Author Affiliations: Bridging the Gap Research Program, Health Policy Center, Institute for Health Research and Policy (Drs Turner and Chaloupka), and Department of Economics (Dr Chaloupka), University of Illinois at Chicago.
Access to competitive foods and beverages in schools—via vending machines, stores/snack bars, and à la carte lines—leads to consumption of unhealthy products,1,2 such as sugar-sweetened beverages (SSBs), which are associated with obesity.3,4 To reverse the childhood obesity epidemic, authorities have called for schools to limit the availability of high-calorie beverages5- 7; the Institute of Medicine (IOM) recommends that competitive beverages in elementary schools be limited to water, 100% juice, and nonfat or 1% milk.8
Previously, we reported on competitive beverage availability in elementary schools from 2006-2007 to 2008-2009.9 Herein, we extend those findings with 2 additional years of data.
We gathered data on school practices via mail-back surveys at nationally representative samples of public elementary schools in the contiguous United States. The samples were developed at the Institute for Survey Research at the University of Michigan, based on public use data sets from the National Center for Education Statistics. Surveys were completed by school principals and food service staff during the spring (second half) of each school year, from 2006-2007 to 2010-2011. The institutional review board at the University of Illinois at Chicago approved the study protocol and survey materials. Extensive methodological detail is given elsewhere.9,10
We conducted analyses in Stata/SE version 10.0 (StataCorp) to account for sampling stratum and for clustering of schools within districts and states. Weights were developed based on student enrollment and adjusted for potential school nonresponse; all analyses were conducted using these weights, which provide inference to public elementary school students across the United States. Time trends were evaluated in multivariate logistic regression models (controlling for school characteristics) with a linear term and a quadratic term to examine curvilinear trends; both were centered at zero.
Student access to beverages in any competitive venue on campus peaked at 61.3% in 2008-2009 and dropped thereafter (Table). The percentage of students who could purchase only IOM-approved competitive beverages increased linearly. Considering specific venues, vending machine access decreased steadily. There were significant curvilinear trends in access to stores/snack bars and á la carte lines, peaking during 2008-2009 and dropping thereafter. In those venues, availability of high-fat milks peaked in 2007-2008, which appears to be driving the corresponding curvilinear trend in availability of non–IOM-approved beverages in stores/snack bars and á la carte lines.
Beverage vending and the availability of SSBs anywhere on campus decreased steadily since 2006-2007. Student access to stores/snack bars and á la carte beverage lines peaked in 2008-2009 and decreased thereafter. As of 2010-2011, one-third of public elementary school students had access to non–IOM-approved beverages in any competitive venue on campus, and only 11.9% had SSBs available.
In May 2006, the Alliance for a Healthier Generation reached an agreement with the American Beverage Association to limit portion sizes and energy content of beverages offered to students. Those guidelines11 are consistent with the IOM recommendations. An evaluation released by the American Beverage Association reported that beverage shipments to schools dropped by 72% from 2004 to 2009, but that analysis relied on bottler-supplied reports of shipments to schools that mostly had exclusive distribution contracts. In contrast, our previous analyses9 indicated that higher-fat milks and SSBs continued to be offered in 2008-2009, perhaps because those products were sourced outside of formal distribution contracts. The American Beverage Association analysis included data for the first half of the 2009-2010 school year, which we then did not include; however, our current data also show that during 2009-2010, the trend of increasing access to competitive venues reversed, as did the availability of higher-fat milks in stores/snack bars and á la carte lines. This is encouraging, as is the current finding that SSB availability in vending machines (ie, the venue most often covered by distribution contracts) steadily decreased. Increases in district policies pertaining to competitive beverages12 may have contributed to these improvements and that association will be examined in forthcoming reports.
While subject to the typical limitations of survey research (eg, reporting bias), the current analyses are based on large, nationally representative data sets. Although there is still progress to be made, the trends are encouraging and show not only that change in the school beverage environment is possible, but that it is already under way.
Correspondence: Dr Turner, Institute for Health Research and Policy, University of Illinois at Chicago, 1747 W Roosevelt Rd, Ste 558, Chicago, IL 60608 (firstname.lastname@example.org).
Author Contributions: Dr Turner had full access to the data and takes responsibility for the integrity of the data and the accuracy of the analyses. Study concept and design: Turner and Chaloupka. Acquisition of data: Turner and Chaloupka. Analysis and interpretation of data: Turner and Chaloupka. Drafting of the manuscript: Turner and Chaloupka. Critical revision of the manuscript for important intellectual content: Turner and Chaloupka. Statistical analysis: Turner and Chaloupka. Obtained funding: Chaloupka. Administrative, technical, and material support: Turner and Chaloupka. Study supervision: Turner and Chaloupka.
Financial Disclosure: None reported.
Funding/Support: Research support was provided by the Robert Wood Johnson Foundation.
Disclaimer: This article was written by the Bridging the Gap Research Program and the conclusions therein do not necessarily reflect the views of the foundation.
Additional Contributions: We thank Anna Sandoval, MPH, for assistance with data collection. We thank the Robert Wood Johnson Foundation for financial support.
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