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Review |

Influence of School Competitive Food and Beverage Policies on Obesity, Consumption, and Availability:  A Systematic Review FREE

Jamie F. Chriqui, PhD1; Margaret Pickel, MPH1; Mary Story, PhD2
[+] Author Affiliations
1Institute for Health Research and Policy, School of Public Health, University of Illinois at Chicago, Chicago
2Duke Global Health Institute, Duke University, Durham, North Carolina
JAMA Pediatr. 2014;168(3):279-286. doi:10.1001/jamapediatrics.2013.4457.
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Published online

Importance  The US Department of Agriculture recently issued an interim final rule governing the sale of foods and beverages sold outside of the school meal programs (“competitive foods and beverages” [CF&Bs]).

Objective  To examine the potential influence that the federal rule may have based on peer-reviewed published studies examining the relationship between state laws and/or school district policies and student body mass index (BMI) and weight outcomes, consumption, and availability of CF&Bs.

Evidence Review  Keyword searches of peer-reviewed literature published between January 2005 and March 2013 were conducted using multiple databases. Titles and abstracts for 1160 nonduplicate articles were reviewed, with a full review conducted on 64 of those articles to determine their relevancy. Qualitative studies, studies of self-reported policies, or studies examining broad policies without a specific CF&B element were excluded.

Findings  Twenty-four studies were selected for inclusion. Studies focused on state laws (n = 14), district policies (n = 8), or both (n = 2), with the majority of studies (n = 18) examining foods and beverages (as opposed to food-only or beverage-only policies). Sixteen studies examined prepolicy/postpolicy changes, and 8 studies examined postpolicy changes. Study designs were cross-sectional (n = 20), longitudinal (n = 3), or a combination (n = 1). Outcomes examined included change in BMI, weight, probability of overweight or obesity (n = 4), consumption (n = 10), and availability (n = 13); 3 studies examined more than 1 outcome. The majority of studies primarily reported results in the expected direction (n = 15), with the remaining studies (n = 9) reporting primarily mixed or nonsignificant results.

Conclusions and Relevance  In most cases, CF&B policies are associated with changes in consumption and/or availability in the expected direction; however, caution should be exercised, given that nearly all were cross-sectional. The influence of such policies on overall student consumption and BMI and weight outcomes was mixed. The findings hold promise for the likely influence of federal CF&B regulations on changes in student in-school consumption and in-school competitive food availability. Further research is needed to truly understand the association between these policies and overall consumption and weight outcomes.

Figures in this Article

Foods and beverages high in fats, added sugars, and calories are widely available in America’s schools.16 Referred to as “competitive foods and beverages” (CF&Bs) because they are sold in competition with the federal school meals, these energy-dense snack foods and beverages are routinely sold in schools à la carte in the cafeteria; sold in vending machines, school stores, snack bars, and in-school fundraisers; and given in elementary schools as a reward for good behavior or performance.

Recognizing CF&B prevalence in schools and obesity trends among youth nationwide, in 2012, the Institute of Medicine recommended that all government agencies at the federal, state, and district levels ensure that strong nutrition standards be adopted and implemented for all foods and beverages sold or provided on school campuses.7 Over the past decade, state and district laws and policies have increasingly focused on restricting CF&B sales or requiring specific nutrition standards for such items. However, nationwide data indicate that only 61% of all districts nationwide included CF&B guidelines in their wellness policies, and such provisions are often the weakest policy element.810 Furthermore, these policies are much less likely to exist or be required at the secondary school levels than at the elementary school level.10

Currently, the only federal CF&B regulation prohibits the sale of foods of minimal nutritional value, which includes carbonated beverages and certain candies in the school cafeteria.11 However, the Healthy, Hunger-Free Kids Act of 2010 (HHFKA) included language that, for the first time, required nationwide standards for all foods and beverages sold outside of the federal school meals (ie, “competitive foods and beverages”).12 On June 28, 2013, the US Department of Agriculture (USDA) issued an interim final rule containing these standards that are slated to take effect beginning with school year 2014-2015.13

Much of the evidence leading up to HHFKA and the subsequent rule was based on natural experiments conducted in states and school districts nationwide, where specific laws and policies were enacted and implemented. To our knowledge, no review has systematically evaluated the influence of these laws and policies. Thus, this review seeks to examine the influence of specific state laws and district-level competitive food policies on changes to student body mass index (BMI) and weight outcomes; student consumption, purchasing, and dietary intake; or in-school competitive food availability and access. Findings from this study will provide useful insight into the potential influence of the USDA regulations.

This review was conducted in accordance with recommended systematic review guidelines (ie, the PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] statement).14

Study Selection and Data Sources

Four sets of Boolean keyword searches were conducted in the PubMed, CINAHL, EconLit, ERIC, and the Public Affairs Information Service (PAIS) literature databases, as well as the Childhood Obesity journal archives database available at http://www.Liebertpub.com (the latter was only recently captured in PubMed). Search 1 contained broad search terms such as competitive food, snack, beverage, and school. Search 2 included several search terms related to “policy” or “law” and CF&Bs in the school environment. Search 3 focused on school fundraisers, while the fourth search was specific to school wellness policies, which have had major implications for the school food environment since their federally mandated implementation in 2006.15 The eAppendix in the Supplement provides a comprehensive list of search strings. Searches were limited to English language, peer-reviewed articles published between January 2005 and March 2013. All search result study titles and abstracts were uploaded to RefWorks (http://www.refworks.com). Figure 1 outlines the literature review process. A total of 1496 results were identified, and, after the removal of 336 duplicates, 1160 articles remained for initial review.

Place holder to copy figure label and caption
Figure 1.
Systematic Literature Review Process Flowchart

BMI indicates body mass index; CF&B, competitive food and beverage; K-12, kindergarten through grade 12.

Graphic Jump Location

In phase I of the review, the first and second authors (J.F.C. and M.P.) examined all 1160 study titles and abstracts to determine eligibility. Sixty-four articles were identified for full review; the studies had to be United States based, quantitative, and focused on the food and beverage environment in elementary, middle, or high schools and to have examined the effects of a formally adopted (ie, “on the books”) big “P” policy16 enacted at the state and/or district levels as the independent variable in the study. Furthermore, the studies had to focus on the relationship between the policy and 1 of the following 3 outcomes: BMI and weight outcomes; student consumption, purchasing, and dietary intake; or in-school availability of or access to competitive foods and/or beverages. Figure 1 presents the inclusion and exclusion criteria.

During phase II, a full-text review of the 64 articles was conducted by 2 authors (J.F.C. and M.P.) to determine relevancy. In addition, cross-checks were performed of the reference lists of the selected articles and 4 review articles identified during phase I to ensure that no relevant articles were missed. No additional articles were identified for consideration. Forty articles were excluded during phase II, including several that examined survey-based self-reports of policy existence by state and/or district respondents or for which the reviewers were unable to assess the influence of CF&B policy components specifically because of insufficient information being reported (eg, wellness policies broadly rather than the CF&B policy components of the wellness policy).

Data Abstraction and Study Review

A Microsoft Access (Microsoft Corp) database was created for the first and second authors to independently evaluate the included articles. Each article was reviewed to capture information on the specific law and/or policy studied; the outcome data sources; study design; and the relationships between the law(s), policy(ies), and the outcome(s). Following the independent article review, the authors conducted a consensus review on each article and resolved differences in their reviews. Most of the differences were due to reviewer oversight or to differences in understanding or interpretation of the study design and/or outcome results.

Assessing the Evidence

Because of the heterogeneity of the policies and outcomes studied, a formal meta-analysis was not possible. Thus, the studies were summarized according to the primary direction of the relationship between the policy(ies) and outcome(s) of interest: E, expected direction; U, unexpected direction; M, mixed results with no predominant E and/or U findings; and N, nonsignificant relationships. Because this review focused entirely on natural experiments and because nearly all studies were based on cross-sectional data, the findings are presented as representing a “relationship,” “association,” or “influence” between the policy(ies) and outcome(s) rather than a causal relationship. In instances where a study reported on more than 1 outcome (eg, consumption and availability), the study is reported in both outcome categories, and therefore the findings reported in following Results section are not mutually exclusive.

Twenty-four articles met the study inclusion criteria. All of the studies were published between 2006 and 2012 (Figure 2), with most (22 of 24) published between 2009 and 2012; the 2 earlier studies examined district and state policy changes occurring in Texas in 2002 and 2004. All of the included studies are listed and summarized in (eTables 1 and 2 in the Supplement).

Place holder to copy figure label and caption
Figure 2.
Publication Year of Included Studies by Policy Focus
Graphic Jump Location
Policies Studied

Fourteen studies (58%) examined the influence of specific state laws,1730 8 studies (33%) examined district policy influences,3138 and 2 (8%) studies39,40 examined both state and district policy influences on the outcomes of interest. Eighteen studies (75%) focused on food and beverage policies,1727,30,3336,39,40 4 (17%) focused on beverage-only policies,28,31,32,37 and 2 (8%)29,38 focused on food-only policies. Seven studies (29%) examined policy influences at the elementary, middle, and high school levels,17,20,23,24,26,27,32 and 7 (29%) focused on high school,18,21,22,28,31,35,36 6 (25%) on middle school,19,25,29,30,33,37 and 2 (8%) on elementary school38,40 exclusively, while 1 study (4%) examined policy influences at both the middle and high school levels34 and another (4%) at the elementary and middle school levels.39

Data Sources

Six studies used coded data sets of state laws and/or district policies nationwide. Two studies27,30 used state law data obtained from the National Cancer Institute’s Classification of Laws About School Students’ (CLASS) School Nutrition Environment State Policy Classification System.41 The remaining 4 studies28,29,38,40 used state law and/or district policy data compiled by the Robert Wood Johnson Foundation–sponsored Bridging the Gap program at the University of Illinois at Chicago.42 The remaining 18 studies were based on within-state or within-district policy changes.

Outcome data were primarily obtained from audits of in-school food and beverage availability or surveys of school officials or individual students within specific states and/or districts. However, 6 studies used outcome data from the following nationally representative surveys of students and/or school officials in states and/or districts nationwide—the Bridging the Gap Program’s annual Food & Fitness Survey,38,40 the Early Childhood Longitudinal Survey–Kindergarten Cohort (ECLS-K),28,30 the National Survey of Children’s Health (NSCH),27 and the National Youth Physical Activity and Nutrition Survey (NYPANS).29

Study Designs

Of the 24 studies, 16 (67%) examined prepolicy/postpolicy changes1721,2325,27,3035,39; the remaining 8 studies (33%) examined postpolicy changes only.22,26,28,29,3638,40 Eleven studies (46%) examined bivariate influences of the policies on the outcomes of interest,1824,3235 and 13 studies (54%) were based on multivariate analyses,17,2531,3640 controlling for confounders and using statistical clustering or multilevel modeling, as appropriate. Most studies (20 of 24 [83%]) were cross-sectional,1822,2429,3134,3640 3 (13%) were longitudinal,17,30,35 and 1 (4%)23 included both cross-sectional and longitudinal analyses.

Outcomes of Interest

The studies were examined for state and/or district policy influences on 3 primary outcomes: (1) BMI and weight outcomes; (2) student food and/or beverage consumption, purchasing, or dietary intake; and (3) in-school CF&B availability or access. Four studies24,28,35,37 examined both consumption and availability and, therefore, are described in both outcome categories. Thus, the data reported are not mutually exclusive. The direction of the policy influences on each outcome are summarized in the Table, and details are provided in eTables 1, 2, and 3 in the Supplement.

Table Graphic Jump LocationTable.  Summary of Findings of Bivariate and Multivariate Studies by “Big ‘P’” Policy Focus
BMI and Weight Outcomes

Four multivariate studies examined the policy influences on BMI and weight outcomes, reporting mixed results overall.27,30,36,39 One study was entirely in the expected direction (ie, reduced odds of obesity or overweight).36 A study to examine overweight and obesity trends following policy changes in Los Angeles Unified School District (LAUSD) and California reported significantly lower rates of increase in overweight status among fifth graders in LAUSD and among fifth- and seventh-grade boys statewide overall; a significantly lower percentage change in the odds of overweight among fifth-grade boys and girls in LAUSD and among fifth-grade boys and seventh-grade boys and girls statewide; however, overweight trends were not significantly different over time among seventh graders in LAUSD or fifth-grade girls statewide, nor were reductions in the percentage change in the odds of overweight for these populations.39 Also, 2 studies used the National Cancer Institute’s CLASS data as the policy source and reported mixed results.27,30 The first, cross-sectional study linked the CLASS data with NSCH student outcomes and primarily reported nonsignificant relationships between various state CF&B laws and the odds of obesity, but also found small statistical associations (odds ratios of 1.03 and 1.04) in the unexpected direction for the association between the strength of state fundraising laws and laws governing venues other than à la carte lines and vending machines, respectively, and the odds of elementary student obesity.27 The second study was longitudinal and linked the CLASS data with ECLS-K student-level data and primarily reported statistical associations in the expected direction between the strength of CF&B laws in 40 states and middle school student BMI and weight outcomes.30

Consumption, Purchasing, or Dietary Intake

Six bivariate studies19,20,24,32,33,35 and 5 multivariate studies25,28,29,31,37 examined the relationship between state and/or district policies and changes to student food and/or beverage consumption, purchasing, or dietary intake. Three bivariate studies reported policy influences in the expected direction based on milk fat policy changes (ie, switching from whole to 1% or nonfat milk in New York City public schools, thereby reducing calories and saturated fats), a district wellness policy for an unnamed county, and state CF&B law changes in California.24,32,35 Three additional bivariate studies, all examining early policy changes in Texas (2 state law studies19,20 and 1 district policy study33), reported a mix of expected, unexpected, and nonsignificant policy influences.

One multivariate, cross-sectional study to examine postpolicy influences of state competitive food laws nationwide on total daily nutrient and caloric intake among California students and students in 14 other states with no competitive food laws found that California students consumed 158 fewer calories per day, with the majority of the difference in caloric intake attributable to changes in in-school consumption.29 Another study reported reductions in the energy density consumed from foods and/or beverages following implementation of the Texas Public School Nutrition Policy in 2004.25

Three studies examined the influence of beverage policies on changes to student consumption.28,31,37 One pretest/posttest cross-sectional district-level study found that the sugar-sweetened beverage (SSB) policy in Boston, Massachusetts, was statistically associated with reductions in in-school and overall student SSB consumption (β ranging from −0.30 to −0.14) 2 years after policy.31 A posttest-only study reported nonsignificant relationships between the SSB policies included in 28 Washington state school districts’ wellness policies (2006-2007 school year) and student consumption; however, the availability of SSBs in school mediated the policy influences on student consumption.37 Finally, 1 nationwide posttest-only study examined the influence of the strength of state competitive beverage laws on in-school and overall SSB consumption using eighth-grade student data from ECLS-K and reported a combination of expected (eg, reduction in weekly SSB purchases if the state law banned SSBs in school), unexpected (eg, increase in overall [in- and out-of-school] daily SSB consumption even when state law banned SSBs in school), and nonsignificant (eg, no relationship between state SSB policies and overall weekly SSB consumption) policy influences.28

Availability and Access

The relationship between state and/or district policies and in-school availability of and/or access to CF&Bs was examined in 7 bivariate18,2124,34,35 and 6 multivariate17,26,28,37,38,40 studies. All of the bivariate studies examined the influence of policies related to both CF&Bs, with 5 of the 7 studies reporting results in the expected direction21,23,24,34,35 and 2 studies reporting mixed results.18,22 Of the 5 bivariate studies with results in the expected direction, 3 examined the influence of California’s CF&B policies on in-school availability21,23,24; the other 2 studies examined individual district policy influences.34,35

All of the multivariate studies examining the influence of CF&B policies on in-school availability and access reported results in the expected direction.17,26,28,37,38,40 These studies examined the influence of district prohibitions on the use of food as a reward on elementary school practices nationwide,38 the influence of SSB or soda-only bans in 40 states on middle school availability of SSBs,28 the influence of district-level SSB policies in 28 Washington state districts on middle school SSB exposure,37 the influence of Arkansas Act 1220 on in-school food and beverage availability,26 the influence of Connecticut’s nutrition standards for schools voluntarily participating in the state’s Healthy Food Certification Program on in-school availability of unhealthy items,17 and the influence of state and/or district fundraising policies nationwide on elementary school fundraiser nutrition limits.40

This systematic review examined the influence of state and/or district CF&B laws and policies on student BMI and weight outcomes, student consumption, and/or in-school availability. While other reviews have addressed CF&B policy influences,4346 to our knowledge, this is the first review to examine the influence of specific, on-the-books (ie, “big P”) laws and policies. This is noteworthy because of the importance of looking at the impacts that specific laws and policies have on improving school nutrition environments, student intake, and, ultimately, BMI and weight outcomes.

Encouragingly, in 15 of the 24 studies reviewed, state laws and/or district policies have influenced outcomes in the expected direction. The remaining 9 studies reported mixed or nonsignificant results, but 3 of those studies19,20,33 were based on bivariate analyses examining district and/or state policy influences in Texas that were enacted in 2002 and 2004—well before most of the policy traction occurred on this topic.8,47,48 Notably, most of the studies reporting results in the expected direction focused on in-school availability and/or in-school consumption, in particular. The studies examining BMI and weight outcomes and overall consumption were mixed.

Because the studies focused on “natural experiments,” traditional randomized study designs were not possible among the studies reviewed, and, as such, the studies are subject to numerous threats to both internal and external validity. However, such designs are often necessary when examining the implementation and influence of public policies.49 In 16 of 24 studies (10 bivariate and 6 multivariate studies), pretest/posttest study designs were used, which is preferable to posttest-only designs (8 of 24 studies); however, several of the posttest-only designs used multiple years of data and controlled for possible confounders. Another study design concern is the lack of longitudinal studies—only 3 multivariate studies were longitudinal, only 1 of which examined longitudinal changes in student BMI and weight outcomes. This latter finding is noteworthy because there are few existing national data sources with appropriate geographical identifiers to enable longitudinal analyses of the influence of state laws on changes in student BMI and weight outcomes, highlighting an area for further research and resources.50

The findings from this review were limited to the included studies that were based on strong inclusion criteria. One purposefully excluded category of articles that others may deem relevant are studies examining the influence of self-reported policies (ie, those typically reported via survey methods by state and/or district officials) or policies “in practice” on availability, student consumption, and/or student BMI and weight outcomes. This was a purposeful omission on our part because such studies are subject to numerous respondent-related threats to internal and external validity,51 and, importantly, such studies do not disentangle formally adopted “on-the-books” public policies from “policies in practice” or what the responder “thinks” the policy may be. Thus, while intentionally narrow, we believe our inclusion criterion is justifiable, given that the intent of this review was to focus on specific “on-the-books” CF&B public policy influences. A second important category of literature that was excluded focused on studies examining the impact of strong competitive food standards and changes on NSLP/SBP (the National School Lunch and School Breakfast Programs) participation rates and/or food service revenues. Research has documented the positive influence that competitive food policies have had on participation rates and revenues21,24,52,53 and, therefore, are an important additional body of literature to examine in future reviews.

Importantly, the findings suggest that on-the-books laws and policies are doing what they were intended to do—namely, they are reducing the in-school availability of unhealthy competitive foods and beverages and in-school student consumption of such items. These findings may be especially useful in promoting changes to all schools, but especially high schools, where CF&B policies are the weakest.10 These findings offer promise for the likely influence that the new USDA standards will have on changing school food and beverage environments and student in-school consumption behaviors, in particular.

At the same time, however, more research is clearly needed to truly understand the influence of CF&B policies on overall (in- and out-of-school) student consumption behaviors and student BMI and weight outcomes. The studies presented herein reported mixed results in both of these areas, and many of these studies lacked rigorous study designs (ie, posttest-only designs and/or cross-sectional studies). Furthermore, many of these studies had very limited (if any) time lags between their policy date and the outcomes examined, which could have contributed to the mixed results.

This review points to several areas for further research and/or resources needed. First, more robust study designs examining prepolicy/postpolicy influences longitudinally are needed, particularly for studies examining outcomes that may take longer to be influenced by in-school policy changes (ie, overall consumption and BMI and weight outcomes). Second, future systematic reviews should also examine the impact of CF&B policies on changes in NSLP/SBP participation rates and food service revenues—2 equally important outcomes that were outside the scope of this review. Third, given the impending implementation of the new USDA rule, studies should examine whether implementation of the federal rule will vary based on the strength of existing state and/or district policies (ie, will federal implementation be more successful when there is already a strong policy environment and, ideally, implementation in place). And lastly, resources are clearly needed for more longitudinal outcome data nationwide. Only 3 studies included in this review included longitudinal data, and 2 of these were bivariate studies in 1 state or 1 metropolitan area. This is a recurring challenge for researchers interested in examining the impact of competitive food (and other) policies on school environment and student outcomes.

On the basis of the studies examined herein, it may take societal changes to facilitate sustained changes to overall consumption and student BMI and weight outcomes. But, as the Institute of Medicine emphasized, schools are the “heart of health” and should be a national focal point for obesity prevention because they play a critical role in shaping children’s food and beverage environments.7 Public policies designed to improve school food and beverage environments are an important starting point, since young people spend more time at school—on average, 6 hours a day—than in any other environment, except their homes. If changes made in schools were reinforced in environments outside the school setting, America’s children could achieve healthier diets and weights.

Accepted for Publication: September 19, 2013.

Corresponding Author: Jamie F. Chriqui, PhD, Institute for Health Research and Policy, School of Public Health, University of Illinois at Chicago, 1747 W Roosevelt Rd, Mail Code 275, Chicago, IL 60608 (jchriqui@uic.edu).

Published Online: January 27, 2014. doi:10.1001/jamapediatrics.2013.4457.

Author Contributions: Drs Chriqui and Pickel had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Chriqui, Story.

Acquisition of data: Chriqui.

Analysis and interpretation of data: Chriqui, Pickel, Story.

Drafting of the manuscript: Chriqui, Pickel.

Critical revision of the manuscript for important intellectual content: Chriqui, Pickel, Story.

Statistical analysis: Chriqui.

Obtained funding: Chriqui.

Administrative, technical, and material support: Chriqui, Pickel, Story.

Study supervision: Chriqui.

Conflict of Interest Disclosures: None reported.

Funding/Support: Support for this study was provided by the Robert Wood Johnson Foundation to the Bridging the Gap Program at the University of Illinois at Chicago (Principal Investigator, Frank Chaloupka) and the Healthy Eating Research Program at the University of Minnesota (Principal Investigator, Mary Story).

Role of the Sponsor: The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The opinions in this article are solely those of the authors and do not, necessarily, reflect those of the University of Illinois at Chicago, the University of Minnesota, or the Robert Wood Johnson Foundation.

Additional Information: An earlier version of this review was developed for the Healthy Eating Research Program.

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PubMed   |  Link to Article
Taber  DR, Chriqui  JF, Chaloupka  FJ.  Differences in nutrient intake associated with state laws regarding fat, sugar, and caloric content of competitive foods. Arch Pediatr Adolesc Med. 2012;166(5):452-458.
PubMed   |  Link to Article
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(3):437-444.
PubMed   |  Link to Article
Cradock  AL, McHugh  A, Mont-Ferguson  H,  et al.  Effect of school district policy change on consumption of sugar-sweetened beverages among high school students, Boston, Massachusetts, 2004-2006. Prev Chronic Dis. 2011;8(4):A74.
PubMed
Centers for Disease Control and Prevention (CDC).  Effects of switching from whole to low-fat/fat-free milk in public schools—New York city, 2004-2009. MMWR Morb Mortal Wkly Rep. 2010;59(3):70-73.
PubMed
Cullen  KW, Watson  K, Zakeri  I, Ralston  K.  Exploring changes in middle-school student lunch consumption after local school food service policy modifications. Public Health Nutr. 2006;9(6):814-820.
PubMed   |  Link to Article
Han-Markey  TL, Wang  L, Schlotterbeck  S,  et al.  A public school district’s vending machine policy and changes over a 4-year period: implementation of a national wellness policy. Public Health. 2012;126(4):335-337.
PubMed   |  Link to Article
Snelling  AM, Kennard  T.  The impact of nutrition standards on competitive food offerings and purchasing behaviors of high school students. J Sch Health. 2009;79(11):541-546.
PubMed   |  Link to Article
Coffield  JE, Metos  JM, Utz  RL, Waitzman  NJ.  A multivariate analysis of federally mandated school wellness policies on adolescent obesity. J Adolesc Health. 2011;49(4):363-370.
PubMed   |  Link to Article
Johnson  DB, Bruemmer  B, Lund  AE, Evens  CC, Mar  CM.  Impact of school district sugar-sweetened beverage policies on student beverage exposure and consumption in middle schools. J Adolesc Health. 2009;45(3)(suppl):S30-S37.
PubMed   |  Link to Article
Turner  L, Chriqui  JF, Chaloupka  FJ.  Food as a reward in the classroom: school district policies are associated with practices in US public elementary schools. J Acad Nutr Diet. 2012;112(9):1436-1442.
PubMed   |  Link to Article
Sanchez-Vaznaugh  EV, Sánchez  BN, Baek  J, Crawford  PB.  ‘Competitive’ food and beverage policies: are they influencing childhood overweight trends? Health Aff (Millwood). 2010;29(3):436-446.
PubMed   |  Link to Article
Turner  L, Chriqui  JF, Chaloupka  FJ.  Healthier fundraising in US elementary schools: associations between policies at the state, district, and school levels. PLoS One. 2012;7(11):e49890.
PubMed   |  Link to Article
National Cancer Institute. Classification of laws about school students. http://class.cancer.gov/download.aspx. Updated 2012. Accessed March 19, 2012.
Chaloupka  FJ, Johnston  LD.  Bridging the gap: research informing practice and policy for healthy youth behavior. Am J Prev Med. 2007;33(4)(suppl):S147-S161.
PubMed   |  Link to Article
Brennan  L, Castro  S, Brownson  RC, Claus  J, Orleans  CT.  Accelerating evidence reviews and broadening evidence standards to identify effective, promising, and emerging policy and environmental strategies for prevention of childhood obesity. Annu Rev Public Health. 2011;32:199-223.
PubMed   |  Link to Article
Schwartz  MB.  Environmental and policy strategies to improve eating, physical activity behaviors, and weight among adolescents. Adolesc Med State Art Rev. 2012;23(3):589-609.
PubMed
Gearhardt  AN, Bragg  MA, Pearl  RL, Schvey  NA, Roberto  CA, Brownell  KD.  Obesity and public policy. Annu Rev Clin Psychol. 2012;8:405-430.
PubMed   |  Link to Article
Kraak  VI, Story  M, Wartella  EA.  Government and school progress to promote a healthful diet to American children and adolescents: a comprehensive review of the available evidence. Am J Prev Med. 2012;42(3):250-262.
PubMed   |  Link to Article
Trust for America's Health. F as in FAT: how obesity policies are failing America 2006. http://healthyamericans.org/reports/obesity2006/. Updated 2006. Accessed September 21, 2012.
Mâsse  LC, Frosh  MM, Chriqui  JF,  et al.  Development of a school nutrition-environment state policy classification system (SNESPCS). Am J Prev Med. 2007;33(4)(suppl):S277-S291.
PubMed   |  Link to Article
Mercer  SL, DeVinney  BJ, Fine  LJ, Green  LW, Dougherty  D.  Study designs for effectiveness and translation research: identifying trade-offs. Am J Prev Med. 2007;33(2):139-154.
PubMed   |  Link to Article
McKinnon  RA, Reedy  J, Berrigan  D, Krebs-Smith  SM; NCCOR Catalogue and Registry Working Groups.  The National Collaborative on Childhood Obesity Research catalogue of surveillance systems and measures registry: new tools to spur innovation and increase productivity in childhood obesity research. Am J Prev Med. 2012;42(4):433-435.
PubMed   |  Link to Article
Campbell  DT, Stanley  JC. Experimental and Quasi-experimental Designs for Generalized Causal Inference. Boston, MA: Houghton Mifflin; 1963.
Wojcicki  JM, Heyman  MB.  Healthier choices and increased participation in a middle school lunch program: effects of nutrition policy changes in San Francisco. Am J Public Health. 2006;96(9):1542-1547.
PubMed   |  Link to Article
Long  MW, Luedicke  J, Dorsey  M, Fiore  SS, Henderson  KE.  Impact of Connecticut legislation incentivizing elimination of unhealthy competitive foods on National School Lunch Program participation. Am J Public Health. 2013;103(7):e59-e66.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.
Systematic Literature Review Process Flowchart

BMI indicates body mass index; CF&B, competitive food and beverage; K-12, kindergarten through grade 12.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.
Publication Year of Included Studies by Policy Focus
Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Summary of Findings of Bivariate and Multivariate Studies by “Big ‘P’” Policy Focus

References

Turner  L, Chaloupka  FJ.  Slow progress in changing the school food environment: nationally representative results from public and private elementary schools. J Acad Nutr Diet. 2012;112(9):1380-1389.
PubMed   |  Link to Article
Turner  LR, Chaloupka  FJ.  Student access to competitive foods in elementary schools: trends over time and regional differences. Arch Pediatr Adolesc Med. 2012;166(2):164-169.
PubMed   |  Link to Article
Turner LR, Terry-McElrath YM, Johnston LD, O'Malley PM, Chaloupka FJ. Beverages sold in public schools: some encouraging progress, additional improvements are needed. http://www.bridgingthegapresearch.org. Updated 2012. Accessed April 1, 2013.
Turner L, Chaloupka FJ, Sandoval A. School policies and practices to improve health and prevent obesity: national elementary school survey results: school years 2006-07 through 2009-10, Vol 2. http://www.bridgingthegapresearch.org. Updated 2012. Accessed March 1, 2012.
Terry-McElrath  YM, Johnston  LD, O’Malley  PM.  Trends in competitive venue beverage availability: findings from US secondary schools. Arch Pediatr Adolesc Med. 2012;166(8):776-778.
PubMed   |  Link to Article
Johnston LD, O'Malley PM, Terry-McElrath YM, Colabianchi N. School policies and practices to improve health and prevent obesity: national secondary school survey results: school years 2006-07 through 2010-11, Vol 3. http://www.bridgingthegapresearch.org. Updated 2013. Accessed April 1, 2013.
Institute of Medicine Committee to Accelerate Progress in Obesity Prevention. Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation. Washington, DC: The National Academies; 2012.
Trust for America's Health. F as in FAT: how obesity policies are failing America 2012. http://healthyamericans.org/reports/obesity2012/. Updated 2012. Accessed September 21, 2012.
Mâsse  LC, Perna  F, Agurs-Collins  T, Chriqui  JF.  Change in school nutrition-related laws from 2003 to 2008: evidence from the school nutrition-environment state policy classification system. Am J Public Health. 2013;103(9):1597-1603.
PubMed   |  Link to Article
Chriqui JF, Resnick E, Schneider LM, et al. School district wellness policies: evaluating progress and potential for improving children's health five years after the federal mandate. school years 2006-07 through 2010-11, Vol 3. http://www.bridgingthegapresearch.org/research/district_wellness_policies/. Updated 2013. Accessed February 28, 2013.
Appendix B to Part 210—Categories of foods of minimal nutritional value. 2009. 7 CFR §210, Appendix B.
Healthy, Hunger-Free Kids Act of 2010. Pub L No. 111-296. 2010.
Food and Nutrition Service, USDA.  National School Lunch Program and School Breakfast Program: nutrition standards for all foods sold in school as required by the Healthy, Hunger-Free Kids Act of 2010. Interim final rule. Fed Regist. 2013;78(125):39067-39120.
PubMed
PRISMA (Transparent Reporting of Systematic Reviews and Meta-Analyses) web site. http://www.prisma-statement.org/index.htm. Accessed August 3, 2013.
Child Nutrition and WIC Reauthorization Act of 2004. Pub L No. 108-265.
Brownson  RC, Chriqui  JF, Stamatakis  KA.  Understanding evidence-based public health policy. Am J Public Health. 2009;99(9):1576-1583.
PubMed   |  Link to Article
Long  MW, Henderson  KE, Schwartz  MB.  Evaluating the impact of a Connecticut program to reduce availability of unhealthy competitive food in schools. J Sch Health. 2010;80(10):478-486.
PubMed   |  Link to Article
Whatley Blum  JE, Beaudoin  CM, O’Brien  LM, Polacsek  M, Harris  DE, O’Rourke  KA.  Impact of Maine’s statewide nutrition policy on high school food environments. Prev Chronic Dis. 2011;8(1):A19.
PubMed
Cullen  KW, Watson  K, Zakeri  I.  Improvements in middle school student dietary intake after implementation of the Texas Public School Nutrition Policy. Am J Public Health. 2008;98(1):111-117.
PubMed   |  Link to Article
Cullen  KW, Watson  KB.  The impact of the Texas public school nutrition policy on student food selection and sales in Texas. Am J Public Health. 2009;99(4):706-712.
PubMed   |  Link to Article
Peart  T, Kao  J, Crawford  PB, Samuels  SE, Craypo  L, Woodward-Lopez  G.  Does competitive food and beverage legislation hurt meal participation or revenues in high schools? Child Obes. 2012;8(4):339-346.
PubMed
Samuels  SE, Bullock  SL, Woodward-Lopez  G,  et al.  To what extent have high schools in California been able to implement state-mandated nutrition standards? J Adolesc Health. 2009;45(3)(suppl):S38-S44.
PubMed   |  Link to Article
Samuels  SE, Hutchinson  KS, Craypo  L, Barry  J, Bullock  SL.  Implementation of California state school competitive food and beverage standards. J Sch Health. 2010;80(12):581-587.
PubMed   |  Link to Article
Woodward-Lopez  G, Gosliner  W, Samuels  SE, Craypo  L, Kao  J, Crawford  PB.  Lessons learned from evaluations of California’s statewide school nutrition standards. Am J Public Health. 2010;100(11):2137-2145.
PubMed   |  Link to Article
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(3):434-440.
PubMed   |  Link to Article
Phillips  MM, Raczynski  JM, West  DS,  et al.  Changes in school environments with implementation of Arkansas Act 1220 of 2003. Obesity (Silver Spring). 2010;18(suppl 1):S54-S61.
PubMed   |  Link to Article
Riis  J, Grason  H, Strobino  D, Ahmed  S, Minkovitz  C.  State school policies and youth obesity. Matern Child Health J. 2012;16(suppl 1):S111-S118.
PubMed   |  Link to Article
Taber  DR, Chriqui  JF, Powell  LM, Chaloupka  FJ.  Banning all sugar-sweetened beverages in middle schools: reduction of in-school access and purchasing but not overall consumption. Arch Pediatr Adolesc Med. 2012;166(3):256-262.
PubMed   |  Link to Article
Taber  DR, Chriqui  JF, Chaloupka  FJ.  Differences in nutrient intake associated with state laws regarding fat, sugar, and caloric content of competitive foods. Arch Pediatr Adolesc Med. 2012;166(5):452-458.
PubMed   |  Link to Article
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(3):437-444.
PubMed   |  Link to Article
Cradock  AL, McHugh  A, Mont-Ferguson  H,  et al.  Effect of school district policy change on consumption of sugar-sweetened beverages among high school students, Boston, Massachusetts, 2004-2006. Prev Chronic Dis. 2011;8(4):A74.
PubMed
Centers for Disease Control and Prevention (CDC).  Effects of switching from whole to low-fat/fat-free milk in public schools—New York city, 2004-2009. MMWR Morb Mortal Wkly Rep. 2010;59(3):70-73.
PubMed
Cullen  KW, Watson  K, Zakeri  I, Ralston  K.  Exploring changes in middle-school student lunch consumption after local school food service policy modifications. Public Health Nutr. 2006;9(6):814-820.
PubMed   |  Link to Article
Han-Markey  TL, Wang  L, Schlotterbeck  S,  et al.  A public school district’s vending machine policy and changes over a 4-year period: implementation of a national wellness policy. Public Health. 2012;126(4):335-337.
PubMed   |  Link to Article
Snelling  AM, Kennard  T.  The impact of nutrition standards on competitive food offerings and purchasing behaviors of high school students. J Sch Health. 2009;79(11):541-546.
PubMed   |  Link to Article
Coffield  JE, Metos  JM, Utz  RL, Waitzman  NJ.  A multivariate analysis of federally mandated school wellness policies on adolescent obesity. J Adolesc Health. 2011;49(4):363-370.
PubMed   |  Link to Article
Johnson  DB, Bruemmer  B, Lund  AE, Evens  CC, Mar  CM.  Impact of school district sugar-sweetened beverage policies on student beverage exposure and consumption in middle schools. J Adolesc Health. 2009;45(3)(suppl):S30-S37.
PubMed   |  Link to Article
Turner  L, Chriqui  JF, Chaloupka  FJ.  Food as a reward in the classroom: school district policies are associated with practices in US public elementary schools. J Acad Nutr Diet. 2012;112(9):1436-1442.
PubMed   |  Link to Article
Sanchez-Vaznaugh  EV, Sánchez  BN, Baek  J, Crawford  PB.  ‘Competitive’ food and beverage policies: are they influencing childhood overweight trends? Health Aff (Millwood). 2010;29(3):436-446.
PubMed   |  Link to Article
Turner  L, Chriqui  JF, Chaloupka  FJ.  Healthier fundraising in US elementary schools: associations between policies at the state, district, and school levels. PLoS One. 2012;7(11):e49890.
PubMed   |  Link to Article
National Cancer Institute. Classification of laws about school students. http://class.cancer.gov/download.aspx. Updated 2012. Accessed March 19, 2012.
Chaloupka  FJ, Johnston  LD.  Bridging the gap: research informing practice and policy for healthy youth behavior. Am J Prev Med. 2007;33(4)(suppl):S147-S161.
PubMed   |  Link to Article
Brennan  L, Castro  S, Brownson  RC, Claus  J, Orleans  CT.  Accelerating evidence reviews and broadening evidence standards to identify effective, promising, and emerging policy and environmental strategies for prevention of childhood obesity. Annu Rev Public Health. 2011;32:199-223.
PubMed   |  Link to Article
Schwartz  MB.  Environmental and policy strategies to improve eating, physical activity behaviors, and weight among adolescents. Adolesc Med State Art Rev. 2012;23(3):589-609.
PubMed
Gearhardt  AN, Bragg  MA, Pearl  RL, Schvey  NA, Roberto  CA, Brownell  KD.  Obesity and public policy. Annu Rev Clin Psychol. 2012;8:405-430.
PubMed   |  Link to Article
Kraak  VI, Story  M, Wartella  EA.  Government and school progress to promote a healthful diet to American children and adolescents: a comprehensive review of the available evidence. Am J Prev Med. 2012;42(3):250-262.
PubMed   |  Link to Article
Trust for America's Health. F as in FAT: how obesity policies are failing America 2006. http://healthyamericans.org/reports/obesity2006/. Updated 2006. Accessed September 21, 2012.
Mâsse  LC, Frosh  MM, Chriqui  JF,  et al.  Development of a school nutrition-environment state policy classification system (SNESPCS). Am J Prev Med. 2007;33(4)(suppl):S277-S291.
PubMed   |  Link to Article
Mercer  SL, DeVinney  BJ, Fine  LJ, Green  LW, Dougherty  D.  Study designs for effectiveness and translation research: identifying trade-offs. Am J Prev Med. 2007;33(2):139-154.
PubMed   |  Link to Article
McKinnon  RA, Reedy  J, Berrigan  D, Krebs-Smith  SM; NCCOR Catalogue and Registry Working Groups.  The National Collaborative on Childhood Obesity Research catalogue of surveillance systems and measures registry: new tools to spur innovation and increase productivity in childhood obesity research. Am J Prev Med. 2012;42(4):433-435.
PubMed   |  Link to Article
Campbell  DT, Stanley  JC. Experimental and Quasi-experimental Designs for Generalized Causal Inference. Boston, MA: Houghton Mifflin; 1963.
Wojcicki  JM, Heyman  MB.  Healthier choices and increased participation in a middle school lunch program: effects of nutrition policy changes in San Francisco. Am J Public Health. 2006;96(9):1542-1547.
PubMed   |  Link to Article
Long  MW, Luedicke  J, Dorsey  M, Fiore  SS, Henderson  KE.  Impact of Connecticut legislation incentivizing elimination of unhealthy competitive foods on National School Lunch Program participation. Am J Public Health. 2013;103(7):e59-e66.
PubMed   |  Link to Article

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Multimedia

Supplement.

eAppendix. Literature Review Search Strings

eTable 1. Summary of Bivariate Studies (n=11) Examining Competitive Food and Beverage Policy Influences

eTable 2. Summary of Multivariate Studies (n=13) Examining Competitive Food and Beverage Policy Influences

eTable 3. Classification of Included Studies by Direction of Results

eReferences.

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