Bethany A. Yon

Reliability and validity of digital imaging as a measure of schoolchildren's fruit and vegetable consumption.

BACKGROUND As more and more interventions aim to increase schoolchildrens fruit and vegetable (FV) consumption, less resource-intensive yet valid alternatives to weighed plate waste (WPW) are needed for assessing dietary intake. OBJECTIVES We aimed to test the reliability and validity of digital imaging (DI) and digital imaging with observation (DI+O) in assessing childrens FV consumption during school lunch. DESIGN FV consumption (in grams) was assessed on lunch trays from third- to fifth-grade children over eight visits (31 to 68 trays collected per visit) to compare WPW with DI and DI+O. SETTING Two elementary schools (327 and 631 students enrolled, respectively). MAIN OUTCOME MEASURES Interobserver reliability of DI. Validity of DI and DI+O compared against WPW. STATISTICAL ANALYSES Reliability was assessed by percent agreement and intraclass correlation coefficients (ICCs). Validity was assessed by Pearson correlations, paired t tests, and Bland-Altman plots. RESULTS Reliability was acceptable for DI; percent agreement was 96% and the ICC was 0.92. FV consumption assessments by DI and WPW (n=159) were highly correlated (r=0.96; P<0.001). Mean FV consumption using DI (96.7 g) was within 1.0 g of WPW and not significantly different from WPW (P=0.56), and Bland-Altman limits of agreement for individual-tray FV consumption were -32.9 to 31.3 g. FV consumption assessments by DI+O and WPW were highly correlated (r=0.98; P<0.001). Mean FV consumption using DI+O (99.3 g) was within 1.0 g of WPW and not significantly different from WPW (P=0.38), and limits of agreement for individual-tray FV consumption were -25.0 to 26.8 g. CONCLUSIONS DI was reliable for assessing childrens FV consumption during school lunch. DI and DI+O were valid for assessing mean consumption but less precise for estimating individual-tray consumption. Valid estimations of mean FV consumption were achieved using DI without cafeteria observations, thereby reducing labor and time. Thus, DI is especially promising for assessing childrens mean FV consumption during school lunch.

School Children's Consumption of Lower-Calorie Flavored Milk: A Plate Waste Study

During January 2011, the US Department of Agriculture issued proposed regulations with substantial changes to nutrition standards for school foods and beverages to improve the healthfulness of school meals. Milk availability is limited to fat-free or 1% white milk and fat-free flavored milk. Most elementary school students choose flavored milk. Milk processors are lowering the calories provided by flavored milks by reducing the fat and/or added sugars content. Milk is an important source of shortfall nutrients; thus, it is important to know how children accept these new milks. Four schools in the northeast and south serving lower-calorie flavored milk (≤150 kcal/8 oz) were selected for a quasi-experimental plate waste study. Five control schools serving standard flavored milk (>150 kcal/8 oz) were enrolled from the same regions. During May and June 2010, flavored milk cartons were collected from 793 third- to fifth-grade students after lunch and individually weighed to determine consumption. Overall, students consumed an average of 5.52±0.10 oz flavored milk. Students consumed an average of 5.88±0.12 oz standard flavored milk (n=497) compared with an average of 4.92±0.17 oz lower-calorie flavored milk (n=296). Using linear mixed models, we found that children drinking standard milk were more likely to consume >7 oz, although the difference was not significant (P=0.09). After adjusting for group differences in socioeconomic status, region, and sex, no differences in consumption were detected (P=0.29). Because none of these milks were in full compliance with proposed regulations, milk consumption should be further monitored.

Weighing in on Added Sugars and Health

In this issue of the Journal, Lustig contends that a reduction in fructose consumption is necessary to combat the obesity epidemic (1). His review is one of many recently that is focused on the adverse health effects of increased intakes of sugars, especially added sugars and those coming from sugar-sweetened beverages. Although registered dietitians have for years focused on fat as the macronutrient most associated with chronic disease, it has become increasingly clear that the amount and quality of carbohydrates in the diet may be equally as important as fats to reduce diet-related chronic disease. Registered dietitians, nutrition scientists, nutrition policy makers, and advocacy groups are increasingly focusing on added sugars. The US Department of Agriculture (USDA) defines added sugars as all sugars used as ingredients in processed and prepared foods (such as breads, cakes, soft drinks, jam, and ice cream), and sugars eaten separately or added to foods at the table (2). Specifically, added sugars include white sugar, brown sugar, raw sugar, corn syrup, corn-syrup solids, highfructose corn syrup, malt syrup, maple syrup, pancake syrup, fructose sweetener, liquid fructose, honey molasses, anhydrous dextrose, and crystal dextrose (2). Added sugars do not include the naturally occurring sugars lactose (in milk and dairy products) or fructose (in fruit).

Impact of the National School Lunch Program on Fruit and Vegetable Selection in Northeastern Elementary Schoolchildren, 2012–2013:

Increasing childrens fruit and vegetable (FV) consumption is an important goal of the U.S. Department of Agricultures (USDAs) National School Lunch Program. Since 2012, the USDAs requirement that children select FVs at lunch as part of the reimbursable school meal has been met with concern and evidence of food waste. We compared elementary schoolchildrens FV selection, consumption, and waste before (10 school visits, 498 tray observations) and after (11 school visits, 944 tray observations) implementation of this requirement using validated dietary assessment measures. More children selected FVs in higher amounts when FVs were required compared with when they were optional (0.69 cups vs. 0.89 cups, p<0.001); however, consumption decreased slightly (0.51 cups vs. 0.45 cups, p=0.01) and waste increased (0.25 cups vs. 0.39 cups, p<0.001) when FVs were required compared with when they were optional. More exposure to FVs in schools through programmatic efforts and in the home environment may help familiarize children with FV offerings and encourage consumption.

Elementary and middle school children's acceptance of lower calorie flavored milk as measured by milk shipment and participation in the National School Lunch Program.

BACKGROUND The United States Department of Agricultures (USDA) new nutrition standards for school meals include sweeping changes setting upper limits on calories served and limit milk offerings to low fat or fat-free and, if flavored, only fat-free. Milk processors are lowering the calories in flavored milks. As changes to milk impact school lunch participation and milk consumption, it is important to know the impact of these modifications. METHODS Elementary and middle schools from 17 public school districts that changed from standard flavored milk (160-180 kcal/8 oz) to lower calorie flavored milk (140-150 kcal/8 oz) between 2008 and 2009 were enrolled. Milk shipment and National School Lunch Program (NSLP) participation rates were collected for 3 time periods over 12 months (pre-reformulation, at the time of reformulation, and after reformulation). Linear mixed models were used with adjustments for free/reduced meal eligibility. RESULTS No changes were seen in shipment of flavored milk or all milk, including unflavored. The NSLP participation rates dropped when lower calorie flavored milk was first offered, but recovered over time. CONCLUSIONS While school children appear to accept lower calorie flavored milk, further monitoring is warranted as most of the flavored milks offered were not fat-free as was required by USDA as of fall 2012.

Dietary Patterns and Sugar-Sweetened Beverage Consumption among Adolescents and Adults

Sugar-sweetened beverages (SSBs) are a major source of empty calories and among the top sources of energy intake in the diets of U.S. adolescents and adults. While consumption of added sugars and SSBs may be decreasing, intakes remain high. Rather than solely focusing on specific foods/nutrients, dietary patterns are useful to evaluate overall diet quality and health outcomes for individuals and populations. SSBs are frequently included as part of a Western dietary pattern, which is related to obesity and poor health outcomes. Additionally, on their own, SSB consumption is associated with obesity, increased risk of type 2 diabetes and cardiovascular disease. This paper reviews the recent literature on dietary patterns and SSB consumption as well as SSBs and health. Reducing the intake of SSBs is a public health priority; new research shows promising results when changes are made in the food environment, including schools and workplaces.

New School Meal Regulations and Consumption of Flavored Milk in Ten US Elementary Schools, 2010 and 2013

Milk is a source of shortfall nutrients in children’s diets, but most children do not consume recommended amounts. We measured consumption of milk by elementary-schoolchildren (grades 3–5) in a diverse sample of schools before and after implementation of the US Department of Agriculture’s updated meal regulations requiring flavored milk to be fat-free. Flavored milk consumption did not change from 2010 to 2013; 52.2% of students in 2010 and 49.7% in 2013 consumed 7 ounces or more of an 8-ounce container. Updated regulations succeeded in lowering the amount of fat, added sugars, and calories in school milk but did not change overall milk consumption, thus improving children’s diet quality.

The Feasibility of Teacher and Parent Volunteers Collecting Digital Image Data of Children's Fruit and Vegetable Consumption during School Lunch

Increasing childrens fruit and vegetable (FV) consumption is an aim of school nutrition programs. Digital imaging (DI) is less time and resource intensive than other dietary assessment tools for evaluating whether these efforts correspond with increased FV consumption or waste. However, it is impractical for a university-based trained dietary assessment team (UDAT) to collect DI data nationally. The study objective was to compare the feasibility of DI data collection by the UDAT to a parent volunteer dietary assessment team (PDAT) and a teacher dietary assessment team (TDAT) at two northeast elementary schools (NES-A and NES-B, respectively) across 19 data collection days. Uniquely labeled lanyards were distributed to children as they entered the cafeteria to allow for the formation of a matched DI pair: pre-image of the lunch tray as the child exited the lunch line (FV selection) and a post-image of the tray before disposal (FV waste). Feasibility was defined as the number of DI pairs captured out of th...