SHPPS 2006 datasets used Nutrition services component analyzed Food Service School Questionnaire Composed of 88 questions divided into 8 categories FS organization Menu planning & food ordering Food preparation Food variety & availability School cafeterias Promotion Collaboration FS manager

Present Study Specific set of questions chosen for analysis Examples of FS items (yes/no) Deep-fried food sold at lunch Salt available if students ask for it Students offered 5 food items containing whole grain each week Examples of healthy food preparation items (never/rarely/sometimes/almost always or always) During past 30 days, how often potatoes boiled/mashed/baked rather than fried/deep fried During past 30 days, how often other seasonings used instead of salt During past 30 days, how often fat drained from browned meat

Data Analysis Factor analysis to determine if nutrition-related items Represented single dimension Represented different characteristics of nutrition environment (sources of variation present) Multivariable regression Outcome (dependent) variables Scores from 5 scales identified using factor analysis

Data Analysis (continued) Multivariable regression (continued) Explanatory (independent) variables = school characteristics Level, type & enrollment number Participation in National School Lunch Program (NSLP) Participation in Team Nutrition Group with primary responsibility for ordering and for cooking food (district, school, other) FS manager Minimum education level for newly hired FS manager Successful completion of state-provided/sponsored FS training program for newly hired FS managers

Data Analysis (continued) Multivariable regression (continued) Interaction terms for school type with Enrollment Participation in NSLP Participation in Team Nutrition Group primarily responsible for ordering food FS manager education Requirement for FS training program

Data Analysis (continued) Multivariable regression (continued) All explanatory variables entered into models initially and retained only if significant at 0.05 level Post hoc comparisons made using Bonferroni correction factors for variables with more than 2 levels

Data Analysis (continued) Complex survey design Required use of survey procedures to account for complex sampling design Results based on weighted data Results nationally representative of public & private elementary, middle & high schools

Results 944 schools answering at least 1 question on FS School Questionnaire (71% response rate) 9 state-administered schools excluded 5 schools not offering lunch excluded 121 schools in which respondent other than FS personnel excluded 11 schools excluded from Healthy Preparation scale & subscales because respondent not able to answer food preparation questions Final sample sizes = 526 (Healthy & Unhealthy Offerings) & 520 (Healthy Preparation)

Results Factor Analysis Factor analysis run on 2 separate sets of questions due to Content Format (yes/no vs. never/rarely/sometimes/almost always or always) First set 17 FS practice questions 2 factors emerged accounting for 53% & 44% of variance

Results Factor Analysis (continued) First set (continued) First factor (5 items) = Unhealthy Offerings Scale Fried food Salt Butter Second factor (10 items) = Healthy Offerings Scale Fruit Vegetables Variety of food offered

Results Factor Analysis (continued) Second set 22 healthy food preparation questions 2 factors emerged accounting for 68% & 22% of variance First factor (11 items) General low-fat/low-sodium food preparation practices Second factor (8 items) Meat-specific food preparation practices 1 scale & 2 subscales created Combination of 2 factors = Healthy Preparation scale 2 individual factors = Low Fat & Lean Meat subscales

Results Scale Scoring Computation = average (sum of individual scale item responses/total number of scale items) Higher scores = healthier food environment Healthy Offerings Scale: higher scores = higher occurrence of healthy practices Unhealthy Offerings Scale: higher scores = lower occurrence of unhealthy practices Healthy Preparation Scale & Subscales: higher scores = greater frequency of use for healthy food preparation practices

Results School Characteristics Type 76% public with mean enrollment = 556 students 24% private with mean enrollment = 304 students Level 46% elementary 31% middle 23% high school

Results School Characteristics (continued) NSLP participation 87% overall 99% public 52% private 52% Team Nutrition participation 98% FS manager Education level for newly hired FS manager 80% required high school/ged 11% required nutrition-related college degree 9% no requirement

Results School Characteristics (continued) 60% required successful completion of FS training program for newly hired FS managers Primary responsibility for ordering food 32% district FS 45% school FS staff 23% other FS group Primary responsibility for cooking food 83% school FS staff 17% other FS group

Results Scale Scores Healthy Offerings Scale Mean score = 0.77 Interpretation = 8 of 10 healthy FS practices present Unhealthy Offerings Scale Mean score = 0.65 Interpretation = 2 of 5 unhealthy FS practices present

Results Scale Scores (continued) Healthy Preparation Scale Mean score = 3.06 Interpretation = overall healthy food practices being followed sometimes Healthy Preparation Low Fat (HP-Low Fat) Subscale Mean score = 2.81 Interpretation = low fat/low sodium practices being followed sometimes Healthy Preparation Lean Meat (HP-Lean Meat) Subscale Mean score = 3.27 Interpretation = lean meat practices being followed sometimes

Results Multivariable Regression School type Healthy Offerings: public > private HP-Low Fat: public > private School level Unhealthy Offerings: elementary > middle > high school Enrollment Healthy Offerings with school size

Results Multivariable Regression (continued) NSLP participation Unhealthy Offerings Healthy Preparation Team Nutrition participation Healthy Offerings Healthy Preparation HP-Lean Meat

Results Multivariable Regression (continued) Primary responsibility for ordering food Healthy Offerings: District FS & Other FS Group > School FS Staff Primary responsibility for cooking food Healthy Preparation: Other FS Group > School FS Staff HP-Low Fat: Other FS Group > School FS Staff HP-Lean Meat: Other FS Group > School FS Staff

Results Multivariable Regression (continued) FS Manager Not significant FS Manager education Healthy Preparation: College > HS/GED & none HP-Lean Meat: College > HS/GED & none FS Manager training Unhealthy Offerings Healthy Preparation HP-Low Fat HP-Lean Meat

Discussion First study to Assess school characteristics associated with healthy and unhealthy FS practices or healthy food preparation practices Nationally representative sample of public & private US schools

Discussion School Type Public schools more healthful nutrition environment as compared to private Not surrogate for enrollment size No supporting literature could be found Possible private schools not held to same standards as public schools Possible lack of kitchen facilities/fs equipment at private schools leads to more outsourcing of school meals (e.g. local restaurants, fast foods)

Discussion School Level Number of unhealthy offerings: elementary < middle < high school Confirms previous findings of progressively less healthy school food environment as students age Larger variety of unhealthy offerings as grades increase FS personnel beliefs Elementary level = less consideration of student choice; more concern with ensuring healthy eating Middle & high school = prepare students for real world by allowing students to make own choices between healthy & unhealthy food items

Discussion School Level (continued) FS personnel beliefs (continued) Potentially misguided Students will choose to replace healthy food with unhealthy foods when made available Suggests need for more formalized, less passive nutrition education methods Training needed to actively provide nutrition education Empower students to make healthy choices in presence of unhealthy choices

Discussion NSLP Participation Association between healthier school nutrition environment & participation in program expected NSLP requires nutrient content analysis of lunches or use of food-based meal pattern for menu planning Upper limit for fat & sat fat may be positively influencing FS practices pertaining to low fat & lean meat preparations May partially explain public schools higher score for Healthy Preparation Scale since more participate in program than private schools

Discussion Team Nutrition Participation Again, association between healthier school nutrition environment & participation in program expected Program involves integrated approach to improve schools nutritional health Participating schools reported presence of 8 healthy FS practices as compared to 7 in nonparticipating schools

Discussion Primary Responsibility for Ordering & Cooking Food Less healthful school nutrition environments apparent for schools in which staff had primary responsibility for ordering & cooking food No supporting literature could be found Possible explanations Educational differences Almost twice as many districts (19%) as compared to schools (10%) required associate s degree or higher for FS managers Buying power Further studies needed to determine reason for disparity

Discussion FS Manager Education & Training Associations between healthier school nutrition environment and higher education & training requirement for FS managers also expected Advanced dietary knowledge & training likely to positively influence both healthfulness of food ordered & preparation practices followed

Study Limitations Cross-sectional Associations but not causation determined Self-report Possibility of under- or over-reporting Minimized by excluding schools whose respondent was not FS personnel Urbanicity & poverty missing for 216 private schools Lack of information concerning competitive foods

Implications for Research & Practice Public & private schools can potentially improve their nutrition environment by Requiring FS managers to hold nutrition-related college degree Requiring FS managers to successfully complete FS training program Participating in comprehensive school-based nutrition intervention program such as Team Nutrition Particularly relevant for private schools not qualifying for federally assisted meal programs

Implications for Research & Practice (continued) Increasing professional qualifications of FS managers one of greatest challenges to improving school nutrition programs Child Nutrition & Reauthorization Act of 2010 may help Requires establishment of required education, training & certification for all school FS directors responsible for management of school food authority Until federal standards put into effect, school administrators should consider voluntarily setting minimum education & training standards

Implications for Research & Practice (continued) Private schools without formal FS program or on-site FS manager should consider Consulting with registered dietitian regarding food & beverages outsourced to local restaurants or vendors Instituting a comprehensive nutrition education program

Acknowledgements Co-authors Lisa Tussing-Humphreys, UIC Corby Martin, PBRC Monique LeBlanc, SELU Stephen Onufrak, CDC Work was sponsored by USDA Agricultural Research Service Project 6435-51000- 009-00D NIH grant K23 DK068052

Become an SNEB member! Benefits of membership Professional Member - $190 per year Associate Member - $95 per year Student Member - $60 per year Subscription to the Journal of Nutrition Education and Behavior Free access to live and recorded webinars Deepest discount to attend the SNEB Annual Conference Membership in an SNEB specialty division Connection to other professionals through SNEB listserv www.sneb.org/join